Thursday, April 24, 2014

Beyond the Birth Wars

The Grieving Parents by Kathe Kollwitz
Since writing two essays which address the natural childbirth movement (first in 2011, then again last week) I feel a bit as if I've been sucked into the tunnel vision of the Birth Wars

Taking a step back, I see it all as a paltry debate among those of us who are lucky enough to have quality and choices when it comes to our health care.

Don't read me wrong; it's clear that there is a whole lot of natural childbirth woo out there that is distinctly anti-science, anti-medical establishment, and anti-feminist. It is clear that lay midwives attending high-risk births in homes instead of hospitals has resulted in the preventable deaths of babies and women. 

It's just that in reading about the broader picture of birth in both America and across the world, I see a much greater concentration of death and harm among the economically disadvantaged, and especially women of color. I feel compelled to check my priorities. It's not that every woman and baby doesn't matter. It's that every woman and baby does matter.    

The Widow II by Kathe Kollwitz
For many pregnant women and their newborn babies, the difference between rich and poor is the difference between life and death. For instance, according to Save the Children's State of the World's Mothers 2013, in Cambodia, babies born to the poorest 20% of parents have a 144% elevated risk of death compared to babies born to the richest 20%. More than a quarter million women die every year because of complications from childbirth.The dead babies (and consequentially the grieving mothers, many of whom must endure their grief without sufficient social or mental health support) number over a million every year. Without question, most of these deaths are preventable, connected to, and exacerbated by the conditions of poverty.   

America's GDP doesn't make Americans immune to the deadly disadvantages of poverty. In 2011 the World Health Organization reported that the USA had a higher newborn mortality rate than 40 other nations. And a 2010 publication by Amnesty International reported about the high rates of maternal deaths and complications associated with pregnancy and birth for American women. 

In addressing these issues, natural childbirth advocates cry out about overused medical interventions and unnecessary c-sections. But it seems apparent to me that the problems for women and babies at higher risk begin long before a woman becomes pregnant. Food insecurity, poor nutrition, unsafe and/or highly stressful living conditions, and inconsistent access to preventative health care set women up with issues such as high blood pressure, diabetes, and obesity, all of which can easily lead to complications in pregnancy, which then may very well require all those interventions and c-sections. 

Then there's the elephant in the room that nobody wants to talk about, and often if anyone does, they are shut down: racism. Race is the strongest predictor of outcomes for birth in America (with black women and babies suffering the worst outcomes), and yet when these huge disparities are reported and discussed, the focus tends to stick exclusively to economic disadvantages and ignore the *gasp* possibility that black women are treated differently by doctors, nurses, and other health care workers (not to mention employers, teachers, social workers, or anyone else they encounter and who might impact their lives.) But is it so hard to imagine that pervasive and damning stereotypes of pregnant black women, especially poor, young, pregnant black women, could have at least a subtle impact on the way they are handled and advised by medical professionals during prenatal care, birth, and postpardum care? 

Authors of the 2010 article Closing the Black-White Gap in Birth Outcomes: A Life-Course Approach, outline a 12 point plan which includes suggestions which seem indirectly connected to pregnancy and birth, such as "Invest in community building and urban renewal", and "Reduce poverty among African American families." People who enjoy strong communities and financial security often take their huge benefits for granted and fail to see how they dramatically impact a person's overall health, behavior, and choices. 

Of course the broad suggestions in this 12 point plan need to be refined into specific programs, many uniquely tailored for particular communities, but the overall point is sound. 

The issues that result in dead or injured women and babies at birth can't be solved by either warm and fuzzy homebirth midwives or even a well-trained OB with a scalpel. The physical, emotional, and social needs of impoverished women not being met are far too great. 

Monday, April 14, 2014

My Failed VBAC Attempt

I attempted VBAC (vaginal birth after c-section) for all the right reasons. 

To run down the list: under 35, not overweight, no gestational diabetes, had only one previous c-section, more than 2 years ago, with a transverse incision. I went into labor before my due date and my daughter was only 7.1 pounds. 

My prenatal care was with a well-trained CNM (Certified Nurse Midwife) with 15 years of experience delivering babies, including VBAC babies, in a hospital setting. The hospital was welcoming to appropriate VBAC candidates, and the staff even had a recent experience with uterine rupture which thankfully had a healthy outcome. I felt confident in their ability to handle an emergency situation. 

