I firmly believe that a court should not ever force a c-section or induction even if it is a medical certainty that both the woman and child will die. As long as she is fully informed about the likely outcomes she ought to be able to choose her own course even if it's mindbuggeringly stupid.

I cannot go along with 1, but would have a fairly high threshold. I'm sympathetic to the woman in this case, but wish she had insisted that she testify, and insisted that her lawyer find a consultant to testify in her favor.

The woman in Ireland who died was about as far along as I was, and I just kept crying. At 17 weeks there is nothing they can do if the membranes rupture, even if the heartbeat doesn't stop.

Conservative family members keep wondering if having a baby means I'm suddenly pro-life, and if anything, it's made me a lot less willing to have medical decisions made by assholes in our legislature.

At some point I'm going to write a paper arguing that using the heartbeat as a sign of life is very bad, if such a paper hasn't already been written. We're holding fetuses to a higher standard than we do car accident victims.

At some point I'm going to write a paper arguing that using the heartbeat as a sign of life is very bad, if such a paper hasn't already been written

Well, it is not like you can use an EEG and the whole brain standard with fetuses. Really the problem was an unwillingness to remove the dying fetus, not the use of the wrong standard to decide when the fetus is dead.

Conservative family members keep wondering if having a baby means I'm suddenly pro-life, and if anything, it's made me a lot less willing to have medical decisions made by assholes in our legislature.

Now that I've been a birth partner, and have attended two other births, I get the same question (and give the same response).

Ahem: http://www.unfogged.com/archives/comments_12825.html#1563574
The constitutional position in Ireland does make a court more likely to think it must intervene.
There is nothing legally or constitutionally here which imposes a "heartbeat" standard, and as Cala says it's a bad idea, especially in cases like Savita Halappanavar where the foetus was obviously doomed and the risk to the mother increasing. In the absence of proper legal standards the hospital IMO went by a religious "only double effect interventions are ok". There doesn't though seem to have been a good grasp of the dangers of infection.
http://www.galwaynews.ie/30346-leaks-savita-report-claim-series-uhg-medical-failures
From a torrent of anecdotal report which came to the fore after this death, the actual practice of Irish doctors has varied a lot and may even have been more pro-women in earlier decades.

From what I can see, childbirth isn't particularly high on the feminist agenda because a lot of women who are very passionate about birth stuff are 'earth mother'y types, who might not work and possibly even homeschool like the Florida woman in the previous case, and those sort of women are not always sympathetic to feminism, and feminists aren't always sympathetic to them.

I do find it weird - this is our one special thing us women can do, why would you not want to make it as good as possible?

a religious "only double effect interventions are ok"

This line of thinking is so insane to me. I encountered it when I was googling around in curiosity about the pro-life position on ectopic pregnancies. To be all pure about it, you can't give a drug that would end the pregnancy. But you can surgically remove a fallopian tube that's going to rupture, and then you just happened to end the pregnancy instead of meaning to do it.

4: What I think needs to be articulated is a standard for fetuses similar to brain death, where although the heart is beating, it's thought to be permissible to remove someone from life support. Or there's a prognosis such that it's permissible to refuse heroic measures.

8: This is one I don't get at all. Double effect is the whole "foreseen but not intended" distinction, but in the case of an ectopic pregnancy, not to put too fine a point on it, they're not just lollying along when they happen to decide to remove a fallopian tube. There is no reason to remove it besides terminating the ectopic pregnancy. It's not like we go around taking out fallopian tubes so we're just going to time this routine removal with the ectopic pregnancy. So how the hell is that double effect?

There is no reason to remove it besides terminating the ectopic pregnancy.

To save a woman's life!

7

I do find it weird - this is our one special thing us women can do, why would you not want to make it as good as possible?

Well some people think this means not allowing women to make stupid decisions which will kill (and/or cripple) themselves and/or their child. Others (see 1) don't.

not allowing women to make stupid decisions

I think we can all agree that not allowing women to make decisions is really the best for all concerned.

Hush, woman, we're trying to make some decisions over here.

Is it really true that childbirth isn't high on the feminist agenda? I mean, I'm not sure how you rank things on the agenda (or where you look the agenda up), but I have the impression that women who think and advocate on childbirth issues tend to be feminists; that the non-feminist position on childbirth is shut up and do what the OB says.

I have the impression that women who think and advocate on childbirth issues tend to be feminists

Even if this were right, it doesn't follow that feminists overall tend to think and advocate on childbirth issues. But as asilon pointed out, I'm not even sure that it's the case: there are lots of essentialist, religious types who are "passionate about birth stuff."

And as you say, LB, it's also a question of where to find this agenda. Look at the comments on Jezebel on a post where someone makes fun of some aspect of pregnancy (say, here) if you want to see a huge catfight. (Not that I'm particularly advocating Jezebel as a bastion of feminism.)

10: Right, but double effect should apply just as much to the chemical treatment in that case. But a shot that preserves your fallopian tube is impermissible, but waiting till it becomes an emergency curable only by surgery is permissible.

My sense is also that the mainstream feminism movement focuses more on access to abortion and prevention of pregnancy, and there's a lot of crunchycon types that focus more on childbirth stuff without being pro-choice, for example.

I seem to have mislaid my copy of the agenda, but I just looked through several pages in the feminism sections of mumsnet, and there is only one (old) thread about childbirth specifically.

Newsworthy stories like this one are more likely to be discussed in more general areas of the site, but I have to say I was quite surprised to only find one.

childbirth isn't particularly high on the feminist agenda

This is the section on maternity and childbirth at RH Reality Check. Plenty of articles from people who run organizations like radicaldoula.com and Spectrum Duala Collective, as well as blogosphere regulars like Amanda Marcotte.

Here's an article from the same site on a forced c-section case in New Jersey. One of the groups involved, National Advocates for Pregnant Women, sure looks like a feminist organization focused on childbirth issues.

