Thursday, June 4, 2009

There's a Fine Line Between Encouragement and Bullying

Good intensions are not enough. The method of delivery determines how information is received. Sometimes, in our quest to promote alternatives to the mainstream like breastfeeding (especially extended breastfeeding or nursing in public) or natural childbirth we can come off so strongly to the person we are trying to help/inform that they are turned off and tune out. That is when the backlash comments like "lactation nazis" and ideas of "us and them" gain momentum. It reinforces the idea that there are only two choices instead of a spectrum: breastfeeding or bottlefeeding, c-section or homebirth, etc.

Every time I hear someone refer to a lactation consultant as a "lactation nazi" I cringe. I cringe for many reasons, not the least of which is the trivialization of "nazi", but mainly because that LC missed the boat with the person they were trying to help. Why did they come off as bullying or so ultra gung-ho that the woman didn't feel supported, but felt attacked? I think part of the problem is that LCs have to deal with the misinformation being spread from all sources, but most notoriously, doctors, and they are angry and so fail to meet the woman where she is and deliver the assistance and information in a way that they can receive it.

On the other hand, you want to make sure that you give enough information in a direct enough fashion that a woman can make a proper choice. You don't want to be wishy-washy and downplay your advice/recommendations to the point that the person doesn't take it seriously, but you can't overplay it, either so that you scare or scold or humiliate the person.

My recent post about planning your "best birth" the first time around got me thinking. Though, I thought I was prepared and making the only choices that I could at the time, I did have other options that might have allowed me to avoid my c-section. As I said in that post, some people tried to tell me, but I didn't listen for a few reasons: my doctors said all the right things and I believed them and I didn't feel like I had any concrete, practical alternatives.

After my c-section, my wiser self started thinking about what they could have said to me that would have possibly changed the outcome? I don't think hysterical anti-c-section rants would have gotten through to me. However, positive experiences with ECV or recommendations of providers who had done breech births who were nearby would have helped. The problem was that they didn't know of alternatives and they wanted to support me. I had a great c-section experience because I was supported. But, I wanted to change the outcomes for others. Maybe that is why my baby#2 was breech so I could experience a successful, easy ECV and spread the word so people would be willing to try it before giving up and scheduling a c-section.

Though I had a good c-section and recovery, I still had some processing to do about it because I felt like I really didn't have a choice. The more I learned about what my choices were and what the risks really were, the more strongly I felt the need to save people from my fate. At a playgroup event, a woman (36 weeks along with her 2nd baby) said she just moved to the area and was going to the OB practice that did my c-section. I immediately launched into a very strong speech about their reputation for being very surgical and their high induction rate (an L&D nurse said it was about 90%, could that possibly be true?) and that she should switch immediately!

"It's not too late to switch,"I said.

I said this to a woman who was new to the area and very near the end of her pregnancy. I said it to with urgency and fear and after I'd done it, I knew I was wrong, that I hadn't helped her and might have hurt her, by scaring her. I didn't have a great alternative to offer, either, because all the practices in that area were very conservative. I was definitely working my own issues out on her and don't think I helped. I never saw her again and don't know what happened or how she took what I said to her, maybe it didn't bother at all, but I do know that is not how I want to communicate. It is not how I would have liked to recieve the message, if I were in her shoes.

Another example is that of a close friend who has several medical problems (migraines and a blood disorder). As soon as she said she was pregnant and was talking about her high risk OB and all the specialists I said,"Your going to have a c-section for sure!"

I wanting to slap myself right after I blurted it out especially because she said,"I hope not." I was able to back track a little with her because it was a longer, continuous phone conversation instead of a chat between chasing toddlers at a playgroup, but again, not how I want to communicate. Then, I sent her a book and some links to resources, which I think was a positive step, but, my initial comment caused me to compensate and leave out some factual information that might have made a difference. I got an e-mail from her after her 39 week visit saying,"I wasn't dilated or effaced at all and the baby is going to be huge so they are scheduling me for an induction The doctor even joked that the baby was just too comfortable in there (how many times have I heard that one leading up to an induction)".

I wanted to scream,"No! Not the "Big Baby Card", don't let them induce you with an unfavorable cervix for that! You'll end up with a c-section!"

