I haven't forgotten that I have a blog. I met a new coworker yesterday, and when she introduced herself with ". . . and I'm a knitter," I heard myself say ". . . and I'm a writer!" So time to get to it. I've been away on vacation, taking my toddler to visit family in Alaska. This is a trip that, a year ago, I would have dismissed as impossible. My husband and I couldn't both manage the time away from work, and a thousand miles of air travel with an almost-2-year old seemed beyond my solo parenting capacity. But as my son has grown from a baby to a toddler, I've grown too. And part of my growth includes a determination to avoid the phrase "I can't" whenever possible. (Not that I'll do anything -- I still reserve my right to the phrase "I won't.") So with his second birthday (and the mandatory full-price airfare that goes with it) looming large, I decided we would go.
But realizing that "I can" fly my son to Alaska didn't solve my anxiety of "HOW on Earth can I?" How could I manage taking his little shoes off when we go through FAA security? How will I know whether to pack new books and toys, or comforting old ones? What if he refuses to eat? Or sleep? How can I be sure he doesn't get lost, or hurt? What if he screams, and screams, and doesn't stop? These kind of fears startled me awake, in the nights leading up to our trip, with my anxiety screaming in my head: "How will I do it?" And at some point, I unbelievably got an answer -- from my intuition, from the depths of my soul, from the universe or God Itself I don't know. And the answer is, "With love, and without fear."
Which wasn't exactly what I was looking for. I had hoped the universe would give me more specific directions. Maybe along the lines of "you will take the second elevator down to the L-2 gate, and then feed him goldfish crackers until he falls asleep." But instead, I got a rough outline that reminded me how I will cope: I will mother my son with love. I will not let fear overwhelm me. When things get difficult, I will rely on my love to calm me and guide my decisions.
So off I went. My newfound conviction found me hauling 30 bundled pounds of little boy up the steep stairs to a little 12-seat prop plane, too small inside for anyone to stand upright but him. And so (after our long trip from Seattle and a longer turmoil of baggage, security and lost stroller issues), we finally took off from Anchorage, across the Kenai wilderness, over the glaciers to chilly-yet-cozy little Homer, Alaska. And the whole trip turned out fine -- to keep my son calm, I found myself affecting a calm attitude even when I didn't feel it. And my "message," or whatever it was, was right. I did it all With Love and Without Fear. It wasn't easy, but we managed. Even bedtimes away from home (which I was dreading without husbandly assistance) went smoothly, with the substantial assistance of my loving and fearless sister who enjoyed the moments of snuggling her sleepy nephew while I enjoyed emptying and loading her dishwasher. With Love, and Without Fear.
And now I'm noticing all the ways this applies to parenting. How will I cope if my son screams and hits when I'm running late to work and straining to buckle him in the carseat? With love, and without fear. How could I ever manage another pregnancy and childbirth? With love, and without fear. How will we get him to sleep tonight? And the next night, and the next? Same answer.
I have a lot more mom-thoughts I'm trying to get down this week: one mess of ideas about "tantrums" and one about "praise." But today I'll stick with the theme: That with my son facing down the Tender, Terrific Twos, I've found tremendous strength in believing that "with love, all things are possible." And that this is ultimately enough -- no matter how much I might personally prefer "all things are easy." In my more difficult moments, I'll try to remember pressing my cheek against my son's silky blond head as we watched out the window of our little plane -- over the trees, I told him, over the mountains and above the clouds -- each of us amazed, for our own reasons, that we really can fly.
Books:
Your Two Year Old
Easy to Love, Difficult to Discipline
Unconditional Parenting
Websites:
Dr. Sears on Why Toddlers are Difficult
Crystal Lutton on Tantrums
Get off Your Butt Parenting
Tuesday, October 31, 2006
Wednesday, October 11, 2006
Evidence instead of Evidence
The Washington Port is reporting concerns about the use of magnesium sulfate in preventing early labor. This fascinates me for a few reasons. I was briefly monitored for possible "early labor" at 34 weeks gestation (my baby would have been born 7 weeks early). I thankfully avoided magnesium, (but got a shot of terbutaline, which is a story for a different day). At it happened, I didn't go into labor early -- in fact not until 10 past my "due date" (41 weeks 3 days, which I'm now learning is exactly average). But I ended up finding magnesium sulfate anyway, when I was diagnosed with mild pre-eclampsia.
