One woman's path through doula training, childrearing, and a computer science Ph. D. program

Saturday, February 25, 2012

Reblogged: How to have a baby in graduate school

Having babies in grad school: what do you need to make it work? This article was published in ACM-W Winter 2011 newsletter, written by three women grad students (two with children, one without). The article highlights why graduate school is an excellent time to have a child, and outlines strategies for success. I reblog it here with permission from the editor, and include tags which link it to the associated Birds of a Feather session at Grace Hopper Celebration for Women in Computing 2011.

A. Holloway, C. Sadowski and L. Vega. Babies in Graduate SchoolMaking It Happen. ACM-W CIS Newsletter: Celebrating, Informing, & Supporting Women in Computing, 2011. 3.

Babies in Graduate School: Making it Happen
by Alexandra Holloway, Caitlin Sadowski, and Laurian Vega

There is never a perfect time to have a baby, but the present is always a good time. For women in graduate school, pregnancy and child-rearing present unique opportunities and challenges. In this article, we discuss ongoing perceptions about mothers in academia, including common prejudices and preconceptions. Although certain trends are helping mothers pursue a tenure-track position or re-enter the work force after starting a family, key challenges still exist for starting a family in graduate school. These challenges include maintaining both good interpersonal relations between partners and good professional relations within our graduate departments. We propose a checklist of the key ingredients for success in childbirth in graduate school—the things we found most important in our own and others’ experiences for starting a family early in academia.

Motherhood is a crosscutting concern for women spanning economic, religious, and cultural groups. A known problem is the “motherhood penalty:” mothers are rated as less competent and committed to paid work than non-mothers, are given less slack about being late, and may be offered a lower starting salary [1]. In fact, within particular demographics the pay gap between mothers and non-mothers is larger than the pay gap between women and men [2].

These challenges are particularly disparaging due to their inequity; children provide a benefit for men and a penalty for women. Fathers are rated as more committed than non-fathers, are given more slack about being late, and may be offered a higher starting salary [1]. In academia, men with young babies are 38% more likely than women with young babies to achieve tenure [7]. Perhaps a partial reason for this difference is the social expectations about who will care for children. For example, a survey of more than 440 faculty in the University of California system found that women with children spend almost twice as many hours per week acting as caregivers than men [7].

Taken together, all of these statistics present a daunting picture for a women thinking about, or starting to venture into, motherhood. Recognizing the problem and educating co-workers is the first step to combating these biases against mothers. Furthermore, research has demonstrated that a mother’s ability to do science does not disappear after having a child. For example, a 2004 survey of German postdocs found that there was not a difference in scientific productivity between scientist mothers and female scientist non-mothers [5]. A similar study looking at working mothers across disciplines in the Netherlands also did not find a productivity difference between mothers and non-mothers [10]. Additionally, working mothers have been shown to have better physical and mental health, higher self-esteem, and financial stability [11].

Much of the difficulty with academia and motherhood is due to the fact that it is difficult to re-enter the pipeline once a woman drops out of the academic workforce [6, 7]. If time is taken off because of a difficult pregnancy or even just to spend time with a young infant, it can be challenging to return to academia. Some programs, such as British Daphne Jackson Fellowships, exist to help female scientists return to the pipeline after taking a leave of absence [5]. Unfortunately, programs to support mothers are not mandatory—not even paid maternity leave. Given the problems apparent at all stages in the academic pipeline, graduate school may be a particularly good time to have children before entering the tenure race.

Recently, awareness has increased of the challenges of combining motherhood with a career in academia as a whole and science in particular [3, 8]. Universities and organizations are taking some steps to improve the position of women who want to combine motherhood with a career in science. Part-time and “stop-the-clock” tenure-track options, which provide additional time before tenure reviews, are becoming more popular [5]. Progress is being made to change the landscape of women in academia.

We present this article for two purposes. The first is to start engaging in the discussions about motherhood in computer science. The second is to raise awareness on aspects of motherhood as a graduate student. With many female graduate students lacking female academic role models (not to mention role models who have children or who are pregnant), computer science as a field is particularly prone to the biases discussed above. To help raise awareness, in this article we describe personal experiences with motherhood in computer science graduate school. We start by discussing problems for women in graduate school, and then provide advice and personal experience on how we combated these problems. We then consider how computer science as a field can respond to—and support—parents in graduate school.

Time Is Ticking
Women in computer science are a rare breed.  Mothers in computer science, at any stage of academia, are an even rarer occurrence. One large problem for any woman in academia having a child is the lack of communal knowledge about and support for this life-changing phase. Computer Science departments may be particularly prone to this problem, particularly at the graduate school level. For example, when one author when told her department chair that she was pregnant and needed to change teaching assignments, the response was not one of congratulations, nor condemnation—but more one of confusion: “What? Students can get pregnant?”

Graduate school involves unique time pressures.  Three considerations in graduate student family life are personal relationships, financial challenges, and the ticking biological clock. We do not have any magic bullets, but we do have key considerations we wish that someone had passed on to us when our babies were “loading.”

Time == Love
Few graduate students strictly adhere to a nine-to-five schedule.  Instead, we work in the evenings, nights, and weekends, playing a careful balancing game between work and personal life. This can lead to multitasking and unclear divisions between work and home life: while our code is compiling we may be heating up a bottle, running a load of laundry down to the washer, or quickly uploading baby pictures. Time is precious, and given how little of it is available, finding time to spend with a romantic partner can be vital. Given that leisure time spent with a significant other is already limited, how can we find the additional time to devote to a baby? Will having a child put too much stress on our adult relationship?

