"You couldn't pay me to have an epidural," I used to say dramatically. This was after my second son's birth, when I was floating so high on my flocculent cloud of mother-love and birth empowerment that my connection to the planet seemed rather tenuous at times. I don't say it anymore, in part because I try to squelch my tendency to be irksomely earnest. More importantly, though, it wasn't getting my point across. The birth junkies knew what I meant already. And the mainstream moms -- well, they probably wished somebody would smack a little sense into my smug self.
I wasn't feeling smug, even though I'm sure it seemed that way. I was contrasting my two birth experiences: the first a cascade -- a veritable Iguaçu Falls -- of high-tech "help" (if you look closely at that picture you might see Alex and me going over in a barrel), the second more like a trip down West Virginia's Gauley River. Sometimes it was a wild ride. I was glad we had a guide. (Hey, that rhymes. It's a poem about my son's birth. My husband will say, "Keep your day job, Jamie.") But even in the roughest spots there was no panic and the scenery was astounding.
I wanted to know why no one was saying bluntly what seemed so obvious to me: pharmacologic pain relief in labor is overrated. It comes at a cost, measured in intangibles as well as dollars. It doesn't guarantee that the pain will go away. And it can cause problems that linger long after the contractions are gone.
One day when I was seven months pregnant with my oldest son I was talking to a patient's mother about birth. She said she'd opted for an epidural. "You must have one," she gushed. The first time, I did. Suddenly I was not a normal woman moving through a normal process; I was a patient, immobile and tethered to multiple beeping things. I spiked a fever and needed antibiotics in my IV. They weren't sure how the baby was doing and placed an internal monitor. I tried to push and could not get that 37cm head to budge. I could go on and on but I won't, in part because I don't need to. It is the litany of American birth today: fetal monitoring, IV, pitocin, epidural, catheter, antibiotics, assisted delivery, laceration repair, forever and ever, amen.
This post began in response to Alicia's question about why some lactation consultants leap to techno-solutions for breastfeeding problems. I believe we are seeing so much medicalized breastfeeding in part because we are seeing so much medicalized birth. I believe too many of us don't trust women's bodies to birth and nourish their babies -- "us" meaning both the mothers themselves and those who help them.
Earlier this year I attended one of La Leche League's Lactation Specialist Workshops, featuring Linda Smith and Mary Kroeger, co-authors of Impact of Birthing Practices on Breastfeeding: Protecting the Mother-Baby Continuum. Virtually any birth intervention can affect breastfeeding. If you were yanked by the head through a tight passageway, would you be in the mood to work for your dinner afterward? Neonates, with their immature livers and kidneys, are routinely exposed to narcotics during birth -- how can they be expected to coordinate sucking and swallowing with breathing when their respiratory function is depressed as a result of the drugs? Is it any wonder that some of them just don't try?
Even interventions that seem innocuous can have unexpected sequelae. Many lactation consultants report a loose correlation between the volume of IV fluids a mother receives during labor and the degree of areolar edema she experiences in the postpartum period. Antibiotics given to a mother during labor can lead to thrush and premature weaning.
LCs, who are under pressure to fix breastfeeding problems in the brief hours before mom's insurance stops paying for her hospital room, inherit complications from L&D. But it's not that simple. Most mothers are clamoring for epidurals. Probably some of the LCs have a techno-orientation to begin with. At bottom it's the culture, the whole technophilic culture.
Some of the problem begins at conception: women are getting pregnant who never could have conceived thirty years ago. Polycystic ovarian syndrome is a major cause of infertility and it can also cause major problems with breastfeeding. Some women who require significant help to conceive may also need significant help to breastfeed.
As breastfeeding initiation rates increase, breastfeeding problems increase too. LCs are stretched thin at most hospitals. If a techno-fix seems faster, they may rely on the techno-fixes. As members of a fledgling profession (so new I'm not even sure what to call it despite being certified in it -- lactation consulting? lactation consultancy?) they are still establishing a place in the medical community. In the American medical establishment, whizbang technology equals credibility. (Okay, I am exaggerating. But is it so far off the mark? If It Is New And Expensive It Must Be Better, no?) Are some of these LCs throwing technology at problems because that's just what American HCPs do?
