Choices

There are some interesting discussions about birthing choices going on over at Jamie's and Jo's places of business, and if you haven't read them, I highly recommend heading over there.

I've been cogitating on what's been said over the weekend, but every time I sat down to write, I started feeling a little snarky and defensive.  Now that the heat wave's broken, I'm feeling a little more sanguine.

So here's thing #1:

Jamie referenced an older post of mine in which I articulated a preference (for me) for a high intervention birth with all the fixings.  In that post, I completely neglected the possibility that some women might be limited by insurance and/or geography--a pretty huge omission--that would force them to have a high intervention birth even though that's not what they want.  That's not a good thing. 

And thing #2:

In that same post, I used a metaphor that going to a high-intervention hospital and expecting low-intervention treatment seemed a little like going to a French restaurant and ordering Eggplant Parmigiana. I stick by that analogy.  Different doctors/nurses/medical staff have different training.  At my high-intervention hospital, for example, patients get IVs on admission to Labor & Delivery.  Since that is the norm there, it suggests to me that that's where the expertise lies--I'm not making a judgment about whether that's the best kind of expertise to have; it just happens to be theirs.  So, if I refused the IV on delivery and needed one in a hurry later, I would guess that IVs on the go are not this hospitals area of expertise--sure, they can do them, but maybe it takes them a little while longer than someone else used to doing IVs under these circumstances.  In other words, I get slightly soggy Eggplant Parmigiana. 

Should my hospital have learned to make impeccable Eggplant Parmigiana?  Maybe.  But see, the hospital across town is really well known for their Eggplant Parmigiana.  Assuming insurance and geography are not a factor (big assumption, I know), I'd go there if I really wanted Eggplant Parmigiana.  But I don't.  Which is why I chose the French restaurant to begin with.

And thing #3:

I'm all for birth choice: be it home birth, midwife-assisted hospital birth, high- intervention hospital birth, or what have you.  But choice means valuing all those things equally, and it does sometimes feel like the only options that are embraced as real choice are home birth or natural birth or what lots of people (including the good folks at WHO) like to call normal birth.*

Oh, the problems I have with the word normal!  I feel like an angsty teenager when I hear it: I want to don my black t-shirt, put on my headphones, and turn up the Smiths really loud.  Have I ever been normal?

I wasn't one of the normal women who got pregnant after a year of timed intercourse or who, once pregnant, had hCG, estradiol, and progesterone levels within the standard ranges.  I wasn't one of the normal women with a three vessel umbilical cord or who doesn't give herself twice daily injections of heparin to ward off thrombosis. 

Now, Jamie writes that "Childbirth is different in important ways, of course, and it certainly does have its dangers.  But it is a well-designed process essential to the survival of the species.  It is normal."  Well, sure it is.  So was getting pregnant to begin with, though, and look at all the help I needed with that.

And thing #4:

There's more than one way to have a child.  You can adopt.  You can conceive using donor eggs and/or sperm.  You can conceive using a surrogate.  You can conceive while you're relaxing on an expensive vacation you paid for using the money you don't have to spend on ART. 

We in the infertile blogosphere would never privilege one of those methods as more sacred and spiritual than another simply because it involves less intervention than another.  Yet, when it comes to birth, it seems like a different story.  Or at least it feels that way.

*According to WHO, normal birth is "spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition."

Comments

[Jan]

I couldn't agree more!! Choices are wonderful and everyone should be allowed to make their own. But once you've been put into the "too hard" basket they start to diminish. Personally, I would have liked to get pregnant first try (I did!) and have a healthy pregnancy (I didn't, I had a miscarriage) and a "normal", WHO-style birth (still waiting for that possibility). Instead I've had 2 1/2 years of miscarriage and subfertility and if I ever do manage to get and stay pregnant, then, like you, I suspect I will be looking for all the medical care I can get. I like Chinese food myself, but I don't expect the rest of the world to come with me to the restaurant. I'm cheering you on all the way!

[Jamie]

Lisa, I am sorry if my post contributed to your feeling snarky or defensive. I hope you wind up with exactly the birth you hope to have.

[Shanna]

I have surprised myself by ordering the Eggplant Parmagiana when I was pretty sure I was a French Bistro kind of girl. I agree that all options are equally valuable to those who choose them, and the pressure to have one "type of birth" over another is strong. My husband and I, for instance, are facing a lot of abuse because he will not be in the room when the baby is born. I don't really want him there, he doesn't really want to be there: both of us have our own reasons, and yet people just find it inconceivable that he would want to "miss" the birth of his child. It's frustrating.