Grad_school != money
Graduate student research assistants are compensated by university fees and a living wage stipend, which is less than minimum wage when factoring in the long hours spent working.  In a family composed of two graduate students and no outside support, money can be stretched thin.  According to the National Association of Child Care Resources and Referral Agencies, child care for infants or toddlers costs between $4,388 and $14,647 per year [12]. To put this within the range of the authors’ graduate stipend, child care alone costs  half of our pay, without even accounting for the additional costs of having a child. We ask ourselves: How can we find the money to have a baby?

Time –= 1
For many graduate students, the refrain is the same: “I will wait until my Ph. D. to have children.”  Then: “I will wait until I have a faculty position.”  Then: “I will wait until tenure.”  For men as well as for women, advanced age can contribute to decreased fertility [13,14], a more complicated pregnancy and birth [15], and other possible complications.  Further, it can take some time—in some cases, as long as a year or more—to become pregnant; then, once pregnant, the normal side effects of pregnancy, such as nausea and fatigue, can negatively affect job performance. How long should we wait to have a baby?  How can can we make time to have a child?

Why Grad School?
With these very compelling constraints, why is graduate school a good time to have a baby?  First, a graduate student’s schedule is malleable.  Especially after coursework is complete, a research schedule is generally flexible, allowing the student to work around the baby’s schedule (and the parents to work around each others’ schedules).  Not all universities support tenure programs like stop-the-clock, nor do all employers support extended time off after giving birth. However, it is possible to take a semester off after having a child.

Second, graduate students have youth—hence, energy and creativity—on their side.  A young person can adapt to circumstantial challenges and can overcome obstacles more easily.  Moreover, grad students are surrounded by equally young peers who can help with occasional, free babysitting to let a new mom (or dad) study or sleep. If the grad student’s parents are available, they are also likely to be younger, making it easier for them to travel and lend a hand.

Third, a grad student’s support network is more flexible. Whether due to pregnancy complications or postpartum mayhem, changing teaching assignments formally within the department, or trading schedules with a peer informally, can be easy as a graduate student.

Finally, we answer a question with a question: Why wait?

Strategies for Success
Having a new baby can be a rewarding yet challenging time for any family. In the first months, the parents are up throughout the night, frequently as often as every two hours—and that is if everything is all right.  Meanwhile, meals need to be made, the house needs to be cleaned, and, perhaps most importantly, graduate work needs to move forward.  These are the ingredients we have found to be key in making childbearing in graduate school a reality.

A Supportive Advisor
An advisor that supports his or her student’s decision, both in word and in deed, to have a baby is a keeper.  The support can be as mild as suggesting ways in which to make sure classes are completed prior to the birth of the child; providing a flexible schedule to allow the student to work in the time between infant feedings; relaxing the deadlines, understanding that the student’s probable decrease in productivity is temporary (although one atypical new mom reported clocking in 80 hours the week after giving birth to twin girls).  One progressive advisor suggested to her student that she Skype in to all of her classes after giving birth, and allowed all work to be completed from home.

If your advisor seems cool to the fact, ask outright about his or her feelings about your impending motherhood.  The battle over work responsibilities will not stop at the baby’s birth but will continue until either you graduate or you move to a different advisor.  If your advisor assumes you will continue producing at the pre-pregnancy level without missing a beat, one of you may end up disappointed.  Think proactively.

Adequate Me-Time
With all the work that is waiting, it is easy to lose focus of what is also important: You. Not to make having a child seem insurmountable, but there are times when your child is first born when time feels like the enemy. There is just not enough of it to sleep, work, and eat. This lack of time can lead to the malaise that overworking and under-sleeping induces. There are two things that can help you re-charge and re-focus. The first is spending time telling people objectively how cute your kid is, and breathing in the new-baby smell of your kid’s hair. The second is taking time for yourself. Find time to read a book, go on a walk, play video games, go to the gym, or do whatever it is you need to do to recharge.

Although it may be difficult, realize that there are times where you might have to put your career first. There are times when your kid is sick, and he really wants to be held, but you have to get that paper edited by midnight. For one of the authors, her baby boy had just had surgery for ear-tubes earlier that day, but because there was an important networking event that night, she had to leave her child with her partner. There will be conflicts between your career and your family. Knowing that sometimes it is okay to put your career first can help with this dichotomy.

An Amazing Partner
A pinch of prevention is worth a pound of cure. If a partner is involved, having an honest conversation with him or her, in advance, about what is expected postpartum can smooth the new-parent transition. Who is going to do the laundry? change midnight diapers? go grocery shopping? If no partner is involved, the bright side is that there will be no conflict about who will do all of these things. There is not any way that you can prepare for everything before the baby comes, but setting expectations will help. For one of the authors, having a partner who understood that she might be a mom, but her career was important, made a large difference. This meant talking about how soon she might want to return to work, what child care options were available, visiting the child care centers together, and setting some ground rules. Those rules included who pays certain bills, who gets to work which nights late, who stays home when the child is sick, and who does the grocery shopping.  If a partner is not responsive to talking about these issues, parenthood, in general, can become very difficult.

A second benefit of an amazing partner is having someone who values your experience. The shock of being walked in on while expressing milk with a breast pump in a mostly male department is, to put it mildly, upsetting. Or, when people start asking you if you are planning on staying in graduate school now that you are pregnant (because pregnant women should be barefoot and cooking), you need someone at home who will let you express your feelings and then help you react. Or, when you get told for what feels like the hundredth time that, “You must have a very supportive partner,” and you realize that a man in the same position would not get told the same thing, a discussion with your partner about the (hopefully unconsciously) biased workplace is key for your own sanity.

