Joy,

Thank you so much for your heartfelt, well-thought-out words.  It is truly a difficult situation that is unfortunately not limited to Turkey.  I appreciate your encouragement and your work and thank you for all of your excellent resources.  The work that we do walks a very thin line between encouraging families to challenge current unnecessary and dangerous medical practices and supporting them in preserving their birth experiences.  It is not at all an easy balance to maintain.

The information you brought forth regarding the new resolution passed by the AMA is truly frightening, and as so many parts of the world take their lead from the US in many ways, the ripple effect could be crippling to women's rights and the natural birth movement.  Thank you for making us aware of this new development!

It seems to me that the best way to work with families is before they are pregnant.  I think that the films Orgasmic Birth and the Business of Being Born are doing an excellent job of reaching the population, encouraging them to reconsider their beliefs about the medical system before they are immersed in it. 

I hope that we can all keep this dialogue going, as it spurs us to consider our practices, question our beliefs, and ultimately enables us to support one another in our efforts to improve circumstances for birthing women.

Julia


Joy Jones wrote:

Dear all,

I can understand and receive and agree that I have never worked or witnessed a birth in Turkey, and so I do not know what will and will not work for a birthing woman in Turkey.

I also agree that asking for what you want clearly and kindly and in a timely fashion is the best and most effective way to go most of the time.

I also applaud all of you who are working your hardest to help the women of Turkey to find better ways of birthing, in whatever ways that you can. May you all have much success in that work.

At the same time, I would like to insert into this conversation that here in the US women have been at the mercy of unnecessary and potentially hazardous medical interventions in the birthing process for over 50 years, and they have been empowering themselves with the knowledge and skills to stand up for themselves and their babies and prevent those interventions for about 45 years. I have been working with women to help them with this process of self-empowerment and self-protection and self-advocacy for about 30 years. And still we have this problem and still we continue to need to work at it more here in the US, as is evidenced by the recent documentaries "The Business of Being Born" and "Orgasmic Birth", and the recent book "Pushed: The Painful Truth About Childbirth and Modern Maternity Care". It is not a problem that is new, nor one that is unique to Turkey.

http://www.thebusinessofbeingborn.com/

http://www.orgasmicbirth.com/

http://www.jenniferblock.com/

I have just learned this week of a new threat to the autonomy of birthing women here in the US. The American Medical Association has just passed a resolution to label patients as "non-compliant" who question their doctors in any way (apparently at the discretion of the individual doctor). This may seem like a benign resolution until you hear that they have also created a new insurance code for this label of "non-compliant", and that insurance companies can apparently refuse to cover your medical expenses when you have that label and that code attached to your chart or your bill. Since for the most part we do not have medical care covered by government funds, and most of us rely on our personal health insurance to cover our medical expenses, this is a significant threat to the autonomy and intelligent decision-making of patients in the US, particularly birthing women who increasingly seek to find ways to pick and choose which medical routines they want to accept and which ones they do not.

So it is an ongoing problem everywhere, with a new face to show us continually. "It" being a lack of a fundamental respect for the intelligence and autonomy and rights of the birthing woman.

I have helped with about 500-700 births of all kinds, from home birth to natural hospital birth to extremely interventionist hospital birth to a premature stillbirth (probably from trauma) in a hut in a remote part of Southern Sudan, and it has been my experience that the more the mothers expressed complete trust in their doctors, the more they were subjected to unnecessary interventions. From my observation, it has seemed to me that it was only the mothers who showed some kind of evidence of having researched the issues and having intelligent reasons for their preferences, and having it down on paper as some kind of birth plan that was included in all of their charts and passed to all of the departments involved with their care -- it was only those mothers who got the respectful care from their doctors that they were seeking, and even then they had to be continually watchful, or preferably to have someone on hand whose job it was to be continually watchful on their behalf, to make sure that those wishes were not disrespected. The ones that said something like, "I want everything that you have to give me, because I trust you implicitly" got exactly that -- every unnecessary intervention that the medical system had to give them.

As a doula, once I personally had to gently hold the wrist of an intern that was about to insert an internal monitor on a laboring woman, when I knew that she did not want that and that it was not necessary in her situation. With that slight delay in time, she was able to simply state for herself that she did not want that, and that unnecessary procedure was not done on her, and she was able to get back to her job of laboring, and the labor was able to proceed.

