Teenage and Unwed Pregnancies

It's hard to go to work every day and see the things that I do and not be affected. I'm sure other people find themselves in this situation. There are a lot of careers that can wear emotionally on a person after some time, like, I don't know, prison jobs, counseling/therapy, or working with any underserved population. Sometimes I feel like I'm working against unbeatable odds. Can I really make a difference in the lives of the people I care for and counsel on a daily basis? Is there anything powerful enough to break the horrendous cycle in which some of my (young) patients are so deeply entrenched?

Kevin gets to hear a lot of my crazy stories. We commonly talk about how grateful we are to have been raised in the gospel, and how that single fact makes our lives so dramatically different from those I come across at work. We also appreciate that it's not only the gospel that has given us such an advantage over these women, but being raised by a mother AND father who taught us to value and respect the power of education, sobriety, sexual abstinence until marriage, civil obedience, and service to our fellow men. Those priniciples can be taught without any reference to religion or a higher power.

Maybe we midwives see a disproportionate number of disadvantaged women in our practice because we don't turn anybody away. We also have a lot of disadvantaged or teenage pregnant patients who come to us because their friends/family members referred them to us. We have a reputation for spending more time with our patients, listening to and acknowledging their problems and concerns, treating them with respect regardless of their situation or status, and offering support. Our prenatal visits range from 30 mins to 1 hour long because we believe in the value of spending more time educating our patients to prevent complications, rather than ushering them quickly through office visits to end up fixing problems later. Most busy OB practices allot 10-15 minutes for a routine prenatal visit. It's a smarter business move, but not necessarily better for the patient. I would estimate that over 75% of our pregnant patients are on Medicaid. I think it's important that the government provides a means for pregnant women to receive healthcare, but I think there is a staggering influx of pregnancies that end up being funded by tax dollars which could and should have been prevented.

Here's a snapshot of a few typical pregnant patients in our practice:

--A 15 year old girl who is an average teenager, states she has never drunk alcohol in the past, but last weekend her cousin (also a teenager, but already a mother) invited her to go to a party out of town with her. This girl makes a bad choice to try alcohol for the first time, gets drunk, and consents to have unprotected sex with a boy she had never met before. Now she is in my office crying because she's pregnant. She doesn't even remember the father's name and has no way to contact him. She's not ready to be a mother, but she's not going to get an abortion. One stupid decision on one night has changed her life forever.

--A 23 year old single mother of two gives birth to twins. Her two daughters are 4 and 2 and now she has two infant boys. She has myriad mental health issues including bipolar disorder and schizophrenia, but somehow manages to care for these four children, reporting only sleeping about 2 hours per 24 hour period. She was employed through a state assistance program with a desk job during her early pregnancy, but would continually not show up to work because it was "too hard on her body" to be sitting in a chair all day. She has complaints of chronic pain in her back, neck, and hips for which we referred her to a physical therapist. She is totally dependent on government and state assistance. She never finished high school. Her two girls and the twin boys were all conceived with different men, none of whom stayed around long enough to find out she was pregnant.

--A 19 year old woman comes in with her third pregnancy. Her first child was given up for adoption because the Department of Family Services deemed her unsafe to have custody of the child. She has a history of IV drug use and alcoholism. She has Hepatitis C. Her second pregnancy was an elective abortion because she was still using drugs and knew she would not be allowed to keep her baby. She is trying to turn her life around and has been sober for 6 months now. She is about 6 weeks pregnant at her first visit. Four weeks later, she states she would like an abortion. She broke her longest streak of sobriety and decided to stop going to her chemical dependency program. Two weeks later, after a domestic dispute with her ex-husband which was reported to police by her neighbors, she states she is moving to Illinois to live with her ex-husband's mother and is going to try to keep the baby. When asking us to fax her records to her new provider in Illinois, she states, "Don't send any paperwork or notes about my decision for abortion." What else does she plan to try to keep secret from these people in Illinois?

Now here are some statistics that I found in a little research I did yesterday. These numbers are from the Center for Disease Control's National Center for Health Statistics.

--After a 14 year downward trend in teenage (age 15-19) births from 1991 to 2005, there was a significant (3%) increase in the number of U.S. teen births from 2005 to 2006. Data from 2007 are still being compiled and analyzed and were not included in this report.

--Unmarried childbearing has risen 20% since 2000, and reached a record high in 2006.

--In the 25-29 year age group, unmarried births increased by 10% from 2005 to 2006.