Trustworthy Child Care
You can’t start code-slinging again when you literally have your baby in a sling. Find someone that you can trust your child with, even if it is for only a few hours.  Trust is the key part in that sentence: check with friends, listservs, and websites  for good home care, child care centers, and nanny shares.  Talk to pregnant women; talk to both men and women swinging their toddlers in the park.  They face the same decisions, and have probably investigated some of the same, or different, options.  One point of advice, though: mom-networks are often sources of second-hand information (e.g., Sally says that Sue says...). Verify anything you hear.

There are many options for trustworthy child care, even though it might not feel like it: day care, live-in nanny, live-out nanny, nanny-share, au pair, and stay-at-home partner are just a few of the options.  Just because you visited a child care center when pregnant and you know that it is the right place for your child, that does not mean that in six months you will still feel the same way, when you leave your kid there for the first time. Similarly, just because you like your child care solution does not mean that your child will. Anything can happen: your nanny might move (or graduate); your child care center might close down; you might realize school is too far from the center. It is important to stay adaptive and recognize that you can find alternate creative solutions.

A Support Network
Tap into your family network: your parents, your partner’s parents, and even cousins, aunts, and uncles.  One of the authors was able to attend classes for a quarter by asking her partner to take her infant every Tuesday, and mother to come every Thursday for ten weeks.  Ask friends.  Be creative, accept help when it is offered, ask for help before it is needed, and be thankful.

Having a baby changes your outlook on life.  Suddenly, your priorities shift entirely, and it can be a bit of a culture shock to realize that you have a hard time relating to the friends who have not yet had children.  If they are interested and supportive of your life’s changes, bring them up to speed and include them as much as they like.  But also, find other new and expectant moms that can share your experiences.  Even if you are the only female graduate student you know, we promise that you are not the only mom in town. Find others who are having kids. Your ob/gyn may know of a working-mom support group, and you could ask your graduate school about any university-wide efforts.

A Positive and Grounded Outlook
As a final note in the checklist, be positive and celebrate your accomplishments as they come.  Enjoy these limited years with Thesis Baby as much as possible and keep the big picture in mind.  In the grand scheme of things, your child’s infancy and toddler years, and your dissertation years, are short.  For many working women, compartmentalizing motherhood and academia is an ongoing battle: when working on your research, you feel like a bad mother because you are neglecting your child, yet when with your child, you feel like a bad student because you are neglecting your work.  Our advice is to remember the big picture, and try not to let the guilt take over.  Being a grad student is mental exercise and is as important as having a child.  Both of these aspects of your life make you a complete, unique, and fascinating woman.

Making It Happen
One mother-professor, known to store expressed breastmilk in her laboratory refrigerator, quoted Gandhi: “Be the change you wish to see in the world.”  The only way to change perceptions of, and biases associated with, mother-students, mother-faculty, and mother-professionals is to gently, firmly, and consistently prove these perceptions wrong.  Show the world that it can be done: mothers defend their dissertations; mothers produce quality work; mothers are incredible, productive professors and industry professionals.

Having a child is a life-altering event, no matter when the child comes.  However, being a student should not impact a mother’s decision to have a child. Computer science and engineering, to succeed as disciplines, are positioned to examine how to support students with lifestyle circumstances such as having a child in graduate school.  Our generation of student-mothers paves the way for student-mothers that come after us.  In this article we presented reasons having a child in graduate school are favorable yet difficult, and have presented some of the tools and strategies that have helped make our experiences with being student-parents easier.  Finally, we end this article with a request from the authors to women faculty: be the kind of role model you would want to have.

[1] S. Correll, S. Benard, and I. Paik. Getting a Job: Is There a Motherhood Penalty? American Journal of Sociology, 112(5):1297–1338, 2007.

[2] A. Crittenden. The price of motherhood: Why the most important job in the world is still the least valued. Metropolitan Books, 2001.

[3] E. Evans and C. Grant, editors. Mama, PhD: Women Write About Motherhood and Academic Life. Rutgers University Press, 2008.

[4] G. Gehring. Mixing motherhood and science. Physics World, 15(3):18–19, 2002.

[5] V. Gewin. Baby blues. Nature, 433:780–781, 2005.

[6] M. Mason and M. Goulden. Do Babies Matter (Part II)? Closing the Baby Gap. Academe, November–December, 2004.

[7] M.Mason and M. Goulden. Marriage and baby blues: Redefining gender equity in the academy. The Annals of the American Academy of Political and Social Science, 596(1):86, 2004.

[8] E. Monosson, editor. Motherhood, The Elephant in the Laboratory: Women Scientists Speak Out. Cornell University Press, 2008.

[9] S. V. Rosser and M. Z. Taylor. Expanding Women’s Participation in US Science. Global Education, 30(3), 2008.

[10] C. Wetzels. Does motherhood really make women less productive? The case of the Netherlands. Bilbao ESPE Conference, 2002.

[11] L. Bennetts. The Feminine Mistake. Voice, 2007.

[12] Parents and The High Cost of Child Care: 2010 Update. National Association of Child Care Resource & Referral Agencies, 2010.  Retrieved from

[13] S Kidd, B. Eskenazi, and A. Wyrobek. Effects of male age on semen quality and fertility: a review of the literature. Fertility and Sterility, 72(2), 237–248, February 2001.