We do not need to have gone to medical school to understand our bodies and our birthing processes accurately. Many times we know intuitively what is right and what is wrong in the birthing process and how it is often skewed by a medical system. But in addition there are plenty of resources out here where women can go to find out more information as they need to. People have been writing about this issue for about 45 years, as I mentioned earlier, so there are many resources available. There are even doctors like Marsden Wagner and Sarah Buckley and others who are writing about these issues, for the very purpose of helping women to be informed and make truly informed choices. When we set aside our personal intelligence for the sake of trust, we put ourselves in a very vulnerable position which is a very risky place to be.

http://www.midwiferytoday.com/articles/technologyinbirth.asp

http://www.sarahjbuckley.com/

For example, when we know that we live with a birthing system in which episiotomies are done about 100% of the time, when they are medically necessary about 1% of the time, we can know that putting our trust in the wisdom of those who work within that system is probably misplacing our trust. As you have said, most of these routine interventions have been shown to be unnecessary and hazardous, and yet they continue to be used, not out of medical wisdom or scientific support, but out of an oral tradition that has been passed down from one resident to another and from one intern to another. As Richard Smith, editor of the British Medical Journal, has said, "Only about 15% of medical interventions are supported by solid scientific evidence....This is partly because only 1% of the studies in medical journals are scientifically sound and partly because many treatments have not been assessed at all."

I agree with you that this is a less than optimal state of mind for a woman to have to carry with her into her pregnancy and labor, because I agree with you that the emotional component of birthing is every bit as important as the physical one. So that is why we have developed the practices of doulas, so that the mother can give birth freely without having to be hypervigilant for herself. I agree with you that without husbands in the labor/delivery rooms and without access to doulas, you have a huge problem to deal with. I sympathize deeply with your predicament and your conundrum. May all of you who are working on this problem in Turkey be greatly blessed with wisdom and creativity as you work to help women to birth the best that they can within that context.

I agree with you that unexpected events can occur in the birthing process, but I also believe that most of the unexpected complications that occur in a context where many unnecessary medical interventions are being used are actually the result of the interventions, rather than the result of unpredictable random acts of nature.

I also agree with you that the beauty and magic of birth can come through in spite of much unnecessary pain imposed by unnecessary interventions. I also know that there are several organizations which have formed to comfort those women who experience PTSD from the anti-natural treatment which they have received in their birthing process. Therefore, I believe that sometimes there is more to it than what a mother seeks to make of it through her will power and frame of mind, when it comes to an event as complex as birth.

I also realize that we have more than an intellectual debate here. We have a mother who is due to give birth any day who came to us for information and advice. I realize that most of what I have said is of no help to her at this late stage of her process. I deeply regret any pain which my words may have caused her. It is my hope that if she reads what I have written, she will be able to sift through it for the pieces which may be helpful to her, even at this stage of her pregnancy, and ignore the pieces which are not helpful to her and her situation.

Rasheeda, may the rest of your pregnancy be blessed with a peace and a wisdom that is supernatural. May you find the words to ask for what you need from your medical professionals--the kind of words that will work well between you and them. May they all hear you accurately and respect your wishes fully. May your labor and your birth be surrounded by love and joy and peace and wisdom and may only the people who carry those traits with them be allowed to enter your birthing space. May your birth proceed amazingly well, and may you give birth in good health and bring forth a robust, healthy baby, and may you do that with much strength and courage and joy.

Peace be with you,
Joy

PS. If anyone is interested in more resources on this subject, they can find some on the following 2 pages of my website....
http://home.mindspring.com/~djsnjones/id5.html
http://home.mindspring.com/~djsnjones/id7.html


On Friday, June 26, 2009, at 05:32 AM, Julia Steils wrote:

Rasheeda and everyone,

It seems Rasheeda's questions have stirred a vibrant conversation going right to the heart of issues in Turkey. I agree with Şebnem and Hakan when saying that asking kindly for what you want will most likely get good results. It is true that most doctors in Turkey perform episiotomy routinely, and have been taught that this is the best way to help prevent tearing. While there is a mountain of current evidence compiled over the past 20 years to disprove this (and Joy has kindly provided links to many of it), it is important to keep in mind that the doctors are acting to the best of their knowledge and with the best of intentions.