My midwife told me not to frighten myself by looking up a bunch of uterine rupture stories, but of course I was going to at least do some looking into the issue. Uterine ruptures are rare, but not that rare - about 7 in every 1000 births. They are a life threatening complication for both the woman and especially the baby. Even for the survivors, it is common for a woman to end up with a hysterectomy, and for the baby to suffer brain damage. 

If you Google "uterine rupture stories" you can find plenty with happy endings (I imagine the people with sad endings don't like to share their stories as much), but they all happen in a hospital and after a terrifying ordeal for everyone involved. 

Of course having another c-section carries its own additional risks, so I decided that as long as I remained low risk throughout the pregnancy and did my VBAC with a CNM (opposed to a non-nurse midwife) in a good hospital, I'd be okay. 

The hospital didn't stop me from keeping Bee in my room.
Thank goodness I took the necessary precautions, because I did have a uterine rupture! After almost two hours of pushing and the baby almost coming out, the OB told me, my husband, and the CNM that she "strongly recommends a c-section." That was enough for me; just show me where I sign the consent form and get this baby out. 

It wasn't until after they opened me up that she saw the ruptured uterus. Apparently my daughter's body was blocking the opening, thus preventing anything from coming out or in. Had I managed to push her out vaginally, everyone at the hospital would have gone into red alert mode trying to save both our lives. 

Mom, Dad, big sis, and baby Bee, all healthy and together.
After they whisked my daughter Eulabee, my husband, and the CNM out of the room I closed my eyes. Thinking I was asleep, the staff went ahead and expressed their shock over what had happened. 

OB: So.... when I opened her up, the baby's shoulder was sticking out of the open scar. 

*a couple soft gasps and some awkward silence* 

ANESTHESIOLOGIST: She's not going to try this again, is she? 

No, siree, I am not! I'm quite happy as the mother of two, and this birth scared the bajeebers out of my husband so bad that he ran out and got an vasectomy as soon as he could. 

I attempted VBAC for all the right reasons, and it failed. 
Because I took all the precautions recommended by the medical establishment, I'm fine and Eulabee is fine. What about those who don't take such precautions?  

I have only ever written about birth and the Natural Childbirth Movement once before. It is still my most frequently read post, attracted the most comments, many of them attacking me for criticizing aspects of that movement. When I wrote that post, I had not yet delivered Eulabee. But I was pregnant, and wrote: 
When I found out I was pregnant again, I immediately called the Birth Center. I found out I couldn't have my second baby there, so I asked for recommended options. I was given a short list of CNMs who work at or with hospitals, which was great. 
But then the person on the phone said, "I can also give you the names of midwives who do homebirths." What!? If it isn't considered safe enough for me to attempt VBAC at a top notch Birth Center across the street from a hospital, why the hell would it be safe for me to try it in my home that is a 20 minute car ride (not accounting for traffic) from the nearest hospital? If the Birth Center is responsible enough to not take on clients with higher risks, why would they be so irresponsible as to recommend alternatives which are even less safe? This is the influence of natural childbirth, a movement that is more motivated by crackpot theories and warm-and-fuzzy feelings than science and evidence.

That evaluation stands. To promote a VBAC for women who fit all the low-risk criteria and who are giving birth in a hospital with staff poised and ready for an emergency is fine. 

But there are lots of people out there promoting HBAC (Homebirth after c-section) and HBA2C, HBA3C, and even HBA4C. Since the increased risk of HBAC is relatively small (although I imagine in hindsight it seems huge for the parents who watch their babies die or suffer brain damage) there are, of course, far more success stories than tragic ones, and these happy endings are blasted all over the Internet as if they are proof that HBAC is generally as safe as VBAC in a hospital. 

On MotherBloom, midwife Christy Tashjian tells the story of one successful HBA4C, frames it as a women's rights issue (opposed to a health care issue - as if the mothers are the ones who would be held accountable for malpractice), and emphasizes feelings over medical facts.

