Tuesday, June 23, 2009

Accidents of Birth

M. and I just returned from 12 amazing days in Vietnam. We marveled at the lantern festival in HoiAn and were overwhelmed by the street life in Hanoi. We ate well, swam in warm water, bowed before Buddha, and visited Uncle Ho at his Mausoleum. But the undisputed highlight of this trip was an incredible over-night home-stay with a H’mong family, high in the green rice terraces of the northwest.

With the exception of two dim light bulbs, a mobile phone, and a few other household items, when we stepped over the threshold of their home, we could have been stepping back several centuries. It is a small structure constructed of sturdy hand-hewn boards and a metal and tarp roof. The floor was packed earth, and the “stove” was a pit in the floor with a metal tripod. All of the furnishings (a couple of bamboo platform beds, a low table, and several very low stools) appeared to be handmade. There was no latrine, just Mother Nature. We slept in their grain loft, next to big bags of rice that they’d grown and would sustain them throughout the year. Three hogs were in a pen just a few steps away and piglets and chickens wandered about.

Also wandering about were four small children, all under the age of 12. (There were two older children in the family as well, a daughter away at school and a son in the army.) They all wore what in the U.S. would be considered dirty rags and no shoes. Two of them had terrible coughs and regularly spit gobs onto the earthen floor. The littlest guy had some kind of splinter in the sole of his foot, which his mother attempted to extract with an unsterilized needle before we offered the tweezers and some antibiotic ointment from our little travel first-aide kit.

We went to visit the home of our other guide, and it was quite similar. (It should be mentioned that we did notice a satellite dish and a latrine at at least one other home in that village!) This home appeared to be part of a larger family compound with several buildings scrunched together on the same small, relatively flat piece of land on the hillside. Again, there were a half-dozen very small, dirty – and adorable – children racing around. We couldn’t communicate well enough to figure out who were siblings, and who were cousins, and who were just extended clan. But we did learn something that really moved us.

We were asked not to go back to part of the compound because the extended family had gathered there to mourn the death of a two-year old niece of the guide, who had passed away the day before. I think we understood that the little one had been sick for a few months, but that her death was unexpected.

What stood out to me is that this situation was probably not all that unusual for these people. More than 23 of every 1,000 Vietnamese children die before their fifth birthday. (Vietnam’s rate is between Albania and Panama. In the U.S., it’s 7.8 children.) This is actually better than I expected. But given the extreme poverty and remoteness – and apparent lack of awareness regarding germ transmission, as evident by the spitting and splinter removal - of the village we visited, I suspect the rates there are much higher than the national average.

During all of our visit to Vietnam, not just in this H’mong village, we saw so many children, in such tough conditions. I hasten to add that none of them seemed to be suffering. But so many of them were working – in the fields, on fishing boats, in the markets, or in the family’s restaurant, hotel, or shop. And we observed many, many young children who seemed to be in charge of their younger siblings, such as girls who appeared to be five or six carrying infants on their backs, with no adults in sight.

I thought a lot about poverty while we were in Vietnam. Does being desperately poor make these people unhappy? Certainly not. But does it limit the possibilities for self-determination? Absolutely. And why do poor people seem to have so many kids? Then again, why shouldn’t they? Does having one more mouth to find make them any less capable of parenting well? Unfortunately, in many circumstances, I think it does. So often, poor parents are just too overwhelmed making ends meet to have the wherewithal to provide the kind attention and support their children need to thrive. I’m not saying that there aren’t wonderful parents with very meager resources. I’m saying that it must just be so much harder when you are also struggling to put food on the table.

Of course, I was also thinking a lot about adoption and the increased opportunities we could provide for a Vietnamese child. But one of the ethically thorny things about adoption – domestically as well as internationally – that has been niggling at me is the likely role that a wide disparity in incomes often plays in placement. If I wasn’t comparatively rich, would I be able to adopt (even adoption through foster care requires a steady income, a safe home, etc.)? If certain birthfamilies weren’t comparatively poor, would they even be considering giving up their child? Am I okay with that?

I’ll conclude with what I feel is a revealing anecdote. M. and I have occasionally gone to support groups coordinated by our agency. At the last meeting, one of the fathers said that he thought it was a real red flag when a potential birthmother indicated her motivation for placement was “because she had other things she wants to do.” He felt this was a horrible reason. I told him I thought it was a great reason, and asked what he thought would be a more encouraging answer. He said he’d feel more comfortable if she was placing because she couldn’t afford to have another baby. I wondered (perhaps more out-loud than I should have) how things might be different if, rather than the agency, this birthmom received our sizeable fees directly.

I’ve wandered a long way from telling you about our trip to Vietnam. I think it is because I returned with more than just many of M.’s incredible photos, some beautiful H’mong textiles, and a touch of jet lag. I have returned with an overwhelming sense of gratitude for being born when and where I was to my wonderful, upwardly mobile family.

Thursday, June 4, 2009

A Few to Spare, Perhaps?

Since late January of this year, I have joined millions of other Americans in an absurd obsession: an irrational fascination with Octomom. When I first heard the announcement that a woman had given birth to healthy octuplets, I didn’t realize that she would touch my life in so many ways.