What impact is this having on society? A classmate of mine at Georgetown did a lecture on teen pregnancy during our Master's program. In a 20-year retrospective study of children of teenage mothers:

--Children of teenage moms had increased rates of school dropout, depression, incarceration, and public assistance compared with children of moms aged 20 or older.

Are you starting to get a glimpse of the sad state of childbirth in our country? And teenage and unwed pregnancies are just one facet of the GINORMOUS problem. I'll probably post on a few of the other contributors in days to come.

This is such a difficult cycle to break. Most of my pregnant patients that come in with their first pregnancy at age 14, 15, or 16 are themselves daughters of teenage moms. A lot of their mothers were still children when they were born, so these girls were raised by their grandmothers. One great thing about grandmothers is that they have a tendency to spoil and/or not discipline their grandchildren. But when a grandmother is in the role of mother, the child seems to grow up under less supervision, less scrutiny, and is not taught about choice and consequences. The nurse that works in my office was raised by her grandmother and she said that is a very representative picture of her growing-up experience.

I don't know how much of a correlation there is, but the daughters of teenage moms also seem to engage in sexual activity at a very young age. Maybe it has nothing to do with the age of their mothers. It could just be a gradual cultural change. Most of my non-pregnant patients that come in for health screening or general health/gyn problems, when asked their age at onset of sexual activity, give an answer somewhere between 12 years old and 18 years old. Very VERY seldomly do I have a woman who tells me she initiated sexual activity after the age of 20. TWELVE YEARS OLD, people! Some sixth graders are twelve years old. By the time most girls here are getting to middle school, they are starting to have sex. By the time they're in high school, they and their friends are all getting pregnant.

Whenever my colleagues or I see a patient that comes to us for prenatal care who is married, planned pregnancy, and has at least one college degree, we take special care to mention it to the other providers in our office because it is such a rare thing. Of the 50 or 60 pregnant women I've met since starting work here, fewer than ten have been married. I can count the college graduates on one hand.

How are these girls going to learn to have respect for the power of procreation? I wish I could help them change their immature way of thinking, but that is a change that needs to take place in the home. I just don't see that happening here, now or anytime soon. These young girls are so flippant about sex. One of the most mind-blowingly immature conversations I have with teenage moms at their first pregnancy visit goes a little like this:

Me:"So was this a planned pregnancy?"

Girl and/or boyfriend: "No, it took me completely off guard."

Me: "So were you using birth control at the time?"

Girl: "No."

Me: "Condoms?"

Girl: "No."

Me: "So, this pregnancy was unplanned, but not prevented."

Girl and/or boyfriend get puzzled look on face at first, think for a second, then smile and say: "Yes! I never thought of it that way. That's exactly what it was."

HELLO??!?!? If you're having unprotected sex, you are asking to get pregnant. If you're having sex at all, you are opening yourself to the possibility that you will become pregnant. Even if you're using birth control, if you are engaging in sexual activity, you MUST understand that there is a possibility you can become pregnant. Where is the logic? Where is the OBVIOUS cause and effect chain of thinking? It's not there. Nobody is teaching these girls. The boys have also learned from society that it is okay to sleep around with multiple girls, dispensing sperm like candy, with no thought for repercussions and no sense of responsibility to their offspring.

I want to be involved in some sort of education program for these kids, but even that seems like it would be futile. They need their parents to teach them, but most of them only have one parent who is not even any more mature than the child is. It is so sad. We need to teach girls about the serious and life-long consequences of deciding to become sexually active at such a young age. When I hear the arguments for abortion and a woman's CHOICE, it screams to me that our society has it all wrong. The choice that a woman should be making is the choice of whether she is financially/emotionally/developmentally ready to bear and raise a child. If the answer is no, she should abstain from sex as this is the only 100% effective method of birth control. Sex is not a hobby, it is not an after school activity, it is a sacred power given to us from God through which we can create human life. Even if a woman doesn't believe in God, she should still revere the fact that her reproductive system has the power to nourish a human body and use it appropriately. A girl or woman who chooses to have sex needs to be taught the seriousness of the possible consequences. We need to reverse the rapid degeneration of the sanctity and/or gravity of the powers of reproduction.

Off soapbox.

Home Birth Revisited

Thanks for your thoughts, everyone! (See about three posts down.) Now it's my turn to share my stance on home birth.

Home birth is an excellent and safe method of childbirth for a woman with an essentially normal pregnancy and few to no risk factors. I think most people's concerns with home birth are that complications cannot be dealt with in as timely a manner as they might in hospitals. Here are my arguments to the contrary.