And it always sucks to be on the receiving end of the judgement stick.

[Brooklyn Girl]

Jamie--Not at all. I appreciate the dialogue.

[Kristine]

Thing #1: I like Eggplant Parmigiana. You mentioned it so many times I simply must have some.
Thing #2: My IV sucked big time. Having it inserted was, I think, the most painful part of delivering my son (so obviously you can tell I had a really rockin' epidural)
Thing #3: I'm with you on the respecting of all opinions/choices related to childbirth. If you get a baby when you're done, you did it right.
Thing #4: Good luck to you! It's almost showtime!!

[expat]

The only problem with this scenario, is that the soggy eggplant parmigiana can kill you.

That's what gets lost in this discussion, every time. The routine IV, the continuous monitoring, the immediate epidural, they're making it less safe for you to give birth - either you or the baby might die because of it.

THAT is why it's an issue - it's not about choice or what we might like to have happen, it's about getting the maximum number of mothers and babies out the other end alive and as undamaged as possible.

So that means you need to acknowledge that the continuous foetal monitoring that ends in an unnecessary c-section may just kill you, when if you'd been momitored intermittently, you wouldn't have died from the c-section.

It's a high stakes game, and I feel ill every time I hear someone claim it's about wants and desires and choices.

[Brooklyn Girl]

Expat--I respectfully disagree. Yes, there's a risk of dying from a c-section in a hospital (the need for which may have been indiciated by fetal monitoring), but there's also a risk of dying from placental abruption at a home birth. Neither is a particularly big risk, but it is a risk.

[getupgrrl]

[i] "We in the infertile blogosphere would never privilege one of those methods as more sacred and spiritual than another simply because it involves less intervention than another. Yet, when it comes to birth, it seems like a different story." [/i]

I'm really glad you said this.

In my opinion, going through an arduous ordeal to conceive can change your perspective on these issues. Although things may not often go terribly wrong during birth, when they do, medical intervention is needed immediately - not in the twenty minutes it takes to get to a hospital. And when you've been on the losing end of the statistics so many times before, I don't think it's unacceptable, harmful, or anti-woman to hedge your bets during labor and delivery.

[getupgrrl]

Stupid italics.

[Kate]

My aunt had her first baby with a midwife, but when there was a medical emergency, and the midwife was slow to call in a doctor to perform an emergency c-section, the baby was born brain dead.

I know that doesn't mean that her experience was typical, or that home births are necessarily at higher risk for such things. But I certainly agree that both come with risks, and that though those risks are relatively low in the grand scheme of things, it's foolish to declare one or the other risk-free.

[Monica]

I've been reading this discussion with great interest because I haven't yet been able to fully process how I feel about my labor and delivery. The bottom line is that I ended up with a healthy baby - and I care more about that than my labor. However, I also have a lot of regret -- not necessarily because I had an epidural or internal fetal monitoring or any other high tech help, but because I feel guilty about it. I'm not sure how that happened - how I convinced myself that I needed to have a "natural" birth in order to feel satisfied. I believe in choice, and yet I failed to allow myself to make one and feel ok about it.

[Christy]

I agree with the idea that once you've been through the difficulties of infertility that your perspective changes. Mine did. I wanted all of the help I could get to deliver my daughter safely. And I did it in the hospital with very little intervention and made all of the decisions WITH my OB.
To assume that when you are having a hospital birth that you simply lay back & lose all of the ability to make decisions is wrong. I made sure that I understood everything that was going on and had the birth that I wanted.
And I also respectfully disagree with Expat who feels that a hospital birth poses a huge risk of death to the mother or child. I'd be interested to see the stats.
I'm so excited for you Brooklyn girl. Best of luck to you! Enjoy the ride !

[liz]

I'd like to point out that any national (US) stats on mortality in hospital settings vs. home births may be skewed due to high-risk pregnancies being delivered almost exclusively in hospitals.

And my sister (mom to two kids) had her first child in a birthing center with absolutely no intervention and went through 36 hours of hard labor and was completely exhausted when her daughter arrived, she didn't recover for weeks. With her second, she went in with an agreement with her midwives: If the birth took over 15 hours, she would get an epidural so that she could sleep for a while (her son was born in just over 12 hours)

[Christy]

Liz,
You're right about the skewed results. I'm still glad we have the right to choose.

