Conversation with my midwife

A few months ago, the midwife I used for Dio’s birth invited me to come to her office and meet a CNM she was thinking of adding to her practice. (Having a solo home birth practice is very demanding. Adding a second midwife would allow her to actually take vacations more than once every few years, to do more well-woman care, and to have more time for breastfeeding support as an IBCLC). Here are some recaps from our conversation.

My midwife Penny and the prospective midwife Holly talked about their backgrounds and how they came to both midwifery and home birth. Both worked as OB nurses for many years before they even thought of midwifery or home birth. Both eventually pursued a CNM degree with the intention of opening a home birth practice. Penny worked for several years in a large university hospital. It was the end-of-the-line for obstetrical cases, where you’d go if a high-risk situation arose in a smaller, less-equipped hospital; if you needed care for a 26-weeker; if you had an extremely complicated obstetrical history. Penny’s time working at Large University Hospital (LUH) taught her the limits of what medicine could do. Sometimes they could save lives and improve women’s and babies’ health. But other times—all too often—all they could do was offer compassion and support, unable to save every life or prevent all bad outcomes. And this was at the most tertiary of tertiary centers.

Penny said that working in such a high-tech, high-intervention setting gave her much more confidence to pursue a second career as a home birth midwife. She knew first-hand what the most advanced medical care could and could not do. There was no mystery or mystique about what a hospital could offer—something she sees as a great advantage, compared to many home birth midwives who have never worked intensely in a hospital environment.

During her years as a nurse at LUH, Penny loved taking care of home birth transfers. She was able to offer excellent care for the specific medical issues that needed addressing, while otherwise supporting and facilitating the woman’s desire for a gentle, unmedicated birth. I remember her telling me the story of catching one woman’s baby in the bathroom and putting the baby immediately on the mother’s chest—something she thought entirely commonsense, but something she got a lot of flack for from her co-workers. It was these experiences that pushed her to become a midwife.

Penny highly values the knowledge and skills she acquired as an OB nurse in a high-risk setting. She is totally fluent in inserting IVs, administering medications, intubating, resuscitating, etc. Now, she hardly ever uses these skills as a home birth midwife, because they are rarely, if ever, needed. (In fact, one skill she says is becoming rustier than she’d like is suturing, because women in her practice hardly tear, and if they do it’s rare that the tears need stitches—something she attribute to her hands-off approach. Dads or moms usually catch their babies; she steps in only if they do not want to catch or if neither parent is in a good position to do so.) But if/when her medical skills are needed, she is really, really good at them.

While we were chatting with Holly, Penny said to me, “you know Rixa, because of your background with unassisted birth, you hired me for different reasons than many women typically hire a home birth midwife. You didn’t need me so much for labor support or guidance. You really hired me for that 5% chance of needing really skilled medical assistance, something that I can do really well.” I thought about that and realized that I agreed with her. I am really independent and pretty much labor and birth all on my own. I don’t rely on my husband or female companions for labor support or encouragement. In fact, I prefer to do things on my own for the most part. So I wanted a midwife not for the 95% of stuff that she does during labor—now, that 95% is quite valuable and many women love the support and guidance their midwife offers during labor—but for the small chance that I’d need some kind of additional intervention or emergency skills.

Which brings me to another point I want to make—the more exposure I have to midwives, the more I realize how credentials and background do NOT translate into a certain style of practice. I have a lot of experience interacting with “lay” midwives, direct-entry midwives (CPMs), and home birth nurse-midwives. A CNM degree does not mean that a midwife will have a more “medicalized” style of practice (although it is true that most nurse-midwifery programs are geared towards preparing midwives to practice in a hospital setting).

Now, I am sure some people reading this are thinking, “Oh, Penny is such a MEDwife!” But nothing could be farther from the truth. She is very professional and very highly skilled. Very respectful of women’s desires at birth. She had such a quiet presence at my birth that I hardly noticed she was there; she honored all of my requests and wishes that we had talked about prenatally. She was especially adamant about not disturbing the immediate postpartum period. She doesn’t care about liability and has deliberately chosen to forego malpractice insurance and go “bare.” She is willing to go beyond the “standard of care,” to borrow a phrase from Dr. Denise Punger. Her attitude is “you need to prove to me why you shouldn’t have a home birth.”