1. Any well-planned home birth includes a plan for timely transfer to the hospital should the need for surgery arise. I don't advocate home births that occur out in the boondocks, a 4-hour drive from emergency services. I understand that there are some people who opt for this, but that is a risk they are willing to take. It comes down to weighing risk vs. benefit and that is a personal choice for each pregnant woman/couple.

2. The notion of "emergency C-section" is misunderstood in a lot of instances. A woman in labor is often in such a state of concentration/anxiety/pain/distraction that her memories of birth can be quite skewed as compared to the "outsider" point of view of the health care provider. Similarly, a woman's support person, boyfriend, or husband can be in a heightened state of anxiety/worry/concern during the birth and the events leading up to it. It's a phenomenon that happens quite often that a mother or father will make a statement about something that happened during a birth that is quite inaccurate, or they will ask questions that make it obvious that they were not aware of what was happening in the moment. And that's perfectly understandable! It's a high-stress time for many people. Things happen quickly in certain instances. Birth is not something that happens every day in a typical person's experience. We as providers, who are around this sort of thing regularly, have a clearer outlook than many of the birth parents. That's why I like to sit down with my patients after births and debrief them. I give them a chance to ask questions and I review the events, interventions, and indications for interventions. It helps clear up any misunderstanding, and gives us a chance to discuss at length the things that may have happened too quickly to adequately discuss at the time of birth.

One of the most common reasons for "emergency" C-section is fetal distress. This is manifest to providers in the form of fetal heart rate decelerations on a monitor strip.

[Quick lesson for those unfamiliar: It is a sign of good fetal neurologic health when the fetal heart rate shows beat-to-beat variability as well as periodic accelerations in the heart rate. It means that the fetus's autonomic nervous system (the one that works without thinking about it) is functioning properly. Decelerations in the fetal heart rate can occur normally as reflex responses to head compression or cord compression during contractions, or if the fetus is in a position that is pinching its umbilical cord. It's hard for me to talk about fetal heart monitoring without getting too detailed, so I'll just stop there. Just know that there are 500+ page books about interpreting fetal heart monitoring strips.]

A normal baseline heart rate for fetuses is 120-160 bpm. When decelerations are repetitive, prolonged (lasting greater than 3 minutes), or especially deep (the heart rate drops below 90 bpm), these are indicative of "fetal distress". It is a strong sign that the fetus's nervous system is no longer coping well with the stress of labor, and that the fetus is being deprived of needed oxygen. If this continues for too long, the fetus can sustain brain damage because of the lack of oxygen and/or the acidotic state it enters (blood pH becomes lower than it should be).

In a hospital setting, it is most often the labor nurses that are continually watching the fetal heart monitor, looking for non-reassuring signs like decelerations. When decelerations are first noted, the labor nurse will usually ask the mother to change positions or roll to her other side if she is in bed. This resolves a large number of decelerations. Other things that might be done in a hospital: starting an IV and giving extra fluid to the mother, putting an oxygen mask on the mother, or placing an internal monitor on the baby's head to more accurately read the heart rate. If the decelerations continue after all of these interventions have been done, the decision may be made to deliver by Cesarean. The point is that in many, if not most cases of "emergency C-section" for fetal distress, there has been a period (sometimes hours long) of warning before the decision is made to do a C-section. If a woman is laboring at home, her midwife or birth attendant is well trained in monitoring labor progress as well as ausculatation of the fetal heart. S/he will recognize early warning sign and his/her threshold for tolerating non-reassuring signs is much lower than it would be at a hospital. At the slightest sign of concern, the woman could be transferred to a hospital for closer monitoring, and to be closer to an operating room should the need arise.

I think a lot of women who have delivered by "emergency" C-section are told that she and/or her baby would have died if the decision had been made as little as five minutes later. This makes the mother/parents feel very grateful and relieved, as they are given the impression that they narrowly escaped death. And now there is a healthy mother and a healthy baby, and that's all that matters. I agree that a good outcome is always something to celebrate. I also feel that people are not informed of the several minutes (sometimes hours) leading up to the decision to do a Cesarean, during which a low-risk woman laboring at home would have plenty of time to be transferred to a hospital.

