"Hey, aren't you a doula?"

This week I've gone on three interviews with potential doula clients, all first-time parents, all of whom are planning "natural" birth. (I put that in quotes because I do not believe a hospital environment is natural. What I would say is that these couples are planning "medication-free" births. However, they all referred to it as "natural." It is splitting hairs, perhaps, but I put a lot of stock into language -- one day I'll post about how breast isn't best, and my favorite list of condescending obstetric phrases, like "incompetent cervix." Siiiiigh.)

I'm not a huge fan of interviews, although the more I do it, the more used to it I become, and I start to feel more comfortable. There are many many many doulas in Charlotte, so it's rare that I meet a couple and we click and that's it. Usually the couple is interviewing at least one other doula. I start out with the usual, Hi, I'm Erika



and ask about the woman's experiences so far, how her pregnancy is going, how she's feeling, what she's planning for this birth, how I can help, and how I can help her partner. Sometimes it's just a natural flow of conversation, sometimes I sort of rely on the checklist in my head (birth plan, location of birth, ob group, newborn plan, postpartum concerns). Once I was genuinely interviewed like, "How are you different from all the other doulas in Charlotte? What do you do if your client wants an epidural?"

Honestly, I'm probably not that different from all the other doulas in Charlotte. I market two things about myself: one is that I've given birth in a hospital with an epidural, in a birth center with a shot of narcotic, and at home with nothing; two, I'm an apprentice midwife and midwifery student.

For the first point, I think it relaxes people to know that I'm just like them, that I traveled on a path to natural birth and didn't just start out knowing that I would do it that way. Because most of the women I meet -- especially first timers planning a hospital birth -- aren't ready for a homebirth with their first baby. And they say that too, "Not with my first baby!" Like the first one is a practice baby. I wish I could go back and have homebirthed all my kids, but with my first three I just wasn't there yet. And I respect their position and I understand where they are coming from, and I want them to know that.

As far as being an apprentice and AAMI student, my leg up is that I know more than the average doula about normal pregnancy and birth. I'm early in the game, but I've learned a lot, and I can't even imagine all the things I will learn in the next three years!

I usually try to work in my favorite doula story, which is that the doula I had for my first birth wasn't a licensed doula, she was just a woman interested in birth who had attended a few births and offered to help me. Her name is Gretchen Humphries and she's very active in ICAN. She was so wonderful, during my pregnancy and my birth. My twins had Twin-to-Twin Transfusion Syndrome; I was induced and I was a first-time mom; my baby B was a foot-first breech; in short, I was a fantastic candidate for a c-section. And yet I had a beautiful vaginal birth. I really credit Gretchen with helping me get there. My doula for my next birth was licensed by several doula organizations, and she was very well-known. I felt lucky to have her. Still, I don't feel we clicked, and for that reason, she wasn't very helpful for me.

The moral of the story is: forget all the labels and the initials behind the name (I am Erika Gebhardt, CD, CCBE, LAMW SC) and go with the person you feel comfortable pooping in front of. Because you will!

And yes, I'm also still a childbirth educator.

(See all my hats?) Tonight I'm teaching part of Leigh's class, on breastfeeding. I've posted before about my experiences with breastfeeding. Leigh and I agree that breastfeeding success is about 95% intention. At the Red Tent I met a woman who had breastfed while having MRSA infection in her breasts! That's pretty incredible. (Although Leigh points out, only HIV/AIDS and Hep B have contraindications for breastfeeding. But still. MRSA! Is there a scarier word? And how the hell did she get rid of it?)

Feeling slightly less totally incompetent

The title is my roundabout way of saying I actually feel slightly MORE competent lately. Which is a relief. I can't point out anything concrete, but I just feel like some clinical things are starting to click in my mind. Maybe it's that checking fundal height is finally getting a little easier -- for some reason, I have a really hard time finding the exact spot on the pubic bone to start measuring. I used to be off by up to five centimeters. Now I'm getting a little more accurate.