But, I didn't. I wrote the e-mail a few times and deleted it a few times. It seemed as if she had made up her mind and was happy with the decision. I wanted to say something, though, so I just wrote,"You know, the sonograms can be wrong, and often are, by a few pounds." I started to go into Bishop's Score, but I deleted that and just sent the one comment.

When she wrote back that they told her,"she was just so huge that it couldn't possibly be wrong in the negative, that the baby might be even bigger", I just left it at that and knew she was going to have a c-section, but did not say so.

She was induced on her due date and..........drumroll........

c-section 8lbs 5 oz baby 10 days after the sonogram

Now, it is important to point out that she is happy with the birth and feels it was the right decision. Even afterwards, I said, gently,"I should have told you about Bishops Score". She said she still thinks it was the right decision. I have to let it go. Even if I had told her, she was not in a place that she would be comfortable going against her doctors' recommendation. I can't say that she was wrong due to her other medical factors and comfort level.

That story was playing out while I was desperately trying to get Eva to go vertex so I could VBAC. I was trying not to impose my desires on my friend. I do wish I would have sent a calm, factual e-mail about Bishop Score and links on "suspected big baby". I don't think it would have changed her mind due to other factors involved in her decision, but it is the way that I want to communicate with people, especially in the areas of lactation and birthing. I want women to have factual information and practical alternatives so that they can make the best decision for themselves and their babies. Not what I think is the best decision, but what they think. I do wish the birthing culture in the US (and many places in the world) were different, but that won't change overnight.

Instead, my goal is to get the word out in a respectful way. I have done that for many people. I am still enthusiastic in talking about breastfeeding, my VBAC, Hypnobabies, etc., but I try to be positive about the alternatives I'd like people to be aware of and consider instead of negative about the conventional options they may choose to take.

Recently, this was put to the test when, after I'd gone half way around the world plus a two hour drive to have a VBAC, a friend chose to have a repeat c-section in a hospital with some policies that were not mother and baby-friendly such as no husband's in the OR for c-section and baby has to stay in the nursery overnight. She said she was not happy with these policies, but didn't want to change doctors, and I strongly (maybe a little too strongly) encouraged her to change providers because the c-section rate is so high in Korea that all the doctors are very experienced. In the end, she decided to stay with her doctor. Her doctor found her an English-speaking helper to take her to the nursery overnight to breastfeed and she negotiated some other things so that she felt more comfortable accepting the hospital policies and staying with her doctor rather than changing.

She was very happy for my VBAC even though she is making a different choice. She just doesn't feel comfortable doing it in a foreign country where it isn't commonly done. She does not have the option of going to her home country for a variety of reasons. She is a very intelligent woman and she has thought things through. She is doing what she is comfortable with and I made sure to tell her that I supported her, because I want her to feel supported, not judged or criticized.

I may not always be successful, but here is how I try to find the balance:

1. Positive enthusiasm, not negative hysteria
2. Present facts and resources so that if people are interested, they can pursue the topic further and make up their own minds.
3. Present practical, alternative solutions (for example, Holland has a great system for birthing, but it is not practical to tell someone who isn't Dutch or is not living there to "go to Holland". Expense-wise most people can't do that. Even for me, when I was in PA and some suggested going to TN to the Farm. It was too far away for me to go by myself with a 2 year old to wait to go into labor. So start with local alternatives, there may be some people in a position to drive 10 hours to another state or fly to another country, but for most, it will just seem unattainable and make them feel even more pressured and trapped into settling for the induction/section their doctor is advocating.
4. Meet people where they are. Some people are more open to learning about natural childbirth and breastfeeding than others who may not be interested at all. You shouldn't give up on talking to someone who is afraid of natural childbirth, you just have to be aware and approach them differently. My own interest in natural childbirth happened accidentally because when I got pregnant, for some reason, I remembered Ricki Lake talking about doulas. This was years and years ago (before BOBB) when I was very far from having my own children. For some reason, it stuck. I hired a doula for my first pregnancy who introduced me to Ina May Gaskin and Birthing from Within which took away my fear of labor. Though, I didn't experience labor with my first, that educational foundation gave me the confidence to pursue VBAC with my second.
5. Finally, remember that these are not your choices. Respect and accept choices that are different from your own.

This is getting really long. i should stop now. Do you have any stories where you blew it by being too forceful with someone? Any stories where something you said made a difference and someone had a completely different (and positive) experience than they otherwise would have had because of something you said? I love it when that happens, especially when you don't realize you've helped at the time.