The Post article doesn't challenge magnesium’s use to prevent seizures. But no matter why it's used, the drug's side effects still "range from highly unpleasant to lethal." I guess this doesn’t surprise me, even though no one told me this before they started pumping the Epsom Salts into my veins. I’m sure I had signed some intake paperwork that waived my right to be informed of drug dangers when something critical like a seizure (maybe, possibly, until we get your bloodwork back) might be on the line.
I can vouch that an IV of magnesium, even without a severe complication like "life-threatening pulmonary edema, in which the lungs fill with fluid," is no walk in the park. Reading the article brought it all back to me: nausea, blurred vision, headache, profound lethargy, [and] burning sensation[s]. They don't mention the mad craving for ice cream (especially acute after going without food and water for 20 hours), which can be tolerated only by playing slightly delirious games where you demand that everyone in the room help you name all 31 Flavors of Baskin Robbins Ice cream (I still can’t believe we couldn’t do it – but then we were all pretty tired).
The Post article is noteworthy for another reason: it quotes obstetricians blatantly admitting what I'm always suspcicious about -- that they are more concerned with malpractice liability than patient safety. As Dr. Michael Gallagher, a specialist in maternal-fetal medicine, or high-risk pregnancy, puts it:
It makes me wonder what Dr. Gallagher would do if all the other obstetricians jumped off the Brooklyn Bridge. Would he follow them? (Maybe if they threatened to raise his insurance premiums?) Or is this beside the point – since it’s the mothers and children, in this metaphor, being asked to line up and jump.
On the other hand, maybe all the doctors are desperate for some sensible freedom from the viscious cycle of standards and liability. It reminds me of Cass Sunstein's hockey helmet theory -- hockey players always knew they'd be safer with helmets, and wouldn't have minded wearing them. But no one wanted to be the first person to be different, so they didn't wear helmets until it became mandatory. According to Sunstein, there's no bright line between what's "rationa" (ie, evidence based medicine) and the "social norms" (how you'll be judged -- literally -- compared to all the other obstectricians). In fact, peer pressure can influence our beliefs until the "norms" become intertwined with our deepest levels of thought. It's easy to imagine this happening in medical education, where new doctors learn not just from research but from the practice, anecdotes and experience of other doctors -- even when this becomes distorted (perhaps through single a dramatic example, like a fetal death) from what what evidence-based medicine would tell us.
Things become even more distorted when we bring "patients’ wishes" into the discussion. Patients know nothing about magnesium – or any medical intervention – until their doctors tell them. And patients facing preterm labor surely pressure their providers to do whatever they can to help. But perhaps this is just another symptom of our inflated faith in what medical technology should do for us. Who’s to blame for that?
As far as the Post article goes, I did find myself touched to read that another OB/Gyn, Gary Cunningham of University of Texas Southwestern Medical Center, had the empathy to once take magnesium sulfate himself to see what it was like. "It was scary," he said. "You feel like you're burning up."
Yep, scary. A burning arm where the IV enters. Double vision, flu-like symptoms, sweating, chills and vomiting. Enough to scare a healthy, symptomless man in controlled research conditions – even scarier for a woman in labor who is fearing a premature birth. And scariest of all -- it probably doesn't help her.
Lonely places.
The Post article doesn't challenge magnesium’s use to prevent seizures. But no matter why it's used, the drug's side effects still "range from highly unpleasant to lethal." I guess this doesn’t surprise me, even though no one told me this before they started pumping the Epsom Salts into my veins. I’m sure I had signed some intake paperwork that waived my right to be informed of drug dangers when something critical like a seizure (maybe, possibly, until we get your bloodwork back) might be on the line.
