HAVING A BABY ISN'T LIKE FIXING A GLITCH IN A COMPUTER program or refining a piece of legislation. But don't tell that to some Washington women.
"Women in Washington are very savvy, professional women. They want control," says Toni Ardabell of the Women's Center at Inova Fairfax Hospital, which handles the most births in the area–11,000 a year.
Washington women can sometimes treat pregnancy like another project at work: They read, research, ask questions, find experts, search the Internet, form e-mail list groups. They visit doctors' offices armed with studies that haven't yet been released to the public.
There's nothing wrong with being informed. But the challenge for many is "giving yourself permission to let things happen as they're going to happen," says Debby Engler, a nurse at Spring Valley ob-gyn–the practice I use–and a childbirth educator at Sibley Memorial Hospital.
It's not just expectant moms who may try to control every aspect of pregnancy. Washington isn't an environment that encourages laid-back mothers. A pregnant belly is a magnet for unsolicited advice. In another town, you might be regaled with old wives' tales; here, the odds are good that your "advisers" have ammunition from three newspapers and a couple of professional journals.
Some women know exactly when they're going to have the baby, because they're delivering by scheduled cesarean. Tell some people that, and you're in for a discussion on the insurance industry, the physiological benefits of a vaginal delivery, and the erosion of women's rights in medicine.
"I got a lot of questions," says Christie Billingsley, who lives in Logan Circle and works for a public health project, about her planned C-section. "People assume you hadn't thought it through. It got arduous to explain."
Ten years before the birth, she had surgery for a brain aneurysm. She recovered, has even run a marathon, but the pushing during labor could have been dangerous. A possibly obstructive fibroid tipped the balance toward C-section. Once people heard her reasons, she says, the interrogation would stop.
First Step: Finding a Doctor
Some women who give birth to a healthy baby can nonetheless feel as though those attending them didn't respect them or acknowledge their wishes. They can end up feeling that they somehow weren't "successful."
"I think how women feel about themselves as a mother begins during pregnancy and peaks during labor," Engler says. It can set an imprint as the first set of a lifetime of decisions and battles and compromises you'll have regarding that child.
Having caregivers you can talk to is an important first step.
Before I had my baby, I'd picked a doctor in Capitol Hill. Then I moved, which added about a half hour to the trip. After a visit to the doctor's office while a mere month pregnant, I knew I couldn't do it again. Driving, parking, getting through the door–all can be deal-breakers, no matter how much you like the doctor, when your ankles are swollen to the size of tree trunks.
The next thing to consider is whether you want a solo practitioner, a group practice, a large hospital-based group practice, or a midwife or birthing center. Each of these makes for a very different pregnancy experience. (For a list of the best obstetricians in Washington, see the Top Doctors list on www.washingtonian.com.)
I ended up with Dr. Malcolm DeSouza at Spring Valley, a solo practice recommended by my sister-in-law. The doctor is available only on Mondays, Wednesdays, and Fridays, but I didn't have any trouble getting through on the phone other times.
One day I was sent downstairs to the Foxhall Ob/Gyn Associates, a midsize group practice, to "borrow" a can of glucola, the super-sweet drink used in the test for gestational diabetes. The place was packed, the waiting room was buzzing–and as attractive–as a hotel lobby. It made me glad I'd chosen a solo practice, but women who use group practices such as Foxhall say they like that there's always a doctor available.
Large hospital practices have access to cutting-edge technology and neonatal care, which can be important in high-risk pregnancies. They can also be more convenient, with more appointment hours. Giving birth at a teaching hospital can mean a parade of residents coming in and out. At George Washington University Hospital, a woman can request not to have residents at her delivery.
Another Option: Midwives
A birthing center provides a completely different experience.
In obstetrics, the dividing line is the epidural, an anesthetic injected in the spine that works from the waist down. Fans say it lets them be mentally present for the delivery without being driven crazy by pain; detractors say the lack of feeling makes delivery more difficult and can lead to a C-section. Nearly everyone giving birth at a hospital has one; birthing centers and home births don't give them.
Seinfeld fans might remember the episode where Elaine was blackballed by doctors after looking at her medical chart. At a birthing center, you not only carry your own chart around, but you can weigh yourself and record it on your chart. This emphasis on full participation and avoiding interventions continues through delivery. You usually work with a certified nurse-midwife.
"When we started in 1975, we had a more granola bunch," says Barbara Vaughey, director of the Maternity Center in Bethesda. "But we have always had a very well-read clientele, older, who have researched the options. They want to be involved in decision-making. We've had people bring their acupuncturist, their massage therapist–whatever works for you."