Going by how many stories they have on various topics, maternity and childbirth are still pretty far down on the RH Reality Check agenda, too. Number of archive pages for the following topics:

Abortion, 152
Politics, 57
Contraception, 44
Law and Policy, 42
Sexual Health, 29
Faith and Ideology, 20
Violence, 16
Media, 15
Sexuality, 11
Maternity and Birthing, 10
Health Systems, 9
Race and Class, 8
Family, 6

19, 20 see 15.

My vague impression is that being earthmom/employing a doula/whatever is basically a class thing for UMC people that has no real connection with political feminism, or no more connection than buying wood instead of plastic toys for your infant.

I would expect fewer articles and generally less activism around childbirth issues simply because there isn't a big group of moderately powerful assholes trying to ban birth as there is with contraception and abortion. The kinds of interventions in the birth process that you see from politicians and legislators in the US tend to be much more subtle and less intrusive than attempts at outright bans.

I suspect also that there's an age skewing of activism, with younger women much more likely to be out there on the barricades pushing the issues most directly affecting them.

20: The first comment on that story is interesting too.

A lot of the people who are super into birthing stuff are also big attachment parenting/La Leche League people, which isn't exactly anti-feminist, certainly not in intent, but can have some pretty serious anti-feminist consequences.

There are a big group of moderately (in their small pond) powerful arseholes trying to make women give birth in specified ways though. (And plenty of lovely, not at all arseholish professionals too, I hasten to add.) But yeah, it's more subtle. And people move on - I would have considered myself one of the passionate-about-birth-stuff people a decade ago and mixed in some interesting circles and did what I could then, but it's hard to sustain (probably partially because you then have small children to squander all your energy on), whereas other stuff is easier to continue being indignant and noisy about because it's more part of being a decent human being. I'm not really interested in men's opinions re birth, I have to admit, so it feels more marginalised, which is ridiculous, because I'm pretty sure more children are born than people are raped or get abortions.

I've found that if I want to get natural childbirth/breastfeeding advice from friends, the ones to talk to are either the extremely liberal vegans, or the religiously orthodox stay-at-home moms. It's a weird overlap.

26, yes, that's what I said in 7.

13 to 29!

And Cala and Blume said too.

28 - well I'm not vegan or religious, but ... yeah.

30 - I guess they only read the blue comments, not the pink ones

The breast-feeding coordinator we saw for NCT locally is definitely a sort of hippy earth mother type, but the horsey-posh jolly hockeysticks variety, which I'd expect is less common in the US.

Our experience (birth not happened yet) so far has been that the hospital have been fairly neutral about what people do, with a bias towards breast-feeding (as you'd expect) but more of a 'whatever you choose is right for you' attitude to natural childbirth versus a more medicalised birth. Definitely fairly laissez-faire. The NCT were pretty deep into the natural childbirth pain-control-is-hurting-your-baby* approach, though.

* slight exaggeration, but not far off.

I don't think any of the choices presented or classes we attended gave much thought to what I'd think of as the needs or wishes of women qua women, though. The overall approach was fairly disempowering. Even the crunchy natural stuff.

Part of the issue, I think, is that there aren't clear feminist right answers to a lot of the childbirthy issues. I have strong opinions, and they're driven by my feminism, but they depend heavily on the facts of the matter and people who disagree with me tend to do so on the explicit basis of different factual beliefs rather than of stated different values.

I mean, think about it -- you're going to get really, really broad agreement that what everyone wants out of childbirth is to minimize maternal and neonatal morbidity and mortality, while to the extent compatible with that making the experience as little unpleasant as possible for everyone involved. There's just not going to be any substantial disagreement about the desired outcomes.

This makes controversies not so much philosophical/value-laden/political as fact-driven; while there are going to be areas where politics correlate with what your factual beliefs are likely to be, it's not surprising that you'd get politically incoherent looking groups of people.

The NCT were pretty deep into the natural childbirth pain-control-is-hurting-your-baby* approach, though.

And I crossed with ttaM who flagged one issue that can be directly political, where the mother's interests are in conflict with the baby's. It's still really, really fact-dependent, though; most people I know who have a strong bias toward unmedicated childbirth do so largely on the basis of a belief that it's often easier on the mother than the reverse, and any beliefs about the negative effects of anesthesia on the baby are subsidary to that.

The NCT were pretty deep into the natural childbirth pain-control-is-hurting-your-baby* approach, though.

I read something semi-recently by the (male) head of some British childbirth association (midwives? my description is really specific and useful, clearly!) that said that women needed to experience pain during childbirth in order truly to understand the seriousness of their undertaking and if they were unwilling to do so, well, then, they were selfish and would be a shitty mother.

where the mother's interests are in conflict with the baby's

It is not uncontroversially the case that pain medication for the mother harms the baby.

37: Oy. I think we can all call that antifeminist, unless he also suggested that fathers accept repeated blows to the testicles to demonstrate their seriousness, at which point it wouldn't be so much antifeminist as just demonstrating that the guy has issues globally.

that said that women needed to experience pain during childbirth in order truly to understand the seriousness of their undertaking and if they were unwilling to do so, well, then, they were selfish and would be a shitty mother.

Oh, lovely. I presume he stabs himself in the leg regularly during his tenure to ensure that he truly understands the seriousness of his position.

38: Right, that's part of what I meant by calling it fact-dependent; you need a very particular set of factual beliefs to find a conflict there. I'd actually thought that epidurals weren't supposed to affect the baby at all.

39: people all over the world (everybody) / grab hammers (grab) / cause some nut pain, nut pain

Anyhow I think the idea that some of this complexity results from the misalignment of what is good for the mother and what is good for the fetus/baby is an interesting one, potentially, right? Those fucking parasites would take everything if the state'd let 'em. The Giving Tree is their manifesto.

Holy crap googling "fetus as parasite" is not something I'd done before.

43: there's some fun stuff on this from the selfish gene POV. Possibly in that book. I love the Giving Tree reference.

37 is nearly Biblical, isn't it? Somewhere near "sweat of his brow"?

Right, there's definitely a Biblical pain-in-childbirth-is-good thing.

Unto the woman he said, I will greatly multiply thy sorrow and thy conception; in sorrow thou shalt bring forth children; and thy desire shall be to thy husband, and he shall rule over thee.