I can vouch that an IV of magnesium, even without a severe complication like "life-threatening pulmonary edema, in which the lungs fill with fluid," is no walk in the park. Reading the article brought it all back to me: nausea, blurred vision, headache, profound lethargy, [and] burning sensation[s]. They don't mention the mad craving for ice cream (especially acute after going without food and water for 20 hours), which can be tolerated only by playing slightly delirious games where you demand that everyone in the room help you name all 31 Flavors of Baskin Robbins Ice cream (I still can’t believe we couldn’t do it – but then we were all pretty tired).
The Post article is noteworthy for another reason: it quotes obstetricians blatantly admitting what I'm always suspcicious about -- that they are more concerned with malpractice liability than patient safety. As Dr. Michael Gallagher, a specialist in maternal-fetal medicine, or high-risk pregnancy, puts it:
. . . jettisoning a long-standing practice [magnesium for preterm labor] in obstetrics involves factors other than evidence, some doctors say. They note that the standard of care -- a benchmark of evidence in malpractice cases -- as well as patients' wishes and the desire to prevent a bad outcome such as premature birth -- all contribute to continued use of the drug . . . "Suppose we don't use it [to stop pre-term labor] and a patient delivers [early and the baby dies]," Gallagher said, noting that might violate the prevailing standard among OB-GYNs. "You find yourself in lonely places."Oh, those lonely places. So even when the hard, scientific evidence casts doubt on a drug’s safety and effectiveness, the "standard of care" still won't change because each doctor is afraid to stand out from the crowd. They're more concerned with the potential "evidence" that might be brought against them in a malpractice lawsuit -- the testimony of trial experts who tell a jury what "all the other doctors do." They are safe from liability as long as they act consistently with each other -- as long as they all do the same thing -- regardless of whether it protects patients.
It makes me wonder what Dr. Gallagher would do if all the other obstetricians jumped off the Brooklyn Bridge. Would he follow them? (Maybe if they threatened to raise his insurance premiums?) Or is this beside the point – since it’s the mothers and children, in this metaphor, being asked to line up and jump.
On the other hand, maybe all the doctors are desperate for some sensible freedom from the viscious cycle of standards and liability. It reminds me of Cass Sunstein's hockey helmet theory -- hockey players always knew they'd be safer with helmets, and wouldn't have minded wearing them. But no one wanted to be the first person to be different, so they didn't wear helmets until it became mandatory. According to Sunstein, there's no bright line between what's "rationa" (ie, evidence based medicine) and the "social norms" (how you'll be judged -- literally -- compared to all the other obstectricians). In fact, peer pressure can influence our beliefs until the "norms" become intertwined with our deepest levels of thought. It's easy to imagine this happening in medical education, where new doctors learn not just from research but from the practice, anecdotes and experience of other doctors -- even when this becomes distorted (perhaps through single a dramatic example, like a fetal death) from what what evidence-based medicine would tell us.
Things become even more distorted when we bring "patients’ wishes" into the discussion. Patients know nothing about magnesium – or any medical intervention – until their doctors tell them. And patients facing preterm labor surely pressure their providers to do whatever they can to help. But perhaps this is just another symptom of our inflated faith in what medical technology should do for us. Who’s to blame for that?
As far as the Post article goes, I did find myself touched to read that another OB/Gyn, Gary Cunningham of University of Texas Southwestern Medical Center, had the empathy to once take magnesium sulfate himself to see what it was like. "It was scary," he said. "You feel like you're burning up."
Yep, scary. A burning arm where the IV enters. Double vision, flu-like symptoms, sweating, chills and vomiting. Enough to scare a healthy, symptomless man in controlled research conditions – even scarier for a woman in labor who is fearing a premature birth. And scariest of all -- it probably doesn't help her.
Lonely places.
Tuesday, October 10, 2006
Simplify a Change of Season
For some reason I was charmed to read yesterday that more parents are becoming open to large families. I grew up in a family of 6, but have never had any particular conviction about the "right" family size. In fact, I'm pretty noncommital about the whole thing -- especially when it comes to deciding when to have more children of my own. For some reason, I find it reassuring to read of contemporary, urban professionals expecting another child (their sixth) with a warm "why not?"