[14] D. B. Bunson, B. Colombo, and D. D. Baird. Changes with age in the level and duration of fertility in the menstrual cycle. Human Reproduction, 17(5), 1399–1403, 2002.

[15] E. Zasloff, E. Schytt, and U. Waldenström. First time mothers’ pregnancy and birth experiences varying by age. Acta Obstetricia et Gynecologica Scandinavica, 86(11), 1328–1336, 2007.

Monday, February 13, 2012

Choosing a birth facility in five easy steps

How do you choose where to give birth? This post attempts to answer the question of how to choose where to give birth -- where to look for data, and what questions to ask yourself.

In the region of the US where I practice, for low-risk pregnancies, there are basically two options: birth at home with a midwife, and birth in a hospital with whoever happens to be on call (sometimes this is your own doctor or midwife).

Birth at home

Choosing a safe homebirth requires forethought. I am not an advocate for unassisted birth, with no medical professional on hand to help. I think that choosing a homebirth is a big deal and requires sufficient preparation. Selecting a homebirth midwife is a lot like selecting a doula, except there is more responsibility involved in a midwife. (And, you should have a doula as well.) Here are some things to ask your midwife when you consider birth at home.

  • How long do you spend in prenatal visits with me? Midwives are known to spend longer in each prenatal visit with their clients than obstetricians or doctors.
  • How do I prepare and educate myself for birth? Some midwives teach their own homebirth childbirth preparation classes.
  • When I am in labor, when will you come to my house? How long will you spend with me in labor? Midwives vary widely on when they will arrive. Some will arrive in active labor and will provide doula-like support throughout the birth. Most will arrive at the end of active labor, in time for pushing, to help you have the baby.
  • How many assistants do you have, and will they be coming to help with the labor? Some midwives send their assistant(s) first for support, and will come later. Others come with their assistants. There should be at least two trained midwives with you: one for you, and one for the baby.
  • What kind of equipment do you provide? Some midwives will bring a birth (yoga) ball and/or birth stool, and may rent a tub for you to labor in.
  • What kind of emergency equipment do you have in your midwifery kit, and under what circumstances do you use it? This should be standard, but should include oxygen, Pitocin, sutures, etc. The oxygen can be administered to the mother or the baby; Pitocin helps with postpartum bleeding; and sutures are used to sew up any lacerations (tears) in the mother.
  • What are the factors that will cause a transfer to the hospital in labor? This is fairly standard as well. Expect answers such as labor before 36 weeks gestation (preterm baby),  induced labor (ask when induction will occur), meconium in the amniotic fluid at any point in labor, baby's heart rate decelerating (measured with intermittent monitoring), bag of waters being open for over a certain amount of time (24 hours, 36 hours), and maternal fever, to name a few. Some midwives will not deliver breech babies and multiples (twins, triplets).
  • How long will you stay with me postpartum, and how often will you check on me and the baby? Expect that the midwife will stay at least a couple hours postpartum, until you are settled with the baby, and will check on you frequently in the following days.
Of course, you can also ask about transfer rates (the percentage of mothers that transfer to the hospital), c-section rates, emergency intervention rates, and so on, but that may not give you a good idea of what the midwife brings to the birth. These numbers could tell you her willingness to relinquish control, or to "allow" interventions to happen to the mother, but there is a chance that all it tells you is whether she has had a run of good luck or a run of bad luck.

Research what other mothers said about their home birth. Check out The Birth Survey project, which is a self-reporting tool in which mothers can enter their own experiences and information in the months after their birth. Keep in mind that these data may be skewed because of selection bias: this is not a randomized study, and mothers choose whether or not to participate.

Finally, skip to Step 5: You are not locked in. Though it may be trickier to switch home birth providers later in pregnancy, it can be done.

Birth in a hospital

Choosing a hospital can be a hairy task. No two hospitals are alike. I hope this guide will help you narrow down your choices.

Step 1: Choose a non-profit hospital.
Nathaneal Johnson of California Watch (2010) reported that for-profit hospitals have a higher c-section rate than non-profit hospitals. And that increase in c-section rates is nontrivial: mothers giving birth at a for-profit hospital have a 17% higher chance of delivering surgically. For-profit hospitals are more likely to perform costly procedures, less likely to serve under-served populations, and less likely to have breastfeeding success.

Step 2: Figure out what's important.
Priorities the importance of the following things: cost of birth, mode of delivery (vaginal vs c-section), c-section rate, breastfeeding success, diversity of population served, infant outcomes, whether you will have a room mate, what language(s) are spoken, where your doctor/midwife practices, how many residents (trainees) there are, how close the facility is to where you will spend most of your labor, and any other factors you consider important to you.

Step 3: Do the research.
There are several ways to look at birth facts. Check out Health Grades and search for the hospitals in your area. In California, you can use California Watch to look at statistics. For example, say I wanted to compare San Francisco General Hospital (SFGH) and UCSF Medical Center (UCSF) -- both non-profit teaching hospitals in the center of San Francisco, California.