Blacktating said...

This was a really excellent post. I think I blew it with a mom the other day. She emailed me to ask about breastfeeding advice. She is supplementing the baby with formula but now the baby is refusing the breast. She said she went to see the LC who is encouraging her to continue trying to get the baby to nurse, but told her it's OK if she switches to formula. I didn't think that was the best advice and asked her if the LC had given her concrete tips and advice on HOW to get the baby back to the breast. Did she say anything besides, "Keep trying." I also said that formula is an OK choice, but you've got to be sure you're making an informed decision. If you read up on all of the facts about formula and feel comfortable, then it's a fine choice. But I didn't want her to think it was a benign choice. I think I may have pushed too hard because she never responded again. If there is anything that burns me up it's a mom who has been supplementing for no reason and the formula is the real cause of her breastfeeding problems (in this case nipple confusion and flow preference). I hope that mom is still seeking help from an LC and ends up with a breastfed baby.

Mama Seoul said...

That situation is a tough one because you can see where they are going and sometimes it is hard to tell whether they really want to fix the problem or whether they want permission to quit.

I had a similar situation and I even went to the this woman's house. He was a sleepy baby and snacking constantly. The baby looked good and I could hear swallowing. He pooped while I was there and it was a small amount, but the right color and consistency. I tried to reassure her that he was normal and looked healthy and as long as he was peeing enough and when he pooped it looked normal, he was doing fine.

Problem was, she was not doing fine. It was too much for her. I got the feeling that she wanted permission to quit (not that she needs mine or anybody's permission, but she needed her guilt assuaged).

I gave her some strategies to wake up a sleepy baby and reassurance that it would get better. I shared my difficulties. I gave her information about pumping and cleared up some misconceptions about how milk is made, how to know if you have enough, the size of baby's stomach, how pumping takes practice, suggested she stop the bottle until he was at least 6 weeks old, told her to sleep when baby sleeps, contact info for a lactation consultant and an invitation to contact me if she needed more.

Then, I gave her permission to quit.

I didn't say "formula is equal", I just said,"If you want to make it work, even partially, I suggest you hang in there with exclusive breastfeeding until at least 6 weeks and then pump and bottle feed if you need a break. If you can manage pumping and use forumla on a limited basis (like once a day), it can get you through the rough spots, but you have to be really committed. But the bottomline is that you can only do the best you can do and you have to make the decision you feel is right for you and your child."

She seemed really at the end of her rope and I wanted to give her resources for the best strategy to breastfeeding success and then a few other strategies that might either get her through the rough patch or result in partial breastfeeding instead of giving up completely. I did that because I felt that if I made it an "either/or" she'd feel overwhelmed and quit completely. It was really difficult and I really tried to tread carefully in light of previous screw ups.

Turns out that she hung in for a few months and then gave up for a few days, felt guilty and started again. I know that she made it to at least 6 months. I haven't seen her in awhile so I don;t know the current status, but I think I was successful in that instance.

It is frustrating how early people start supplementing with formula because they are told by family members or doctors that they need to in order to ensure baby is getting enough. Then, breastfeeding relationship is derailed!

My friend had a c-section (for breech) and her breastfeeding was derailed by the "low blood sugar thing" that you went through (read on Motherwear) and then antagonistic in-laws.

Despite the misses, I like to think that we help more than we miss!

Elita said...

I'd also like to think we help more than we miss. Now that you mention it, maybe that mom did email me because she wanted permission to quit. I always assume if someone is emailing me, a breastfeeding blogger, that they want me to encourage them to hang in there. Maybe I should stop assuming that.

bergeson said...

great post~~ this is an issue i think women in particular (because we are generally taught to accommidate and avoid conflict) have in their relationships. They want to keep their friends, not offend them, support them in all their decisions. yet sometimes, we end up acting as release valves, allowing friends a space to vent or cry, without them actually solving their problems (minor ones or biggies like spousal or substance abuse).

so i agree it can be hard to 'push' for what you think is the healthiest of choices (especially if you are somewhat of a relativist or constructivist) without pushing your friend away.

i agree with your ideas about how to approach women in various mindsets about natural childbirth (and any other issue i see as feminist) in a way that doesn't scare or attack them but still clearly asserts what you think is best and facts supporting that.

its still a little funny to me though, because it reminds me of the days when I was raised mormon and the way that they talk about every member being a missionary everyday, heh heh. but now i see that thoughts and opinions can go by many names: religion, lifestyle, philosophy, tradition, culture, politics, but are the same in the way people feel about them and 'preach' them. ^^

Amynf said...