There are reasons for Cesarean section that are truly emergencies and are life-threatening with little advance warning. Some of these are placental abruption (the placenta separates before the baby is born), uterine rupture (the uterus gets a hole in it), or umbilical cord prolapse (the umbilical cord comes through the birth canal before the baby does). In the instance of home birth, these risks are miniscule because of the screening that occurs to qualify a woman for safe home birth. Abruptions happen most frequently when labor is induced. Inductions do not happen at home deliveries; labor begins on its own. Uterine rupture most often occurs when an old C-section scar is reopened by the force of labor. VBACs (vaginal birth after Cesarean) are most commonly done in hospitals with an in-house surgical team ready in case of this complication, and even then, rupture is extremely rare when labor begins on its own. And a baby with umbilical cord prolapse can be kept safe during transfer from home to a hospital. These are also most likely to happen when the water breaks and the fetal head is not well-applied to the cervix, or the head is not the presenting part, and is a rare complication.

[Whew! I could write forever... Take a minute to go get a snack or use the bathroom if desired.]

In general, over the past 50 years or so, our society has completely medicalized birth. No matter that women have been successfully giving birth and populating the earth since the beginning of time. Sure, we can save more of the premature babies and we can do surgery for women whose babies don't tolerate labor or are in a position that is not conducive to vaginal delivery. I think that's wonderful. But we still have a CRAPPY infant mortality rate. People probably feel that they are getting the best labor and delivery care here in the U.S., but the truth is that even though we spend more money than anyone else in the world on pregnant women and babies, we are not getting the best outcomes. In fact, we are second to last among developed countries! There are European countries that have dramatically more home births than ours (or consider home birth the norm) and have much better birth statistics than we do. Just because we have technology for women whose births are medically complicated, doesn't mean that it should be used for even the normal, uncomplicated births. In fact, the widespread use of continuous fetal heart monitoring has only increased the rate of vacuum- and forcep-assisted vaginal births and Cesareans, and has not improved maternal/fetal outcomes compared with intermittent auscultation.

About 1/3 of births in this country are by Cesarean. And a LARGE number of these are unnecessary. Don't even get me started on C-sections. Midwives have anywhere from a 5-10% C-section rate as opposed to the national statistics. Our birth statistics and outcomes are better than those of obstetricians even after taking into account the differences in patient population. Shouldn't midwives' wonderful statistics reassure our society about the safety of low-intervention hospital, home or birth center births? Most midwives actually do deliveries in hospitals, but our philosophy is to intervene with normal labor and birth as little as possible. Low-risk women have much smaller chances of developing life-threatening complications during labor, and those who choose to give birth at home are actually saving tremendous health care dollars! If we get out of the mindset that all births must happen at a hospital, and encourage the low-risk, healthy mothers to deliver at home or in birth centers, imagine the money we could save, and how our birth statistics would actually improve!

There's a lot more I want to say, but I'll stop now. There are so many good research articles out there. I think it's so important to try to educate ourselves and our daughters about the options for childbirth and start reversing the medicalized view of childbirth, and start revering childbirth as a normal part of a woman's life again. Pregnancy is not a condition that needs to be treated.

My version of the wedding guest book

You may be asking yourselves, "What does Jamie do with her life when Kevin is not around?" Or you may not even care, which is more likely. In case you're bored, I'll tell you. I do pretty much anything that reminds me of Kevin or involves getting ready for our wedding, etc. I'm a bit obsessed with the fact that I'm getting married in 3 months, but isn't that how a bride-to-be should be? (Nod head now.)

This is an idea I got for our wedding guest book, and the beginning stages of the idea came in the form of sketches on scratch paper during Sacrament Meeting -- hee hee. It was going to be a quilt, and the guests at our wedding would write their names on oversized buttons which would be incorporated into the quilt, and displayed as a wall-hanging in our home to remind us of the special day.
I made friends with the local quilting store (The Silver Thimble) manager, who talked things through with me, listened to my idea and helped me decide how many yards of each color of fabric I would need. I told Kevin that this woman is to me what the local fly shop manager is to him. The idea evolved little by little, and I took pictures of it in its several stages.

I sewed the green fabric around the edges of the off-white fabric to make a border and then colored a black line all the way around the inside with black conte (like a soft pastel mixed with a crayon). It needed a little more "pop". I used the small black and cream floral print fabric to make the corners more interesting, and colored behind each piece with charcoal before hand-sewing the pieces to the background.

After comparing a lot of fonts on the computer, I chose one that looked like the perfect blend of casual and cursive, printed it off in a very large font and then traced it onto the fabric with permanent marker.

Then I decided it needed a bit more shading so I filled in more of the white space with some charcoal, and added our wedding date.