Figure 1 shows the California Watch page for SFGH. Interesting things to note here: the decreasing trend of the low-risk c-section rate across three years, and the most recent reported average is 11.10% in 2007, much lower than the US average of 33%. This is very reassuring if mode of delivery is important to you and/or you wish to avoid a c-section. The Hospital Info section below tells you that SFGH is a non-profit teaching hospital that caters to under-served families, with over 60% of the patients coming from a low-income household. If breastfeeding is important, the 88.90% exclusive breastfeeding rate is a very good sign, and there is a positive correlation between beginning breastfeeding in the hospital before discharge and continuing to breastfeed for at least a few months postpartum. Finally, the (risk-adjusted) VBAC (vaginal birth after c-section) rate is a promising 30.23%.
Figure 1: Decreasing c-section rate for
San Francisco General Hospital (California Watch)
Click to enlarge

Figure 2 shows the California Watch page for UCSF. You will notice that it is very similar to SFGH: relatively low c-section rate of 14.20% in 2007 (compared to the US average of 33%), even when you look at the base c-section rate: 19.47% of all mothers, even high-risk mothers, deliver surgically. About 30% of the patients are low-income, judging by the insurance carrier. The breastfeeding success rate is 74.77%, which is still very good -- three quarters of all babies born at UCSF are exclusively breastfed when they check out. The risk-adjusted VBAC rate is 24.23%, which is fairly good.
Figure 2: Information on the University of California - San Francisco
Medical Center (California Watch)
Click to enlarge
Another thing these charts do not tell you include whether or not vaginal breech birth is attempted at each hospital (it is).

Health Grades gives both of these hospitals one star for maternity (worst grade possible), but it is unclear why. So let's take a look.  Figure 3 shows that San Francisco General Hospital (SFGH) and UCSF Medical Center (UCSF) each has one star. SFGH reports 64% of the cases that UCSF received in 2011 -- implying that SFGH is a smaller hospital. But here is where it gets interesting.

At SFGH, 2544 women delivered vaginally (79.62% of all women that delivered at SFGH in 2011), 12.23% (N=311) had complications related to the vaginal delivery.  But the national average for complications is 8.21% so we would expect only 209 women to have had complications. So more women have complications at SFGH due to vaginal delivery than the US average.

We know that SFGH had a 11.10% c-section rate (in 2007) from Figure 1 and we will assume the same c-section rate in 2011. In Figure 3, we see that there is a 20.28% c-section complication rate. That is, of the 651 women that delivered by c-section at SFGH, 20.28% of them (N=132) had complications related to the surgery (e.g., infection, excessive bleeding, etc.).  But, the national average is 4.34% so we would have expected only 29 women to have had complications. So, the c-section complication rate at SFGH is more than four times the US average.

At UCSF, 3745 women delivered vaginally (74.81%). Of these, 15.09% had complications (N=565). The national average for complications related to vaginal delivery is 8.21%, so we would have expected only 308 women to have complications. The vaginal delivery complication rate at UCSF is almost twice the US average.

Now, UCSF's c-section complication rate is a little worse than SFGH's, at 13.16%. That is, of the 1261 women that had c-sections, 13.16% of them (N=166) had complications. Since the national average is 4.34%, we would have expected 55 women to have had complications. The c-section complication rate at UCSF is three times the US average.

Health Grades does not explain the "Newborn Survival" column so we have to take it at face value, and, if possible, compare the newborn survival (text) across the hospitals we wish to examine.

Figure 3: One-star ratings in maternity care for San Francisco General Hospital
and UCSF Medical Center (Health Grades)
Click to enlarge

If we wish to investigate whether there is a difference between any of the following, we can run a quick Chi-square on the data from Figure 3.

  • SFGH and the national average, in terms of vaginal and c-section complications
  • UCSF and the national average, in terms of vaginal and c-section complications
  • SFGH and the UCSF, in terms of vaginal and c-section complications

We find that indeed, there is a difference in all of these categories. Although calculating Chi-square does not give us the direction of the relationship, we can see that SFGH and UCSF both fare poorer than the national average, and that c-section births at UCSF are more than twice as likely as expected to have associated complications. Yikes! Figure 4 contains all of these calculations.
Figure 4: All correlations for SFGH, UCSF, and the national average.

Research what other mothers said about their birth experience at the facility you choose. Check out The Birth Survey project, which is a self-reporting tool in which mothers can enter their own experiences and information in the months after their birth. Keep in mind that these data may be skewed because of selection bias. For example, SFGH has 60% under-served population; are mothers from this group more or less likely to fill out an online survey than higher-income mothers, in the interests of science?

Ask your friends about their experiences in the facilities. One gal I know praised her birth facility for its harp music and tea time in tones that I understood to be insincere. Then she divulged that she had a room mate, and she hated the experience of someone else's baby crying in the night next to her own bed. No amount of tea could make that memory go away.

Step 4: Visit.
Knowing, on paper, that these hospitals are so similar, how can you choose the right one for you? Visit. Maybe it is a prenatal appointment with a midwife or obstetrician. Maybe it is a procedure, like lab work or the 20-week ultrasound. Maybe it is a maternity center tour. Get a feel for the dynamics of the hospital, for the nursing staff, and for the check-in and check-out procedure. Imagine arriving in labor at rush hour. Is it crazy, with papers flying and nurses pulling their hair out? Or is it a smooth and calm atmosphere? If it is a teaching hospital, ask when the new residents start their training. If their first week corresponds to your due date, and that makes you nervous, that could be a strike in the "no" column. If you are taking a tour, look around the birth room and ask what kinds of things the nurses usually try to help a mother labor. Look for answers that promote relaxation (e.g., birth ball, music player), movement (e.g., waterproof wireless fetal monitors), and hydrotherapy (e.g., bath tub, shower). Ask about routine procedures and if any of them can be skipped (e.g., pubic shaving, IV, Pitocin for labor augmentation).