Here is the story.

"A large number of women want to avoid pain. Some just don't fancy the pain [of childbirth]. More women should be prepared to withstand pain," he told the Observer. "Pain in labour is a purposeful, useful thing, which has quite a number of benefits, such as preparing a mother for the responsibility of nurturing a newborn baby."

39 unless he also suggested that fathers accept repeated blows to the testicles to demonstrate their seriousness

No, see, men are innately serious.

Recently a postdoc was saying something to me about how one of the older male faculty members had so much gravitas. Me: "huh? he's goofy and wears t-shirts with weird jokes on them". Postdoc: "yes, but he has that beard. The beard is enough to give him gravitas".

So men demonstrate their seriousness by not shaving, I guess.

No pain, no bairn.

Pain is an infant leaving the body.

In the case of the NCT course, there was a fair bit of empirical evidence presented, so it wasn't just 'pain medication is hurting your baby'. So the discussion focused around things like the likelihood that an epidural (or opiates delivered after early labour) would retard breast-feeding, or bonding during the first couple of hours after birth. But there was also definitely a judgemental undertone to some of it, and the evidence felt a bit selective, and there was less emphasis on maternal choice than I think* would have been ideal. The hospital antenatal classes were a bit more 'fuck it, it'll all be OK whatever you choose, and it's up you'.

* not that I'm the one who'd be actually in labour, so possibe 'bloke, knows nothing' caveats here.

48: For once I'm glad I read the comments! "Load of misogynist codswallop" is a great phrase.

I don't know where I'd get gravitas from, personally. This is in fact something that has bothered me in the past! I think I am pretty well resigned to my gravitas-free existence now, though.

re:41.last

I think the idea is that the drugs used in the epidural do cross the placental barrier, and can prolong labour, reduce the likelihood of the baby breastfeeding during the (apparently crucial) early window after birth, among other negatives. With the positive of 'less pain' not being discussed that much.

45.1: yeah, that's roughly where I was getting it. The additive sum of what the selfish, selfish genes want tells you that the fetus cares something somewhat less than half as much about the mother's survival as its own survival and the mother cares something somewhat more than half as much about the fetus's survival as she cares about her own survival (depending on her future expected number of children). Which means war!

Is there any real evidence that the first few hours of maternal bonding are particularly important? Our doula was of the view "evil nurses will try to take your baby away for testing but you must not let this happen or you will have trouble bonding and your baby will be broken forever" (only a slight exaggeration).

The only way to actually break a baby is by having them watch ten minutes of video in a developmental psychology lab.

51: I've found that a number of the natural childbirth and breastfeeding advocates seem to be militant all out of disproportion to the evidence. Probably because they've had to do a lot of work to get taken seriously at hospitals (and the default around here is fairly medicalized).

This pulls me two ways. On the one hand, I'm temperamentally anti-interventions/medicines; on the other, I have doctors and researchers for friends and I'm allergic to woo. So I'm delivering at a hospital attended by a midwife who believes in science.

I am half-convinced that the midwife that Blume saw who ordered a totally unnecessary extra test was trying to bend over backwards to prove to us that she believes in science. Because otherwise she's just an idiot, and I don't want to think ill of her.

12

I think we can all agree that not allowing women to make decisions is really the best for all concerned.

You all are all for allowing women to make their own decisions until you aren't. Like with prostitution.

Oh, fuck off, James.

59: There are idiots out there. I had a genetic counselor try to talk me into an amnio on the basis of a weird AFP result that predicted a condition that would not have been either confirmed or disconfirmed by the amnio.

IIRthedetailsC, which I probably don't because it's fourteen years ago, high AFP means maybe Downs, low AFP means maybe spina bifida. Downs shows up on an amnio, spina bifida doesn't. I had low, and she wanted me to get an amnio for it. Either she was an idiot, or there was something about the situation that made an amnio make sense that she completely failed to communicate to me despite repeated questions.

Yeah, in truth I think she was some combination of an idiot and newly back on the job after a long break. Still, it was something we figured out was no big deal with cursory googling. The test wasn't invasive, or otherwise a particularly big deal, but it was a lot of hassle and totally unnecessary worry when we had a lot of other stressful things going on.

I had to threaten to discharge myself AMA a few times, when they admitted me for high blood pressure. No, I don't have pre-eclampsia; I have white coat issues. No you can't induce. I want to go home now.

Yeah, in truth I think she was some combination of an idiot and newly back on the job after a long break.

I unfortunately lean toward the former, in combination with a weirdly arrogant distrust of me (a new patient) and my previous OB.

One thing that drives me crazy about a lot of the pregnancy literature is that the following inference is quite common:
1) $foo has shown to be clearly better for mother/fetus/whatever.
2) therefore, anything less than $foo is going to kill your baby.

ignoring that "clearly better" might mean "very clearly a little bit better."

the discussion focused around things like the likelihood that an epidural (or opiates delivered after early labour) would retard breast-feeding, or bonding during the first couple of hours after birth

Did they talk about the possible connection between epidural and further interventions? I'm way less worried about immediate bonding with the baby than about losing the ability to feel what my body's doing and what I need to do to help it along (changing positions, pushing effectively, etc).

Yesterday I made a really tasty lamb and beef ragù, which my wife declined to eat because I used a bunch of sage in it, and sage reportedly decreases milk supply (we're a bit marginal on supply as it is). As best I can tell, this is unstudied herbalist legend, but it's repeated everywhere. I was upset that my work cooking was effectively spoiled by this, and by how tenuous the information is we have to work with.

66: Yeah, this. It is certainly possible for, say, epidural anesthesia to have effects that could measurably be characterized as negative for some babies, and for it still to be absolutely worth it for pain relief where necessary -- pain relief isn't automatically less important than any other aspect of childbirth.

68: Learn to cook with fenugreek? I have no idea what it tastes like, never had any, but it's the first thing anyone mentions talking about milk supply.

Learn to cook with fenugreek? I have no idea what it tastes like, never had any

You've probably had it. Have you had collards or other greens at an Ethiopian restaurant? Its flavor is pretty prominent in that. It's also in lots of Indian food, but maybe harder to pick out of the spice mix.