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Midwives in the news

A selection of articles and essays about and by midwives that I've come across lately...

In New Life, New Lessons, midwife Ame Solomon writes about how she discovered her profession. Her essay is an excerpt from "Birth," part of the anthology Ask Me About My Divorce: Women Open Up About Moving On, published this year by Seal Press.

I noticed how women were stunned by how drastically different the world looked when they were pregnant: how it changed the entire landscape of their lives. It was as if they were starting life anew. I took that element and tried to apply it to my predicament, so that when I had no idea what to do next, I made an effort to comfort myself in the open range of possibilities. In the laboring mother, I witnessed how her pain was inescapable and raw and overtook her entire being. I saw her writhe in agony, breathe through tremendous difficulty, somehow make peace with her situation, surrender to the process, and face her deepest truth as she brought forth new life. Most remarkably, I saw women reach deep inside and access a warrior-like internal strength beyond compare. Every birth inspired me to reflect on the power and wisdom women possess, and to have faith in my own inner fortitude. I marveled at the natural process unfolding for women as they let go without self-judgment. I observed how they hurt more if they became scared, and seemed more at peace with their pain when they accepted it. I learned from them that there was pain with purpose, and that we can make it through the most horrific, mind-numbing, excruciating pain, even though we sometimes think we can't. In the end there is triumph, joy, and empowerment beyond imagination.

In a Lifeless Birth, a Midwife’s Opened Eyes is a heartwrenching story in The New York Times about a new midwife, called to attend a birth of a baby who had recently died in utero. She learned how to face death, rather than pretend it did not exist, from a more experienced midwife.

Not sure what else to do, I filled the silent birth room with the sound of my own voice. I told her all about my training in midwifery, my hometown, my likes and dislikes. I learned that she was a graduate student in crop management, that she grew up in Ohio, that we both liked a movie that had come out the week before.

The time dragged, the monitor spewed forth paper, and I kept chattering. I remember that I was proud of myself for coping with this difficult situation with diplomacy and tact.

I had been there for several hours when Barb arrived in a burst of energy. She wore faded jeans and flip-flops. Her jade earrings swung at the side of her neck. She threw her arms around the patient, hugged her a long minute, and then said, “I’m so sorry.”

My patient collapsed into uncontrollable tears. Barb sat on the edge of the bed, her hand on the patient’s arm, and they spoke in halting, slow, tearful words about the awful momentousness of what was happening. I sat in my chair in silent shock.

Death had been in the room but had been nicely hidden under the sheets, under our cheerful demeanor, under the silences of things left unsaid.

In Delivering Affordable Health Care, Miriam Perez (who blogs at Radical Doula) explains why midwives offer a cost-effective solution to rising health care costs.

Washington, one of the first states to license CPMs, now has an out-of-hospital birth rate twice the national average and has seen these claims of cost effectiveness come true. The most recent Department of Health cost-benefit analysis showed that licensed midwifery care in Washington saves the state $3.1 million every two years in Medicaid costs.

In The Big Push: Birmingham hosts national midwifery conference, Jesse Chambers discusses past and present legislative efforts to legalize and license direct-entry midwifery in the U.S. I love the poster!

“What our state advocates are facing in their respective statehouses are these nearly surreal David vs. Goliath situations,” Hedenkamp says. “We’re talking about moms and dads wearing their tires bald driving hours and hours to the capitols and home again in order to do advocacy with policymakers on even less than a shoestring.”

On the other side, she says, are well-funded lobbies such as the American Medical Association (AMA). “Since the Big Push for Midwives Campaign began, we have organizing the grassroots together in order to stand up to these very well-financed opposition forces,” Hedenkamp says. She is able to cite at least a few states where the midwifery movement has had some success, including Idaho, where a bill was passed this spring to legalize CPMs.

And finally, an oral history video about midwife Anna Grier. Betty Sue Gunthrope speaks to the influence of early twentieth century midwife, Anna Grier and the role of African American women as frontline health providers.

