Recently, I helped a mom give birth to her third baby. Carrie’s first, a daughter, lived with her and her boyfriend. Her second had been the result of rape, and was born precipitously, a vaginal breech in an ambulance on the way to the hospital. That baby was adopted by a family member. Now she was engaged to be married and happy about this forthcoming arrival.
Carrie had begun her prenatal care rather late in pregnancy, over half way through, but she had then come frequently thereafter, for a total of twelve visits. Significant prenatal issues included smoking one-half pack of cigarettes a day, mild asthma, being Rh negative, and having bacterial vaginosis that was treated. As per our protocol, we had requested her permission to urine drug screen her because of her late onset of care. She had one positive THC screen and then two negatives. She was also negative on her screen upon admission to labor and delivery. I met her at the hospital for an induction at 39.3 weeks secondary to her chronic hypertension worsening at the end of her pregnancy (pressures of 160/90-100). She had a favorable cervix and we agreed upon a plan of using Pitocin and rupturing membranes rather than using prostaglandins.
Carrie’s supportive partner was present. She did not want anyone else there, alluding to her history of childhood abuse and adulthood rape influencing her need to keep her birth experience low-key and private. She was comfortable with having me and two nurses in the room for the delivery. We got going with IV Pitocin and as soon as her cervix started to thin, I ruptured her membranes for a free flow of clear water. She was ready to push within the hour and gave birth beautifully without any pain medications, breathing her baby out in just a few minutes. Her six-pound nine-ounce third daughter had 9/9 Apgars and immediately was rooting to nurse.
At this point the baby nurse said, “I have to call the pediatrician to see if we can let her breastfeed, because of her positive drug screen in the third trimester of pregnancy.” I said, “But she had three negatives thereafter, including today.” The nurse replied that that’s the protocol and she was sorry. The pediatrician said to tell the mom that we advise against her breastfeeding, and will not allow it in the hospital. I sat down with Carrie and her partner and asked her to tell me more about her drug history during pregnancy.
She explained to me that she had been cooped up one rainy Portland day in a small area with some heavy marijuana smokers. She did not smoke it herself. She felt badly about the exposure to the baby, and felt she had made an error in judgment that day, but assured me she was not interested in smoking pot while breastfeeding, nor would she use any other drugs. I told her and her partner that given this information, and the fact that she had three negative screens, including today, I was willing to take this edict of no breastfeeding to the head of the pediatric department and personally challenge it. I assured her that I supported her breastfeeding her baby and would do what I could to assist her.
This newly delivered mom, minutes away from having birthed her child, face still glowing from her effort, vagina weeping womb blood, looked at me and said with moist eyes, “I just can’t fight any battles right now. I don’t want to have to hassle with this. I’ll give the baby a bottle until I go home” I said, “Are you sure?” Her reply was, “I don’t want you to get into trouble, Sharon.” I answered, “Look, Carrie, this is not right and I am OK with fighting it for the sake of your family, but only if you want me to.” She reiterated no, and asked for a bottle.
It amazes me, and appalls me, that in the year 2000 I work in a place where given this scenario, women are not allowed (allowed!) to breastfeed. To me, this is blatant hypocrisy, and flies in the face of both my intuitive beliefs about the best start for families as well as the copious literature on the benefits of breastfeeding.
I do not condone drug use during pregnancy or breastfeeding, including the use of marijuana. Marijuana use, in my mind however, is not the same as use of harder drugs—cocaine, amphetamines, heroin, and so on. Alcohol and cigarette use, while legal, certainly cause more harm on a widespread level than marijuana use. While I do not buy the argument that marijuana is a “natural” herb, and therefore OK or even beneficial to use in pregnancy (which has been promoted to me by a number of moms and even some midwives I know), I cannot place infrequent exposure to it as reason to disallow breastfeeding.