I have no idea what it tastes like

Methi chicken/methi ghosht? I bet a NYer like you has encountered it somewhere.

71/72: Probably, I just couldn't identify it in isolation. All I know about milk supply is secondhand, but everything I ever read was fenugreek and oatmeal. And hops, but I sort of figured people were just making excuses to recommend beer on that one.

My objection to epidural anesthesia is that it turns the whole labor from a natural process into a medical procedure and increases the chance of a cesarean section and other complications.

I don't think we ever properly inform women that at least 1/3 of our patients have fetal heart rate decelerations due to the drop in blood pressure that the epidural causes. We also don't tell them that it will slow their labor down, because we just plan to Pit it back to where it was before. We certainly don't discuss the increased risk for cesarean section. We only inform them of the direct risks to the mother of the procedure: spinal headache and "long term neurological effects," which no one has ever asked the anesthesiologist to define. Some of them mention "very rare complications including cardiac arrest and death;" most don't.

The epidural is disempowering, too. Almost every mom ends up expressing her enduring gratitude to the OB and anesthesiologist. The most common: "I couldn't have done it without the epidural." Well, of course you could have. You just chose not to.

I miss watching a woman give birth and scream, "I did it!" I wonder what difference it makes in their lives afterward--whether she felt powerful when pushed out her baby and reached down and pulled him up to her chest, or whether she felt helpless when she was strapped to a table and had him removed and waited for someone to bring him to her.

"You are a midwife. You are assisting at someone else's birth. Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. If you must, take the lead. Lead so that the mother is helped, yet still free and in charge. When the babe is born the mother will rightly say, 'We did it ourselves.'"

-- Lao Tzu, in Tao Te Ching

My objection to epidural anesthesia is that it turns the whole labor from a natural process into a medical procedure and increases the chance of a cesarean section and other complications.

This, the whole "cascade of interventions" thing.

What often seems under-emphasized is how an early epidural differs from a later epidural. The more labor you endure, the more momentum your labor has and the less likely to stall out.

Similarly, that's the main reason inductions are more likely to lead to c-sections: being induced is often more painful than going into labor naturally, depending on how heavily they dose you*, and then the woman gets the epidural more early than she otherwise might have, and cascade, cascade, cascade.

*my friend's nurse kept saying "How's your pain?" and my friend would say "I can handle this", meaning "I can't handle much more, but I can handle this" and the nurse would say "Then I'll turn up the pitocin, because you shouldn't be able to handle it." There are at least two nurses at the local hospital who are borderline sadistic and cruel.

I can understand why some people see breastfeeding and natural childbirth advocates as "militant," but often this really means "criticizing what other people consider to be their well-informed and carefully considered choices, and trying to make them feel bad."

I would like to point out that today's cigarette smokers would be considered militant anti-cigarette activists in the 60's. Think about it. They don't even ask whether it's OK to smoke in your home. They go outside automatically!

Back in the day, doctors advocated smoking for control of appetite and "nerves." Smoking was a social activity. Everyone had an ashtray for guests. Restaurants were all smoke-filled. Asking someone to go outside would have been astonishingly rude.

Formula has been proven to cause more morbidity and mortality than smoking cigarettes in the presence of the child. Yet any of us would feel comfortable condemning a mother for smoking. None of us would feel comfortable condemning a mother for using formula.

Let's look back in 50 years and see if this remains true. I doubt we will continue willingly making ourselves sick while paying for the privilege, forever.

76.4: Say what? There is no shortage of people who will criticize a mother for using formula.

I can understand why some people see breastfeeding and natural childbirth advocates as "militant," but often this really means "criticizing what other people consider to be their well-informed and carefully considered choices, and trying to make them feel bad."

There's also a complicated issue, militancy-wise, w/r/t questioning decisions made by doctors. As I was saying the other day, the c-section rate seems to be wildly incompatible with all of those sections being medically necessary. Saying that at all is a really aggressively negative thing to say about OBs generally; as a group, they're doing a shitload of unnecessary surgery. But there really isn't any way to talk about the issue without saying that aggressively negative thing.

"What often seems under-emphasized is how an early epidural differs from a later epidural. The more labor you endure, the more momentum your labor has and the less likely to stall out."

That's true! On the other hand, the "now-I-really-can't-handle-it" epidural during transition means risking a medical procedure for a few minutes of pain relief--and it's more likely to end up with a wet tap because it's hard for mom to stay still. We had a failed epidural on Wednesday because the mom's labs didn't come back soon enough. Kid slid right out just like the Lord intended. Tragic!

By the way, we need the labs because if you have an unrecognized clotting disorder and bleed at the site, you could be paralyzed.

If I tell an occasional guest to smoke outside because I don't like the smell on my furniture, that's one thing, and if I tell them to smoke outside because I'm afraid that exposure to their smoke is going to lead to my getting cancer, that's another entirely.

Formula has been proven to cause more morbidity and mortality than smoking cigarettes in the presence of the child. Yet any of us would feel comfortable condemning a mother for smoking. None of us would feel comfortable condemning a mother for using formula.

I'd tend to take this as a statement (assuming your stats are right) that secondhand smoke is overblown as a hazard rather than that formula is all that bad.

"they're doing a shitload of unnecessary surgery"

Every mother who consents to a cesarean thinks she is one of the ones who needs it. And no mother who consents to a cesarean section thinks she is one of the ones who is going to end up in the ICU on a vent, alive thanks to the blood bank and three anesthesiologists.

Some of them are wrong.

re: 67

Yes, they did. I didn't have an issue with the basic facts, more the slant on them. The person giving the course [this is a private thing, not hospital run] was fairly into evidence-based medicine and all that, but with a fairly poorly concealed bit of the sort of logic Cala gives in 66 and a bit of crunchy judgmentalism. I don't think the practical advice given on the course was at all bad.

Shamhat, would it be fair to say that you're pretty much in agreement with the midwife in 48?

Formula has been proven to cause more morbidity and mortality than smoking cigarettes in the presence of the child.