Step 5: You are not locked in.
Even if you have made your choice of birth facility, or obstetrician, or midwife, or doctor -- whatever -- you are not married to that choice. You can always, always switch. Remember that you are paying good money for the services that will be rendered to you. You are hiring a medical professional. If you are unhappy with your choice, and you are unable to reconcile it (by talking about it, e.g.), you can switch. I have asked doulas, midwives, and nurses in the past: When is it too late to switch providers? The answer: After the baby has come.

Good luck, and happy birthing!

Tuesday, February 7, 2012

HypnoBirthing for Birth Professionals: A seminar

Last weekend, I attended a seminar called Supporting the HypnoBirthing Mother and her Partner: A Workshop for Birth Professionals. You may know me as a scientist. As a researcher. As a critically-thinking repository of information. You probably do not know me as a HypnoBirther. Which I am totally not.

But this workshop left me with several ideas of how to use aspects of the method to help a mom and her partner feel calm and confident. These are using slow, deep breathing with some position change, and using positions in which the weight of the body is being held. Having confidence in visualization suggestions is also key in creating an atmosphere in which the body can relax.

But perhaps the biggest benefit of HypnoBirthing is that it gives the mother and her partner something to do throughout her entire labor.

What is HypnoBirthing?

HypnoBirthing, also called the Mongan Method (after its creator, Marie Mongan) uses hypnosis to enhance the trance-like altered state of active labor. That is my definition. Maybe yours is different.
In effect, HypnoBirthing is relaxation, breathing, and visualization.

Figure 1: Fear-tension-pain cycle, as per G. Dick-Read.
The crux of many popular modern childbirth philosophies is the "fear-tension-pain" phenomenon. When you are afraid or anxious, you tense up. When you tense up, you feel more pain. And when you feel more pain, it is scary. So if you can teach your body to relax, you can nip the cycle in the bud and things will hurt less. At the risk of using Comic Sans, I have illustrated the cycle on the right in Figure 1.

The idea is that the mother and her partner  begin preparing for a hypno-birth early -- around the 20th week of pregnancy, much earlier than the typical childbirth education which is usually around 35 weeks -- and the preparation includes childbirth education (that is the Birthing part) and guided meditation (that is the Hypno part) which is to be practiced at home in the months to come. The focus of the meditation is deep relaxation, the kind you get when you can no longer tell where you are or how long it has been, with a particular emphasis on breathing and visualizing the baby. And when the time comes to birth the baby, the mother has practiced relaxation so much that she can enter that state of deep relaxation easily and willingly. Add in some breathing and visualization techniques, and you have it.

What are these doctors doing here?

The instructor of this seminar for birth professionals, Rachel Yellin, a spunky gal with a huge mane of curly hair draping her cheeks, shoulders, and back, addressed the roomful of birth professionals. There were seventeen women and one man (a man!) in the room. Most were birth doulas, some were also yoga instructors and massage therapists. There were two obstetricians (the man was one) and a midwife; two grandmothers or soon-to-be grandmothers; and a few volunteers from the doula organization to which I belong. And there was me, researcher, marked by academic articles seeming to fall out of my ears.

I was as surprised (pleasantly) as Rachel to see obstetricians in the audience. It was surprising because douas are taught that obstetricians only come to deliver the baby. They do not participate in labor support. So what were these three clinicians (two OBs and a midwife) doing in the audience? It turned out that Jack was going to be supporting his brother and sister-in-law in the coming months, in the birth of their child, and he was terrified: having never been in a position of support, especially in early labor, and especially continuous, he was lost. As a birth professional, he did not want to take a full-blown childbirth education class, so he came here instead. Blair, the other obstetrician, and Alice, the midwife, wanted to learn how to help their hospital staff support HypnoBirthing couples. Learning more about the process of HypnoBirthing would help them not startle anybody and break the focused flow the mother had established for herself.

They really stole the show. Doulas had so many questions -- about obstetric interventions, procedures at their hospital, and, most importantly, how doulas can help. I touched on this a bit in a previous blog post, Why I'll Never Be a Nurse: some newer doulas have just enough education to be a nuisance, but not enough to be an asset to a birth team. I watched the collaboration unfold, and in the fifteen short minutes that the conversations proceeded I saw the doulas' eyes light up, and some were taking notes. There really does need to be more training for doulas about hospital procedures, regulations, and liabilities. But I digress.

Do you want me to help you?

This is the first question any support person should ask any supportee. Do you want me to help you? Sometimes the answer is no. Sometimes the mother may want to feel miserable for a while, or to complain, or to find her own way. In that case, be present and wait.

But if the answer is yes, the support person will have some work to do.

HypnoBirthing is not a comfort measure. At least, not in the common sense of the words -- which HypnoBirthers are encouraged not to use. The connotation of "comfort measures" is that something you can do will make the mother more comfortable. The idea is not to get more comfortable, but to dive deeper into the sensations. The idea is to relax more, enter a state of deeper relaxation: one that will allow the mother to open herself to the point of letting the sensations of labor sweep over her body.

Labor as an altered state of consciousness

Especially starting with active labor, when the mother can no longer ignore her body, and must concentrate her energy inwardly, the mother enters an altered state of consciousness. HypnoBirthing tries to harness this potential and works with it to help the mother enter this state of consciousness sooner and deeper than otherwise. The mother's focus turns inward and she uses the techniques outlined above and below. Because the mother is in an altered state of consciousness, she is susceptible to suggestion. The altered state of consciousness can be considered meditation, and here is thus dubbed hypnosis. And because in this altered state, the mother is more keenly aware of suggestions, we call this altered state suggestion hypnosis. It is a relaxed altered state of consciousness.