A family larger than four (mom, dad, two kids) is virtually unheard of in my circles. All the lawyers I know have a pair of children, almost as if they order a stair-stepped "Zach and Molly" set from the American Girl catalog. Families with three or more kids seem to have suffered some unexpected accident (an older lawyer, whose second pregnancy led to twin daughters, told me that women lawyers tend to have more twins "because we're OLD.") Obviously, busy city people like us have limited time, money and real estate -- as well as goals for career, travel and personal achievement to pursue when our children are grown. But the logistical considerations aren't enough to describe the small-family epidemic among professionals. It makes me wonder what we've convinced ourselves of, and what we might be missing.
Why not have children? It’s such a refreshing question. My parents had four children because they didn't want five. Yet I've always had to ask myself all the hard questions: Why have children? How many? When? I understand all too well the burdens of adding more people to the family. And it's our responsibility to decide to have children (right?) Yet no matter how I put my mind to it, my intellectual and intuitive capacities have failed to guide me.
How do I know I'm ready to have a child? I think that women of my generation, along with our powerful right to control our own reproductive destinies, feel an acute responsibility to determine, rationally, when to have each child. If our careers or finances are not in order, we are to use artificial contraception until we are ready. This is true even of women who are fully capable supporting whatever children they have. When women expose their fertility to chance, they're perceived as sloppy, even negligent -- Britney Spears being a recent example of this.
The concept of "birth control" promises more than it can deliver. Having babies is both mundane and mystical. It's not a simple matter of ordering up Zach or Molly for a scheduled delivery date. These little people, running around your house yelling about bananas and tipping over the dog's water, are an obvious yet enigmatic result of our biological and social sex lives. Conception is a curious alchemy of physiology and intimacy. It can happen in an accidental instant, or it can evade months of concerted effort. Yet I'm asked, and ask myself -- How did we decide to have this baby? When will we have more?
In other times and places in global history, parents have had far less luxury and leisure time to dedicate to their families. But here, in our relatively wealthy culture, it's socially acceptable to have children only at an appropriate time: Planned Parenthood, for example, supports individuals "to have children when and if they are ready." The idea of "reproductive self-determination" (intended to describe our fundamental privacy rights) can pressure us to "determine" each and every choice we make. Each day, each month. And who decides when we’re "ready" to have a child? I just reviewed Planned Parenthood’s "readiness" checklist and learned that I've got a ways to go before I'm ready (I still need to "come to terms with my own childhood experience," and "cope with tighter budgets"). And my son turns two next month.
This dilemma isn't just for pregnant teens who suffer problems of domestic violence and drug abuse. There's no "them" and "us." More mothers than I can count – women I admire and consider mentors if not role models – originally became parents in difficult or accidental circumstances. And many of us -– financially stable, established, deliberate parents –- jump confidently into the cold water of motherhood only to flounder, overwhelmed, in its cold, black depths. We're a continuum of women, from young to old, conflicted by our desires, our means, and cultural messages about what is expected of us. How much of successful parenting is maturity and preparation, and how much is inherent to our character? How much is luck?
Of course, this implicates religion, too. Yesterday Pope Benedict XVI exhorted Catholic families to be missionaries of love and life (which I like). Protestant fundamentalists, while less doctrinal about contraception, often describe themselves as "quiverfull" (from Psalm 127) in giving their family planning over to God. It's easy for the secular mainstream to dismiss these kind of "open to life" attitudes as irresponsible or even oppressive. But it's not that family is a religious issue – it's that family is important. In any paradigm, our fertility is a critical – even sacred – part of who we are as people, both individually and in relationships. If faith deals with anything relevant to our human experience, it must speak to families and the mystery of new life. And maybe the underlying value of fertility, if not the exact paradigm, is an important one for our culture to keep hold of.
When faced with the question of having children, I haven't found any analytical framework much more useful than religious doctrine. No matter how I calculate the months, the hours, the dollars and the square footage that would be required by another child, I'm left feeling less capable than when I began. With all due respect to Planned Parenthood, maybe there is no "ready" to have a child (although there is surely a category of "not ready," perhaps that's less obvious than we think).