Has it now. By comparison to what?

82 -- Right, but it's not the fault of the woman that she hasn't learned enough to make reasoned judgments, one way or the other, on either point. It's completely on the doctors. Folks suggesting that women who haven't learned enough to tell the difference between a section that is necessary and one that is not should nonetheless adopt a firm position beforehand -- no matter what the doctor says, I will say no -- seem to me to be asking for trouble.

I suppose the internet makes this a little better: a woman in stalled labor can google up the stats on how necessary sections are given symptoms a, b, and c.

For the record, I loved the fuck out of the epidural I got. I've done one birth without and one with.

74 We certainly don't discuss the increased risk for cesarean section.

You're not discussing it now either, really. What numbers go along with all the statements you're making?

(I don't think epidural was standard for the first kid. For the second one, they kept saying 'too early, too early.' Then 'whoops, too late.')

I suppose the internet makes this a little better: the partner of a woman in stalled labor can google up the stats on how necessary sections are given symptoms a, b, and c.

We had a failed epidural on Wednesday because the mom's labs didn't come back soon enough. Kid slid right out just like the Lord intended. Tragic!

And why are you sneering here? This "slid right out" and sarcastic "tragic!" business is every bit as dismissive of the woman in question as anything you might do from the other side.

Folks suggesting that women who haven't learned enough to tell the difference between a section that is necessary and one that is not should nonetheless adopt a firm position beforehand -- no matter what the doctor says, I will say no -- seem to me to be asking for trouble.

Has anyone ever suggested that? The militant position on c-sections is to get yourself signed up with a provider who shares your opinions and you trust not to order one unnecessarily.

I had an unmedicated labor with Jane and was pleased to have had the experience, but it is also a fact that pain hurts and that it is not stupid or crazy to dislike it.

90 -- Sure, if you're comfortable compromising the autonomy of the mother in that way. What kind of feminist are you?

94: Nothing's ever as much fun as a good game of let's you and her fight.

but often this really means "criticizing what other people consider to be their well-informed and carefully considered choices, and trying to make them feel bad."

I'm pretty down with considering this a negative thing.

Oh wait, I'm having trouble parsing 76.1, I think. Is the criticism coming from the militants or the anti-militants? Doesn't much matter I suppose: bad either way.

We went with a midwifery practice because (a) the misogynist OBs in this town can fuck right off and (b) the midwives were actually willing to talk to us about data and support whatever choices we made. There were more woo trappings than we would normally choose, but they knew we were scientists and woo-averse, and that was fine by them. I'm as convinced as one can be without a control that Teapot's birth was much easier and faster because I was attended by midwives I like and trust than it would have been if I'd been attended by the doctor who makes my blood boil.

A friend who reported a 100% positive experience in the hospital here said, in the same breath, that birth was a totally horrific process. Telling, I thought.

96: What if they're wrong? I don't mean to specifically agree with all the fact claims Shamhat is making, but sometimes people have what they think are well-informed and carefully considered choices that are not, actually, well-informed, either because they're idiots (which many people are) or because they've been accidentally or intentionally deceived. And while it's hard to tell someone they're wrong without insulting them, if it's an important issue sometimes it makes sense to do it anyway and deal with the insultingness as best you can.

99: how about presenting the case as if I'm an educated intelligent woman, instead of drawing an inflammatory and inapt comparison? Like you would if this were a course of action in any other area of my life?

Well, how wrong are they? Are they wrong that they have really reached their pain limit in this labor, and they would like an epidural now? Are they wrong that they want to stop trying to balance full-time work with pumping, even though the babe isn't six months old yet?

I get it: it may be that they're wrong (underinformed) about the risks of epidural. But then the solution is better education and a change to institutional (hospital) norms. The "trying to make them feel bad" part is still a problem.

100: nono, you should feel bad. Bad, bad, bad. Never mind the evidence. That's besides the point, which is that you're bad.

102- They already elected a Pope, there's no need to keep campaigning by espousing Catholic doctrine.

100-102: Not Shamhat, can't speak for her, some of the things she's said I don't agree with. But the specific thing from her 76 we're talking about sounds to me as if what she meant is that disagreement about the facts and the evidence, coming from 'militant' childbirth advocates, tends to draw reactions from people who are attached to their prior positions on the same issues as if disagreement were pure insult intended to make them feel bad. This seems to me like a pretty common dynamic in all sorts of sensitive areas of disagreement.

I am reading the "their" and "them" in Shamhat's 76 to be referring to the perceived-militants. I mean I'm pretty militant about my own choices for myself and my family, because yes, they're my fucking choices and of course I think I'm right OTHERWISE I WOULDN'T BE DOING THIS - e.g. home educating. I have been accused of being anti-school, anti-teachers, despising the system, thinking my children deserve better than others, etc. I don't give a shit what you do, but I'll defend my own bloody choices, and some people like to dismiss that as militancy because it's easier than possibly having to reconsider their choices.

Relevant table from a Huffpo story

I agree with 104 that it's a common dynamic. But a lot (a lot a lot) of the things being discussed here are like my two examples in 101.1: you can know all the facts and evidence, and still weigh your decision differently.

"Shamhat, would it be fair to say that you're pretty much in agreement with the midwife in 48? "

I don't think the pain is particularly transforming, although I don't see the point of marathons either.

It's just that there is no such thing as a free lunch. The epidural isn't benign. It changes everything. The thing is, we can drug you out of the pain of contractions pretty well, but post-op pain is what it is. And it lasts a lot longer.

It's difficult to tell how much effect the epidural has on c/sec rate. At first there were a bunch of English studies claiming "Epidural does not increase c/sec rate (but forceps rate doubled)" while simultaneous American studies trumpeted "Epidural does not increase instrumental delivery rate (but c/sec rate doubled)."

Then there were a bunch "definitive" studies done by anesthesiologists. The control group wasn't no anesthesia, it was the "old protocol" vs. the new one that they were advocating. Its true that they dope up women a lot less now than they did in the 90's because of these advances, but it still doesn't answer our question.

