Birth Story

The most telling finding of a new study on cesarean sections in hospitals in the United States is that 31.2 percent of first-time mothers had C-sections.

"Reducing primary cesarean delivery is the key" to bringing down the overall C-section rate, the researchers concluded. In 2007, the last year studied, America's C-section rate stood at 32 percent, a new high.

The study, an analysis of nearly 229,000 births at 19 hospitals between 2002 and 2008 published on-line ahead of a print article in the American Journal of Obstetrics and Gynecology, was conducted under the aegis of the National Institute of Child Health and Human Development.

The study found that 44 percent of women attempting a vaginal delivery were induced. Half of the women who had C-sections for dystocia — slow or difficult labor — were cervically dilated to less than 6 cm, far short of the 10 cm dilation that signals that birth is imminent, when the decision was made to operate.

Of the 29 percent of women in the study who had previous C-sections, and were allowed a trial of labor, 57 percent delivered vaginally.

The overall cesarean rate was 30.5 percent.

The abstract of the study concludes, "To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate (sic) is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor."

Many of the births included in the study took place at teaching hospitals, where more complicated birth often land, the study's authors noted.

This is my 101st post! With summer winding down, I'm heading into triple digits.

I love this time of year because it promises a fresh start. Shopping for school supplies with my daughter Maeve, I like to buy a few pens and notebooks of my own, just to get that sense of excitement a new school year brings.

What ideas do I have for Birth Story this fall? I have been an independent writer for 10 weeks now, but more of a full-time mom, really. Now I have to get back to work in earnest. I'm looking forward to it.

One resolution is to do more multimedia posts. This morning, I took my trusty camera (a Mother's Day present) to Foster Beach, a mile or so from my house in Chicago. I wanted a picture to evoke the end of summer — an empty beach. As you can see above, I got that picture. There was indeed a stretch of sand and birds and little else.

However, I can show you other aspects of Foster Beach as it looked this morning as well. I can show you this:

And even this, from a tiny dog beach at the north end:

This weekend, Foster Beach will host two entire triathlons plus a leg of another one. It will look very different from the way it looked today.

I couldn't help thinking, while I was framing my "empty beach" shot on this busy strand, that every one of my posts  is a kind of snapshot as well.

No one of them tells the whole story. Even all 101 taken together don't tell the whole story. But I am telling the Birth Story as I understand it, one post at a time. Thanks for joining me.

My 12-year-old daughter Maeve was a full day old before I met her.

I had suffered an amniotic fluid embolism before she was born by emergency Caesarean section, and spent the night of her birth, and the following day, in the intensive-care unit at Northwestern Memorial Hospital in Chicago.

My obstetrician promised me Jello if I would walk across the skybridge back to Prentice Women's Hospital, the NMH facility where Maeve was born. The real incentive, though, was the chance to see Maeve and hold her. She was quite a little beauty, with bounteous dark hair.

I don't remember much of our early experience of breast-feeding but it progressed slowly. Maeve, who was just shy of seven pounds at birth, had had several bottles of formula before we met, and the formula kept coming, along with breast-feeding.

No one told me this at the time, but the fact that I had hemorrhaged during Maeve's birth raised the question of whether I would be able to breast-feed at all. Severe blood loss can cause a condition called Sheehan's Syndrome, in which the pituitary gland, starved for oxygen, is damaged to the point where it cannot produce the hormones necessary for lactation. The damage can be partial or total, and can cause other problems as well.

Before Maeve and I went home five days after her birth, a couple of her pediatricians went through the drill with me: Every two hours, around the clock, I was to breast-feed, and then "top her off" with formula.

Now, remember, I had nearly died. I had undergone two emergency surgeries, a Caesarean section and a hysterectomy. I had lost a colossal amount of blood and had been pumped so full of fluid that I weighed thirty pounds more walking out of the hospital with a baby in my arms than I had walking in with her in my belly. I had several oozing sores from a reaction to the tape that had held in the needles attached to various drips. I was a wreck.