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Biodynamism: body and soil

I came across my comprehensive exams for my PhD this morning and had a fun time reading through the essays I wrote. One of the questions for my U.S. Environmentalism exam asked me to connect my interest in midwifery with my environmental interests. I've reposted my response below. Keep in mind that this was part of an 8-hour long sit-down exam (and another 8 hours the day before for my other field of study), so the grammar and organization won't be as polished as they would be in a research paper.

Question:
Among the graduate students with whom I’ve dealt at Iowa since 1992, you are rare in that you come with another profession--midwifery--already in place. I’m aware as well that another part of your written comprehensive examination will deal with medical issues within American culture, and having read your position paper, I see how your repositioning of American Studies as a field depends to some extent on your own professional background and experience. My questions here are, not surprisingly, more specifically related to the connection between your two fields: how do you link your environmental interests with your practice of midwifery? How would you construct a justification, at once intellectual and personal, for the practice of midwifery in this age seemingly dedicated to increasingly scientific intervention of all kinds? What are the implications--for our concept of the environment or for “environmental studies” in general--of your “non-traditional” medical background? How, in your preparation for this exam, did your environmental reading and your medical reading--or your actual practice of midwifery--reinforce one another? You are not obligated to answer all four of these sub-questions in order to answer this overall question successfully; rather, the sub-questions are intended only as guides to your meditation as you illustrate the link between your interest in midwifery and your interest in, and concern for, the biotic environment.

The Case for Biodynamic Birth

When I first chose my two exam fields, I must admit that I didn’t see very many connections between the two at all. They were just two areas I was interested in. After all, the history of medicine and especially the history of childbirth and midwifery are fairly “internal” fields, often focused on the body and on the lived experience of birth. On the other hand, most of my environmental history courses had concentrated on “external” problems: pollution, resource depletion, overgrazing, erosion, or wilderness preservation. Some of the first connections I started seeing between the two fields were in areas of disease and public health. Historical susceptibility to certain diseases was contingent upon one’s environment (in the sense of one’s physical surroundings). For example, I learned that polio became a real threat only when sanitation improved. Some diseases affected poor urban dwellers disproportionately, such as cholera, while others were more dependent on the immediate geography and climate, such as yellow fever. Hence cholera was initially understood as a moral problem, while yellow fever never acquired the same moral valence.

One of the first books I read that explicitly made a connection between environmental issues and childbirth was The Farmer and the Obstetrician (2002), by Michel Odent. (It’s not on my reading list but it should be!) Odent is a French obstetrician who was in charge of a maternity hospital in Pithiviers in the 1970s and 80s. With the help of midwives, he transformed the hospital rooms into homelike birthing spaces and eliminated most of the drugs and procedures common to Western childbirth. His focus was to discover the basic physiological needs of laboring women and to design rooms than enhanced, rather than slowed down, labor. The rooms had no delivery bed, but low comfortable mattresses and chairs. He was the first to introduce large pools of warm water into a hospital for women to labor and birth in. Women received no pain medications and rarely needed surgical or pharmacological assistance to give birth. He argues that the basic needs of women in labor are privacy, freedom from feeling observed or fearful, feeling secure, and not having their neo-cortex or “thinking” part of the brain overly stimulated. Odent has been extremely influential in childbirth reform and now heads a Primal Health Research Center in London that explores the connections between what happens at the period surrounding birth and human health and behavior decades after birth.

In The Farmer and the Obstetrician, Odent points out the connections between industrialized farming and industrialized childbirth, and between the organic farming and natural childbirth movements. He argues that industrialized farming and industrialized childbirth are two aspects of the same phenomenon: both are “typical ways to deviate from the laws of nature” (19). One is about non-human life, while the other concerns humans. Let me first explain what Odent means by industrialized farming and childbirth. The main features of industrialized farming, which arose in the early 1900s, are feeding cattle animal protein, heavy mechanization, synthetic chemicals, monoculture, hormone/antibiotic treatment, and scientific feeding. He defines industrialized childbirth as a phenomenon largely beginning in the 20th century with the transition from home to hospital births, from midwives to obstetricians, routine forceps and episiotomy deliveries, manual extraction of the placenta, heavy use of pharmacologic agents for pain relief and for controlling labor, machinery to monitor labor, routine IVs, and a recent explosion in cesarean section rates.