Therefore, as many have already said, it is important to know what you want going in, ask for it clearly and kindly, and to also be prepared if things do not go as you had hoped.

I think this is especially important for those living outside of Turkey to keep in mind when advising women birthing in Turkey. Yes, it is true that commonly used interventions such as pitocin, IV, fetal heart monitor, rupturing the membranes, stirrups, fundal pressure, episiotomy, manual removal of the placenta, routine deep suctioning of infants, and many many more have been proven in recent years to interfere with the normal progression of labor, impede maternal and infant bonding and in some cases can cause injury or death to mother or child. Obviously, it is a good idea to avoid these procedures unless they are medically necessary.

However, it is important to keep in mind the circumstances under which the birth is taking place. Here in Turkey, traditional midwifery care is not the norm by a long shot. Most women do not have access to an adequate childbirth preparation course and have not seen other women birthing. Birth is highly medicalized, and in some hospitals, women are lucky to be allowed to have their husbands with them. One other midwife and myself are the only "doulas" I know of in all of Turkey, so telling a woman to hire a doula in such a situation is not very helpful. Most women are birthing here on their own, or if they are lucky, with their husbands or a female relative. The woman's supporters are not usually trained, and are "only" there for her emotional support. I think that it is a lot to ask of these individuals in the heightened emotions of birth to be expected to keep an eye on and challenge the doctor. The reason women are birthing in the hospital with a doctor is because they need to feel safe. It is vital to keep this perspective in mind when advising women about how to proceed.

In countries where these interventions are no longer routine (which are few, I must add), it was a slow process, with parents leading the way. For this reason, it is important for parents who have the power to ask for what they want, work with their doctors in partnership and respect, and perhaps even provide access to recent medical literature.

But because the process of birth is not merely a medical one, parents must keep in mind that they are going through extreme emotional and spiritual changes as well, and the later stages of birth and delivery are so overrun by the ecstatic birth hormones and excitement over the baby, that it must be acceptable for both mother and father (and other non-professional supporters) to succumb to this excitement. Attempting to birth in a hyper-vigilant war zone is not any more conducive to a healthy birth than an unnecessary episiotomy (vs), and parents should not feel guilty for not stopping the doctor for doing something which was essentially out of their control to stop.

In short, parents should ask for and work towards their desires regarding the birth experience, be as pro-active during their birth as they feel comfortable, but should also keep in mind that there is a reason they have chosen to birth in the hospital, and that at some point one has to trust one's doctor, as we have not all gone to medical school. Be prepared for the unexpected, as this can and does happen in any birthing environment. And keep in mind that is not the event itself which is traumatic, but the ways in which our minds perceive it (and usually the ways in which we blame ourselves for this or that event).

On a final note, one of the most powerful birth experiences I have had was a couple of months ago at a typical hospital birth. There was pitocin, there was AROM, there was an epidural. The birth was not at all how the mother or father had imagined it. But they both maintained their connection to themselves and one another. They were aware and present for each decision made, even when they were not entirely happy about making it. They quietly expressed and negotiated their needs with their doctor, who in turn did her best to honor their requests. And in the end, the light and energy that filled the room as the parents welcomed their baby was so tangible, it made me cry, which doesn't happen often.

Your birth experience is what you make of it.

I wish Rasheedah a safe and sacred birth experience, however she births her child, and thank all of those members who have contributed their thoughts and advice.