Larissa Guran, now manager of perinatal programs at Holy Cross Hospital, had her first child at the Maternity Center. Between contractions she dozed, snacked, took a walk around the track at Walter Johnson High School next door, took showers, tried out the jet tub, and pretty much did as she pleased. Such activities are rarely encouraged at hospitals. The aftermath is different, as well–women keep their babies with them, not at a nursery.
If complications arise at a birthing center, you'll be sent to an affiliated hospital. Affiliation does not always mean agreement.
"The nurses didn't respect the midwives. It made for a pretty tense room," says Kathleen Murray of Takoma Park, who started out at the Bethesda center but had to be moved to Shady Grove Adventist. She saw nurses "rolling their eyes" as she worked with the midwife and asked questions about her care.
The Maternity Center offers free classes and seminars, so expectant parents can get a look at what makes a birthing center different. It's at 6506 Bells Mills Road; 301-530-3300; www.maternitycenter.com.
Some physicians integrate midwives into their practice. The Physician and Midwife Collaborative Practice in Alexandria (4660 Kenmore Ave., 703-370-4300, and two other locations) says it combines "high tech" and "high touch," with patients cared for by both doctor and midwife. There is also a midwifery service affiliated with Providence Hospital in Northeast Washington and with Georgetown University Hospital. Many insurance companies will reimburse for midwives and birthing-center charges, but the process might not be as streamlined as in a hospital birth.
To find other collaborative practices or a midwife, visit the American College of Nurse-Midwives (202-728-9860 or www.midwife.org; click "Find a Midwife" and choose "Select by State").
In Virginia, BirthCare & Women's Health in Alexandria (1501 King St.; 703-549-5070) provides care from certified nurse-midwives for home births as well as at its birthing center. They're licensed in all three jurisdictions and can serve clients within a 45-mile radius of Alexandria. In this area, only certified nurse-midwives are permitted to attend home births, and insurance worries mean few take the risk.
For more help selecting an ob-gyn or midwife, the Maternity Center Association, a national organization (not affiliated with the Bethesda center), provides lists of questions to ask doctors and midwives. See www.maternitywise.org.
Nursing You Through Ups and Downs
I found out I had the right doctor the hard way: I had a miscarriage.
I had been sent for several sonograms during the first three months because I had previously had an ectopic pregnancy, one where the egg is stuck in the fallopian tube. It looked like the egg had implanted well this time, but technicians couldn't find a heartbeat. It might be too early or it might be a miscarriage; all we could do was wait.
This is when I found out that the nurses in a practice are even more important than the doctors or midwives. They're the ones you see every visit, they're the ones answering your questions, and later, in the hospital, they can make it easier to bond with your baby and get your strength back.
I had just finished editing an article about listeriosis, a food-borne illness that can cause miscarriage, and I was spotting and terrified. Debby Engler sat across from me and listened with compassion as I babbled about cleaning cutting boards and whether it was safe to eat raw vegetables.
As hope faded, both doctor and nurse helped me face the end of the pregnancy; we decided to let my body expel the fetus naturally. When I talked to other women who had endured hospital visits or surgery and didn't know that they might have been able to let things happen naturally, I was glad I hadn't had to make a tough situation worse.
Washington Women: Pregnant and Older
Eight months after my miscarriage, I noticed that my pants weren't fitting right. I was pregnant again, and happy.
Despite my age, 38, and my history, I was never considered at risk during my pregnancy. The idea that just being older than 35 is a risk factor is starting to fade as women's general health has improved. Although older eggs can present greater birth-defect risks, it's the chronic conditions that can go along with age–obesity, diabetes, hypertension–that often present problems.
Doctors say Washington mothers tend to be older, and a Virginia Department of Health study shows those in Northern Virginia are older than elsewhere in the state. "Seeing a 22-year-old just out of college and having her baby is kind of unusual" in this area, says Candice Sullivan, education coordinator for women's services at Inova Health System.
My only concession to my age: I chose a hospital birth rather than a birthing center. I wanted everything available that modern medicine could offer, just in case.
For those with serious risk factors, Washington is an excellent place to be: Perinatologists, who specialize in high-risk pregnancies, abound; neonatal intensive-care units (NICUs) at hospitals including Georgetown, George Washington, and Children's National Medical Center are internationally known. Inova Fairfax has 30 high-risk pregnancy beds and a 67-bed NICU. Holy Cross Hospital, which delivers 7,200 babies a year, the most of any Maryland hospital, is expanding to offer a larger NICU and high-risk center.
Gene Testing? You're in the Right Place
As the home of genetic biotech research, the Washington area has excellent genetic counseling.