I have also long proclaimed that I know nothing about midwifery, but as I'm delving deeper into AAMI, I can say that though I may be an idiot currently, I'm going to be a freaking genius by the time I graduate from AAMI. The coursework is all copyrighted so I can't say much, but suffice it to mention that the sheer volume of readingis enormous. And that's not to mention notes, papers, reviews, commentaries, and critiques.

For those (my three readers!) who are considering midwifery school, I recommend AAMI. Just looking at the small bit of curriculum I have now, I'm going to get a very thorough education. It takes a while to get used to AAMI-isms, but once you start drinking the Kool-Aid, it makes more sense. Plus the other students are very supportive and will share how they are balancing everything -- life, apprenticeship, education. The most difficult part is probably the money, which unfortunately is not something we have a lot of. Just this last week my oldest dog, Deuce, had an emergency vet appointment and treatment (she's fine now), and Dustin accidentally broke one side of the double-paned window next to our front door. Babysitting costs is what really kills me, although I appreciate the situation I have: a woman and her 5 daughters babysit the kids. The daughters were all homeschooled and are all (except one) married with kids and live close by. So I almost always have coverage, and I don't have to drive far, and next year when we're homeschooling, they will understand that and not think it's weird that 6yos are home during the day. It has really worked out nicely. The daughters are all into natural birth, so hopefully one of them will use the birth center in the future!

Last night I went to a Mother's Blessing ceremony for my friend and fellow doula and midwifery student, Brooke. This is her third pregnancy in four years; she is ridiculously fertile and has very fast labors. I didn't know her before her last Mother's Blessing, but apparently everyone gave her candles which she never even had time to light during the labor. It was less than two hours. We all joked that if she doesn't get a chance to use the candles with this labor, she can save it for the next one. HA. Soon she will be tandem nursing three children. Go Brooke!

The Ethics of Formula Companies

Copyright Erika Gebhardt, 2009. May not be reprinted without permission.

In 1981, the United States became the only country to vote against the World Health Organization’s International Code of Marketing Breastmilk Substitutes. Although the United States eventually supported the Code, little has been done in nearly thirty years to enforce it and the United States lags behind many countries who call for more strict regulations on the sale and promotion of formula.

Formula companies market relentlessly without concern for health ramifications, as each pregnant and postpartum woman is a possible consumer who will bring in revenue. Once a mother’s breastmilk dries up, she is dependant upon that substance to nourish her baby for up to a year or longer. Although the Innocenti Declaration of 1990 encouraged all countries to maintain the Code by 1995, in practice, the Code is rarely enforced.

The Code’s main provisions include no free samples to mothers, no advertising, and no gifts or personal samples to health care workers. With regards to the last rule, formula companies circumvent it by donating samples to health care organizations – such as hospitals or medical offices – rather than specifically targeting health care workers. These gifts are not just the formula itself but also helpful parenting tips (including the “breast is best” adage), diaper coupons, and, more often than not, a free diaper bag. These tactics are particularly manipulative with regards to lower income families – especially non-Hispanic black women, who have the lowest breastfeeding rates in the United States – as the free gifts are an important aspect of their birth experience. However, the increased financial cost of uninsured mothers receiving formula from WIC burdens all taxpayers. The gifts may be free, but the long-term ramifications are costly.

Forced not to advertise directly, formula companies came up with a brilliant trick: “follow-up” formula for babies who have been weaned. As follow-up formula targets mothers of babies who have been weaned, its promoters claim freedom from following the Code’s guidelines. Unsurprisingly, manufacturers advertise this formula for babies as young as three months. This type of formula – which has the same name as the infant formula, making it nearly indistinguishable from the infant version – is marketed with pictures of cherubic, smiling babies drinking formula from bottles.