[Cat]

When this whole trip started I dreamed of home birth and natural birth. I read books about it and shopped the city for birthing centers. I couldn’t imagine having a child in a hospital. Now all that feels important is baby and I surviving the pregnancy and birth. By any means necessary we will get to that goal. The road that takes us there seems unimportant after everything that has happened.

I hope your trip comes to a very happy ending very soon.

[Anne]

"The road that takes us there seems unimportant after everything that has happened."

Amen!

[eliz]

I have to agree that infertility/loss can change your perspective on these things and I'm glad you're making that point. While I'm in awe of women like Jo who seem to have survived infertility with a fabulous attitude about pregnancy and birth, I think it is more common to end up like myself and Brooklyn Girl and welcome medical intervention as an almost necessary conclusion to what has been such a difficult journey.

In my case (secondary infertility + 3 losses) while I was very relaxed and with my first pregnancy and birth, I have found myself much more paranoid with this one. For my son's birth I had a low intervention pregnancy and delivery. This pregnancy (seemingly successful at 31 weeks) has been monitored much more closely, at my request, and I am hoping to be induced sometime between 38 - 40 weeks. I may change my mind when we are closer to the birth, and value the fact that I am able to do so, but at this point I just want to get to the end of the road safely and feel like having close medical management is the way to get there.

I also think that emotionally I am in a very different place then I was with my first pregnancy when I was very calm and serene and confident everything would work out. Now, I am much more anxious and appreciate having high-intervention caregivers who will (still) send me to be monitored whenever I feel anxious.

All the best Brooklyn Girl, it is getting very close for you, so exciting.

[Misha]

Oh...we women have too much guilt. I ended up having a c/s after almost 24 hours of labor. (never moved beyond 7cm) I cried like a baby when the doctor told me that my son's HB was slowing and that we needed to go get him. In the end though it was all about the outcome and having a beautiful (9lb, 3oz) baby boy. I had a little PPD over having a c/s and would sob in the shower over my failure as a woman to push my baby out. All I say is..thank goodness most of us have top of the line health care available to us and that c/s are routine. Otherwise, Ty and I might not be here right now.

[Julesie00]

Amen, sista.
It's not the 9 or so months of carrying the baby, the 24 or so hours of labor, the 3 or so hours of pushing, the 30 minutes or so of the baby coming out that matters. It's the next (god willing) 30, 40, 50, 60 years of your life with this wonderful person. The actual birth is a mere blip in the course of your and their life. You realize this after the baby arrives - that it really never mattered how they got there, just that they did.

[Melissa]

Long time reader delurking here.

I too suffered infertility, went through numerous forms of ART before finally getting pregnant through IVF. After having a tough time getting pregnant, I had a tough pregnancy, too. Low amniotic fluid levels, weekly NST's, many failed fetal kick count tests, gestational hypo-thyroidism, three trips to L&D before the 3rd trimester, bed rest for pre-term labor, etc.

To me it didn't matter how my daughter would arrive, I just wanted her healthy and alive. I welcomed, two+ trips to my OB per week, all the NST's,and the 15 ultrasounds I received.

One thing that came out of it was I had the easiest delivery--far easlier than I ever thought possible. I give credit to the fine medical intervention I received... I had an OB who respected the "little" birthplan I had and I'm grateful, for that epidural which helped me enjoy my whole L&D experience.

I do give credit to those women out there who are calm enough in their pregnancies and can go through it with low intervention--you're much stronger than I. But if I am ever lucky enough to get to that point again, being the nervous-nellie I am, I would again take the high-intervention-road.

[Jo]

God, I want eggplant parmigiana now.

First, I have to say, it's a lovely thing to behold, the strength of your conviction in your obviously informed choices. I'm positive you'll have a beautiful birth, and I'm looking forward to reading about it. I'm glad you're able to get what you need -- and what you want -- from your caregivers. That's an awesome thing.

I think that as individuals, we can and should value our choices equally. Every woman who gives birth -- and every woman who adopts, for that matter, or who uses a gestational surrogate, or whatever path to motherhood she might take -- deserves to be proud of the experience, deserves to have it celebrated as she wishes (or mourned if that's what she wishes). As a society, we can and should examine our common practices -- but as women, we need to honor our experiences and be honored by others.

At the same time, though, I do think that our culture as a whole is much more accepting of the current norm in birthing -- which is absolutely hospital birth, usually with epidural and pitocin. It's funny, this reminds me so much of the mommy drive-by battle between "mainstream" vs. "attachment" parents -- whichever side you lean to, you get the attacks from the other side (not that I buy the whole idea of two exclusive sides, but you see what I mean). People swear up and down that they get loads of crap about formula feeding, whereas I'm already dealing with a ridiculous amount of judgment about using cloth diapers (and really, who cares?) -- my point is, I think whatever decisions we make, we catch hell for it, and that leaves us all on the defensive.