Holly on Homebirthers and Hopefuls tries to downplay the risk of uterine ruptures by saying: 
The main risk that midwives and consultants are concerned about with VBACs is uterine rupture, however, this is a much misunderstood and extremely rare occurrence. The vast majority of uterine ruptures will not result in mortality for mother or baby. Rupture can also occur in an unscarred uterus and can happen before labour begins, which means that it can happen whether you plan a VBAC or an elective caesarean.  
The majority of uterine ruptures do not result in mortality for mother or baby because of treatment that is only received in a hospital! More importantly, if treatment is delayed even by minutes, that severely increases the chance of death or brain damage. 

Also, extremely rare? The overall rates are 7 uterine ruptures for every 1000 births. Given how many women are giving birth every day, that's a lot of uterine ruptures! 

The CNM attending my prenatal care and birth had already done over 1000 births (I'm not sure how many VBACs) by the time she got to me, and she boasted that she'd never seen a rupture. After mine, I jokingly apologized for ruining her stats, and she jokingly said, "no it's fine, now I've had my one so I hopefully won't see another before retirement." But I could tell she was really shaken up. Uterine ruptures are no joke. When they happen they are serious threat to the lives and health of the mother and child. 

What this means is that midwives who attend HBACs have resigned themselves to needlessly endangering the lives of seven woman and their babies for every thousand, for the sake of giving the other 903 women a more pleasant birthing experience. That hardly seems ethical.  

Vicki Williams, a "Birthkeeper, Doula, Breastfeeding Specialist, and Lactation Consultant" (so no medical credentials), goes so far as to encourage a homebirth after a uterine rupture

Some women, such as Aneka who managed a successful HBA3C, are portrayed in the media as rather heroic. After watching Ricki Lake's documentary The Business of Being Born, she said she realized:
I'd been robbed of the birthing experience. If possible, all women should be allowed to birth naturally.

Aneka wasn't robbed of her good health and success in having three healthy children by c-section. Yet she expresses only disdain for the medical establishment that delivered those healthy babies. Had she been one of the minority who experience uterine rupture and lost her fourth baby because of the time it took to get to the hospital, would that have been worth the "birthing experience"? 

Then you just have this sort of insanity on website such as MamaBirth, which really hypes the "pride" and "empowerment" and how it "feels" to give birth naturally at home, and just outright disregards the increased risks of complications such as breech, as well as VBAC. 

Really, I've just touched the tip of the Natural Childbirth iceberg when it comes to advocating homebirth for VBAC and other higher risks pregnancies. Surf around the Internet for an hour and discover gobs more crazy for yourself. 

Since so many people seem to be moved by personal birth stories, Dr. Amy of Skeptical OB writes a lot about the unfortunate and grieving minority whose babies die or experience brain damage because they attempt high risk homebirths. HBAC examples include baby Vera, whose mother attempted an HBA3C, just like Aneka, baby James, baby Liam, a baby whose mother was hoping for an "awesome HBA2C story", the mother who attempted a VBAC at a birth center without continuous electronic monitoring, the mother of 6 who attempted an HBA2C, a mom who bragged online about her HBAC, despite the fact that her baby suffered brain damage, and many more. (I can only stand reading so many of these before I want to crawl into a closet and cry.) 

In his article Ten Thoughts On VBAC, Nicholas Fogelson of Academic OB/GYN - who favors VBAC attempts in hospitals and under the right circumstances - writes: 

VBAC should not happen at home.   I have recently referred to that as a game of Russian Roulette, and defend that view here.   In this case the gun has 100 barrels, but the bullet will kill the baby just the same.  If a woman can honestly say they are willing to take a 0.5% to 1% risk of disaster, then fine, but to me that risk is way too high.  I think home birth is an acceptable option in many cases, but VBAC is not one of them.
HBAC? Please! I could have died, mama!
Note the lack of touchy feeling bullshit. 

I attempted VBAC for all the right reasons, and it failed, because birth is inherently risky, even more so after having a c-section. 

To any women out there thinking about VBAC, I strongly advise only doing so if you are low risk, and then finding a OB or CNM working in a hospital that is totally supportive. 

For those planning an HBAC, I urge you to reconsider. HBAC is simply not safe enough. Had I made such an attempt, my spunky toddler Eulabee would not be here to make funny faces as she grabs for my cellphone. 

As any adoptive parent knows, welcoming a new son or daughter isn't about the birth experience. It's about bringing them home. 