Because of my age, I chose to get amniocentesis, a procedure in which some amniotic fluid is removed and tested for genetic defects. My doctor referred me to the Wilson Genetic Center at George Washington University; the amnio was done by Dr. John Larsen, head of the OB unit at the hospital.
An alternative would have been chorionic villus sampling, which can be done earlier in the pregnancy; my doctor felt the long experience of those performing the amnio outweighed the advantages of CVS, a newer procedure. Both procedures carry a miscarriage risk, but the skill of the person performing the test affects that risk.
Some women opt for a simple maternal blood test, often called the triple-screen. This is effective, but not as thorough as a full genetic test, and sometimes results in false positives, so a woman ends up getting an amnio anyway for confirmation.
A screen positive–out of 100 women who show possible genetic problems on the blood test, only two or three actually have a baby with any disorder–can be the most upsetting event in a pregnancy.
We had a scare for about a week after the results came back. There was no evidence of Down syndrome or neural-tube defects, but the geneticists had seen a mutation. The next step was to test my blood and my husband's for the same mutation. If it showed up there, the assumption would be that the mutation was harmless. It turned out fine.
Ultrasound is another prenatal testing tool, usually done at a hospital in the fifth month. Some doctors have machines in their offices, and while these might not provide the detailed pictures usually taken at a hospital, you can get a peek.
Commercial centers offering 3-D ultrasounds, which can give a detailed picture of a baby's face, are still too expensive for general use. Doctors have mixed opinions on their value, calling them "entertainment ultrasounds" and saying they're mostly good for making pricey baby-book pictures. A two-dimensional ultrasound with a skilled reader remains more useful in finding potential health problems, doctors say.
Next Milestone: Childbirth Classes
Childbirth classes put the fear of pain right in front of you, impossible to ignore. Most women and their partners begin classes 24 to 28 weeks into the pregnancy.
Hospital-run classes run the gamut from a simple tour of facilities to seminars on breastfeeding and childcare, with some offering special tours for grandparents and big brothers- and sisters-to-be.
Among hospitals, GW offers a wide array of classes–for example, there's a special series on natural childbirth and a class on pregnancy massage. The advantage to taking hospital classes is that you can get familiar not only with the hospital policies but with its nurses as well.
Touring parents ooh and ahh over such amenities as hardwood floors and private whirlpool baths and test the comfort of bedside chairs. At area hospitals, labor and delivery rooms can resemble upscale hotel rooms, complete with cable TV and CD players. Birthing centers provide a similarly elegant, yet more homey, atmosphere–the Victorian and Charleston rooms at Bethesda's Maternity Center are popular.
The tours are a good chance to ask questions, such as about a hospital's policies on private rooms and how rooms are assigned. Hospital classes dwell less on breathing techniques than on simply letting parents know what is going to happen.
"Everyone worries about getting to the hospital in time," Engler says. "I tell them that with a first baby, you could drive around the Beltway four or five times, in rush hour, and still get there on time."
One thing stressed by caregivers: Mothers of infants should find a good support group. Hospitals offer these as well.
Just Say No?
Those who would like to give birth without drugs often take classes with Lamaze (800-368-4404 or www.lamaze.org) or the Bradley Method of Natural Childbirth (800-4-A-BIRTH; www.bradleybirth.com). Their Web sites can direct you to local classes.
"Lamaze has become a generic name, like Kleenex," says Lamaze president Barbara Hotelling. "There are other classes and certifications that call themselves Lamaze but aren't really Lamaze." A Lamaze class should have a certified teacher and a small student-to-teacher ratio and be interactive rather than a lecture.
And there is more to the classes than huffing and puffing, she says.
Lamaze classes include breathing and relaxation techniques as well as a thorough explanation of labor and delivery. Bradley takes this approach even further, focusing more strongly on active participation of the father-to-be as coach.
A recent study at the University of Florida at Gainesville found that hypnosis could reduce pain and the need for anesthesia or surgery in childbirth. The reason it worked, researchers say: It "gives women a sense of control."
Women interested in using hypnotherapy as a relaxation and pain-management technique, usually in conjunction with natural childbirth, can find more information through the HypnoBirthing Institute at 623-772-7738 or www.hypnobirthing.com.
For another useful directory for local birthing classes–including underwater birth–see www.our-kids.com/classes_for_parents.htm.
Monitoring My Every Move
Many Washington women aren't used to asking for help, but women often need support around childbirth.
"Women are taught to be self-sufficient, that that's how to succeed," says Engler. "They feel, 'I've done it on my own so far, I can do this on my own as well.' I think DC women are overwhelmed with new motherhood. It's like it's a crime to ask for help."