At home, we had a major learning curve to address. I had been planning to breast-feed Maeve exclusively, as I had done with her sister, Nora, and we knew nothing about bottle-feeding a newborn. My husband, Ben, who had taken several weeks off work, had to buy some bottles. We had to learn on the fly how to sterilize them. (No one in the hospital had addressed the need to sterilize bottles. Maybe they thought everybody owned a dishwasher. We didn't.) In the short-term, we bought prepared formula.

Then there was the every-two-hour feeding protocol. As if. It worked to a degree during the day, when Ben could help me, but our exhausted family slept through most nights, and Maeve regularly went for eight hours without food. She lost a full pound in her first month of life — a dangerous trend for a developing baby.

We had no help. I don't recall anyone from the hospital calling to see how things were going. We were so depleted that we stumbled from task to task, day to day, though we were in contact with Maeve's pediatrician. But I did persist with breast-feeding, and with time, my milk came in. By the time I went in for my six-week check-up, Maeve was gaining weight and thriving.

Perhaps because it was so hard in the beginning, I cherished breast-feeding Maeve. For the two of us, who had shared a near-death experience, it was a daily chance to refresh our bond. We continued on for three years, encountering more and more raised eyebrows as the months passed. One of my doctors in particular, a specialist I saw a couple of times a year, began to grow shrill after a year about the psychological damage I was doing Maeve by tethering her to me by the breast. I ignored him because breast-feeding had made him nervous from the get-go.

I finally stopped because Maeve was in pre-school and the principal, a woman I liked and trusted, told me I was holding back Maeve's social development by continuing to breast-feed her, by that time usually only at bedtime. I think now that the principal was wrong, but we did have to stop some time. I guess.

At a baby shower before my older daughter, Nora, was born, I held up each newly unwrapped garment and device for the shower guests to admire  with a big, stiff smile, because I had no idea what to do with any of it. I was the youngest of four children, and while I babysat as a teen-ager, I was never the girl people were clamoring to have watch their infants. In any case, baby technology had moved along quite a bit since then.

The theme for my first few months as a mother was discovery  — oh, yes, indeed, many, many discoveries, made usually in a panic, in the middle of the night. Breast-feeding, like everything else, was uncharted terrain for me. My mom had tried to breast-feed a couple of my older sisters but told us she was too "nervous" to succeed. As a baby, I was premature and colicky, and wound up thriving on soy formula.

I don't think either of my sisters who had children breast-fed. (They are both deceased, or I would ask them. Mamas, don't let your babies grow up to be smokers.)

By the late 1980s, though, breast-feeding was common but still spottily supported. Interviewing pediatricians a few months before my due date, I remember my delight when I found a male (!) doctor I liked a lot who supported my plan to breast-feed exclusively for several months. (His wife had breast-fed their four children, which can dispose a male doctor to be more supportive of breast-feeding than he might be otherwise.) He left the practice about a week before Nora was born. So much for planning.

At the time, my employer offered an unpaid 12-month maternity leave. Even though my husband was then serving an apprenticeship as a reporter at the old City News Bureau of Chicago, pulling down $11,000 a year, we had saved prodigiously and agreed I should take the full 12 months. So I was free to breast-feed without the constraints of a job.

It went well — not perfectly, but well. I vividly remember the early days, holding the newborn Nora on my forearm, her head against the crook of my elbow, her tush cradled in my hand.

At one point, though, I had a bout of mastitis, which was terrifying while in progress, as my breast hardened, heated up and turned red. I managed to find a lactation specialist who advised me over the phone — they seemed to be scarce and far-flung at the time. My best source was a calm old book, Nursing Your Baby by Karen Pryor, which a friend had recommended. It never failed me.