The friendly staff at Triple S Building Supply (Service, Savings, Satisfaction) helped me figure out the best way to mount this piece of fabric. I decided I didn't want to quilt it anymore, but to stretch it around something like a piece of wood. They made the genius suggestion of foam. It's stiff, but lightweight. That meant I could secure the fabric to it with straight pins instead of worrying about hammer and nails or a staple gun.

There's a closeup of one of the corners after having the fabric trimmed and pinned to the foam. The only thing left was to cover the edges for a clean, finished look.

Thanks to Ginn at JoAnn Fabrics, I decided on a satin ribbon and upholstery tacks. The ribbon is duct taped to the back of the foam, then wrapped around the edges and pinned to the front with black upholstery tacks.

And the finished product (minus the buttons) -- which looks crooked in this picture, but it's only because my camera has a wide-angle lens and if you take pictures too up close, it has a fish-bowl effect. Now it just needs to be hung up on a wall in my apartment. It's part of the home makeover I'm doing before Kevin comes to live with me in December. Yay!

84 more days 'til the wedding, but who's counting?

Out with the blue, in with the new...

This blue beauty represents the nicest bed I have slept on in the past two years. It's an Aerobed, the cadillac of inflatable beds. Unfortunamente, when I was moving this bed from my storage/spare room to my bedroom approximately 3 weeks ago, I bumped it into the corner of my kitchen counter which happened to be uncharacteristically sharp! The SHHHHHHHHHHH of air escaping from my once-firm-and-supportive air mattress was echoed by the sound of a good night's sleep escaping from my life. What compounded the problem was that my backup air mattresses, which I had been sleeping on since September 2006, had recently lost their perkiness too, subject to slow leaks. Grrr.

Many attempts with rubber cement and duct tape failed to remedy the situation. I would go to sleep on a seemingly well-patched mattress and wake up being the filling inside an air mattress taco. Yum, tacos. Ouch, muscles. Why, you might ask yourself, was Jamie sleeping on air mattresses for two years?? Well, she is a nomad, and thanks to her reluctance to buy large pieces of furniture while living on the east coast, she was able to make the cross-country move back to Utah with all of her earthly belongings fitting inside her meager 2-door Ford Focus! A fact she is quite proud of. So anyway, this story has a happy ending. After hearing of my plight, the future in-laws decided to buy me and Kevin our wedding present early -- a new queen size bed! This is the first bed I have ever owned.

(I've lived in a lot of furnished apartments during my college years.) My bed shopping experience was pretty fun. I kept calling Kevin to give him the updates, "Well this one is pretty comfy, but I think it's not supportive enough" and then, "Ooh, this one makes me want to take a nap right now. That's a good sign, right?" He was really cute. Too bad he doesn't get to enjoy his half of the present until December!

Thank you, thank you, thank you a million times, Vern and Cheryl!

Visit Toxi-world!

For those of you unfamiliar with the funky town in which I reside, my colleague told me about this video that I think speaks volumes.

Now remember, this is two years old, so Butte has come a long way since then ;)

Home Birth

I've had a few interesting conversations with young mothers in my ward recently regarding our feelings on home birth. Then yesterday a classmate of mine from Georgetown, who is also a practicing midwife now, sent me a link to an upcoming Dr. Phil episode about home birth which looks like it will be pretty one-sided.

This is a topic that can actually get me fired up, and if you know me, you know that I am not one to be involved in heated discussions. There are a few subjects (mostly in the realm of women's health) that I am passionate about, and can defend my stance confidently because of my educational background. Politics is not one of these. :) I think I know what the majority of Americans feel on the subject of home birth, but I'd like to hear what your stance is. And, if you have time, a few comments on why you feel the way you do...

I'll tell you mine afterward, and that's fair because I'm the boss of my blog.

My welcome back to Montana

What a sweet fiance I have... He sent me this bouquet of roses for my first day back at work after our whirlwind Labor Day weekend. They were delivered to my office during lunch.

Just so you know, they smell AMAZING. And in other news, my Kevypoo is a sicky-poo. He started feeling really dizzy and light-headed on Labor Day and has just gotten weaker and weaker and is finally going to the doctor today (thanks, Brandi!). I wish I could be there to take care of him, but alas, I am once again over 2000 miles away. My poor baby :(

And he still had time to think of me and send me these beautiful flowers. What a guy. The countdown at the bottom of the blog is the longest it has ever been since we've been dating. Ugh. Pray with me that time flies!!!