Philosophy

Some time ago, a college student interviewed me for an article she was writing on birth alternatives. What follows is her list of questions and my responses.

 I am including it here as a way to get to know my philosophy of care and who I am as a midwife.

1. What is your role as a midwife during labor and birth? Tell us about the connection between a mother and her midwife. In your opinion, how does this differ from the role of a doctor?

I believe my role starts prenatally. About 2% of what my clients and I do prenatally are clinical – checking blood pressure, measuring baby’s growth and heart rate, etc. The remaining 98% of prenatal care within my practice is building relationship. Typically, prenatal visits last about an hour long (compared to the average six minutes with an MD) and we discuss emotional issues, nutrition, plans for the birth, etc. I offer all my clients full informed choice on prenatal testing and options in birth. This ensures that they know exactly what the risks/benefits are of any given procedure or test – and they are not told they “have” to do any of them. The only thing I ask is that they read the information to be able to make an empowered choice on these issues. Discussion around the birth is really important – how my clients and their partners want the birth to happen, what things are important to them (dad or partner catching the baby, not announcing the sex, being able to labor in whatever position they want, birthing in water, etc). We’re able to discuss various things that could hinder any of these plans and options ahead of time. This way, none of my clients are caught off guard during an incredibly vulnerable time in their life. During visits with a doctor, most women do not receive explanation of various things that are done, or even asked if they prefer certain tests or birth positions. The typical doctor visit lasts about six minutes and questions are answered hurriedly, if at all. It’s not uncommon to have a doctor falling behind in the schedule of appointments, so any concerns are usually blown off or answered impatiently. It's not uncommon for women with specific birth requests to be faced with ridicule and / or a patronizing attitude. In addition, in my practice, I am available 24/7 for my clients. They have my home number and ways to reach me directly. They know that they will see me and only me for their appointments and that I will be there for their birth. This rarely happens with physicians – it’s usually a rotation of various providers and the woman gets whoever is on call when it’s time for her birth, regardless of which she may have bonded with prenatally.

2. What aspects do you feel are most important for a successful birth experience?

Informed choice. True empowerment can only come from women becoming responsible and active in their health care. Too many times women turn over care to “the professionals” – people that supposedly have more knowledge about their own bodies than they do. Most MDs cannot offer true informed choice in care because their malpractice or practice protocols restrict what they can and cannot do in regards to plans of care. Women are not given options in pregnancy and birth – they are told that they “have” to do something or that, if they’re lucky, said doctor will “let them” do something in their birth experience. Allowing women to have their own experience and to find their own way to birth is vital as well. Too much direction is given by so many care providers – sit here, lie down here, and breathe like this. A woman’s body will lead her in ways that will help facilitate labor and ease her discomfort during contractions. Having a provider that trusts in this rule will have a positive impact on the birth – the role of a provider is to hold the space so a woman may feel safe enough to follow her intuition and her body to birth her baby. If a woman needs assistance – or a baby needs assistance – then we are there to lovingly and consciously offer our knowledge. No two women birth alike.

3. How are the father and family involved in a home birth experience? Does this differ from a father’s participation in a hospital birth?

Fathers are encouraged to be a part of prenatal care. It is imperative that they know and trust the midwife’s role in the birth, and that the midwife knows of his/her fears, concerns, and hopes for the birth. In the hospital, many partners understandably find themselves lost in the paperwork and the shuffling. By entering the hospital, they are on unfamiliar turf. During birth, very personal and intimate things happen – many fathers feel helpless and often misplaced by staff and providers. They want to support their partners, but unsure as to how this can happen and what they should do. There is a belief that he should be the “coach”, telling his partner how to breathe, timing contractions, remembering everything that was learned in childbirth education class. At home, the midwife also supports the partner. The partner is able to participate as he/she wants to. The birth of the mother's partner is overlooked in our culture. Partners often go through their own “labor” during the birth process. Some partners want to be very involved; others just want to support their partners in ways that are familiar: that of a lover, supporter, and partner, equal. They need to feel safe and not that they should be fighting off staff or procedures at every turn. At home, midwives offer the partners suggestions that they can relay to the laboring mother. We bring them food, drinks, and remind them about bathroom breaks. We take over when they need to nap. The father or partner is invited to catch the baby at the birth.

