Earlier this year, I announced on this blog that, for the first time, bloggers would be eligible for Lamaze International's Annual Media Award. The Media Award is intended for individuals or organizations shaping the public discourse about natural, safe and healthy choices for childbirth. With blogs and other social media now firmly on the scene, it was clear that restricting our award to 'traditional media' would have been looking too narrowly.

The response was tremendous, and we faced a difficult task of choosing from among many wonderful and informative blogs written by mothers, fathers, nurses, childbirth educators, doulas, midwives, and consumer advocates. But one blogger rose to the top. Rixa Freeze, MA, PhD, blogs at Stand and Deliver, and reaches over 30,000 readers a month. Known for her warm, thoughtful tone and expert critical analysis of all things birth- and mothering-related, Rixa has built a strong community of engaged readers who comment often, challenge Rixa and one another, and shape and shift a conversation about birth that very often trickles onto other blogs and online forums and, occasionally, even the mass media. Rixa will receive her award, along with the recipients of Lamaze International's other prestigious awards (to be announced this Fall), on October 3 at the 2009 Lamaze International Annual Conference in Orlando.

Stand and Deliver, like many pregnancy and parenting blogs, started as a family affair. Rixa launched the blog as a way to explain to her family and friends why she was making certain pregnancy and birth choices, without the emotion involved in sharing these choices with unsupportive loved ones face-to-face. Over time, her blog has evolved to include a wider range of posts: research updates and analysis, guest posts, meditations on birth and mothering, academic essays, critiques of North American obstetric practices, links to blogs and news articles, birth stories, and book reviews. And, of course, updates and pictures of her beautiful family!

Rixa may be best known for her choice to have a planned, unassisted home birth, and later, to complete her doctoral dissertation (PDF) on the modern unassisted childbirth movement, the first analysis of its kind. Let's be clear - Lamaze International does not endorse unassisted childbirth,and granting the Lamaze Media Award to Rixa should not be considered an endorsement of unassisted childbirth. But we feel that Rixa's personal and academic journeys to explore the entire range of childbirth choices can help us better understand the practices that facilitate normal physiologic childbirth, and how to humanize childbirth in all settings.

Rixa agreed to answer some interview questions about her blog, her philosophy, and what she would like to see change in our maternity care system. We hope Science & Sensibility readers enjoy hearing from this powerful voice in the birth blogosphere.

Lamaze: Did you have an 'a ha' moment about natural birth? How did you come to your beliefs about birth and our maternity care system?

Rixa: During my first year as a PhD student at the University of Iowa, a fellow graduate student had a baby. I had a few conversations with her about her pregnancy and birth. She initially wanted a home birth but was unable to find a midwife. (Direct-entry midwifery is currently illegal in Iowa, and there are very few nurse-midwives who attend home births. I knew next to nothing about midwifery, let alone that direct-entry midwifery was illegal in my state.) So she went with the CNM practice at the university hospital and was very disappointed with her experience there. She asked me if I had ever considered home birth, and I said something to the extent of: 'Well, nurse-midwives in a hospital seem like a good idea, but I would NEVER give birth at home!'

Ha.

As it happened, I was also looking for a paper topic for a feminist research seminar I was taking. I decided that writing about home birth midwifery in Iowa would be really interesting, so I started reading. I checked out stacks of books. The first one I read was Peggy Vincent's memoir Baby Catcher. I still remember the hallway and chair in the library where I read that book. It turned my worldview upside down and inside out. When I started reading, I imagined that when I had a baby I'd go to a hospital, have a nurse-midwife because they spend more time with you and are more personal than physicians, probably have an epidural, and that would be the end of my story. By time I finished the book, I was transformed. I knew deep in my soul that I would birth my babies at home.

Discovering the world of midwifery and home birth changed the way I think about birth. I used to see childbirth as disempowering and degrading. I resented that we as women had to go through such a horrible experience. And I felt that men definitely lucked out. Some of these attitudes came from a passive absorption of cultural images and beliefs about birth. In film, for example, giving birth is always horribly painful - the woman is screaming and sweating and out of control, swearing at her husband, and lying on her back with her legs spread open, exposed to the world. In addition, hearing stories of my own experience of being born certainly had an effect on me. My mom gave birth to me upside-down, strung up from the ceiling by her ankles, only her shoulder blades making contact with the bed. This was not her choice. Her physician believed that giving birth upside down would prevent hemorrhoids. My mother screamed to be let down, to no avail. (And she never had hemorrhoids, either, not with my older sister or any of my other siblings who were born more conventionally.) That was all I knew about birth until my graduate student years.

In a way, naming my blog 'Stand and Deliver' brings the story of my own birth full circle. My mother was lain (upside) down and delivered of a baby. When I was in labor, I stood up and delivered both of my babies myself, with full autonomy over my body and my labor.

Lamaze: You have written extensively about both midwife-assisted and unassisted home birth, had an unassisted birth of your own followed by a midwife-assisted home birth for your second child, and for your doctoral dissertation examined the modern unassisted birth movement (PDF). Can you briefly discuss what you think the existence and apparent growth of the unassisted birth movement means for the broader maternity care reform movement?