Friday, April 11, 2014

Barbie at the Book Fair

Advertisements masquerading as children's literature.
Barbie showed up at my four-year-old's school Book Fair. She was there in all her blond and blue-eyed, plastic, dead-eyed, all-surface-no-depth glory in the form of five "based on the movie!" board books and two sticker storybooks.

Stickers - they're interactive! (And chocking hazards for half the kids at my daughter's reverse mainstream preschool. Not to mention a cheap gimmick to distract kids from desiring and delving into actual children's literature. But I digress.)

Like many of her friends, my daughter wanted to buy a Barbie book. I observed that they came with plastic toys or stickers and were poorly written and illustrated, so I said no. Instead she picked out Fancy Nancy: Fanciest Doll in the Universe, written by Jane O'Connor and illustrated by Robin Preiss Glasser, and Princess Grace, written by Mary Hoffman and illustrated by Caroline Binch.

THIS is children's literature.
What a difference a professional author and illustrator make! The characters of Nancy and Grace feel like real people with distinct personalities. While Nancy does at first seem to be the typically girlie girl who adores fancy stuff such as tutus and accessories, she's also a quirky designer with her own unique style, and is sometimes clumsy or tacky. She is rather dramatic with both her words and body language, capable of intense anger, but also forgiveness. With the character of Grace, too, the traces of typical girl melt away as we learn what really grabs her interest, and how her ma, nana, teacher, and friends (her daddy moved away and is re-married) influence her views.

These books are stories about the human experience, particularly what is can be for children. How the reader perceives the surface appearances changes as we get to know the personalities and personal dramas of the characters, and that provides a meaningful connection to our understanding of real life, with all its bumps and blemishes.

I don't have serious problems with Barbie as a doll. I don't like the re-enforcement of unrealistic beauty standards, but I must admit that I loved playing with fashion dolls as a kid. Even a child without her own fashion dolls will likely encounter and play with them at a friend's house. Much creativity, social, and intellectual development ensues when children play pretend games with dolls.

But Barbie in books? No. No no no no, a thousand times no.

That goes for LEGO in books, shamelessly stealing attention away from quality children's literature in order to advertise their line of Chima and Ninjago toys. Toys are one thing. Books are another.

That goes for all the books based on animated children's shows and films, such as Disney Princesses, Bubble Guppies, and yes, even Elmo.

I have read enough of this crap to know that the vast majority of it is poorly written and poorly illustrated.

For instance, Barbie the Pearl Princess takes the form of a board book (books marketed to toddlers), but the actual text is far too long-winded for that age group. It reads like a straight-forward synopsis of the movie. The words merely describe the bare facts of what has transpired, and so any personal human experience, character development, building of suspense, impact during climax, or emotional satisfaction found in the resolution of conflict, is dulled.

The illustrations are equally awful. Don't get me wrong - they are pretty. Glossy, brightly-colored, slick and shiny. But in every image the characters appear as if posing for a movie poster, rather than behaving naturally. Every page made me think of the cover of a fantasy novel, but with a plastic fashion doll used as the model.

Worse yet, the pictures had only the most superficial connection to the text. For instance, on one page of Barbie the Pearl Princess, the words tell us Caligo had "spies everywhere." This is a perfect opportunity for the illustrator to show the dangers in Lumina's midst, but instead we're shown just another pretty picture of Lumina as a child playing with her adopted mother. The problem is that an hour-long film is being crammed into a 24 page picture book. Countless great story-telling opportunities are sacrificed for the sake of forcing something that doesn't really work to work.

THIS is also children's literature

In a good picture book, words and pictures also interact and compliment each other. Words tells us that Fancy Nancy's little sister JoJo is "a handful, which is a nice way of saying really naughty", while the illustration shows JoJo dressed as a cop in a menacing stance, tying her playmate to a tree. Words tell us that Grace has decided to be an African princess wearing a dress made by her nana out of Kente cloth, while the illustration shows us how regal and unique she appears on the float.

In books based on toys, shows, and movies, oftentimes no author or illustrator is even listed on the cover. Indeed, why would they be? These books are not the brainchild of any artist and/or creative writer. These books are an assignment for commercial writers and illustrators. They are in every meaningful way advertisements that merely take the form of a child's picture book.

To quote a poignant scene from the satirical show Futurama, where the character Fry discovers that in the future commercials are broadcast right into people's dreams.