The next marketing ploy used by formula companies is promoting breastfeeding. Since formula companies cannot state that formula is superior to breastmilk, they must concede that breastmilk is best and advertise as such. However, these pamphlets, books, and videos often contain advertisements for the formula company. In addition, many depict breastfeeding mothers as exhausted, nursing in a dark room by themselves. This is a marked contrast to the smiling woman bottle-feeding her chubby baby, surrounded by family and friends.

When trying to market formula that is nearly as good as breastmilk, formula companies have again damaged babies and mothers. Specifically, formula companies have added laboratory-produced oils that contain DHA and ARA in order to compete with breastmilk, which naturally contains both fatty acids. However, the DHA and ARA found in formula are extracted from fermented algae and fungus, via hexane, a solvent known for being neurotoxic. Formulas marketed to contain DHA and ARA only contain 40-50% of each fatty acid, with the rest made of components not found in human breastmilk – resulting in diarrhea in babies who consume this formula.

The most conclusive evidence that formula companies place profit above health comes from the Philippines, where three large United States-based companies – Wyeth, Abbott, and Mead Johnson – attempted to block the introduction of formula marketing regulations similar to the WHO code. In fact, the three companies sued the Philippine Government in order to prevent ethical marketing guidelines for formula. The WHO estimates that 16,000 babies die in the Philippines each year because they are not adequately breastfed, and that 90% of babies under six months who die are bottle-fed and fed foods other than breastmilk.

Serendipity: Coming soon to a computer near you!

So, in my last birth-related post I blogged about wanting some more experience breastfeeding, or at least wanting to learn more about breastfeeding, particularly about troubleshooting. I was even thinking about taking the Aviva Institute breastfeeding educator class. Today I was going through my AAMI emails and found that lo and behold, Christine, my AAMI mentor and real-life friend and fellow apprentice, is actually teaching a course on this very subject! Fantastic. It's free for AAMI students -- and only $10 for non-students. I love when life is serendipitous like this. It's an online class, and I think I can attend it, even with my crazy schedule. (Christine, btw, is an IBCLC and a RN, and she's thisclose to being a midwife. And she's also an amazing woman!)

I'm working my way through Helping Hands, the Apprentice Handbook, which was written by Carla, the director and founder of AAMI. It's pretty interesting. It's a workbook, and a chance for me to record my thoughts and experiences with midwifery. It's really good for helping me to answer the questions, Why am I in midwifery school? How am I going to complete midwifery school? What will I do when I complete midwifery school? What are my goals and hopes for being a midwife? How will this affect my life? How will this affect my family?

Because Boobs are the Best!

One aspect of midwifery education/experience in which I am sorely lacking is breastfeeding. Of my four children, I only breastfed one for longer than a month, and that was Sydney. (I will explain the whys later.) Sydney and I had not a single problem during our breastfeeding relationship, and while I'm really happy that our experience was so positive, I realize that I lack the ability to address problems based on my own experiences! She had num-nums for about a year and we both loved it.

I think that my best personal characteristic for being a childbirth educator and doula and midwife-to-be is my vast array of birth experiences. I've given birth in a hospital -- in an O.R. -- in a birth center and at home. I've given birth with an epidural, a shot of narcotic, and medication-free. I've experienced labor starting with contractions that got longer, stronger and closer together, and labor that started with my water breaking. I've experienced a labor that didn't start for nearly 2 days after my water had broken, which really tested my patience and my faith in my body! I've had one baby born with a cord around her neck. I've had to change my birth plans based on needed medical care. I've had a great birth experience and not-so-great birth experiences. I think those experiences are my greatest personal assets to a client.

But not so much with breastfeeding.

First, a confession: I had a breast reduction when I was 16, not thinking about ever breastfeeding in the future, or how having a reduction would affect it. Then, when I was around 20, I had a boyfriend who had a baby that was 100% formula fed in bottles. She was a sweet happy baby, and that was my first experience with seeing a baby eat. Later I had a friend who had a baby (my first doula client) and she breastfed for a year, but she experienced overwhelming feelings of sadness when she first breastfed -- there's a word for it, but I can't remember it.