Anyway. The word "normal" is a touchy one, especially in our crowd; I've spent a lot of time not being normal, and it's a shitty feeling when judgment gets attached to it, which it often does. But I think that standard medical definitions of "normal" are a necessary thing, first just from a statistical viewpoint (normal, as in, Conforming with, adhering to, or constituting a norm, standard, pattern, level, or type), and second as a means of identifying issues as they arise, or assessing risk ahead of time. I just wish the feeling of judgment were removed from use of the term.

[Kez]

It's not only infertile women who decide on a high intervention birth. I have conceived without ART and I will be having my baby in a hospital, delivered by an OB, with an epidural firmly plugged into my spinal column. I will also be bottle feeding. And the crap I have copped already, from family, friends, workmates, even my shrink, about my choices is incredible.

That's why I'm so glad to see this discussion taking place on several blogs. There are many differing opinions, but nearly everyone seems to agree that choice is personal and what is right for one is not necessarily right for another. It's good to see women respecting each other's differences for once. Now, if I could just convince several of my aging aunts to shut up about the epidural already, things would be perfect.

[Jan]

To quote Disraeli (or Mark Twain): "There are three kinds of lies: lies, damned lies, and statistics".

While I don't think that all statistics are lies, they do have to be read with a lot of knowledge about the sources of the figures and the underlying effects before they make much sense. For instance, it seems likely to me that a lot of women who go for high-intervention births will choose to do so, or be encouraged to do so, because they have some advance indication that the birth is likely to be a high-risk one. If this is the case, then one wouldn't be surprised to find that the statistics indicate that high-intervention births have higher fatalities. Similarly, in this country (UK) at least, they will offer forms of low-intervention if there is a strong indication that all is very "normal" (note the quotes!) with you and your baby. And, if *this* is the case, then one wouldn't be surprised to find that the incidence of fatality is lower.

Of course, you can end up being misplaced in either of these situations - we're all human, including the medics. In the end, even if we were medically trained (and specialists in obs and gynae to boot) and had scoured the statistics and then evaluated the research that leads to them, we would probably *still* have differing opinions on what is the right thing to do. Given that, we might as well make our personal choices and try hard not exert pressure on or cause guilt in those who make a choice that is different from our own - chances are there are statistics somewhere to support that one too!

[LizM]

Everytime people talk about birth I always feel that I have to defend my c-section. What would you do if all you wanted was a "natural birth" and you were at 42 weeks with a baby estimated at 10.5 lbs and you hadn't had a single contraction?? What are you supposed to do when labor just isn't happening and you've had two failed inductions? Why do people have to make it sound like I had some kind of choice? Even if I had planned on delivering at home I would've ended up in the hospital because mid-wives aren't allowed to deliver past 42 weeks (usually). As most people are stressing, the health of the mother and baby are SOOOO much more important than the process. A c-section seems like a small price to pay when you think that I could've just kept waiting and hoping that the placenta didn't degrade before I went into labor. Then I could've had a "normal" birth but a sick or dead baby. I was not willing to pay that price for a "natural" birth.
Anyways, I'm sure I haven't said anything that wasn't already said but all these posts (by you, Jo and Jamie) evoked a really emotional response in me (and in others) and I just wanted to have my say.
Thanks.

[Toni/taquita]

I hear you! We drove 70 miles to the biggest, newest hospital in the area. And thank God we did! DS spent the first hours of his life in the NICU. Did I want him nestled in my arms breastfeeding minutes after birth? Of course I did, but then there is that pesty little thing called reality. We had a very difficult birth, bordering on c-section, and he had a bit of a rough go of things at the start. I hadn't struggled nine years w/ infertility and depression not to bring home a healthy baby!

[Ellen]

My choice was to have an epidural in a hospital (also induced, due to high blood pressure) and I've gotta say, it rocked. No pain, my daughter and I were both fully alert and "engaged,"-- in fact, we watched the Super Bowl between pushes. The nurse said it was one of the most pleasant and happy births that she had ever attended. And I refuse to feel guilty about it.

[patricia]

As you say, every choice is valid. And I think most people are ultimately happy with their choice.