There are also studies that group women based on the group they were randomized to at the beginning of the study, yet what actually happened was not what they claimed. In one, the "epidural group" had about 40% decline the epidural, and the other the "no epidural" group had 40% who eventually had an epidural--so they are comparing 40% epidural vs. 60% epidural, not none vs. all. I kid you not.

You also find a lot of studies that look at timing. Before 4cm, after 4cm, etc. They all had an epidural.

There was one study in St Louis in the mid-90's that was retrospective: compared the rate in a facility over time. The epidural rate climbed from 15% to 90% yet their cesarean rate remained the same. That's very convincing. However, the facility (it wasn't Barnes) had an overall rate of 6% when the national rate was 22% and the local rate was 23%. They never explained why this place was such an outlier in the first place.

There's a cute little neighborhood hospital in New Jersey that had a c/sec rate in the low teens while the national rate was mid 20's. They didn't have an anesthesiologist dedicated to L & D; they could call one in from home but the OB had to sit there the whole time the woman was under. So the docs didn't advise them. When they finally got into line with modern practice their rate when right up with the rest of them.

You probably already know that doula studies show that the doula halves the c/sec rate. That's actually the no epidural effect.

Modern medicine does not want to answer this question. Our pay is contingent on remaining ignorant. I would guess that the typical anesthesiologist would say it doesn't affect it at all, the typical OB would say a little, and the typical midwife would say the epidural doubles the rate.

When you look at midwifery clients, it turns out the only thing that makes them "low risk" compared to obstetric clients is that they chose a midwife.

The mechanisms I can think of, off of the top of my head, that the epidural causes cesareans are:

Fetal heart rate decelerations caused by blood pressure dropping. Sometimes it's dramatic, down for 5 minutes and we crash section the mom immediately. Yesterday my patient had subtle lates that started right after the epidural, and I was able to finesse them for a couple of hours with IV fluid, ephedrine, and terbutaline, but when the OB arrived she told the parents that the baby was stressed and "called it." Not one decel before the blessed pain relief.

Malpresentation. It's not just that moms with OP babies feel more pain and ask for medication. It's been shown that babies end up OP after the epidural when they weren't before. Lack of mobility decreases the chance that the baby will rotate.

Cephalopelvic disproportion. If you are giving birth to the biggest baby that will fit through your pelvis you need the biggest diameter possible. This is when the mother is standing or on her hands and knees. If the mom physically cannot get into those positions then that baby simply will not fit. Think of a mare giving birth on her back with her legs in the air. (If your facility delivers everyone in lithotomy anyway, you gave up this option when you walked in the door.)

Failure to progress. Ofter a woman who is contracting every 2 minutes will space out to 8-10 minutes apart after the epidural without augmentation. Ladies, if you took the epidural, now is NOT the time to get all granola and decline Pitocin. Maybe we can fix it and maybe we can't.

Failed inductions. If we try to get you into labor and we can't, we will send you home and wait for labor or try again. Unless we gave you an epidural or broke your water. Sorry.

yet what actually happened was not what they claimed

I read the 2008 book Pushed: The Painful Truth About Childbirth and Modern Maternity Care a couple of months ago, and this seemed to come up with a lot of studies. (According to the author, anyway.)

Do you happen to remember what non-Barnes hospital that was in St. Louis, Shamhat? Just curious, since I'm familiar with St. Louis hospitals.

When you look at midwifery clients, it turns out the only thing that makes them "low risk" compared to obstetric clients is that they chose a midwife.

This, I'm surprised by. I thought the deal was that there were a bunch of high risk conditions that meant that generally a midwife wouldn't take you as a client, so the midwifery clients were 'low risk' in that no one had those conditions.

It's possible that I shouldn't be participating in this discussion, never having given birth, but as someone who has no dog in this fight, can I just say how strangely unbalanced discussions of pregnancy and birth are, at least among the people I know?

It's partly what Cala's pointing to, that any action that benefits the baby is seen as a necessary thing, no matter how demanding the action or marginal the benefit.

It's also that people spend a lot of time thinking about how the mother's body affects the child (what she eats, whether she breast feeds), but hardly any time at all thinking about the effect that the mother's happiness and well-being might have. (I have a friend who was so committed to breast feeding that she continued to breastfeed even through a terrible nipple infection that lasted for more than a month: she would burst into tears at the sound of her baby crying, or even the sound of him waking up, at the thought of the pain that was coming and then she'd weep the whole time she was feeding him, but nobody was worried about the effect *that* might have on their bonding.)

And finally, setting aside the fact that this might have marginally improved the baby's immunities or lessened his chances of having allergies or whatever, there was my friend, crying all the time because of terrible pain! Will no one think of the mothers?

I wish I could've appended an emoticon to that comment directed to GaBath.

Not having a dog in this one any more, except someday as dad or father-in-law (and does anyone rank lower than that for purposes of advice giving?), I guess I'm down on judgmentalism. Towards a mother who makes one choice or another, towards a mother's friend who advises one way or another about those choices. It's not my experience that militants want to make people feel bad as much as they hope to educate them. Maybe criticizing a decision that's been made and can't be reversed, or one that was made based on facts not known to the militant isn't the most effective way to go about this. But mindreading bad motives into the thing isn't helping anyone either.

Unnecessary surgery should fall outside the standard of care. One would hope that enough instances where it does get enough attention that the worst abuses get reined in. Or, maybe when we get to single payer, the incentive structure will get changed around enough . . .

110 is right, IME. I've had friends who were pregnant with twins, for example, and were sent away from the midwives back to traditional doctors. And friends with breach babies.

Now that I'm not typing on my phone while waiting for a check-up concerning apparently early pre-term labor...

I'm the one that introduced the term 'militant', and I should explain that I don't take anyone's defense of her own choices to be militant in this sense. (As I'm militant myself in that sense!) Rather, I'm referring to a pervasive kind of rhetoric, typical of pregnancy advice books, that proceeds from the apparent assumption that the pregnant woman needs to be managed by fear tactics, which then becomes unreflective conventional wisdom. Don't sleep on your right side! Fetal alcohol syndrome may result if you have even one milliliter of beer!