Julia

--- In naturalbirthturkey@yahoogroups.com, Joy Jones <pregnancydiet@...> wrote:
>
> Dear Rasheedah,
>
> I would encourage you to do whatever you can to avoid an episiotomy.
> Not only does the use of episiotomy often result in an additional 200cc
> of blood loss, but it also can cause unnecessary pain which makes
> sexual activity more difficult for many months after the birth.
>
> Also, contrary to what you may be told by those there in the Turkish
> medical system who support the use of episiotomy, a natural 1st to 2nd
> degree tear heals much faster and hurts much less than an episiotomy
> does.
>
> Also contrary to beliefs by those who believe in using episiotomies,
> 3rd and 4th degree tears are NOT prevented by the use of episiotomies.
> In fact, those kinds of tears are much MORE likely when an episiotomy
> has been used.
>
> The issue of episiotomy is not a minor one, in my opinion. I suggest
> that you have one person there, hopefully an experienced doula, whose
> job it is to watch for the doctor's hands and scissors at all times,
> but especially at that point in labor, so that no episiotomy is done.
> Otherwise, it can be done SO quickly that it will be done before anyone
> has a chance to object. If they see that one is about to be done, they
> can gently hold the doctor's hand by the wrist (behind the sterile
> glove, so as to not break his sterile field), and say to you, "The
> doctor is about to do an episiotomy. Do you want an episiotomy?" When
> you say "No", and the father can re-iterate "No, we definitely do not
> want an episiotomy", and the doula can turn to the doctor and say "The
> mother and her husband do not want an episiotomy." Then the mother and
> father can even suggest that they sign whatever the doctor might like
> for them to sign as a legal waiver so that he is not liable in any way
> if he does not do an episiotomy.
>
> Here are some resources which might be useful for you as you try to
> negotiate for your preferences with your care-givers.
>
> http://www.mothering.com/saying-no-episiotomy-getting-through-labor-
> and-delivery-one-piece-0
>
> http://www.sheilakitzinger.com/Research.htm#Episiotomy%20Research
>
> http://www.naturalchildbirth.org/natural/resources/labor/labor07.htm
>
> http://www.naturalchildbirth.org/natural/resources/labor/labor05.htm
>
> http://www.naturalchildbirth.org/natural/resources/labor/labor03.htm
>
> http://www.midwiferytoday.com/enews/enews1005.asp#main
>
> http://www.midwiferytoday.com/enews/enews0125.asp
>
> http://www.midwiferytoday.com/search/
> default.asp?query=episiotomy&x=21&y=8
>
> May you have much success in having a natural childbirth and a healthy
> labor and baby in this context.
>
> Best wishes,
> Joy
> (a nurse/midwife's assistant/former doula/former childbirth educator)
> http://home.mindspring.com/~djsnjones/
>
> On Wednesday, June 24, 2009, at 03:25 PM, Tamahine Alemdar wrote:
>
> >
> >
> > Dear Rasheedah,
> > i,m sure we are all wishing you good luck for your birth! Please let
> > us know how things go.
> >
> > Much encouragement
> > Tamahine
> >
> >
> <image.tiff>
> >
> > To: naturalbirthturkey@yahoogroups.com
> > From: hakancoker@...
> > Date: Tue, 23 Jun 2009 17:19:34 +0300
> > Subject: Re: [naturalbirthturkey] Re: living in Mugla - wanting
> > natural birth, no circ, etc...Help! :-)
> >
> >
> >
> > I think you might leave the rest of the talk to that day. ASs Serbnem
> > wrote to you, If you are polite and determined about your preferences,
> > I am sure they will try to help you.
> >
> > The most important think will be emotional and pysical support during
> > the labor. Who will be there to support you for these? Will she be
> > enough experienced to do the negotiation between the health care
> > providers?
> >
> > These are all important issues waiting for you.
> >
> > Best wishes in your labor. A healty nice babay will arrive, dont
> > worry...
> >
> > Hakan
> >
> >
> >
> > ----- Original Message -----
> > From: Rasheedah
> > To: naturalbirthturkey@yahoogroups.com
> > Sent: Tuesday, June 23, 2009 1:43 PM
> > Subject: [naturalbirthturkey] Re: living in Mugla - wanting natural
> > birth, no circ, etc...Help! :-)
> >
> > Dr. Hakan Bey,
> >
> > Thank you so much for your words of advice. You actually cleared up
> > some confusion we were having about our doctor who has both a private
> > and public practice. We were seeing him at the public hospital and
> > wondering why he wouldn't be attending our birth.
> >
> > I have to say that my husband and I were disappointed to learn that it
> > will be so difficult to avoid the episiotomy but from hearing the way