I breast-fed Nora almost exclusively for about five months. (She did get the odd bottle, including one her first night of life, in the hospital — not my idea.) I thought breast-feeding was beyond easy — always available, always satisfying, and so blissful for both of us. However, I did feel like a combination of Cinderella, always scampering home from the ball in time for that next feeding, and Bossy the Cow.

Nora had eight teeth by the time she was eight months old, when she hit on a delightful (for her) new game. She bit me, hard, at the end of every feeding. She never broke the skin, but she hurt me. She would laugh heartily while I jumped and howled, and then she would hop down and crawl off. Every feeding.

I spent two weeks soliciting advice, reading books, trying all kinds of things to get her to stop. Nothing worked. It seemed to me that giving me that good painful chomp was the best part of breast-feeding for Nora now, while I dreaded every session. She was eating all kinds of food and drinking from a cup. Most women I knew breast-fed for several months — seldom more than a year — and the recommendations hadn't yet come down that advise staying the course for at least a year.

So I weaned Nora. It took two weeks. She was nine months old when we finished. She was a bright and busy girl, and she barely noticed. At first, I wept, then I was sad for a long time.

But I had a life again. I was still Nora's mom, I still wasn't back at work, but I could move freely out in the world. My mind began to re-focus on activities and issues that went beyond parenting. At the time, I felt relief weighing against the regret. I still think it was not a bad thing for that child, at that time, or for me.

My children are 10 years apart in age, and one thing that has struck me since Maeve's birth almost 13 years ago is how much more complicated the world grows as they get older.

When children are small, you can see clearly how their perfect lives will roll out. You can see them graduating from Harvard — or perhaps Yale; you devote serious time to considering which would be better — going into law or medicine, gliding along until they finish up as President of the United States. Along the way, of course, there will be sports trophies, prom dresses, all the trimmings.

Reality sets in gradually. It turns out the kids have learning disabilities, or strange hair, or no interest in sports — whatever, and likely in multiples. Ten years or so after spinning all those perfect dreams, you might find yourself praying they'll finish high school. Or even, please, God, let them stay alive through high school.

When Maeve was in preschool, I remember sitting in a group listening to moms in the Harvard vs. Yale stage, while my mind was on the then-exotic sensation some teen-aged boys in Nora's vast social network had created by sending nude pictures of girls they had probably known since kindergarten out across the Internet. I remember thinking that perhaps I had seen some of those boys, and those girls, on swings in the park or at a library reading hour when they too were small.

What I mean to say is that many of the things that seem critical when children are little get put firmly in perspective as they grow.

Poking around Lisa Belkin's Motherlode blog on the New York Times website this week, I landed on a post called "A Breast-Feeding Guru Who Uses Formula," which attracted me because I have been writing about breast-feeding. Through Belkin, I discovered Katie Allison Granju and her mamapundit blog. (I know, where have I been?)

Granju is a writer and digital-media expert who has become an authority on breast-feeding. Nevertheless, she found with her fifth child, Georgia, now seven weeks old, that she was unable to breast-feed. "I did have colostrum for the first week or two, but I never got the full enchilada," she writes in a post on Babble.com.

She tried "pumping, herbs, supplemental nursing system, plenty of skin to skin with baby, nursing on demand, nipple shields," all to no avail.

She is "resigned" now to the fact that Georgia is a bottle-fed baby, and she does what she can to inject warmth and meaning into an experience she never expected a child of hers to have.

But Granju believes that a horrific recent event in her life has contributed to her inability to breast-feed.

"I suspect that the biggest factor in my inability to produce milk at the moment is that my oldest child died in my arms only a few weeks before G was born. God only knows what the shock of that experience did to my body and its normal functioning," she wrote.

The death of Granju's son Henry from a drug overdose is about as terrible as this world gets. We dream for our children but they live the lives we give them. My heart goes out to the Granjus.

British and Australian midwives are pushing back against a recent editorial in The Lancet, a British medical journal, which builds on a study released last month that appears to show that home births are less safe than those that occur in a hospital.

"Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk," stated the unsigned editorial from July 31.

In an interview today with the Guardian, a British newsaper, Cathy Warwick, the general secretary of the Royal College of Midwives, said that midwives believe home birth is "being unfairly pilloried by some sectors of the global medical maternity establishment."

Hannah Dahlen, the president of the Australian College of Midwives, weighed in as well. "Intense medical lobbying and strategically released journal articles" had put midwifery in her country "in the hands of the medical profession," she said.

Warwick said, "What shocked us about The Lancet editorial was its language and tone and how it pumped the hype about the dangers of home birth, and made sweeping and misogynistic statements."

"The Lancet said it stood by its editorial," wrote Randeep Ramesh in the Guardian article.

The impetus for the piece in The Lancet was a meta-analysis scheduled for release next month in the American Journal of Obstetrics and Gynecology, a peer-reviewed journal published jointly by a number of organizations that includes the Society for Maternal-Fetal Medicine. The meta-analysis was presented at the SMFM meeting in Chicago in February.

The article, published on-line last month, "provides the strongest evidence so far that home birth can, after all, be harmful to newborn babies," according to The Lancet editorial.

Home births account for about 3 percent of births in the United Kingdom, according to the article in The Lancet; in the United States, the figure is about 1 percent.

American midwifery groups and out-of-hospital birth advocates like The Big Push for Midwives have already questioned the findings of the AJOG article.

The Coalition for Improving Maternity Services called the report a "poorly designed and methodologically unsound study," expressed itself "outraged" that AJOG accepted it for publication, and suggested the report was rushed on-line as a ploy to stop legislation then pending (since signed into law) in New York that will make the practice of midwifery easier in that state.

"Pregnant Graffiti" by Petteri Sulonen

One of Hanna Rosin's grievances against breast-feeding in "The Case Against Breast-Feeding," her article last year in The Atlantic, is that it prevents women from doing work that would be more productive, or at least more lucrative.

"It is a serious time commitment that pretty much guarantees that you will not work in any meaningful way," she wrote.

Hello? This week alone, as the mother of a 12-year-old at the end of summer vacation, I have spent a morning at the beach, an entire day at a water park, and an afternoon turning Gatorade bottles into papier mache fish. Need I say that no one gave me one shiny dime for any of this activity?

To the extent that women do it themselves, motherhood is a career-wrecker. Six months or so of exclusive breast-feeding at the front end seems hardly worth mentioning.

I have not worked more than 30 hours a week (most years much less) since my older daughter, Nora, was born almost 23 years ago. It was my choice, but I paid a price in diminished salary and less prestigious assignments — in opportunities.

Even so, I would do it again if I got a do-over.

Why is that? Because I can't think of anything I would rather have than time and relationships with my husband and my children. That was true when the girls were little, and it's true now.

Nora has moved 2,000 miles away this summer. When she calls me, I drop everything to talk with her. And even though, if I added up our phone/Skype sessions, the total would probably look like a serious time commitment, I don't ever worry about how much valuable time I'm losing.

(For a twist on this perspective, see "Putting a Price on Motherhood" in today's New York Times.)

The anger and ridicule Gisele Bundchen attracted when she advocated a "worldwide law" requiring new mothers to breast-feed for six months mostly has to do, I would say, with the fact that mere mortals perceive she shares very few of the frustrations the rest of us deal with us on a daily basis.

But I think some of the rage comes from a certain rancor around the topic of breast-feeding, which has been presented in the last several years as the only acceptable choice for nourishing an infant, not only from a health standpoint, but also from a moral one. Not breast-feeding — for whatever reason, including such a worthy and often necessary one as a full-time job — has come to be regarded as thoughtless at best, abusive at worst.

But do women who reach for the formula deserve the sneers they get from breast-feeding partisans? Writing in The Atlantic last year, Hanna Rosin, journalist and mother of three, made "The Case Against Breast-Feeding," and an intriguing argument it is.