I find this situation hideously ludicrous and frustrating because I see it more as an issue of power and control and violation of basic civil rights than an issue of health. Let me give an example. I have gone to school, earned a degree, and been licensed so that I can deliver babies in the hospital. Because I’m the one in a white coat, I can say to the moms who come in to have their babies at my hospital, “What are your plans for pain relief in labor? Oh, you are unsure? Well, you can go natural, and I will help you with breathing and walking and massage and showers. You can have IV pain medication, which can help take the edge off your labor. The drugs are narcotics, and do pass through the placenta to the baby and can have certain side effects. Or you can choose an epidural, which numbs you from the chest down, takes the pain of the labor away, but can potentially cause certain problems. The choice is yours.”
In other words, I can help these moms take powerful mind and body altering drugs that certainly can have effects on the baby during labor and afterward, but because I have the legal right to offer these drugs, people don’t think twice about their use. I can give these moms any number of narcotics or sedatives postpartum, and they are encouraged to breastfeed by the nursery staff. But if a mom dares to self medicate due to whatever circumstances in her life lead her to find that necessary, she is penalized, not allowed to breastfeed, and usually referred to social services, which might very well include a call to Children’s Protective Services. The fear these moms go through at this incredibly vulnerable time is heart wrenching to watch.
Carrie asked to go home in twenty-four hours. The midwife following me was happy to send Carrie home then, as she felt well and was medically stable. The nursery staff told Carrie her baby needed to stay forty-eight hours and treated her in a manner Carrie told me later was demeaning and cold. The midwife said to her, “You know you have a right to go home with your baby now (who was perfectly fine), and here are the names to write letters to about your experience here.” Came and her boyfriend took her baby home “AMA,” against medical advice. I called her two days later, and she had already written the letters. Meanwhile, I went to my clinic director and clinic social worker to vent about this unnecessarily nasty situation and plan to bring it up with our medical director at our next quality assurance meeting.
I have been thinking a lot about another woman in our practice right now whom I have seen a couple of times. When we took Tina’s history, she admitted to using pot frequently. We documented this and asked her to stop, explaining why. We also asked permission to drug screen her.
The policy at our hospital is that a woman who meets certain criteria such as late onset of prenatal care, minimal or erratic visits, or recent history of drug use, is then asked if she will permit us to perform random urine drug screens. If there are three negative screens documented in the last trimester and no positives, she will be “allowed” to breastfeed in the hospital. The idea is not to be punitive or shame anyone, but rather to educate and offer treatment as appropriate to our patients, and not expose babies to dangerous or illegal drugs.
The reality for Tina is that at thirty-five weeks when I revisited this issue, she became very agitated and declined testing because she knew it would be positive. She told me she hated to come to her appointments with the midwives because we keep asking her about smoking pot, and she doesn’t want to discuss it anymore. She said to me, “I wish I had never told you that I smoked—if I had lied this wouldn’t be such a big deal, and I’d be able to breastfeed my baby in the hospital. My friends lied to their doctors, and they got to breastfeed, and their babies are just fine.” She looked at her chart that I was holding and said, “I just want to steal that chart and erase that I ever told you about it—I’m being punished for telling the truth.”
I felt awful as I sat in our exam room, at a loss of what to say to this vulnerable pregnant woman. I finally said, “You know, I’m less concerned about your smoking occasionally than I am about why you are smoking and find yourself unable to quit, when you knew months ago what it would mean in terms of not being able to breastfeed after birth. Can you talk to me about what is going on in your life that you feel the need to smoke?” So we sat and talked a long time about it and ended with me saying we would not ask her anymore about her smoking, that I would put a note in her chart—declined testing—and that she would just expect to bottlefeed in the hospital. I asked her if she would be interested in switching to a homebirth, that I could give her referrals, but she said no, she knew she wanted an epidural as soon as possible in labor. We ended the visit with her thanking me for talking about it and saying that she didn’t think she would dread coming in for her next visit. I felt sad and unsettled and wished I could figure out better how to help her and her baby.
It bothers me to know that this woman will come in soon to have her baby with our practice, and she’ll get her legally and medically sanctioned drugs and epidural for labor, and her baby its mandatory bottle. I’m left with the question, whose agenda is being met here? Is this what is best for this mom and baby?