So, when I was a single mom-to-be of twins, my focus was mainly on having a vaginal birth, and not so much on breastfeeding. I went to a La Leche League meeting, but I just didn't give breastfeeding a lot of thought. I had been told by my doc that my babies would likely be in the NICU, and they'd be tube-fed high-calorie formula if they were preemies. (This was all determined by the fact that they had Twin-to-Twin Transfusion Syndrome and would likely be born prematurely.) I could breastfeed if I wanted, and I could pump and store milk, but they would be tube-fed and then bottle-fed before they could go home from the NICU. And I just didn't really think about the transition and how difficult it would be, and whether or not I even believed I could get them 100% breastfed because of my reduction. So, I pumped and bottle-fed them for about three weeks, at which point my level of exhaustion was so great that I made the informed (or so I thought, but looking back I was woefully uneducated) decision to formula feed. Pumping and feeding IS exhausting; someone on motheringdotcommune once calculated that she spent an extra 40 hours per week on pumping and feeding -- 40 hours that she didn't spend with her baby or family.

With Allegra, I had much better intentions. I dutifully breastfed. It was painful and I didn't give my breasts much time to heal. I didn't give myself much time to bond with Allegra either -- I was hell-bent on not taking any time away from Rory and Tiger, and it was to my own detriment and to the detriment of my relationship with Allegra. (In retrospect, I wish I'd done a "babymoon" or a "laying-in" period with Allegra, which I did do with Sydney. It's basically a time just to focus on breastfeeding and bonding with your newborn. It's lovely.)

At three weeks after Allegra's birth, I developed this terrible pain in my stomach, and I went to the ER and had emergency gallbladder removal. I came home the next day and we went back to breastfeeding. But after that, I developed a post-op infection and spent the next week in the hospital, without Allegra. The hospital told me I couldn't have Allegra with me because hospitals are full of sick people (aside: if it's so full of sick people, why is it okay for babies to be BORN there?!?!?!) and my doctor suggested I dry up and stop breastfeeding her.

I was devastated, and I followed his advice, but I was so incredibly sad. Later I tried to re-lactate, but it was just too difficult. I really tremendously regret following that advice, and saying okay to Allegra not being with me in the hospital. It was such wrong advice on so many levels. I wish so much that I'd had some of the friends I have now -- friends who would have provided me with a pump and support in continuing to breastfeed, friends who might have even nursed Allegra themselves so she didn't forget how to breastfeed!

But Sydney was my baby where I really tried to do everything "right," and that included breastfeeding. I did a laying in with her for two weeks, during which we cuddled and breastfed and I caught up on "One Tree Hill," that terrible show on CW. By the time Dustin went back to work, I felt comfortable with my new baby and with breastfeeding her. I felt more than comfortable -- I felt bonded and attached. It was a fantastic feeling. I can't even really describe it. She looked at me, drunk on milk, and I look back at her, drunk on oxytocin. We were a pair.

I would have liked to breastfeed her longer than a year, but I desperately needed to have weight-loss surgery. I was morbidly obese and was starting to experience some common comorbidities with morbid obesity. I didn't want to put it off for another year.

So that's my story on my breastfeeding experiences: three kids for about three weeks, and one kid for a year with no problems. I never had any mastitis, let-down problems, engorgement, over-supply, infection, thrush or any other types of problems. I can spot and possibly correct a bad latch, but I don't have the personal experience with breastfeeding issues that other CBEs and doulas and midwives have. And I'd like that experience.

I know there are some doulas and CBEs and midwives who don't even have children, who have never been pregnant or breastfed. I also know that anecdotal experience is not the entire picture. There are tons of aspects of midwifery that I've never seen, things that are probably even considered common. I haven't had a c-section and I don't particularly want that experience! But this is something I can learn about.

Aviva Institute, where I took my CBE class, offers a three-week Breastfeeding Educator course, and I'd really like to take it.