4. Are the births you’ve attended similar to the commonly perceived television birth with screaming, pain and the need for medical intervention?

I wish more TV and movie producers could see normal birth – but then again, it would appear so boring, so without drama, that it couldn’t possibly entertain most Americans! I rarely – if ever - see screaming. I see loud moaning, groaning and grunting. I see women kissing their partners during their labors. Sighing heavily. I hear the sounds of working hard – of labor and birthing a baby. These are different than sounds of fear, panic and suffering, which Idon’t hear, thank goodness! I doubt I could do this work if births happened the way they are portrayed on TV.

5. Many women, especially first time mothers, are concerned with pain. What techniques do you use to help women manage the “pain” of childbirth?

Being in an unfamiliar environment with strangers while doing the intimate work of childbirth will create tension. Our bodies, perfectly designed, respond to this tension with adrenaline. Adrenaline will not only lower our pain tolerance, it will also create more pain and reduce the effectiveness of our labors. It is our body’s way of slowing things down so we can essentially run away from the danger. Women who don’t eat or drink enough, as in hospital births where they’re restricted from eating, will also see a decrease in pain tolerance. In a homebirth, there are only a few people aside from you and your partner. You know these people very well and they know you…you have INVITED those attending. You are in your own environment, surrounded by people that love you and believe in you. You can have water – showers, bathtubs or special birth tubs – that ease the pain of labor. You are encouraged to be upright and move which often leads to relief in pain. You are not silenced – you can moan, sing, chant or make any noise that helps you with your birth process. Your partner and care providers at home bring warm hands for massage, essential oils that soothe the mind and body, and whispers of support and encouragement. These very simple things are more powerful – and more empowering – than many narcotics found in hospitals. There is a line between experiencing pain and suffering. One suffers when they are afraid, lonely, and on the defensive. Women in hospitals are routinely kept in bed, on monitors, with judgment about how long their labor may be taking. Bright fluorescent lights, strangers wanting to put their hands up inside them, and a restriction of movement all increase pain for most women. Some pain is expected in childbirth. However, the pain does not have to be intolerable or negative. Many women find that birthing their babies naturally provides them with an empowerment that carries over into all areas of their life.

6. Medicalized births depend largely on standardization and numbers. For example, in a hospital a mother may typically hear the following statements: “12 hours from the water breaking, infection can set in”; “When you’re 10 centimeters dilated you can push”; “If your labor doesn’t start back up in ‘x’ amount of time, we’ll have to start a pitocin drip to speed things up”. Please share you thoughts on what you deem a “normal” birth to be.

A normal birth is what is normal for a particular woman. There are no rigorous time frames that say a woman “should” do something at a given time. Each woman and baby unit finds their own way to birth. It’s a long process for some and shorter for others. If the mother and baby are doing well, there is no need to intervene with an expectation of time. Left to her own devices, with warmth and support, women birth most easily on their own. Medicalized births happen because of the belief that all women’s bodies function the same way. This is like saying that all women get turned on or have orgasms from the same things or positions. Nothing could be farther from the truth. Western medicine views our bodies in a very linear fashion: that a “normal” menstrual cycle is 28 days and that all women “normally” ovulate on day 14. That all “normal” pregnancies are 40 weeks long. It’s this type of thinking that leaves women feeling like their bodies failed them (“I couldn’t dilate”, “I couldn’t make enough milk”, “I cannot start labor on my own”), when, in fact, it is the system that fails their bodies.

7. In all of the deliveries that you’ve attended, how many actually needed medical intervention? What constitutes medical intervention? What situations can a midwife attend to holistically, that a doctor may choose to treat medically?