My immediate reaction was, “Wow! Clomid overdose! Someone wasn’t being appropriately poked and prodded.” Clomid is the “gateway” fertility drug, often doled out before there is any real diagnosis of the problem conceiving. Its main function is to boost the number of eggs that ovulate during each cycle. Responsible doctors and clinics will require their Clomid patients to come in on a regular basis (like every other morning during some weeks, in my case) so that their egg follicle development can be monitored closely via vaginal ultrasound. This monitoring has a couple of very important functions. First, it should reveal when there is a follicle ready to ovulate – thereby indicating a good time to meet up with sperm, either via Intra Uterine Insemination (IUI) or the other, much more romantic way. Second, it should show how many follicles are ready to go.

In most cases, if there are more than two or three follicles of a certain size, health professionals will cancel insemination and strongly discourage intercourse. The most catastrophic side effect of Clomid and other follicle stimulating medications like it is multiple births. So, when I heard about the octuplets, I assumed that either someone had made a huge error in counting developing follicles, or the mother had ignored the advice of her doctor. (Of course, we’ve now learned that I was wrong about this; Octomom conceived through the reckless implantation of at least six embryos during IVF, while the best practice for a woman her age is implantation of no more than two or three.)

How can I call eight healthy babies a catastrophic side effect? Well, of course the births of healthy multiples aren’t that for the parents who so desperately want children. In fact, I bet many subfertile parents of twins and triplets feel like they hit the jackpot. After all, if they’ve always envisioned having more than one child, the prospect of repeating treatment for a subsequent baby must be daunting, and multiples are often welcomed as an “instant family.” (In some circles, boy/girl twins are considered the gold standard.)

But I’m not talking about twins, or even triplets (although study after study shows that even their gestation can be very dangerous, for them and for their mothers). I’m talking about higher order multiples, which have skyrocketed in the last couple of decades and are a hot topic among fertility specialists and medical ethicists.

So when I first heard about Octomom, it was with some sense of connection and gratitude that I had received more responsible care than I supposed she had. Then I learned that her children were born at the same hospital where we went for our treatment! It came out later that she arrived at Kaiser Bellflower already very pregnant, but for awhile there, I wondered if it was MY docs who’d goofed!

My sense of a bizarre personal connection was further strengthened when I learned that she lived in the town to which I’d just moved. In fact, her mother’s home, where she was reported to reside, was less than a half-mile from my office. When we learned Octomom’s name, I discovered the weirdest of all my personal connections. Her last name is what we call our precious cat! (Maybe I’ll share how Suleyman got his name sometime. For now, I just want to be sure everyone knows he got it long before Octomom’s 15 minutes of fame. As proof, his name is spelled differently than hers.)

These coincidences piqued my interest. They also generated a lot of conversations around me, many of which I found fascinating, and some of which I found very disturbing.

To be sure, this case of a woman - who already had six young children with the help of a sperm donor and a fancy Beverly Hill doctor, who was manipulating public assistance - brings up controversial issues about reproductive freedom, the role of government intervention and support, medical responsibility and liability, privacy, and good parenting.

One interesting conversation I had was about selective reduction, which some would say is the recommended medical procedure in pregnancies with high order multiples that removes one or more fetus so that others can thrive, and to prevent sometime life threatening complications for the mother. Others would say it is the heartless murder of innocent life. At the risk of getting overly political here – and even worse, spouting off about something I’ve never been faced with, thankfully – to me it seems ironic that many of the people who become pregnant with multiples but refuse selective reduction for religious reasons are the same people who relied on extreme medical technologies to achieve conception and pregnancy. Why does Octomom think it was God’s will for her to have eight babies at once, but not His will for her to be infertile?

Perhaps the most interesting – and heated – conversation I got into about Octomom was with another waiting adoptive mother. We began by only half joking that it seemed she should share her good fortune with us, and that we’d be glad to take a few of her children off her hands. It led to discussing whether the government has the right – or the responsibility – to remove some or all of Octomom’s kids. And then in meandered even further, to whether the government has the right – or the responsibility – to prevent Octomom and other parents deemed “unfit” (by whom?) to have more children. Yes, I agreed with my friend that it is horrible that abusive/drug addicted/homeless women sometime seem to get pregnant without any concern about the difficult lives to which they have almost certainly doomed their progeny. But I vehemently disagreed that it is the role of my government to sterilize such women. (I must say, I believe I have more faith in my government than most Americans; I feel that – for the most part – it is still a democracy of, by, and for the people. But I suppose I don’t trust my fellow citizens enough to make such deeply personal reproductive choices. And I imagine most of us can identify atrocities committed by leaders of nations who were democratically elected.) This increasingly difficult chat with my buddy ended when I blurted out a somewhat non-sequiter: “So, you don’t want your tax money to be used to ensure everyone has access to good health care, including safe abortions. But you do want it to be used to eliminate the opportunity of parenthood to anyone who’s made some bad choices at one point in life?!”

By far the hardest things for me to hear about Octomom, though, have been the angry statements that she and her family should not receive any further support. To me, what gets so lost in the outrage about Octomom are those eight (errr…make that fourteen) innocent little children.

All of the vitriol does not help them. And they need help. As distasteful as it may be to swallow, ensuring that their likely unstable mother has the resources to keep them in school, receiving attentive care, eating well, etc. is probably the best chance they have in life. Unless she is truly neglectful or abusive, removing them from her home and placing them in (and out, and back in to) foster care - separating them from each other and their extended family - would not improve their lots in life.

Truly, I wish Nadya Suleman and all of her many children the very best. Perhaps I’ll invite one or two of them over for playdate someday.