> > my GYN and sister-in-law (who was trained as a nurse) spoke about it,
> > I was beginning to get that feeling. We met with the nurse midwives
> > once before and they seemed very sweet and helpful - which was
> > comforting to me. We are wondering if it might be worth it to meet
> > with them once more to ask more questions or if it is better to simply
> > talk with them when we arrive.
> >
> > Thank you again for your thoughts and advice. Should we begin this
> > process again, we would know where to look!
> >
> > Thanks so much,
> > Rasheedah
> >
> > --- In naturalbirthturkey@yahoogroups.com, Op.Dr.Hakan Çoker
> > <hakancoker@> wrote:
> > >
> > > Dear Rasheedah,
> > > In Mugla state Hospital your cesarean rate will be approximately
> > 50-60%. This was the rate in most of the state hospitals. (Getting
> > down recently)
> > > I can quarantee that you will not be offered to have any painkillers
> > or epidural anestezia because it is never used in that state hospital.
> > But I can not guarantee some interventions. Your labour might be
> > fastened with induction, you might be forced to not to eat anything
> > and have drops.
> > > You epiziotomy rate will also be nearly 100%.
> > >
> > > But if you dont have any private doctor agreement for the state
> > hospital, you will be cared by the midwifes. If you have a nice
> > correspondence than you will probably have a very nice labor. If you
> > trust and respect them, they will respect you more. And definately
> > they will try to help you a lot.
> > >
> > > So good luck to you in your labor.
> > >
> > > Dr.Hakan Coker
> > > www.dogaldogum.com
> > >
> > > ----- Original Message -----
> > > From: Rasheedah
> > > To: naturalbirthturkey@yahoogroups.com
> > > Sent: Monday, June 22, 2009 3:28 PM
> > > Subject: [naturalbirthturkey] living in Mu&#287;la - wanting natural
> > birth, no circ, etc...Help! :-)
> > >
> > >
> > >
> > >
> > >
> > > Hello All,
> > >
> > > I am new to this group and stumbled upon it because my mother was
> > reading an article in Today's Zaman that mentions this group and
> > midwifery today (which mentions Dr. Hakan). I am an American citizen
> > and my husband is Turkish. We are at 40 weeks right now and are
> > expecting the baby any day now. We are big on natural birth but this
> > is our first baby and we have both recently relocated to Turkey (so,
> > we have been used to the American medical system and resources there).
> > >
> > > So far, all is normal in our pregnancy and the due date is June
> > 25th. I am wondering if there are any tips and suggestions you might
> > be willing to share to help us prepare and advocate for a natural
> > birth at the state hospital here (Mu&#287;la Davlet Hastanesi). I
> > would like to deliver vaginally without the use of any painkillers and
> > hopefully without an induction or any other interventions if possible.
> > >
> > > I really wish I had seen these resources sooner because I swear I
> > had been seeking out advice wherever I could find it. We wanted to go
> > the slightly inexpensive route so, because we have state insurance, we
> > see a private hospital doctor occasionally because she is my Gyn but
> > have been mostly meeting with a recommended Ob/Gyn at the state
> > hospital and making occasional visits to the Sa&#287;l&#305;k
> > Oca&#287;&#305; as requested by them. We personally supplement this
> > with prenatal yoga, lots of online research, and an Our Bodies,
> > Ourselves and Dr. Sears pregnancy books. If I had known of midwife and
> > home birthing options and doulas here in Mu&#287;la, I would have
> > jumped at that opportunity.
> > >
> > > Again, any tips you can share about how to go about a natural birth
> > (we are about 10 minutes from the hospital) from how long we should
> > stay at home during labor to once we get to the hospital are very much
> > welcomed. Also, after delivery, what do we HAVE to do? I was told the
> > baby will be given to us and they will try to do tests (blood and
> > shots and so on). The sa&#287;l&#305;k oca&#287;&#305; says to insist
> > they wait on those and come visit them a couple of days later for that
> > kind of stuff. We are a bit confused on what to do.
> > >
> > > Also, we are big on not doing unnecessary surgeries. Neither of us
> > are practicing Muslims or Jews so we feel no cultural pull to have a
> > circumcision but we know that is practice here. Anyone else who
> > decided not to do this have any thoughts or suggestions/tips?
> > >
> > > Thank you so much,
> > >
> > > Rasheedah
> > >
> >
> >
> >
> >
> >
> <image.tiff>
> >
> > Hotmail® has ever-growing storage! Don't worry about storage limits.
> > Check it out.
> >
>