So I wonder if a pregnancy is something I can "decide" on at all. I don't believe in fate or think my family size is preordainted. But I still don't understand how much control I have over it all. And even if I have another "well-timed" pregnancy, the entire process is a cascade of growth and change over which I have little direct control. When our modern reliance on technical management of gestation and birth has resulted in so much risk and pain, it makes me wonder. What would happen if we just let go? What if our "reproductive self-determination" is a determination to set down the calculators and calendars, and live our lives as they come to us?
Why not?
A family larger than four (mom, dad, two kids) is virtually unheard of in my circles. All the lawyers I know have a pair of children, almost as if they order a stair-stepped "Zach and Molly" set from the American Girl catalog. Families with three or more kids seem to have suffered some unexpected accident (an older lawyer, whose second pregnancy led to twin daughters, told me that women lawyers tend to have more twins "because we're OLD.") Obviously, busy city people like us have limited time, money and real estate -- as well as goals for career, travel and personal achievement to pursue when our children are grown. But the logistical considerations aren't enough to describe the small-family epidemic among professionals. It makes me wonder what we've convinced ourselves of, and what we might be missing.
Why not have children? It’s such a refreshing question. My parents had four children because they didn't want five. Yet I've always had to ask myself all the hard questions: Why have children? How many? When? I understand all too well the burdens of adding more people to the family. And it's our responsibility to decide to have children (right?) Yet no matter how I put my mind to it, my intellectual and intuitive capacities have failed to guide me.
How do I know I'm ready to have a child? I think that women of my generation, along with our powerful right to control our own reproductive destinies, feel an acute responsibility to determine, rationally, when to have each child. If our careers or finances are not in order, we are to use artificial contraception until we are ready. This is true even of women who are fully capable supporting whatever children they have. When women expose their fertility to chance, they're perceived as sloppy, even negligent -- Britney Spears being a recent example of this.
The concept of "birth control" promises more than it can deliver. Having babies is both mundane and mystical. It's not a simple matter of ordering up Zach or Molly for a scheduled delivery date. These little people, running around your house yelling about bananas and tipping over the dog's water, are an obvious yet enigmatic result of our biological and social sex lives. Conception is a curious alchemy of physiology and intimacy. It can happen in an accidental instant, or it can evade months of concerted effort. Yet I'm asked, and ask myself -- How did we decide to have this baby? When will we have more?
In other times and places in global history, parents have had far less luxury and leisure time to dedicate to their families. But here, in our relatively wealthy culture, it's socially acceptable to have children only at an appropriate time: Planned Parenthood, for example, supports individuals "to have children when and if they are ready." The idea of "reproductive self-determination" (intended to describe our fundamental privacy rights) can pressure us to "determine" each and every choice we make. Each day, each month. And who decides when we’re "ready" to have a child? I just reviewed Planned Parenthood’s "readiness" checklist and learned that I've got a ways to go before I'm ready (I still need to "come to terms with my own childhood experience," and "cope with tighter budgets"). And my son turns two next month.
This dilemma isn't just for pregnant teens who suffer problems of domestic violence and drug abuse. There's no "them" and "us." More mothers than I can count – women I admire and consider mentors if not role models – originally became parents in difficult or accidental circumstances. And many of us -– financially stable, established, deliberate parents –- jump confidently into the cold water of motherhood only to flounder, overwhelmed, in its cold, black depths. We're a continuum of women, from young to old, conflicted by our desires, our means, and cultural messages about what is expected of us. How much of successful parenting is maturity and preparation, and how much is inherent to our character? How much is luck?
Of course, this implicates religion, too. Yesterday Pope Benedict XVI exhorted Catholic families to be missionaries of love and life (which I like). Protestant fundamentalists, while less doctrinal about contraception, often describe themselves as "quiverfull" (from Psalm 127) in giving their family planning over to God. It's easy for the secular mainstream to dismiss these kind of "open to life" attitudes as irresponsible or even oppressive. But it's not that family is a religious issue – it's that family is important. In any paradigm, our fertility is a critical – even sacred – part of who we are as people, both individually and in relationships. If faith deals with anything relevant to our human experience, it must speak to families and the mystery of new life. And maybe the underlying value of fertility, if not the exact paradigm, is an important one for our culture to keep hold of.
