Thursday, February 21, 2008

Brains and guts

One thing that came up during my first Birth Center prenatal appointment, while going over my general medical history, was that I have a few episodes of depression and/or anxiety in my past. No huge drama, no hospitalization, not even any medication for it, but still it's there. The nurse-midwife cautioned me that women who have such a history are more likely to suffer from post-partum depression than women who haven't had past problems. That doesn't mean I will have PPD, but that I should be alert to the possibility. She said that many women have trouble recognizing the signs because there's so much else going on at the same time - sleep deprivation, the physical recovery from birth, sore breasts from starting to breastfeed, body image issues, the sense of huge new responsibility, and the list goes on. With all that, it's hard to say what's "normal."

I wondered whether that might happen to me - would I be able to tell if I was having problems more than just the usual adjustment period to being a new parent? Thinking about it made me realize that at least for me, mental health is nowhere near as self-evident as physical health. I know at any given time whether I'm in a good or a bad mood, but if it's a bad mood I can't say whether it will go away in an hour, or a day, or whether it might drag on for much longer. I can tell after a specific stressful event that it caused a stress reaction, but if it's the more ongoing, long-term kind of stress, I can't easily say whether it's getting to be too much, or if I'm coping well. I can't tell by "asking myself" whether I'm just having a bad day or a bad week, or if it's something that I need to take steps to fix.

Then I realized that I do have an excellent built-in barometer of my overall mental health: my stomach. I may feel stressed or moody, but if I'm eating normally, that's a good indicator that it's nothing too serious, and will resolve itself soon. When I lose my appetite or feel sick to my stomach and there's no obvious physical cause, it's a probable sign that there's something that I'm having trouble dealing with. In particular, during a few times in my life that were especially stressful, I thought that I had some mysterious stomach ailment; eventually I figured out that I was having panic attacks, but without the stereotypical hyperventilating and heart-pounding.

So for me, as for many people, a "gut reaction" is a not just a metaphor. It's an interesting example of the inseparability of mind and body. I wonder whether this tendency to physically express mental turmoil evolved for some reason - can there be any possible advantage to having physical symptoms of unhappiness? Or is it just a side effect of the fact that the physical brain is part of the body, and that having thoughts and emotions is a chemical process, and is not independent of the rest of the body's workings? It just seems funny that for all its power, the brain isn't very good at identifying and troubleshooting its own problems.

Thursday, February 7, 2008

Unintended consequences (long post)

Two weeks ago, Vlad and I went to a "tour for expectant parents" at Abington Hospital. I suppose such tours are intended to familiarize couples with the layout of the hospital, and reassure them that the hospital is a wonderful place to deliver a baby. I went to the tour assuming that's exactly what I would get out of it.

I was wrong.

Let me go into some background first, then I'll explain.

When I first found out I was pregnant, my general practitioner recommended Abington Hospital, which is one of the largest hospitals in the area. I hadn't been thrilled with my prenatal experience at the UPenn Hospital during my first (brief) pregnancy, so I thought okay, I'll try Abington. The first or second ultrasound showed that I had a low-lying placenta, which can cause problems in delivery. Before I found out about that, I was mulling over the idea of delivering at a birth center instead of a hospital. But with the low-lying placenta issue, I put those ideas on hold and remained at Abington through the first and second trimesters, because a birth center will typically only accept low-risk pregnancies with no complications.

About 6 weeks ago, when I last had an ultrasound, the placenta had moved up and was no longer a concern, and everything else looked fine. I was delighted, and although I didn't get around to it right away, I soon called the Birth Center at Bryn Mawr (a suburb of Philly) hoping to transfer there. They took a week to get back to me, and then it was only to tell me that they were booked for April, and weren't accepting any more patients due then. I sighed and figured that I'd just resign myself to having the baby at the hospital, like a normal person - and anyway, hospitals offer epidurals and most birth centers don't. Who wants to face a painful experience without at least having the option of some heavy-duty pain relief at hand? I wasn't sure I did, even if "birth center" does evoke a much more warm and fuzzy image than "hospital."

So, back to the tour. We arrived early, and I was impressed by the big atrium in the lobby, complete with a fountain - it looked almost more like a large hotel than a hospital. The conference room in which all the new parents gathered was also very sparkly-modern. So far, so good. I was pleased, and looking forward to the tour. But then our tour guide, a perky blonde RN, started to talk. With nearly everything she said, I could feel my stress level ticking higher. EFM, IV's, pitocin, alarms, c-sections, NICU, bathroom privileges (privileges?!). The supposedly "home-like decor" of the labor and delivery room consisted of a few pastel watercolor pictures on the wall, one of which turned out to be a clever hiding place for an array of medical instruments. At one point she mentioned a birth plan, asked how many couples there had one. About a fifth of the audience raised their hands. Vlad whispered to me, "What's a birth plan?" I indicated that I'd explain it later. On our way out, I told him through clenched teeth that a birth plan is a document intended to make a woman feel as if she has some control over what happens once she walks through the hospital doors. Everything I had heard made me feel certain that whoever would be in control, it wouldn't be me. And I didn't like it. At. All.