Rixa: Although some women choose unassisted childbirth (UC) solely out of a desire to have an autonomous, undisturbed birth, many come to it from some sort of previous trauma, fear, or disappointment. Today's obstetric climate pushes many women into considering alternatives, from birth centers to midwife-attended home birth to unassisted birth. Other women have had disappointing experiences with their home birth midwives - some traumatic, others highly disturbed and controlled - and they conclude that the only way to have a safe and satisfying birth is to have no one there to boss them around. Some women choose UC because all of their local hospitals have banned VBAC and they refuse to have an unnecessary repeat surgery. Whatever one's perspective on unassisted birth, there is no question that the existence and growth of unassisted birth is, in large part, a vote of no-confidence in our maternity care system. Some women would still have a UC regardless of how many other options were available, but others would hire a midwife or perhaps even have a hospital birth if they felt that they would have control over what happened to them in labor. I was probably in the minority, because I choose an unassisted birth for my first baby. I had never had a traumatic birth experience that left me leery of all birth attendants. I wasn't fighting for the right to have a VBAC. I choose UC freely, because I felt an intense need for privacy during this pregnancy and birth. I also came to UC from a deep background in midwifery. I had apprenticed with a home birth midwife for a year. I had read hundreds of books about birth. I had attended births in both home and hospital as a doula. I was certified in neonatal resuscitation.

The existence of UC has been used as a political tool to garner support for legalizing home birth midwifery. Advocates of home birth midwives argue that women will continue to choose home birth, and if midwives are not legal, they will choose 'riskier' unassisted births rather than going to a hospital. While I'm not enthusiastic about this approach, it does seem to work.

I have mixed feelings about the increasing popularity and visibility of unassisted birth, because it is a choice that should never be made lightly. During the time that I have been following UC communities on internet discussion boards and forums, I have witnessed a trend devaluing education and preparation, dismissing midwives and physicians too quickly, and valuing intuition and the need to 'trust birth' over everything else. Unlike other birth choices, unassisted birth carries a lot more responsibility on the parents' end, as there is no one else there with birth skills or knowledge. I would almost prefer that UC remain invisible and 'unpopular,' rather than the somewhat trendy thing it has become on the internet, to be sure that no one makes that choice for the wrong reasons.

Lamaze: You have written a lot about hospitals, and blogged about your experience touring local hospitals while pregnant with your son. What would you like to see change in hospitals? Do you think those changes are likely to happen?

Rixa: At a bare minimum, all hospitals should implement Baby-Friendly and Mother-Friendly protocols. US hospitals have shown remarkably slow progress in adopting the Baby-Friendly Hospital Initiative. It began in 1991 and was introduced in the US in 1997, yet as of July 2009, only 83 hospitals and birth centers have Baby-Friendly status. Contrast this to the 19,000+ facilities around the world that have become Baby-Friendly. Implementation of Mother-Friendly protocols, which share many of the same conclusions as the Six Lamaze Healthy Birth Practices, has been even more sluggish. Surely we can do better!

There is a great deal of resistance to changing institutional protocols, even when those changes would benefit both mother and child. I like to call it institutional inertia. It's discouraging to see how long it takes for evidence to translate into practice. We've known for several decades that the supposed benefits of episiotomies are nonexistent and that they are more harmful than helpful. Still, somewhere around 25% of women still receive them, and almost three-quarters of those women were not asked for their consent before the cut. For example, the first birth I attended as a doula was with an OB who had an 80% episiotomy rate for first-time moms, and a 50% rate for multips. And he saw that as a good thing. At this birth, the mom pushed the baby out too quickly for him to cut an episiotomy - a fortunate thing, given she was a first-time mom and had a heavy epidural - and he told her afterwards in a regretful tone that he didn't have time to do one. And another thing: this mom was adamant that she did NOT want an episiotomy. Did her OB know that? I don't know, but I doubt it. Did she know about his episiotomy rate? Nope. Was the OB aware of the vast research showing that episiotomies cause more harm than good? Either he wasn't aware of the research at all, or he knew about the research and chose to ignore it. I don't know which of those two scenarios is more disturbing.

Another pressing issue is the widespread ban on VBACs. ICAN recently surveyed all maternity hospitals in the US and found that 49% banned VBAC, either through formal written policies or by a defacto ban (no doctors would do VBACs at that hospital, even though they were not officially banned). With the national cesarean rate at 31.8% and rising, VBAC bans affect a vast number of birthing women. It is unethical for the ACOG to support women's right to choose elective cesarean section while maintaining policies that are directly responsible for the VBAC ban and the subsequent rise in the national cesarean rate. Cesarean sections are not without a host of risks, and each successive surgery becomes more and more dangerous.

I know this would be nearly impossible to implement in a country where only 2% of women give birth out-of-hospital, but I would love for every hospital-based provider (nurses, midwives, and physicians) to have experience witnessing out-of-hospital births. I think a lot of hospital-based providers would do things differently if they had sufficient exposure to women laboring without all the gadgets and protocols. If you've never seen a woman kneeling or squatting or standing up to give birth, you'll probably stick to what's comfortable and familiar: the woman lying down with her legs pulled back, her perineum in full view.