So what makes these two phenomena similar? How might the problems facing the environment inform my midwifery studies? Odent explains that industrialized farming and childbirth are both manifestations of a human desire to dominate nature. Both of these methods involve intense technological and material investment, were adopted quickly with little knowledge of their long-term effects, require large amounts of energy and intervention to maintain a functioning system, and rely on controlled manipulation of various factors.

Let me explain more in depth these similarities by providing some examples. In industrialized childbirth—which characterizes most births that take place in modern hospitals—very few women give birth physiologically, without large amounts of external manipulation and intervention. For example, a woman in labor entering a hospital will usually be required to change her clothes, receive an IV, have a vaginal examination to determine cervical dilation, and wear monitoring belts that record the contractions and baby’s heart beat on a computer printout. Wearing these monitors requires women to stay still, preferably in bed, as to not disturb the monitors. This has the effect of slowing labor and making it more painful. Industrial solutions to these problems include narcotics and anesthesia (which often renders women even more immobile and slows labor further) and artificial hormones to speed up labor. Because adrenaline directly inhibits the release of oxytocin, the hormone that causes the uterus to contract and labor to progress, women who are fearful, insecure, cold, or surrounded by strangers and bright lights will often experience a delay in labor. In addition, lying down often contributes to slowed or stopped labor, in part because the baby must work against gravity and the woman cannot move her body to help the baby into a more favorable position. Because normal physiology is often interrupted in the industrialized process, surgical interventions are frequent. Today over one quarter [now close to 1/3 as of 2006] of all American women undergo abdominal surgery to give birth. Most receive one or more types of pain medication, and a majority receive the synthetic form of oxytocin some time during labor or immediately postpartum.

Similarly, industrialized farming replaces normal biological “physiology” with artificially controlled environments. Monoculture of crops often leads to soil depletion and insect damage. Chemical fertilizers and pesticides are a temporary solution, but often heavily fertilized soils lose their fertility and must rely on further doses of chemicals in order to produce crops. Mechanization compacts the soil, while heavy plowing can lead to soil erosion. As with industrialized childbirth, certain actions have a “cascade” effect, with unintended consequences requiring even more intervention and energy. These systems are not infinitely self-sustaining, but require heavy amounts of energy investment in the form of mechanical labor and petroleum-based chemicals. In her essay on “Farming and the Landscape,” Jane Smiley critiques modern industrial farming because it has little biodiversity (animal, plant, or human) and must be cared for 24/7. The basic assumption of “new agriculture” that she finds problematic is that humans can and should manipulate nature at its very foundations for the sake of feeding as many people as possible. Instead she advocates a complex system of agriculture—biologically complex—that takes care of itself (Placing Nature, 1997).

The most interesting idea to arise from my environmental readings in regards to midwifery and childbirth is that of biodynamism. Odent himself uses the term in his book. He proposes “radically new attitudes” (105) towards childbirth based on biodynamics. He defines the term as “understanding the laws of nature and working with them” and as understanding the true physiological process, not just the culturally or medically controlled one (133). How does this compare to definitions of biodynamics as it relates to the environment?

During his career, Aldo Leopold gradually evolved towards a biodynamic ethic that respected the interactive, complex processes of nature. During the first part of his career, he would routinely shoot wolves and prevent forest fires—in other words, micro-manage the land—because the prevailing wisdom taught him that predators and fires were undesirable. He gradually learned that controlling these elements led to a cascade effect of unwanted consequences, such as exploding deer populations and terribly destructive fires. He advocated “the recognition of invisible interdependencies in the biotic community....Wildlife management...has already admitted its inability to replace natural equilibria with artificial ones, and its unwillingness to do so even if it could” (237). By 1936-37, he had come to a mature understanding of the complex processes of a biotic community (See his essays “Threatened Species,” “Means and Ends in Wild Life Management,” and “Conservationist in Mexico” in River of the Mother of God.) A more recent definition of “ecological health” by Jim Karr and quoted in Grumbine’s Ghost Bears further explains a biodynamic approach:

A biological system—whether it is a human system or a stream system—can be considered healthy when its inherent potential is realized, its condition is (relatively) stable, its capacity for self-repair when perturbed is preserved, and minimal external support for management is needed.

