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Denis Walsh, mommy wars, and coming together On Common Ground

Last week, I was thrilled and humbled to be asked to contribute to the On Common Ground collection at RH Reality Check. My assignment was to write a piece from the maternity care perspective that represents common ground for people on opposing sides of the abortion debate.On Common Ground

I was asked to help readers who cannot agree even on the basic precepts of an issue discover concerns and beliefs held in common. I hope I succeeded. But I may have stepped from one divisive debate right into another. In my article, Improving Maternity Care: A Mother and Child Reunion, I discuss how what happens in birth can affect a woman’s transition to motherhood, and even her biological bond with her baby. Sound familiar? This is a bit like what midwife and researcher Denis Walsh is reported to have said in a recent article. The article, published in the Daily Mail’s Online Edition, ignited a storm of attacks against Dr. Walsh, who is a man, for allegedly saying that epidurals can complicate maternal-infant attachment and breastfeeding. A look at the hundreds of comments on the feminist site Jezebel will give you a sense of how unpopular his remarks are.

Whether Denis Walsh said what was reported or not (there’s a good chance he didn’t), this isn’t the first time any of us have heard the claim – and even the science behind the claim – that epidurals disrupt the biological processes of maternal-infant attachment and breastfeeding. These claims are made about cesareans, too. But clearly, even the most eloquent and informed among us (for example, Denis Walsh) are unable to talk about these effects in language that resonates with the majority of women.

Is there a better way we can talk about the impact of maternity care practices on mother-infant attachment? I think so.

In my article at On Common Ground, I discuss the beneficial effects on maternal-infant attachment of two practices: continuous support in labor and skin-to-skin contact between mothers and newborns after birth. I give an example from a randomized controlled trial comparing women who had continuous support from friends or family members trained as “lay doulas” with other women who labored without such support. I also discussed the findings of a Cochrane systematic review of studies of skin-to-skin contact. In both cases, beneficial effects included easier transitions to motherhood and improved maternal-infant attachment.

These are practices we can offer women whether or not they have epidurals, and regardless of how they give birth. More importantly, they improve mother-infant attachment whether or not women have epidurals and regardless of how they give birth.

In the doula study, postpartum effects were profound. Women who had continuous support were more likely to describe their babies as “very easy” and to believe that their babies cried less often than other babies. They were more likely to pick up their babies when they cried and to report that they were able to sense their babies’ needs “very well.” Regarding their own postpartum experience, they were more likely to say that the transition to motherhood had been “very easy” and to report that they had received support from others in the previous week. Women assigned to the doula  group also scored more favorably on measures of self-worth including sense of self as a woman, sense of their bodies’ physical strength, and ability to be a good mother. Do you want to know what did not differ? The rates of epidural use (85% doula group vs. 88% no doula group) and cesarean surgery (19% doula group vs. 18% no doula group).

The systematic review of skin-to-skin contact included mostly studies of vaginal births in women without epidurals, but one study included in the review looked only at women who had scheduled repeat cesareans under spinal anesthesia. This study in fact yielded some of the most impressive differences in maternal-infant attachment behaviors of all of the studies included in the review. Some of the differences in maternal attachment behaviors persisted an entire month after giving birth.

I believe that mothers and babies experience physiological and emotional benefits when the woman has an unmedicated vaginal birth. But in our culture, women are not given a fair shake to achieve unmedicated vaginal births, and are fed messages that they shouldn’t care how they give birth as long as there’s a healthy baby. Even when care is top-notch, some women will still need epidurals or cesareans. Do we really want to tell these women that they might not be able to parent effectively?

The Healthy Birth Practices that Lamaze International has been championing for years allow us to have our cake and eat it too. Taken together as a package of care, they decrease the need for cesarean surgery and pharmacologic pain management. As we have seen in the two examples here (which represent two of the six Healthy Birth Practices), they may also mitigate or even overcome the effects of epidurals and cesareans on maternal-infant attachment. How’s that for a win-win?

We need to find common ground with women when it comes to talking about birth and bonding. Focusing on outcomes, which can result from choices, circumstances, or system effects, dooms us to alienate some women and ultimately fail to reach them with information that matters. Let’s instead advocate for better, safer care in labor – The Healthy Birth Practices – and fight to make sure no woman is denied access.

Research for Advocacy, Science & Sensibility , , , , , ,

  1. July 20th, 2009 at 08:49 | #1

    Great thoughts!

    Even though we don’t need science to tell us that natural birth is better for mother and baby – it’s nice to live in a time when science is starting to support it’s advocators and hopefully it will continue as so many parents today depend on it for guidance.

  2. July 20th, 2009 at 10:50 | #2

    I think that’s a really useful approach. And I think we need to find ways to express to people that doulas aren’t exclusively for supporting unmedicated/low-interventions labors. It seems to me that many women assume a doula’s knowledgeable, empathetic, continuous support would be pointless for them because they anticipate using epidural anesthesia–which, interestingly, means doulas are often understood either as some sort of alternative pain relief or as help for ‘enduring’ scary unmedicated labor. But so much of the point of this kind of support extends across birth choices and has little to do with pain, as you describe here. Compelling stuff.