Fry: That's awful. It's like brainwashing. 
Leela: Didn't you have ads in the 20th century? 
Fry: Well, sure, but not in our dreams. Only on TV and radio. And in magazines and movies and at ball games, on buses and milk cartons and T-shirts and bananas and written on the sky. But not in dreams. No, sir-ee!

Call me a snobby bibliophile, but books for kids should be off limits. Or at least the ones being sold at book fairs in schools should be off limits. Children's literacy is too important to turn their books into advertisements for cheap, plastic crap.

We let this happen, and we will become a society of anti-intellectual dupes who run out and buy every piece of shiny shit dangled in front of our eyes, oblivious to the harm all this junk is doing to our intellect, our aesthetic senses, our emotional experiences, not to mention our budgets.

But maybe it's too late. To quote one of the many 5 star reviews of Barbie the Pearl Princess:
My daughter may be 8yr old but she loves her Barbie books! This was easy for her to read and the story is always a learning tale. I love the happy endings. Gives a girl something to dream of herself. :) Thanks for always giving my girl something to dream about. :)

See, advertisers don't need to develop any futuristic technology to broadcast their cheap, plastic crap into our dreams. They already found a way in.

Thursday, April 10, 2014

Despite Many Choices, Low-Income and City Kids Still Lose Out

A year from now I could be registering my eldest child for kindergarten. I write "could" because I haven't decided whether I even want her to go to school given our bleak options. While there are many wonderful private schools within a few miles of our home, our family cannot afford the tuition at any of them. None-the-less, living in Philadelphia, we have literally dozens of school choices to explore.

Welcome to parenting hell.

In his TED talk The Paradox of Choice, psychologist Barry Schwartz laments the depressing consequences of having too many choices.

Schwartz starts out speaking about little stuff like salad dressing and stereo systems. Then he gets into the heavy stuff: Choices about medical treatment. Choices about the timing of marriage and kids. Choices about gender identity. Choices about work. He doesn't specifically mention parents choosing an educational path for our children, but considering that school is where kids spend most of their waking hours, certainly that falls into the category of Major Life Decisions.

Schwartz argues that having too many choices creates a sort constant stress of decision making, second guessing ourselves, and what he calls "paralysis rather than liberation." He gives the example of a study which found that for every additional 10 choices of retirement funds a company offered its employees, enrollment in any program went down. This makes me wonder if the increase in "school choice" through charters and vouchers is one reason for the increase in homeschooling.

After looking at the choices offered to my kids, I definitely feel a lot of the "paralysis" Schwartz spoke of, and I'm seriously considering homeschooling. Or if not that, moving to the *groan* burbs.

If I stay in the city, here are my kids' school options:

1. The public school for our catchment: Oh hell no. This school doesn't even have a playground. We're talking barely passing test scores in math and reading, poor student attendance, high turnover of both students and faculty, and 99% of students are "economically disadvantaged" - which is not at all reflective of our neighborhood's economic and racial diversity.

2. Lots and lots and lots of questionable charter schools: Enough that I get dizzy trying to do my own amateur research on them all. Some will brag about test scores, but leave out some of the icky strategies they use to achieve those scores, such as expelling even mildly troublesome students, or sacrificing joyful learning experiences for grueling test preparation. I have a friend who is a passionate educator with a Masters degree and 8 years of teaching experience. She was suddenly fired (along with almost all the rest of the faculty) by one of Philly's charters simply because her (mostly poor and at-risk students) didn't have high enough test scores. Gee, all their teachers being fired must have been great for the students! Many charters have only recently opened and don't have much of a track record, and could close down just as quick as they pop up.

3. A few good charter schools: The more established charters with good reputations and high test scores are usually nowhere near my neighborhood, and they all have big lotteries and long waiting lists. These fall into the category of Yeah, You Wish!

4. Public schools outside our catchment: There are a couple K-8th grade public schools just outside of my catchment where we can't afford to buy a home, but the schools have higher test scores, genuine economic and racial diversity, and often serve as feeder schools for the best magnet high schools. I have repeatedly heard that principals at these schools can grant students outside of a school's catchment permission to enroll. The idea is to convince the principal beforehand that my kid is a benefit to the school and that my family will be helpful and involved. However, budget cuts have curbed this practice, and until my kid is actually enrolled, there are no guarantees.

Like I said before, parenting hell.