This is bad because it leads to unnecessary anxiety, and I think in some cases bad decisions. If you're told that you can't work out without taking your temperature rectally every 20 minutes, are you going to take the horrible risk of exercising?

This strikes me as unique to pregnancy. (Though maybe it's like the worst science journalism advice, but with the weight of knowing that if you do wrong, you keel ur baybee.) Everywhere else we seem to be better about trade-offs and compromises with respect to health. And I guess from my perspective, it's not like I'm about to forget that I'm pregnant because the half of my brain that isn't going "baby. baby. baby." all the time remembers pretty often that I'm pregnant because I'm getting kicked in the ribs.

So, half of your brain has turned into a doo-wop group?

Pretty much.

This strikes me as unique to pregnancy.

I think so, yes. I mean there's similar horrible paranoid science-journalistic, and/or completely unnecessarily dogmatic and ideological, advice about all stages of child rearing, but it's far far easier to tune out, and increasingly so as the baby gets older.

similar horrible paranoid science-journalistic, and/or completely unnecessarily dogmatic and ideological, advice about all stages of child rearing, but it's far far easier to tune out

And while that advice is certainly about your behavior, it doesn't intrude on your bodily integrity in quite the same ways, I don't think.

And that, I would say, is an issue that can reasonably be addressed as one of feminist values/politics. You could describe it as saying that the woman's comfort/effort/whatever is not a factor to be considered at all -- that the only factor to be considered is the best interests of the fetus/future baby, to the point that it doesn't matter how trivial or speculative those interests are. Once there's a suggestion that something's better for the baby, the woman can be completely ignored. (Could we call this What-to-Expectingism? Probably shouldn't, it's a stupid name for it. But something like that.)

That's an antifeminist position -- women have interests of their own, and those should be considered. It gets really complicated thinking about it, though because (a) most women, even ones who have the temerity to value their own interests at all, also value the interests of their future children highly, and (b) most of the burdensome pregnancy advice is actually bullshit, so it's hard to separate out disregarding it because you're valuing the mother's interests over the child's from disregarding it because it's stupid.

It would be very strange if the book was called "What to Expecting".

To add to 119.b: it also is complicated by the fact that a lot of women seem to get some perverse pleasure out of following all the rules. "Oh, I can't eat that. I'm pregnant you know."

That characterization is probably unfair. (And goes in the same direction as that terrible "Pregnant Women are Smug" song.) It's probably more that pregnancy - especially early pregnancy - is a really uncertain time, and holding fast to as many rules as you can is a way to do something, to try to exercise some control over things.

But I think that song is funny!

Could we call this What-to-Expectingism? Probably shouldn't, it's a stupid name for it. But something like that.

Placental-Agent Problem?

I must say that several of Shamhat's comments make me long for the nuanced understanding of motherhood, culture, and medicine that read once provided. I can't tell which is worse: the "you fucked everything up by getting an epidural when you had your baby, you coward" version, or the "oh, sweetie, I don't really blame you; it's all those nasty doctors who made you suffer more by telling you you were going to suffer less" version. It's all pretty awesome.

Labor was several orders of magnitude more painful than anything I had been prepared for by anyone else's accounts. It felt something like having someone try to shatter your pelvis as slowly as possible from inside. I got the epidural (at maybe 6cm?) because I feared that, once the pain got as bad as it was going to get at 10cm, I would be incapacitated and unable to make informed medical decisions about anything. As it turned out, this was unlucky: the baby's head was large and turned sideways, so I had to push for four hours on my back/side; while pushing I broke the epidural catheter and had the great joy of doing the last two hours of pushing unanesthetized. The doctor finally used a vacuum extractor to get the baby out, and I ended up with a third-degree tear. I couldn't really walk for days, and my milk supply was delayed by a day or so.

Peculiarly, after all that, my reaction to hearing that it was all avoidable and so on is something very sophisticated like "fuck you. Have you met my daughter, haters?"

My point is chiefly the disconnect between my great machismo about pain, encouraged by nearly everyone around me, and how bad it actually was. (Also, no one expected the baby's head to stay crooked all the way through the birth canal -- but she could turn her head while lying on her stomach when she was 5 days old, so this may just have been her style.)

124.1: I can completely see why Shamhat's comments would be seriously irritating to someone who had your experiences in labor. But I don't think she said anything that could be fairly paraphrased as either of your quotes.

I dunno. I thought redfox's 91 was right on.

Hyperbole is to argument as pain is to... never mind. It may have been the first comment I've posted while angry. Sorry.

Comments are angry leaving the body.

127: You could have posted without being angry. You just didn't want to.

I think Shamhat needs a more congenial working environment.

Labor was several orders of magnitude more painful than anything I had been prepared for by anyone else's accounts.

This resonates with me, too. A lot of the "you can do it naturally!" encouragement soft-pedaled the sheer pain of it, including the approach of our doula.

It's a really impossible message to convey, though. Maybe it's not so painful for other people, maybe it will be different for you, this new person, you're tough, etc, etc.

129 made me laugh.

131: Yeah, I think there's a huge range of how painful it actually is. I'm not particularly tough about pain generally, but childbirth, while certainly painful, and besides being painful sort of physically overwhelming in a way not limited to the pain, was distinctly not the worst pain I've ever been in. I'm pretty clear that I, personally, had a straightforwardly pleasanter and more comfortable experience by doing it unmedicated, but that doesn't mean a thing about anyone else's experience.

129 is right. I need a commenting doula.

A lot of the "you can do it naturally!" encouragement soft-pedaled the sheer pain of it

The Bradley Method book I read does this. Women don't feel pain in childbirth, they just feel pressure! If they're feeling pain, it's because they don't understand it correctly!

As someone who thought unmedicated childbirth wasn't all that bad, I will say that calling it not painful at all is crazytalk.

The Bradley method is #1 on my list for "militancy disproportionate to the evidence." Hypnobirthing is full of woo but I like the breathing method better.

I was going to bring up breathing. It worked absolutely great for me, but lots of people don't seem to have gotten much out of it. Thirteen years later, I still pull it out if I have warning that something that's going to hurt is coming.