My own reaction took me by surprise. I've never considered myself anti-hospital, anti-Western medicine, anti-authority, anti-technology, or anything along those lines. When it comes to alternative therapies, I'm interested but skeptical - it drives me crazy to hear people talk about herbal remedies as if they're inherently safe because they're natural. If natural equals safe, go snack on some Atropa belladonna. Likewise, I distrust anyone who says that because birth is natural, it is safe.

So why then did the hospital tour leave me foaming at the mouth and ready to bite anyone in a white coat who'd come near me? I'm not sure, but I think it has to do with having some pre-existing exposure to the idea that the way hospitals approach childbirth is not necessarily ideal for the mother or the baby. Without specifically looking for such information, I had come across various arguments that the fewer interventions, the better, unless a specific situation required otherwise.

I learned when we did the hospital tour that my opinions and feelings are a lot stronger than I thought. I knew I wanted a minimum of medical intervention, but I didn't fully realize that if I went to the hospital, I would immediately have an IV stuck in my arm, and an electronic fetal monitoring device strapped to my belly - that these weren't merely available options, but pretty much mandatory. I hadn't thought about the fact that if I am sick or injured, I'm fine with handing over control to the medical establishment, but birth is not an illness, and shouldn't automatically be treated as such. At the same time, I'm aware that the birth process doesn't always go smoothly or safely, so I don't want to be too far away from all that fancy medical technology should it be needed.

So I started looking into other options in our area, and found the Wilmington Birth Center. They will provide the happy medium that I'm looking for - the freedom to move around as much or as little as I want, to eat and drink if I feel like it, to give birth in whatever position feels the most comfortable. The freedom to wear my own clothes and not a hospital gown, to go to the bathroom when I damn well feel like it, to have a calm environment free of the hospital's hurry and noise. And importantly, the support of a certified nurse midwife who can reassure me that everything is going well, and knows what to do if it isn't. They have arrangements with St. Francis Hospital (just a block away) and Christiana Hospital so that if necessary, they can quickly transfer a patient.

One of my worries was that perhaps birth centers aren't as safe as hospitals - they are, after all, less equipped to handle emergencies on the spot. I thought about various scenarios, mulled it over. Then I realized I don't have to rely on intuition and guessing - I have access to all sorts of primary medical literature, so I looked up some numbers.

A 1989 study of birth center outcomes for 11,814 women, published in the New England Journal of Medicine, found that there were no maternal deaths, and a neonatal mortality rate of 1.3 per 1000 - which is less than the overall rate of around 4.5/1000 as of 2003. Cesareans were 4.4%, compared with a recent national statistic of almost 25%. Another study in Australia with data from 1999-2002 had very similar perinatal mortality numbers, and a few smaller studies also found that birth centers are quite safe.

Just to confirm what I was already fairly sure of - that I'd be happier and just as safe at a birth center - I asked some questions of my ob/gyn at Abington at my appointment last Thursday. Found out that yes, I would be hooked up to an IV as soon as I was admitted, and not allowed to eat. Next, I asked about electronic fetal monitoring - that too would be required as soon as I was admitted, and I was surprised by what the ob/gyn said next. "Bad things happen to unmonitored babies, we've seen bad things happen. Not long ago we had a woman who didn't want monitoring, so we basically sent her to a birth center instead because we're not comfortable with that." Wow. Scary-sounding, yes?

As far as my research has been able to uncover, her statement does not hold up. Electronic fetal monitoring hasn't been shown to improve outcomes for the baby, especially in low-risk births, but it does increase the likelihood of a c-section. I couldn't find a single study that showed any real advantage to it. Even the American College of Obstetricians and Gynecologists, a rather conservative organization, states that intermittent monitoring by handheld Doppler or electronic fetal monitoring can be used, and they do not recommend one over the other. So was the obstetrician lying to me? Or was she misinformed? Either way, it further reinforced my feeling that Abington wasn't right for me.

I had my first visit to the Wilmington Birth Center yesterday, and what a difference! In the waiting room, there's a large bookshelf full of books about pregnancy, birth, childcare, and women's health - you can borrow books by signing them out. Any place that has its own lending library has already made a big leap towards earning my respect, bookworm that I am. The nurse-midwife who examined me took plenty of time to explain how the birth center does things, and to ask and answer questions, whereas at Abington I always felt like the doctor had one foot out the door already when they asked if I had any questions. And she sent me home with a hefty binder full of information about pregnancy, labor and birth, and postpartum care of mom and baby. Now, much of this information I had already found on my own - but definitely not from my doctors!

Several people, upon hearing that I plan to give birth without an epidural, have expressed sentiments that I'm either really brave, or crazy, or some combination. Crazy I may be, but brave has nothing to do with it. It's simply that I'm more afraid of the hospital than of birth pains.

If you've read this far, you probably have at least a little bit of interest in the subject of childbirth. If that's because you (or someone you're close to) might have a baby at some point in the near future, don't be like me and wait until trimester 3 to think seriously about this stuff! Early on, maybe even before conceiving, find out the options available to you, and decide for yourself rather than letting the path of least resistance decide for you.