About 8% of the births I have attended needed medical intervention in the sense of a transport to a hospital. The most common reason for transport to the hospital is fatigue by the mother, usually a first time mother, in a long labor. Often, just an IV to replace fluids, some medication or an epidural to rest, is all that is needed. There are also times when we transport for issues with the baby – usually it’s non-emergent, just some heart rate patterns that I feel better about being in the hospital for monitoring. Typically, these births turn out perfectly fine with healthy moms and healthy babies. Nearly all transports to the hospital are non-emergent and we call in ahead of time, drive to the hospital and are received warmly by people who are expecting us. There have been a couple situations in my seven years of practice in which a new baby was a bit slow to start – not breathing right away and color wasn’t great. Two times, I actually used mouth-to-mouth, then with one I went further with a bag mask to help the baby breathe. Another the baby was watched closely, stimulated in mom’s arms and the mother was encouraged to talk to her. The baby came around beautifully. Homebirthed babies respond quicker to even the most gentle stimulation / resuscitation efforts because they are not drugged during labor. I also leave the cord attached until after the placenta is born to ensure that the baby is continuing to get oxygen from this source while he/she comes around, either on their own or with some help. Prenatally, nutrition can play a large role in the prevention of common illnesses or diseases of pregnancy and birth. I use herbs, nutrition, and homeopathic remedies for most common discomforts. I also feel fortunate to have relationships with MDs who I can refer clients to should they need more allopathic care during pregnancy or birth.

8. What do you bring with you to a birth?

Luckily, I bring more things than I ever use! I bring an oxygen tank, a resuscitator bag mask for baby, herbs, homeopathic remedies, gloves, labor support items (hot packs, oils), stethoscope for mom and baby, a doppler and fetoscope to listen to baby during labor, IV supplies, materials for suturing or tears after birth, sterile instruments to clamp and cut the cord after the birth, medications to stop hemorrhage after birth, optional Vitamin K and eye ointment for baby, and sterile gloves. What is interesting is how many people worry about the mess, then after the birth they ask where all the mess is! We typically leave the house so clean that nobody knew a birth had just taken place!

9. What pre- and post-natal services do you provide?

The same prenatal schedule that is provided in the hospital: every four-weeks, about an hour long prenatal, then at 30 weeks, it’s every two weeks until the last month when it’s every week. I do all appointments but the home visit in my office. Postpartum, we provide visits at 24 hours, three days, one week, two weeks in their home and six weeks in my office. This is much more intensive and more time than a woman would receive from a hospital based care provider. In addition, we are on-call for breastfeeding and newborn help, so it's likely we see women more often than the basic schedule. The six week visit is very difficult and bittersweet. Leaving a family after sharing such an intense, intimate experience with them is never easy. I keep in touch with many of my clients.

10. What midwifery credentials do you possess? What training did you undertake to receive your credentials? Could you give a brief overview of your state’s laws regarding the practice of midwifery. Do you fear that as more laws restricting midwifery are enacted the Licensed Midwife may be forced out of the birth process?

I hold a nationally based credential as a Certified Professional Midwife. This credential is available to all midwives in the US that document attendance and participation in a particular number of births, pass a written exam and model skills through a skills exam. In my state of Oregon, licensure for midwives is voluntary. The state of Oregon recognizes the CPM credential as a pre-requisite for state licensure. In Oregon, any one can practice as a midwife legally without being licensed or credentialed. Oregon also covers homebirth midwifery through the state Medicaid program. I want licensure in every state to be voluntary. Medicalization of birth is creeping into the homebirth midwifery field – and I believe that more state involvement in homebirth midwifery will only seek to remove choices that families have. As it is currently, there are states where midwives are being jailed and prosecuted for practicing. This is horrific and wrong in my opinion...parents deserve the right to choose where they want to give birth and who, if anyone, should attend them.