When a new mother's family lives far away, having family members come to help can actually be stressful–if they all come at once. When they leave, the void can be devastating.
Women originally from other countries are less reluctant to call in support. One reason Holy Cross is expanding to offer all private rooms is to accommodate these extended families.
My parents came in from Northern California more than a week before my due date. The due date came and went as we sweated out three midsummer weeks.
Three times, we packed up and shuffled off to the hospital, thinking I was in labor, and three times we got sent home. My doctor suggested the following Monday for induction, and I agreed.
That Saturday evening, I was having pretty regular pains, about five minutes apart. Still, I'd be darned if I'd go back to the hospital just to be sent home.
My husband went to sleep. I remembered advice from childbirth class: Don't go to the hospital until you absolutely have to. I took showers until the hot water ran out, then leaned on the walls, knelt by the bed, paced, and took more showers.
I made it until 8 the next morning and wish I'd waited longer. I wasn't afraid of pain; I have migraines and still contend that they're worse than labor. What gets me panicked is being confined, stuck in one spot–and I knew that was what was waiting for me as soon as I got to the hospital: the fetal monitor.
The Final Push: Natural or Not?
An external fetal monitor is like a big belt pulled around your middle. It keeps track of the baby's heartbeat and the mother's contractions. (A high-risk pregnancy is likely to get a more invasive internal monitor.) But to get an accurate reading, you have to hold still. That is the last thing a woman in labor wants to do. Every childbirth class tells you to keep moving to control the pain and to keep labor progressing.
The ability to keep tabs on a baby's heart rate, a crucial indicator of distress, is hard for doctors, nurses, and mothers to pass up. Caregivers say that you'll still be able to move with a monitor on. But mothers tell stories of nurses snarling and tsking if the woman moves and the monitor shifts.
Interventions, defined as anything aside from the natural birth process, tend to be higher in urban areas, where "there are a lot of doctors and lawyers," says Lamaze president Hotelling.
Natural-childbirth advocates say caregivers can get results through occasional monitoring with stethoscopes or Doppler.
Some hope that despite its usefulness, electronic fetal monitoring might go the way of the prep shave and the enema, two practices that used to be routine but are now rarely used.
The Maternity Center Association's groundbreaking "Listening to Mothers" survey last year also pointed to a reality that surprises many women: There's a good chance your doctor won't deliver your baby.
Nineteen percent reported they didn't meet the person who delivered their baby until they were in labor.
You and your doctor may have talked about interventions you do and don't want; the problem is that another doctor doesn't have that insight. (The doctor on call when I went into labor used enemas; my doctor arrived in the nick of time.) After fetal monitoring, the next most common interventions reported in the survey–occurring in more than half of the women–were IVs, used for antibiotics, anesthesia, or fluids; intentional rupturing of the membrane; and being given oxytocin, a synthetic version of a hormone that speeds up contractions. Although episiotomies, the painful cutting of the perineum in an attempt to make more room for the baby, occurred in more than half the women, they're being used less often.
After nearly a day's labor–literally 9 to 4, with no break for lunch–I was given oxytocin to try to move things along. But I was still dilated one centimeter less than needed to deliver safely.
The impression women might get from the natural-childbirth side is that all interventions, no matter how minor, are on the slippery slope toward a C-section. A C-section is surgery and carries surgery's risks. Those on the other side say vaginal delivery can cause problems, such as incontinence, that are avoided with a C-section. Recent studies are just as ambiguous, coming down on both sides. A C-section can make a later vaginal birth more risky, but some mothers and caretakers chance it.
The national C-section rate is about 24 percent. Your caretaker should willingly share his or her C-section rate, but remember that a high rate could reflect a provider's specialization in high-risk pregnancies. Conversely, a birthing center's low rate can be a result of its turning away risky pregnancies.
The phenomenon dubbed by tabloids as "too posh to push," in which well-off women get elective C-sections to minimize interference with their lives, is a media myth, caregivers say. Even Victoria Beckham (a.k.a. Posh Spice), for whom the term arose, reportedly had a C-section under a doctor's advice. Most doctors and most women in this area demand compelling medical reasons for a C-section.
Everyone on all sides agrees that ultimately, the only thing that matters is a healthy mother and a healthy baby. As one mother says her doctor warned her, "You realize that if something goes wrong, you don't get any choices."
My daughter, Sydney Mayfield Pollack, arrived by cesarean section 5:26 PM August 12, 2001, perfectly formed and already babbling. She weighed ten pounds, six ounces.