I opted to be in the highest tech hospital -"just in case." It turns out I had a C-section. Without boring you too much with my birth story, my son was not breach, but was facing the front of my pelvis, not the back as is preferred. (Back labor from hell, which I call butt labor, because I thought my ass was going to explode. Gross, sorry)

Anyways, my baby was jammed! He was 8 and 1/2 lbs (1 week late) and I have narrow hips. When they did the C-section he had little cuts on his head from ramming at my pelvis. The next day my OB - who was wonderful - told that 100 years ago we both would have died. I would have bled to death and he would have suffocated. Nice.

Labor is natural, our bodies are made for it, but when I heard that I was sure glad that I had this high tech, modern, hospital to have a baby at.

[Kimberly]

Not related to your post, but I did want to let you know I am thinking of you, hoping things are going well. Would love an update!

Also, read the article about the 9/11 widow in this month's Vanity Fair. She lives in Park Slope, described in the article as a quaint neighborhood. I could not help but think of you immmediately. Her husband was a member of Squad 1, firemen based in Park Slope. Moving article.

Again, thinking of you, hope all is well.

[tpon]

The beauty of choice is that you can decide to do what works for you and your baby.

Woudln't it just be great if we could stop judging each other and the choices we make and just SUPPORT each other.

Good luck and enjoy your eggplant!

[beaver girl]

BG- I agree with you. We need to switch places!!! Then we can both relax and be more "normal" according to the "experts" in our area. Hang in there. I'm rooting for you!

[Molly]

It seems to me that any birth that ends with a healthy baby and a healthy mama is a good birth.

[Anna H.]

Thinking of you as the time draws near, dear Brooklyn Girl.

xxoo

[Jamie]

I have been going around and around about whether to comment again, but here goes.

I'm thinking that Ellen's comment about being "engaged" is referring to the piece of my post that talks about unmedicated birth allowing me to be "fully engaged -- mind, body, and soul." It's funny, sometimes, the way your words mean different things to different people. For me, birth is one of the rare occasions when my whole self is attending to one thing. I'm not thinking about whether there's laundry in the dryer, whether I have any new email, when my children will stop prattling away. I am completely present in that moment, focused on one thing only.

For me, watching TV during pushing would be like watching TV during sex. I know it works for some couples, but it seems a little odd to me personally. I posted about it last year--

http://selkie.typepad.com/selkie/2004/11/its_not_only_na.html

--but be advised that it is a post from way over in my earthy-crunchy corner of the world and it may rub you the wrong way. (It says "normal" a lot!)

Ellen, I'm glad you had a good birth experience, and Lisa, I'm wishing you all the best with your birth. I only wanted to pop back in and say that for me being engaged in the birth process means something different from watching the Superbowl. Thanks for hosting the discussion.

[Jamie]

Aarrggh, poster's regret.

Ellen, I truly didn't mean to seem critical about your choice to watch TV during birth -- I'm only talking about what works for me personally.

[JustBreathe]

Watching this discussion from the sidelines has been very enlightening. Great topic, great perspectives and writings on all sides.

Ideally, everyone would get the birth they want. And no one else would just their choice.

Until then, it is great to hear intelligent women speak about their choices.

[Susan R]

Thanks for hosting the discussion.

[Amber]

Not related to your post, but I did want to let you know I am thinking of you, hoping things are going well. Would love an update!

[will barrette]

It's not only infertile women who decide on a high intervention birth. I have conceived without ART and I will be having my baby in a hospital, delivered by an OB, with an epidural firmly plugged into my spinal column. I will also be bottle feeding. And the crap I have copped already, from family, friends, workmates, even my shrink, about my choices is incredible.

[Mariah]

I just came across this, and obviously this is an older entry, but I couldnt read without posting. I was a complete believer in super-natural birth-no drugs of any kind, no epidural, laboring at home as long as possible etc. Thats how my first was born. Then my second baby died at 37 weeks inside of me. I am now in third trimester of my subsequent pregnancy and I tearfully understand the women who posted here...At this point i just want a BABY TO TAKE HOME.

But I do have one more thing to say. I feel that to make the right choice for you, you have to be educated about your options. And too many women these days are not. They simply have NO CLUE the risks pitocin carries with it. And they need to have a clue, they need to be educated about it. Because, sadly, you can lose your baby BECAUSE of one of these wonderful interventions, yes even in this day and age of highly medicalized and managed birth. Not every doctor will tell you the truth-some will just tell you the convinient for them version of it.
So women, please, educate yourself. Read and research. Its YOUR birth and you should know what the hell you are doing.

And to the person who posted before me-
how can you make up your mind on wether you will be bottlefeeding before you even have the baby and try to offer the breast?