LCs are like lifeguards on duty while the tide is changing. Few of today's grandmas breastfed for very long; a mother who did not watch babies being breastfed when she was a child has missed something that should be a part of American girlhood. No LC can infuse her with the inner understanding of how you hold a hungry baby and guide him to the breast that little girls acquire when they watch their younger siblings nurse. Maybe that's another reason why the LC breaks out the nipple shields instead.
We live in a quick-fix culture and the quick fix for breastfeeding problems is formula. We don't have the attitude that breastfeeding is simply what you do, even when it's tough. With a roomful of voices chorusing "just give him a bottle," the LC may be scrambling to pull a rabbit out of her hat.
Another component of the problem is the paternalistic attitude of some HCPs, coupled with unwillingness to acknowledge that birth interventions and artificial feeding can have undesirable consequences. Why would you suffer when you don't have to, honey? The myth that epidurals don't affect a baby is widespread. It's nothing but a myth, though; the anesthesia literature documents that epidural medication gets through the placenta. Similarly, a shocking number of doctors withhold information about the health effects that attend infant feeding choices because they say they don't want mothers to feel guilty. Let's pretend, they seem to say (the data notwithstanding), that epidurals and bottles are perfectly harmless.
Normal birth choices in our culture are simply not normal physiologically. Last week a friend of mine was saddled with a random OB resident when her midwife was unavailable. While her baby was crowning, the doctor was demanding that my friend roll over from her hands-and-knees position onto her back. (Crowning, I kid you not. What say we tell that doctor to do some gymnastics while she has a head half out of her vagina? Because we all know women are supposed to compress their aortas when their babies most need oxygen, and push uphill while they're doing the hardest work of their lives.) The doctor was rough during the post-birth exam, and my friend protested. The response? "Well, if you had had drugs, this wouldn't hurt." (At that point my friend invited her to leave.)
So many women talk about unmedicated birth and breastfeeding in the same way: I'm going to try it, they say. And really, that's all anyone can say -- the most diehard natural birther can end up with a transverse baby and the most dedicated breastfeeder can birth a baby with an inborn error of metabolism. The best-laid plans gang oft agley and all that. Far far far be it from me to suggest that new mothers just aren't trying hard enough to do things in The Right Way. But there is an unfortunate misperception in this country that natural birth and natural feeding are optimal but optional. Nice if you can manage it, but don't knock yourself out.
And yet -- and yet. From my own first birth experience I have beaucoup de sympathy for anyone who feels she simply cannot manage the pain of birth any longer. I know, too, that breastfeeding can be excruciatingly painful and difficult. This is not a post questioning any woman's individual decisions, decisions made during some of the most vulnerable and volatile days of her life. But I wonder (quietly, because it is not a popular curiosity) what it does to us as a culture when so many women give birth without sensation and feed their babies at a remove. What happens when we as a nation are numbly watching "Malcolm in the Middle" reruns during one of the most intense moments of human experience? I guess my answer to Alicia boils down to this: I think the average American birth experience explains a lot about the average American breastfeeding experience.
I feel a bit like a foreign-language speaker when I talk with women who plan, before the first contraction strikes, on having epidurals. For me, the calculus is straightforward: the number of minutes of pain between 5cm and birth is a far more manageable problem than the annoyance of numb and useless legs, the risk of a sepsis workup and possible thrush after an epidural fever and antibiotics, the prospect of weeks of painful sitting and who knows how much uncomfortable sex as a result of trying to thread a watermelon through a thimble without being able to feel what I'm doing. There are studies on the psychological effects of epidurals (these may include a spectator role for the mother, less interaction with baby, and less mastery of the mothering role a year later -- references available if you'd like them), but I'm not thinking just about the science here.
I am thinking about reading the first chapter of the gospel of John in one of my college Greek classes, and about the professor who said something I will never forget: the word "child" in the verse "...to become children of God" is a participle, teknon, meaning "one having been born." It connotes, he said, the tender love of a mother for the child she has labored to bring forth with sweat and blood and anguish and cries from a place beyond words. I believe the rending groans of an undrugged mother (the ones that cause cranky L&D nurses to poke in their heads and say, "Pipe down! You're scaring the other women on the floor!") are an analog to her baby's birth cries: they signify the birth of a mother.
I cannot explain the alchemy of my younger sons' births. But they took me to a place I had never been, a place from which my heart has never quite returned.
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