Cartoon by Signe Wilkinson
In his TED talk, Barry Schwartz mentions doctors shifting responsibility onto the patient, and how this is problematic since the doctor more often than not has the experience and knowledge to make a wiser decision. I can't help but compare this to choices about education. We have scores of people with Masters and PhDs in Education, teachers and administrators with decades of experience, and yet we don't have an approach to public K-12 education that provides every parent and child with a single, quality option.

Let's face the real issue here, more affluent communities have excellent public schools. Parents in those communities don't sit around agonizing over pages of data, trying to figure out what schools are excellent, mediocre, or shamefully substandard without sufficient context or expertise, and then keeping track of methods and deadlines for applications, open houses, and stressing out over lotteries, wait lists, and meeting minimum standards for magnet schools. In affluent communities, most typically there is one public school option, and it has reasonably high test scores, well-trained faculty who seem to like their jobs, fine facilities, a variety of extracurricular activities, and appropriate interventions and aids for special needs or gifted students.

As much as the political liberal and progressive educator in me hates vouchers, charter schools, standardized testing, not to mention a public school model with roots in factory-worker-style conformity, I dare say that none of that is the big issue. This is not a question of educational philosophy. This is an issue of economic justice. The best predictor of school success is household income. 

In other words, the problem is poverty. Schools in poor communities have way more problems (due to violence, over-crowding, food insecurity, inadequate healthcare, etc.) but because of the way we fund schools, instead of getting way more funding and resources, they get less. It isn't a coincidence that charter schools serve more low-income students. I feel like instead of dealing with poverty, especially the horribly high levels of child poverty plaguing the USA, we're throwing a bunch of equally lame or worse school options at those families and saying, Isn't this great? Now you have a choice! 

A bunch of crappy choices isn't any better than one crappy choice. In fact, if Schwartz is right, it's worse, because at least if there's only one crappy choice you can complain to the Powers That Be. With all these damn choices, parents are left feeling that we alone are to blame if we make the wrong choice. If the cities want to keep middle class and affluent families from fleeing to the burbs, they need to put more money into the schools. If they want to reduce the hardships of poverty for their most vulnerable citizens, they need to put more money into the schools. Money for more teachers, counselors, tutors, and other support staff who make all the powerful one-on-one connections with students in greatest need.

But Philly is making school budget cuts. So I guess come the fall of 2015, I might be homeschooling my kindergartner, seeing as I'm one of the few parents lucky enough to have at least that option.

Friday, April 4, 2014

Is Food In America Cheap?

Perhaps you have read, as I have on several occasions, that in the USA, "food is cheap". At least compared with both our nation's past and to other nations when we look at what percentage of Americans' household expenditures pay for food.

According to the latest numbers from the USDA, Americans spend about 10% of our disposable income on food, and this is the lowest in the world. If you do your own Google image search for "percent of disposable income spent on food by country" you can find lots of similar charts such as this one from the Economist and articles with data from the last few years repeating similar data.

When I do the math based on Americans spending 10% of disposable income on groceries, I find that an individual with an annual gross income of $30K (twice minimum wage) is spending about $40/week on food - which seems barely manageable, even for just one person.

Also according to the US Department of Agriculture, an American family of 4 must spend between $147 and $289 per week on food to meet basic dietary requirements for good health. That seems about right since I have a family of 4 and we spend about $150 per week on food. I've tried to get it below that, but I can't without resorting to buying junk food instead of healthy food.

With a weekly grocery bill of at least $147 a family of 4 that spends that as 10% of their disposable income on food must have a gross income of more than $90,000 - that's a hell of a lot higher than the median gross income of just below $70K for an American family of 4.

Additionally, median incomes only can tell us so much when income disparity in America is so pronounced. 15% of Americans live in poverty (that same percentage, according to the USDA, received food assistance through SNAP in 2013.) Many more live in the gap between being eligible for government food assistance and actually earning enough to be spending merely 10% of disposable income on adequate nutrition.

The reality is, many American families are being forced to choose between adequate nutrition and junk food, or worse yet, between food and other expenses, such as heat. Or student loans, as millions of borrowers are now in deferment for financial hardship or default.

So regarding this claim that American food is cheap, what gives? Because it seems to me that in reality, either food is too expensive, or... ooooooooh. Wages for most Americans are just too low.