Today is the final installment in a weekly series  that has been leading up to the Lamaze International 2021 Virtual Advocacy Summit on September 27-29.  There is still time to register! The virtual summit is an opportunity to connect with your fellow Lamaze Certified Childbirth Educators from around the world, who will be meeting to address the most critical and timely policy issues that affect prenatal care and childbirth outcomes. In this series, blog readers will have an opportunity to meet perinatal professionals and read their personal essays on why they advocate for evidence based care, improved policies and funding that impact birth outcomes.  You can find the entire "Why I Advocate" Series here. - Sharon Muza, Connecting the Dots Community Manager.

In 2004, our small family - myself, my husband Shahram, and our two girls - moved to India for a year of graduate study research. I was eight weeks pregnant. I was still in that stage where occasionally I rubbed my belly unconsciously, taking some delight in the “secret” only my closest family and friends knew about. Jet Lag and travel by plane, automobile, and rickshaw was rough on top of the nausea and bone-deep weariness of the first trimester. These inconveniences were largely offset, however, by the excitement of sharing the joys of new smells, sounds, and sights with my eager two and five year olds. After spending a week in New Dehli with some friends, we moved temporarily into Shahram’s Uncle and Aunts’ home in Marredpally, Hyderabad until we found a place of our own. 

The first day after we arrived we went to a local church. I was wearing a cotton white salwar kameez with hand knit applique - something I was gifted on our last visit to India. I used the restroom, and noticed some bright red spotting when I wiped myself. I returned to my seat and said to the elderly woman I had just met, “I’m eight weeks pregnant…and I think I’m bleeding.” I sat there stunned. She was very kind and shared her sympathy and stories of her own miscarriages. I was still in a state of disbelief and just sat there with tears rolling down my cheeks for the remainder of the service. When it was done I used the bathroom again - by that point my white sarwal kameez was covered in blood. We quickly arranged a rickshaw ride to the hospital, and confirmed via ultrasound that the heart had stopped beating. 

As I lay there with tears running down my face the nurse scolded me, “what are you crying for? You already have two beautiful children, what do you need a third for? You’re young. If you want more you can always try again.” I felt conspicuously white in a sea of brown and embarrassed that my clothes were covered in blood. I was ashamed that I was publicly weeping for a child that was barely more than a clump of cells and tissue and in response to an experience that I knew intellectually nearly every woman went through. The nurse was right, I was fortunate to have two healthy children and I was young, I could try again. I recognized all of this while simultaneously feeling the depths of heartbreak and sorrow that accompany the loss of a child. It didn’t matter that my child was more fiction than reality, more a composition in my head and heart than a finished masterpiece. Loss is loss.  

After a few days, I was still passing large enough clots that my provider - a friend of the family at a private clinic - recommended a D&C, a procedure to manually remove any remaining tissue from my uterus. I showed up for my appointment the next day. Shahram was told to wait in the waiting room. I was shown into a room and asked - through pantomime and gesticulation - to disrobe and place a blanket over the lower half of my body. Once I was on the table, the medical tech approached me with what I recognized at once to be the instruments used to shave the pubic hair and perform an enema. I had been a doula for five years and knew enough to know that those procedures were no longer considered evidence-based or necessary. Unable to articulate my thoughts in a language that would be understood, I curled up in a ball and shook my head. The tech looked at me in confusion, and so I repeated the word “doctor” until she called my provider. Stretching the long spiraled chord across the room, the tech handed me the phone. I explained my preferences to skip both procedures, and then handed the phone to the tech so the doctor could convey my wishes. 

The tech put down the instruments, and instead motioned for me to wrap the blanket around my waist and follow her to the surgical theater. Once there, the doctor spoke English, and asked me to lie on the bed with my feet in stirrups. Lying on a table with my legs spread wide, my head lower than my body, my feet up in stirrups, and a bright white light shining on one of the most intimate parts of my body - I felt exposed like never before. The doctor held up a large syringe, and asked me if I wanted anything for the pain of the procedure. After I inquired what it was, she explained that it was Ketamine. I had already given birth twice without any pain medication and was unsure of how I would respond to Ketamine, so I declined. The procedure was not long. It quickly moved from uncomfortable to painful. I used all my birth coping skills - deep breathing, visualization, vocalization, buzzing my lips - and eventually we were finished. I was given some brief instructions on warning signs and when to return to the clinic for a checkup and then the doctor left.

The medical tech helped me off the table and led me into a bathroom across the hall. My legs were unsteady and blood was streaming down my thighs. Inside the bathroom, she filled a bucket with water several times, splashing the water on the lower half of my body to rinse me off. She used the clean corners of the blood covered sheet to dry me off, and then helped me back into my clothing. Thankfully I had brought a pad with me. Then she escorted me to the waiting room and we went back to our Uncle’s home. When I shared my experience with our relatives, they looked at me wide eyed and said, “you mean you didn’t bring your own supply of pads, towels, and sheets?” I shook my head. I didn’t know.

As I reflect on this experience years later, I think, is this why I feel compelled to work and advocate for better reproductive health care. Do I advocate for others because in a moment of vulnerability I was able to ask for what I needed and advocate for myself and I feel compelled by unspoken rules of reciprocity to empower others who are on a similar journey? Do I advocate for improving health care and settings because I had a glimpse of what it was like to face language and cultural barriers to care and want to make sure others have a better experience? Or does my desire to advocate come from someplace darker, a misplaced sense of self-righteous moral obligation? So, is this experience really why I advocate? Maybe. I don’t know if anyone can ever point to a single reason for why we do what we do. Perhaps there isn’t an experience or an external reason at all. 

Perhaps, as Rainer Maria Rilke eloquently described, we do what we do because when we “ask [ourselves] in the stillest hour of night: must I [advocate]?” the answer is simply “I must.”  Why do we need any other answer or justification than that? There are anecdotal stories, statistics, and public health arguments I could draw on to justify my commitment to reproductive advocacy work. But I’m not confident that is where my motivation comes from. Rilke said “Everything is gestation and then bringing forth.” Like an artist, I feel compelled to give life to a new way of doing and being. No one asked me, why did you bring this new life into the world when I became a mother. It is the same voice that called me to create life, that calls me to health advocacy. Advocacy work is creation. We are creating new ways to circumvent broken systems. We are creating new traditions to replace lost ones. We are creating new ways of being that reflect our evolving values and priorities. Through advocacy, I sculpt new shapes and forms for the way we see our bodies, paint new pictures and landscapes for where we care for our bodies, and write new stories to pass on to new birthing bodies. I advocate because I am a creator, and I must create.

About Sarah Paksima

Sarah (she/her) has been supporting families for 21 years in the United States, Kuwait, Oman, India, and Jordan as a doula, childbirth educator, and maternal health advocate. Sarah and her husband work hard to keep up with their five kids. She maintains her sanity by raising their children in a town with no stoplights, eating copious amounts of dark chocolate, and stocking their pantry with food kids will eat. When she’s not attending births, she enjoys reading, gardening, watching movies while folding endless piles of laundry, and letting kids bury her in the sand at the beach.

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