Another excellent post Karen. As a doula, I tread lightly but firmly on some of these topics. I answer questions as honestly as possible with reference to the facts and without too much personal touch because I have to, as a doula. On the inside though, sometimes I WANT to be that pushy, overbearing person and just say "no, no, no! Don't do that or believe that!" There's a necessary balance that has to be kept because most doulas get into this business to help women have better births, one at a time. We don't want to damage the possibility of another woman not using a doula because of something she heard from someone else, or at least that's how I feel anyway. I am not saying that I never blow it but now that I am a doula I am much more aware of the delivery and for me (the very opinionated, type A type;) it is very much a growing experience.

And Bergeson, your little one will be arriving soon, right? How are you?

San said...

This was a very nice post! There was a time when I was freaked out by natural births. But for some reason I do not know, now a days I feel, normal birth is always the best option just becoz it is a natural way. But yet I donot know many things about it. I dont know how people will be able to stop their C, coz atleast in most of the cases, the docs somehow convince that normal will not be possible or normal may lead to complications. Frankly we don know the medical conditions we will be in, and so we wont be in a position to argue or reason with the doc why we need a Normal birth!
When I think of this, I just dont know what my condition will be at the end of my preg, and I really donot know how I can make the doc agree for normal, if in case he insists on C.
We have still not decided whether I will hav my delivery here in Seoul, or in India. I am scared dcs may opt for C in India. And even in normal, tey giv stitches. A friend of mine delivered here in Seoul last month. She was in labour for almost 18 hours and the doc waited till she had normal, and no pain killers. She cudnt bear the pain and she asked for a C. But the doc din agree.
Just dont know how I will cope up!

I read your review abt the prenatal yoga DVD. From your exp, what kinda exercise do you think is better for preg, and to help in achieving normal birth? Should I join some class, or is it oaky to learn it by ourselves at home?

Mama Seoul said...

San, I think those books I recommended will give you a lot more confidence in natural birth.

Also, a REALLY, REALLY recommend Hypnobabies. I did the Homestudy course and you can order it online and it at home as well. There is another women that comments here a lot Bergeson who is doing Hypnobabies. She is due any day now. She has really enjoyed using it during pregnancy and will be able to report how it worked for her in labor very shortly.

There are several Hypnobirthing instructors in Seoul if you prefer an in-person class, but I think Hypnobabies is a better program and costs a lot less. The first Hypnobirthing instructor in Seoul is leaving at the end of June. I am not sure if the others have taught any classes, yet since they just got certified in February, but you can contact Lisa Fincaryk:

Her website also lists contacts for midwives, birth centers and homebirth.

If I am still in Korea for my next pregnancy, I think I would use Dr. Chung:

He is very pro-natural birth.

Using a midwife is much cheaper, but their English isn't quite as good. But I would consider a midwife as well. It just depends on what you feel comfortable with.

Hiring a doula is a good idea as well. Lisa Fincaryk is a doula as is Amy from Doula Momma

They will help you and your husband during labor.

As for exercise, walking, water aerobics, and yoga are all good forms of exercise. I like to take classes in person rather than use DVDs, but because I had Ian, I needed to use DVDs because I didn't have anyone to watch him. If this is your first baby, taking classes in person might be more fun.

I also walked on the treadmill to get exercise. Indoor exercise is great for when the air is bad or it is too hot or too cold outside.

Congratulations on your pregnancy!

San said...

Thank you so much for the info! I guess I will soon buy some books!

Since this is my first pregnancy, I am kinda in the deep deep dark and having starting trouble as to what to do or when to do etc. Midwives etc are new to me and even the classes. But I am slowly trying to understand them.
From when are we supposed to atten these classes? Only after my first scan on 15th June, we hv decided to think over where to hav my delivery, here or Chennai. SO I am kinda in a very vague state. But wherever I am I need to attend these classes and educate myself on VB.

Mama Seoul said...

People usually take classes somewhere between the end of the second trimester and the beginning of the third trimester. Since you are trying to decide which country to have you baby in, taking the classes earlier rather than later might be better for you.

You have plenty of time to decide but it is good that you are starting to investigate your options early!