When faced with the question of having children, I haven't found any analytical framework much more useful than religious doctrine. No matter how I calculate the months, the hours, the dollars and the square footage that would be required by another child, I'm left feeling less capable than when I began. With all due respect to Planned Parenthood, maybe there is no "ready" to have a child (although there is surely a category of "not ready," perhaps that's less obvious than we think).
So I wonder if a pregnancy is something I can "decide" on at all. I don't believe in fate or think my family size is preordainted. But I still don't understand how much control I have over it all. And even if I have another "well-timed" pregnancy, the entire process is a cascade of growth and change over which I have little direct control. When our modern reliance on technical management of gestation and birth has resulted in so much risk and pain, it makes me wonder. What would happen if we just let go? What if our "reproductive self-determination" is a determination to set down the calculators and calendars, and live our lives as they come to us?
Why not?
How can you have too many children? That's like having too many flowers -- Mother Theresa
Wednesday, October 04, 2006
Yes, more of this
I wrote a letter to the Editor of the New Yorker today:
For Publication
Editor:
Atul Gawande's article about birth and modern medicine raises the bar for birth journalism -- his historical treatment and surgical descriptions are eye-opening -- but I find myself deeply disappointed by the ending of Elizabeth Rourke’s story. Dr. Rourke’s misery and debilitation following her cesarean section were not “stupid feelings.” As one of the many women who suffer from what Gawande calls medicine’s "tyranny" against birthing mothers, I observe that mixed feelings after a cesarean, while varied and intimate, are far from stupid. The pain of women like me– from IV bruises and infections, from confusion and anxiety – is real, even if it is usually invisible to institutional healthcare.
It’s not just medicine that lets us down. It’s our culture and community – often other mothers like Rourke – sending the constant message that all that matters about birth is a healthy baby. As if, were our child only “gorgeous” enough, our gratitude only deep enough, then we could ignore these “stupid feelings” of pain and regret. Like all mothers, I value my healthy son more than my very life. But I’m not alone in grieving a birth I never knew I wanted (I being one who yelled for my epidural before I had my shoes off) until it was lost.
When the most recent evidence (perhaps published after fact-checking for this issue) suggests that cesareans nearly triple the risk of maternal and neonatal death, the damage we face is not just sentimental. The prevalence of cesarean delivery is threatening every doctor’s ability to treat patients and every woman’s right to choose the safest birth for herself and her family. Only with accurate information, and honest emotional support, will this begin to change.
Robin Grace
Member, International Cesarean Awareness Network (ICAN)
For Publication
Editor:
Atul Gawande's article about birth and modern medicine raises the bar for birth journalism -- his historical treatment and surgical descriptions are eye-opening -- but I find myself deeply disappointed by the ending of Elizabeth Rourke’s story. Dr. Rourke’s misery and debilitation following her cesarean section were not “stupid feelings.” As one of the many women who suffer from what Gawande calls medicine’s "tyranny" against birthing mothers, I observe that mixed feelings after a cesarean, while varied and intimate, are far from stupid. The pain of women like me– from IV bruises and infections, from confusion and anxiety – is real, even if it is usually invisible to institutional healthcare.
It’s not just medicine that lets us down. It’s our culture and community – often other mothers like Rourke – sending the constant message that all that matters about birth is a healthy baby. As if, were our child only “gorgeous” enough, our gratitude only deep enough, then we could ignore these “stupid feelings” of pain and regret. Like all mothers, I value my healthy son more than my very life. But I’m not alone in grieving a birth I never knew I wanted (I being one who yelled for my epidural before I had my shoes off) until it was lost.
When the most recent evidence (perhaps published after fact-checking for this issue) suggests that cesareans nearly triple the risk of maternal and neonatal death, the damage we face is not just sentimental. The prevalence of cesarean delivery is threatening every doctor’s ability to treat patients and every woman’s right to choose the safest birth for herself and her family. Only with accurate information, and honest emotional support, will this begin to change.
Robin Grace
Member, International Cesarean Awareness Network (ICAN)
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