  3. July 20th, 2009 at 10:55 | #3

    Your comment about “win-win” jumped out at me–in my classes I always make a point of sharing that these care practices are not just about mom and “mom’s birth experience”–what is good for the mother, good for the birth, is good for the baby! It is all connected–a “good birth” IS good for the baby!

    This is one of my “hot” issues–the comments that are raised so often that imply that by not wanting a laundry list of interventions and routines a mother is choosing a “good experience” over a “healthy baby.” I think Lamaze’s 6 Healthy Birth Practices make it abundantly clear that the two go hand in hand!

    Another nice post! Thanks!

    Molly

  4. avatar
    Susan Jaszemski
    July 20th, 2009 at 11:15 | #4

    Thanks for this article. You give a very kind and logical solution to a perceived problem that women experience when they look forward to their birth experience and fear that it will not measure up to the “perfect” birth they have planned in their mind. I have often talked with women who had an unplanned Cesarean or an epidural when they planned to “go natural”, and the disappointment they express in their experience is heartbreaking.
    With Healthy Birth Practices being implemented, I believe a pregnant woman can anticipate labor with confidence that her mothering experience- whatever unique form it takes- will be a positive opportunity for introducing baby to life.

  5. avatar
    JessicaE
    July 21st, 2009 at 06:18 | #5

    So many wonderful thoughts in this post, I agree wholeheartedly with much of what you have said. Thank you!

    However, I take exception to the idea that we should not focus on outcomes. I’d like to challenge Lamaze, in fact, to take outcomes much more seriously. How will we ever know if we are making a difference in birth? To say, “let’s just spread our message, but not look at effectiveness because we don’t want anyone to feel badly” seems incredibly odd, to say the least.

    I teach a natural childbirth class. We talked of course about an empowered, centered birth journey, wherever it leads… That birth is a force of nature, and most of the time it rains and snows and the wind blows within normal ranges, but very occasionally you get a flood, or a hurricane, or a tornado. And if those dramatic forces impact your birth, of course you need to seek the shelter of interventions. But I also teach NORMAL, NATURAL birth. And it works. Less than 15% of my students have c-sections. If they have a vaginal birth, over 90% do so without pain medication. Among those who don’t achieve a natural birth, almost across the board there is some complex medical factor at work, and those women tell me they felt empowered by the decision-making and the process, not guilty or defensive. And these women are very aware of the benefits of natural birth (including to bonding), but they also have tools to make a birth with unexpected interventions as mother- and baby-friendly as possible.

    I would hate to see Lamaze “cop out” by saying that outcomes don’t matter, and we shouldn’t focus on them because the problems are just too big. Outcomes DO matter, and we must take responsibility for creating better ones. We can have a huge influence on choices, circumstances and system effects, and if we’re effectively teaching the six care practices, empowering women with solid information and advocacy tools, we should be seeing results.

    I appreciate the forum for discussion, and hope that teaching with an eye toward outcomes might be a future evolution for Lamaze. I don’t think the organization can truly be a voice for normal, natural birth without that focus.

    Jessica English, LCCE, CD(DONA)

  6. July 21st, 2009 at 13:10 | #6

    JessicaE :

    Among those who don’t achieve a natural birth, almost across the board there is some complex medical factor at work, and those women tell me they felt empowered by the decision-making and the process, not guilty or defensive. And these women are very aware of the benefits of natural birth (including to bonding), but they also have tools to make a birth with unexpected interventions as mother- and baby-friendly as possible.

    Jessica, thanks for your really thoughtful response. My intention was to point out that we are unlikely to effectively reach women if we only talk about the outcomes of care and diminish the processes of care that help produce those outcomes. I think your comment quoted above illustrates exactly what I meant – if women understand the six Healthy Birth Practices and are confident, informed, and empowered to demand these in labor, then if the outcome (needing drugs or surgery) doesn’t match up with what was hoped for, then they can (and often, though not always, do) take some comfort in knowing that they needed those interventions in order to safely give birth. And (the key point I was trying to make) they still reap benefits of those care practices, regardless of outcome. Continuous support is good for reasons other than that it reduces epidurals and operative delivery. Skin-to-skin contact after cesarean can mitigate some of the effect on bonding of surgical birth and the prolonged separation that often accompanies it. Likewise, I believe the other care practices may well enhance maternal and newborn health and wellbeing and promote mother-infant attachment, even when they don’t result in the desired “outcome” – unmedicated vaginal birth.

    With all that said, *of course* we should stay focused on reducing epidural use and cesarean delivery. And part of doing that is being truthful with women about possible effects of epidurals, cesareans (and episiotomies, pitocin, etc. etc. etc.) on the physiology of mother-infant attachment, on breastfeeding, and on postpartum recovery. I intended to argue that we should not make this the sole focus of our work.

  7. avatar
    JessicaE
    July 25th, 2009 at 19:40 | #7

    Amy, thanks for the further clarification. :) Great to see that we are more on the same page than not. Thanks for all you do to support birth!

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