Rachel said, "Remember that anything and everything that happens around a woman or to a woman during labor is a suggestion." You look at the clock? Suggestion (too slow). You look at the read-out from the monitor? Suggestion (what's wrong). The nurse does a vaginal exam? Suggestion (things go in, not out).

She said as labor support persons, we must be mindful of everything we do and the suggestions we give off, even unintentionally.

I could not agree more.

Three reasons for purposeful breathing

Rachel explained that there were three main reasons for purposeful breathing in labor, which is breathing while really concentrating on the breath going in and out of the body.

  1. Oxygen. That is, you need it to survive. And so does the baby. Bringing oxygen to all the parts of the body that are doing the Big Work of Birthin' is the main reason.
  2. Sound. When the mother is concentrating on the sound the breath makes as it passes her throat and her nose (like yoga breathing), she cannot possibly concentrate on anything else. She cannot talk and (especially) complain, and she is forced to relax. It helps her enter and maintain that altered state HypnoBirthing is known for.
  3. Bridge from Mother to Baby. Visualizing the baby and its uterine cocoon helps the mother's body go through the steps of birthing a baby. And a continuous flow of oxygen to the baby is very important for the baby's and the mother's wellbeing in labor.

The good, the bad, and the skeptical

For me, there are two sides to every coin. Here are a few of those coins that hit a bell for me.

Relaxation in labor
The idea: Relaxing in labor helps labor move faster and hurt less.
The good: Certainly key! How many mothers exhaust themselves in early labor, pacing or cleaning? Rachel explained the importance of relaxation and breathing. She said to imagine a mother in labor as she is climbing up and down stairs or pacing the hallway to get things "moving," as mothers in early labor are apt to be encouraged.

Figure 2: Slumped forward over baby
"Pain in labor comes from the baby pressing against a dehydrated uterus," she said, meaning that the uterus lacks oxygenated blood. "Where is the oxygen? It is in the thighs, as she mounts each step; in the heart, beating faster, in the arms, holding on to the handrail." Consider how much more blood her uterus would be getting if she were sitting, slumped over her baby (Figure 2); or lying on her side, curled around her baby; or on all fours, letting the weight of her body be held by a yoga ball. As an aside, I could not find a single freehand drawing program on my entire hard drive -- my apologies to the woman pictured in Figure 2.

"The idea is," said Rachel, "that all this movement and letting gravity help will bring on stronger and harder surges." Oh, I forgot to mention. Contractions were renamed as surges because you want to give the idea that things are loosening, not tightening. Surges. Say it with me, and have some granola. It is good for you. "The harder surges may not be doing anything for the mother besides exhausting her." Rachel's implication was that the active mother's uterus depleted of oxygen is the reason her surges are getting more intense, not that labor is actually moving faster.

Thus, the HypnoBirthing method relies on supported-body positions that do not require much exertion by the mother for two reasons:

  1. Oxygen getting to the uterus, and
  2. Mother staying very relaxed.

The skeptical: None, really, but I wanted to mention one thing: The supported-body positions must be changed on a regular basis. Because in the end, we do rely a little on gravity, and we need to help the baby traverse the narrow passage. As an active participant, the baby needs to tuck and turn and twist, and changing position frequently helps baby do just that.

Three types of breathing
The idea: Practicing three types of breathing (sleep, balloon, and birth breathing) helps the birth process. 
  1. Sleep breathing is a medium-length inhale and long, slow exhales lasting twice as long as the inhale: count in, in, in; and out six times. 
  2. Balloon breathing is similar to yoga breathing, using the sound in the back of the throat as a focal point in the meditation. Think about saying "haaaa" so that the whole room can hear you. Now do it with your mouth closed.
  3. Birth breathing, or "breathing the baby down," is a sequence of short, light grunts with which you expand the size of the stomach. They are like stomach thrusts using the air in your belly. This breath is supposed to be used in the second stage of labor.
The good: Sleep breathing promotes oxygen exchange through the body. Way to oxygenate that uterus, girl! Balloon breathing helps focus! And birth breathing helps the baby move into position gradually, come down the birth canal slowly, and be born gently with little danger to the perineum and little stress to the baby.

The skeptical: A few comments.
  1. Early iterations of the Lamaze method tried to teach breathing. Remember the "hee-hee, ha-ha" breaths that movies always implement? That is Lamaze from the 70s. Researchers found that not only does Lamaze breathing not work as a labor support tool, but also the mother hyperventilates with these quick breaths. Good thing they got rid of that, right?
  2. No animal has birthing breathing rituals in the wild. Have you ever seen a dog giving birth to puppies while yoga breathing?
  3. When Rachel got to birth breathing and how it is meant to be performed in the second stage of labor (i.e., pushing), showing us how to do it, with her stomach bouncing rhythmically, we (that is, the class) imagined a woman in labor doing this and roared with laughter. "I have never seen a woman do this," Alice (the midwife) said, "and I have seen a lot of HypnoBirthers." When the body bears down, there will be no such breathing.

Remove the reference to pain
The idea: If you reframe the sensations a mother experiences, she will not be tempted to see it as pain. "Pain is when your body says something is wrong," Rachel explained. "When you are in labor, there is nothing wrong. The sensations you are having are perfectly normal. They can be uncomfortable, sharp, stabbing, tightening, tingling -- whatever!" She said that if you cut your finger, that hurts, and that is painful. Your body sends the signal to your brain so you can fix it. But in labor, there is nothing to fix.