I still pull it out if I have warning that something that's going to hurt is coming.

I have done this for a long time with different kinds of breathing from yoga, and it freaked my dentist right out. I was having a cavity filled, and each time they went to give me a shot of novocaine I would do a long and audible breath out through my nose. Because the shots are the most painful part! But the breathing would make the dentist and his assistants think something was wrong, and they would frantically ask me if I needed more pain medication. Which of course I couldn't answer, because my mouth was jacked open with stuff in it. I managed to grunt some sort of "no" each time, but what I really wanted to say was no, I'm breathing this way because I am so very calm, people.

Oh god yes, I do labour breathing at the dentist.

Well, I used to. I don't now, because I'm somewhat in love with my dentist and tend to be distracted by the feeling of her ample bosom leaning on my head. An enterprising doula should try that method of pain relief.

I still pull it out if I have warning that something that's going to hurt is coming.

That's what he said...no, she said...no, wait...

Guys, completely off topically, it turns out that my habit o acquiring and then not paying multiple LA parking tickets has put me on an ultra exclusive "Scofflaw List" where they tow my car automatically whenever there are more than $50 in unpaid parking tickets. So I now am WALKING two miles just to get a rent a car to begin the process of extracting my glorious car from the impound lot. Frankly, I think Lurid Keriyaki's pain is nothing compared to mine.

Remember to breathe.

Only available car is a Dodge Charger. Things are looking up.

Maybe you should get a bicycle!

Also two whole miles?!?!

(Thanks for making that explicit Sifu)

As long as you don't eat fish, Halford, you're a friend of the earth.

Fuckin A I am, plus I'm about to make a big donation to City government, plus I'm driving a sweet Charger and you're not.

143. Someone has hijacked your identity to make you seem less likeable. Change your password.

If only 150 were true. My identity is not likable! Or pregnant. But hey muscle car.

Halford, didn't you once, not terribly long ago, find yourself horribly forced to take the bus because your car was towed due to unpaid parking tickets? When is the message going to get through, sir?

It's true. The bus was shockingly easy. But I thought hey this time I can let $75 slide for a bit, right? That's not too much. But no it turns out I'm an officially designated scofflaw.

Did you forget to move your car for monday, wednesday, friday, sunday opposite side street-cleaning?

There's a 2% chance you could have inconvenienced a street-cleaner that way, you know.

And I guess from my perspective, it's not like I'm about to forget that I'm pregnant because the half of my brain that isn't going "baby. baby. baby." all the time remembers pretty often that I'm pregnant because I'm getting kicked in the ribs.

I … I don't think that's how it works, Cala.

Which part?

Cala isn't pregnant because she's getting kicked in the ribs. That's not how pregnancies are either initiated or sustained.

Therefore, she can't remember that she's pregnant because she's getting kicked in the ribs.

154: Oh, is that how Halford keeps racking up all these parking tickets? I see, I see.

she can't remember that she's pregnant because she's getting kicked in the ribs

I don't see why getting kicked in the ribs would affect her memory.

Really?

I think getting kicked in the ribs would definitely affect my ability to remember things not connected with getting kicked in the ribs.

Well I guess it's really an empirical question. Sifu can you get us a grant to study this please?

The baby's not wearing steel-toed boots or anything.

Okay, we're going to need a pregnant group, a control group, and a someone with sturdy shoes.

154 --Nah I committed the cardinal sin of staying 15 minutes too long in Hollywood.

I don't have a degree in your so-called "logic" but 158 sure seems wrong.

165 doesn't make any sense. We just need to get neb pregnant.

Yeah I'm confused. Nosflow, you know who is doing the kicking here, yeah?

The thread seems to be no longer on topic so... if you were wondering if anyone actually uses the phrase 'running dogs of' as in 'running dogs of capitalism' you'd find they do, sort of. Except you'd have to re-imagine it as 'running dogs of anti-Church forces' used by a leading Polish right wing ultra-clerical pundit when attacking journalists writing stories about Francis I's connections with the Argentinian junta during the Dirty War. To be fair, this is someone who IIRC once said Franco was Europe's greatest twentieth century leader, and when writing about Pinochet said he may have been too mild, so not really a surprise. But still, 'running dogs'? You'd think he'd have a bit more self-awareness.

From a fun little column mocking the Polish right for it's sudden enthusiastic outrage at the idea that working with a dictatorship's secret police is in any way blameworthy.

Prawica już nie wierzy w teczki

Let me clarify 158 for you, Halford. I didn't mean to say that (a) Cala isn't pregnant and (b) the explanation for her not being pregnant is that she is getting kicked in the ribs. I meant to say, rather, that it is not the case that the explanation for her being pregnant (for I acknowledge that she is pregnant) is that she's getting kicked in the ribs.

Nosflow, you know who is doing the kicking here, yeah?

Shivbunny?

For want of a comma, the thread was lost

I mean that seems like a kind of private question. But it's also immaterial: Sifu, you aren't really suggesting that a woman becomes, or remains, pregnant in virtue of being kicked in the ribs, are you?

So I now am WALKING two miles just to get a rent a car to begin the process of extracting my glorious car from the impound lot. Frankly, I think Lurid Keriyaki's pain is nothing compared to mine.

Well, if you're walking, you don't have to keep grabbing your junk every time you need to shift. If it gets truly bad, I still have an unused bottle of Vicodin.

There's a bun in the oven, if it kicks her.

Whatever. What I want to know is why she can't REMEMBER that she's pregnant. Seriously, I don't think it's because she's getting kicked in the ribs, but I admit I don't have any proof of this.

I have boots, so I volunteer to do the kicking in May. You all can sort yourselves into control v pregnant.

ben, ben.

175 made me grin.

We need evidence based boot trials, obviously.

Cala, Cala.

The thing I find most odd about discussion of pregnancy in this our contemporary world is the degree to which it's discussed as though it's an illness.

Well, it sure can get in the way of self-actualization. Ah, fuck, I stacked the Maslow pyramid wrong again.

The Maslow Pyramid of Hanoi takes an age to rearrange.

182 made me snicker.