First, let it be said that Rosin did breast-feed her children. However, by No. 3, some of the negative aspects of breast-feeding — the huge investment of time it requires, and the toll Rosin believes it takes on the ideal of co-parenting with Dad, to name a couple — were making her wonder if the health benefits were really all they were cracked to be.

Rosin found evidence that they aren't. She writes:

Most of the claims about breast-feeding’s benefits lean on research conducted outside the lab: comparing one group of infants being breast-fed against another being breast-fed less, or not at all. Thousands of such studies have been published, linking breast-feeding with healthier, happier, smarter children. But they all share one glaring flaw.

The flaw is that the studies are observational, not randomized controlled trials, Rosin writes. Other variables than just breast-feeding might more easily affect the conclusions drawn from an observational study.

Exploring some of the studies that have given breast-feeding its good reputation, Rosin concludes that there are "clear indications" breast-feeding protects against gastrointestinal disease, at least in some cases, but only "murky correlations with a whole bunch of  long-term conditions." The evidence on enhanced intelligence in breast-fed individuals suggests "a small advantage," Rosin writes.

She writes:

So overall, yes, breast is probably best. But not so much better that formula deserves the label of “public health menace,” alongside smoking. Given what we know so far, it seems reasonable to put breast-feeding’s health benefits on the plus side of the ledger and other things—modesty, independence, career, sanity—on the minus side, and then tally them up and make a decision. But in this risk-averse age of parenting, that’s not how it’s done.

New mom Gisele Bundchen touched off a firestorm of criticism when she told the British edition of Harper's Bazaar that mothers around the world should be required by law to breast-feed for six months.

Gisele Bundchen

Boston Herald columnist Margery Eagan called Bundchen "a silly twit." Mark Marino, writing on CNN Entertainment's Marquee Blog, ventured that the 30-year-old Brazilian-born supermodel "might have made a boob of herself," based on responses from indignant readers of the blog.

Those included one woman identified as "Angela," who said that having "just popped out a kid" seemed to have given Bundchen the idea she "knows what's best for children and mothers."

Eagan admitted that her "catty little heart leaps with joy" to see a woman so "lucky in looks, in love, in life" whose "perfect foot" keeps finding its way into her "perfect pouty mouth," first touting her painless home birth eight months ago, now with her pronouncement that everyone should be legally required to breast-feed. And in that, Eagan probably stands in for a great many of us who can't help but notice that Bundchen's life is not exactly lived in the trenches.

Bundchen did back down from her provocative statement, writing in her blog, "I am not here to judge.... I think as mothers we are all just trying our best."

Of her backtracking, Eagan wrote, "Too late! Too late!"

But here's the thing. Bundchen has a right to her opinion (she did say it was her opinion), and she is in a position where people ask her her opinion and then print it up in glossy magazines.

Here's another thing: She's not wrong. She's not saying parents should hang their kids out the window by their heels; she's saying every mother should breast-feed for six months.

Sure, plenty of women can't breast-feed, others simply don't want to, and working mothers in this country, at least, have to be highly motivated to keep it up for any length of time. And the logistics — and the politics — of enacting a "worldwide law" mandating six months of breast-feeding for every baby make it, let's say, unlikely.

However, the health benefits of breast-feeding are well documented. The World Health Organization and the American Academy of Pediatrics join Bundchen in recommending that infants be breast-fed exclusively for at least six months. The AAP suggests mothers continue to breast-feed, even as a baby begins to eat other foods, for at least a year in all; the WHO recommends two years or more.

"Breast-feeding can decrease the incidence or severity of conditions such as diarrhea, ear infections and bacterial meningitis. Some studies also suggest that breast-feeding may offer protection against sudden infant death syndrome (SIDS), diabetes, obesity and asthma among others (conditions)," the AAP stated in its 2005 position on breast-feeding.