I would also love to see hospitals and care providers 'giving' (as much as I hate that word, since it's not really theirs to give in the first place) women more autonomy in their pregnancy and birth care. I personally know women whose OBs have dropped them from care for refusing certain prenatal tests or procedures (such as amniocentesis or prenatal Rhogam) or for making their home birth plans known. I'd guess that many women do not even know they can refuse hospital protocols - they are told they 'have' to have IV access, they 'cannot' eat or drink during labor, they 'have' to have continuous monitoring. If women do not even know they can say no, we have taken away their ability to make crucial decisions about their care, their bodies, and their babies - decisions that may affect them for a lifetime.

Lamaze: Do you think blogs and bloggers have a role influencing the quality and safety of maternity care? If so, how?

Rixa Freeze, MA, PhD

Rixa: This is a question best answered by my readers! I would hope that I and other birth bloggers have made a difference. I imagine that blogging has helped individual women think more critically about their maternity care and their birth options. I am a little less optimistic that blogging has, or will be able to, dramatically affect maternity care on a systemic level. But who knows? Perhaps our message needs to reach a critical mass and then - wishful thinking here - changes will start occurring rapidly. Think of the impact that Dooce, the mother of all mommy bloggers, will have on birth after she wrote about her empowering natural birth (in three parts: Part 1, Part 2, and Part 3) and enthusiastically endorsed Ricki Lake's and Abby Epstein's documentary The Business of Being Born and book Your Best Birth.

Lamaze: Your blog strikes a remarkable balance among personal testimonial, comprehensive and nuanced analysis, sociopolitical commentary, and more light-hearted fare. It's a balance that I think really resonates with your readers and sets your blog apart from many others. How do you determine this balance? And how do you decide when the personal is personal and when the personal is political (or 'blogworthy')?

Rixa: There's no formula or pattern I try to follow; it's how I avoid blogging boredom. I sometimes worry that my personal posts - you know, the everyday stuff like 'we went the park and Dio spit up on me 5 times and Zari said something really funny' - are too mundane. But if I didn't have those things about my everyday life, my blog would become too one-sided, too heavy-handed. What I post also depends on how much computer time I have. Reporting news or sharing interesting links is much faster than writing original essays or critiques. Since the birth of my second child, I've had much less free time to blog. I often need to put the computer down and spend more time with my family, especially my husband. My computer time is usually in the evenings once the kids are sleeping, but that's also the only time my husband and I have to share with just the two of us.

Lamaze: What are some of your favorite posts?

Rixa: In rough chronological order:

Better is not good enough

My hospital rant

I am selfish

Cesarean sections and SUVs

Pregnant women are second-class citizens

Formative words

Is fat a moral failure?

Vision of Unity

10 Responses to ACOG's statement on home birth

Let's talk about pain (with links to earlier posts about pain)

On your back, please

More! Better! BirthTrack (TM)!

Mother who have lost children to death

Have patient's rights undermined obstetrics?

Is brown the new green?

Biodynamism - Body and Soil

Conversation with the ultrasound tech

Working through some conflicted feelings and The root of my worries and midwife's role at my birth: about hiring a midwife for my second pregnancy after having an unassisted birth

Not staying true to my word... whatever that means

Belly photos

What does giving birth feel like?

Litigation and the obstetric mindset

Burn the male midwife!

And, of course, the birth stories of my daughter (a planned unassisted birth) and my son (a midwife-attended home birth)

As I browsed through my blog to choose these posts, I was struck by the evolution in my writing and thinking. I'm still mostly the same person I was three years ago, but I see a definite maturation in my posts: more nuance, less emotion (although my passion for all things birth & breastfeeding still occasionally escapes), less dogmatism. I'm glad to see these changes; it means I am continuing to evolve as a blogger and as a mother.

Lamaze: What are some of your favorite blogs (birth-related or not)?

Rixa:

Taurus Rising: An Aussie who writes about food, sustainable living, gardening, and occasionally birth stuff

Balance: Chou writes all about food, food, and more food (and is a good friend of mine). She's currently doing a PhD in food studies. Lots of great recipes and ideas.

Casaubon's Book: food, peak oil, sustainability, gardening, farming

The Unnecesarean: sharp, sometimes biting, often funny blog about cesareans and VBAC.

Baby Makin(g) Machine: a future mama thinking hard about how she wants to mother

House Fairy: a fierce, honest mama of five

Keyboard Revolutionary: mama of 2, first born by c-section and second a HBAC, I love her birth posts

Feminist Childbirth Studies and The Feminist Breeder always give me things to think about

Nursing Birth and Reality Rounds are both fantastic L&D nurse blogs

The Happy Sad Mama: mother of three children; the first, Charlotte, was stillborn at term

Mom's Tinfoil Hat: ob-gyn student who trained with midwives in a freestanding birth center before medical school

I am stopping here, otherwise the list will become too long! I have links on my sidebar to the many other fantastic blogs I visit regularly. (I'm still working on updating my breastfeeding links, so keep an eye out for them in the future.)

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