The good: The woman in active labor is already in a deep state of relaxation, and an altered state of consciousness, so asking about pain and entertaining conversations about hurting are all very suggestive to her. Perhaps because pain is scary, and fear leads to tension, and so on. Refraining from bringing a mother's attention to pain is probably a very good idea.

The skeptical: Alice, the midwife at the session, said she frequently sees HypnoBirthing patients come in and she cannot tell, at all, how far along in their labor they are because they are relaxed and smiling. She says it can be a real challenge, because they are the same patients that try to forego vaginal exams to determine labor progress. Rachel agreed and said the only way she can tell if a HypnoBirthing mom is pushing is she sees her stomach contract rhythmically.

So perhaps a strong benefit of HypnoBirthing is that nobody sees you in pain. When the mother is in a state of deep relaxation, nobody can tell how much discomfort she is feeling. That includes her care staff and her partner. If her partner is more relaxed (i.e., not worried about the sensations she is feeling), he or she can provide better care for her. Anxiety related to the mother's pain level is a major fear factor for birth partners.

When HypnoBirthing women recall their experience, they do say things like "Oh, it hurt like hell," or, as Rachel retold, "It felt like being stabbed by a fire poker." So clearly, simply not thinking about pain does not make the pain go away. But it does alter other peoples' impressions of the mother's sensations because outwardly, she is not complaining.

The Benefits of Relaxation

A pamphlet about assisting women in labor using the HypnoBirthing techniques [doc] published in 2010 by Brandy Astwood, a HypnoBirthing childbirth educator, outlines the relevant research supporting HypnoBirthing and provides helpful suggestions for birth partners and nurses on how to help a woman that is using deep relaxation as her primary labor strategy. Her pamphlet collects results from several sources and is repeated here.
Fear, stress and tension have long been known to be associated with increased levels of pain as reported by patients. Grantly Dick-Read, MD, described the “Fear-Tension-Pain Syndrome” in the 1920s, and since that time obstetrical care providers have noted that education and stress management strategies have been effective in decreasing the level of pain reported by women in labor.

Hypnosis has been used effectively in the management of pain for over a century, but fell out of favor with the advent of safer, more effective analgesia/anesthesia. Over the years, several studies have been undertaken to research the efficacy of hypnosis in childbirth. A meta-analysis of these studies, “Hypnosis for Pain Relief in Labour and Childbirth: A Systematic Review,” appeared in the British Journal of Anesthesia in 2004. The article states
This report represents the most comprehensive review of the literature to date on the use of hypnosis for analgesia during childbirth. The meta-analysis shows that hypnosis reduces analgesia requirements in labour. Apart from the analgesia and anaesthetic effects possible in receptive subjects, there are three other possible reasons why analgesic consumption during childbirth might be reduced when using hypnosis. First, teaching self-hypnosis facilitates patient autonomy and a sense of control. Secondly, the majority of parturients are likely to be able to use hypnosis for relaxation, thus reducing apprehension that in turn may reduce analgesic requirements. Finally, the possible reduction in the need for pharmacological augmentation of labour when hypnosis is used for childbirth, may minimize the incidence of uterine hyperstimulation and the need for epidural analgesia.1
Obstetrical patients using self-hypnosis have been shown to have lower scores for pain associated with childbirth, shorter duration of both first and second stage labor, increased number of spontaneous births, decreased use of analgesia, anesthesia and labor augmentation and infants with higher average Apgar scores.

HypnoBirthing® teaches women to relax quickly and completely with uterine contractions, and to use visualization to help facilitate cervical effacement, dilation, and fetal descent. Women and their birthing companions are taught that fear and tension lead to increased levels of catecholamines, which ultimately causes increased pain during labor. The positive effects of visualization are thought to be similar to those achieved by athletes using mental imagery to prepare for competition. Rather than using multiple types of breathing and imagery to distract the laboring woman from her discomfort, HypnoBirthing® allows a woman to become deeply focused upon the birthing process.

When in labor, a woman using this method is not asleep or unconscious, and is receptive to suggestions made by her birthing companion and others. For this reason, references to pain, medications and procedures are best kept to a minimum. Women using HypnoBirthing® will ask for analgesia or anesthesia if they need it.

HypnoBirthing® encourages the laboring woman to allow passive descent in second stage and to “breathe the baby down” with release of air as she “feels the urge.” The HypnoBirthing method discourages Valsalva pushing, and beginning to push before the woman has the involuntary urge to do so. Recent studies have shown few risks and some benefits in allowing the mother to “labor down” in second stage, allowing passive descent, as opposed to “pushing” as soon as cervical dilation is complete. With passive descent, there are fewer fetal heart rate decelerations and less fetal acidosis. Maternal benefits include a shorter period of “pushing” and less fatigue. Unless specifically instructed otherwise, women begin bearing down spontaneously when the fetal presenting part is well down in the birth canal; they will generally wait until the contraction peaks and then give a series of “mini-pushes” with air release.

HypnoBirthing® stresses that the goal is a gentle and safe birth for the baby. Staying relaxed and focused upon her baby and the birthing process enables the birthing woman to remain calm and more comfortable. Her companion(s) will help her to maintain this calm focus with music, dim lights, soft touch, and speaking words of encouragement. They will also help her to remain well nourished and hydrated and assist her in moving about. The companions will advocate for the mother and baby if interventions are suggested and help the woman to make informed decisions.

We find that, no matter what turn the labor and birth may take, most couples are very satisfied with their birthing experience. Because they are calm and relaxed, they will feel empowered to make good decisions if interventions become advisable.
--  Brandy Astwood's pamphlet, 2010 [doc]

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