Researchers recently teased out some of the specifics of the good things breast-feeding does for babies, concluding that breast-feeding represents "an intriguing strategy" to maximize an infant's chances for survival.

But breast-feeding still gets a bad rap from a squeamish public, and even, down in those trenches, from doctors.

"It is tragic that a supermodel-mom dispenses better advice than many doctors and most governmental agencies," wrote pediatrician/author Jay Gordon MD on the Huffington Post. "We must listen if her advice and high profile can save babies' lives."

Lastly, I must say that the world is full of women who think that the fact that they popped out a kid or two makes them experts on parenting. Just usually not as big an expert as people who have never popped out a kid.

Image from Wikimedia Commons

In an article in the Aug. 2 issue of the New Yorker, the surgeon/writer Atul Gawande MD considers Americans' ars moriendi, the art of dying — or rather our lack of one. There are some interesting parallels with birth, such as our society's propensity to throw technology at situations that often might be better left to nature, taking its course in its own time.

What I found fascinating was the honesty with which Gawande writes about his own discomfort with talking with patients who are looking to him to guide them through a fundamentally human experience, one his skills as a surgeon don't equip him to handle.

Of the team of physicians treating Sara Monopoli, a young mother dying of lung cancer, Gawande writes:

You’d think doctors would be well equipped to navigate the shoals here, but at least two things get in the way. First, our own views may be unrealistic. A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three per cent of doctors overestimated survival time. Just seventeen per cent underestimated it. The average estimate was five hundred and thirty per cent too high. And, the better the doctors knew their patients, the more likely they were to err.

Second, we often avoid voicing even these sentiments. Studies find that although doctors usually tell patients when a cancer is not curable, most are reluctant to give a specific prognosis, even when pressed. More than forty per cent of oncologists report offering treatments that they believe are unlikely to work. In an era in which the relationship between patient and doctor is increasingly miscast in retail terms—“the customer is always right”—doctors are especially hesitant to trample on a patient’s expectations. You worry far more about being overly pessimistic than you do about being overly optimistic. And talking about dying is enormously fraught. When you have a patient like Sara Monopoli, the last thing you want to do is grapple with the truth. I know, because [Monopoli's oncologist, Dr. Paul] Marcoux wasn’t the only one avoiding that conversation with her. I was, too.

Gawande had been called in to talk with Monopoli about surgery on a secondary, treatable thyroid cancer. Though he thought she would die long before the thyroid cancer became a serious problem, Gawande relates miserably dancing around the subject of death with her.

Determined to be more honest in talking with patients with a poor prognosis, Gawande tried to communicate the stark truth as he saw it to a woman with advanced colon cancer. After she went on to have a better-than-expected recovery,  she told Gawande that their early conversation had made her feel "as if I'd dropped her off a cliff."

In a long section on the importance and nuance of effective communication, Gawande concludes that "the words you use matter."

It appears that conversation — just words — during a terminal illness might help people avoid medical interventions. Gawande cites a 2004 initiative by Aetna insurance company that allowed terminal patients to proceed with aggressive medical treatment, while at the same time using the emotional supports of a hospice facility. (The two approaches are not typically used together.) The patients' hospital stays decreased by more than two-thirds, and the cost of their care went down nearly a quarter.

"The program’s leaders had the impression that they had simply given patients someone experienced and knowledgeable to talk to about their daily needs. And somehow that was enough—just talking," Dr. Gawande writes.

He writes,

We pay doctors to give chemotherapy and to do surgery, but not to take the time required to sort out when doing so is unwise.... But the issue isn’t merely a matter of financing. It arises from a still unresolved argument about what the function of medicine really is—what, in other words, we should and should not be paying for doctors to do.

My apologies to Gawande for shoehorning his thoughts on death into this ongoing discussion of birth, but I think his honest consideration of a doctor's role in helping people negotiate life's last major threshold is worth thinking about relative to the first.