Grumbine comments that these standards are “serviceable at all scales, local, regional, global, because they embrace an ecosystem perspective” (184).

Several of my environmental readings illustrated how biodynamics plays out in specific situations. Rick Bass, writing about the reintroduction of wolves into Montana (outside of the national parks), noticed that the resurgence of wolf populations had a positive and unanticipated cascade effect on both plant and animal communities. The presence of wolves changed grazing patterns in their prey, which had a positive impact on areas that used to be overgrazed. In addition, once certain areas such as stream banks could recover from overgrazing, important native plant species re-established a foothold (The Ninemile Wolves, 1992). When rancher Dan O’Brien converted his South Dakota cattle ranch back into bison habitat, he learned that reintroducing one part of an entire ecosystem had a positive multiplicative effect. The soil became healthier because of the grazing patterns of the bison, which helped promote native prairie grasses and more plant biodiversity. Bison were more self-sustaining than cattle; they required far fewer external expenditures such as feed, water, vaccinations, or shelter in extreme weather. In addition, he noted that bison meat is much healthier for human consumption than beef (Buffalo For the Broken Heart, 2001). With the addition of wolves and bison, the biotic community became more stable and self-sustaining.

The principle of biodynamics can be a powerful framework for understanding and advocating changes in childbirth as well as in the environment. In fact, midwives and childbirth reformers have been following biodynamic principles even before Michel Odent applied the term to childbirth in 2002. A key principle of midwives, especially homebirth midwives who work outside of an institutional setting, is to promote and facilitate the natural process whenever possible. For example, instead of requiring laboring women to forego food and drink and accept an IV line (in case they have an emergency surgery under general anesthesia and aspirate their vomit), homebirth providers will encourage a woman to eat and drink freely as she desires. This keeps a woman from becoming dehydrated, hungry, or exhausted and prevents possible complications such as fluid overload or electrolyte imbalance. It also preserves the body’s normal physiology of digestion, thirst, and elimination.

Another example of biodynamics at birth is how homebirth midwives often approach slow or prolonged labor. The industrial/technological solution is to artificially stimulate labor with hormones, break the amniotic sac in the hopes of speeding things up, or to resort to an operative delivery. These approaches all have a cascade of consequences and frequently require additional drugs, interventions, or monitoring. A biodynamic approach, on the other hand, would determine first whether or not the “slow” labor is a problem. Most often, a midwife will encourage her client to rest if she is tired and labor slows down. A biodynamic caregiver might also seek to eliminate anything that causes the release of adrenaline, which has an antagonistic effect on the hormone oxytocin, which I described earlier. This could include asking certain people to leave the room, raising the room temperature, dimming the lights, giving the woman some privacy, or ensuring that she is not hungry or thirsty. They might also encourage the woman to move or change positions, based upon what feels good to the woman. These solutions all rely on the woman’s normal physiology to help labor progress, rather than substituting an artificial solution that often requires further management or intervention.

There is a measurable difference in outcomes between biodynamic and industrial approaches to childbirth. For example, the midwifery practice at The Farm, Tennessee, had a 1.4% cesarean rate between 1971-2000, compared to a national rate of over 27% [now 31.1%]. Infant mortality rates are comparable. (The Farm’s statistics include situations labeled “high-risk”—such as breeches, twins, or premature babies). Both systems have the same end “product”: living mothers and babies. However, the biodynamic system relies on the woman’s own complex physiology whenever possible to accomplish the birth, rather than on external hormonal, pharmacological, or surgical procedures. A biodynamic system is simply managed (if at all), inexpensive, and diverse, while an industrial system of childbirth is complex in its management, expensive, and fairly uniform in terms of interventions and procedures (see Davis-Floyd’s Birth as an American Rite of Passage and parts of my position paper).

A critic of homebirth midwifery might ask, “What’s the fuss all about? After all, most women and babies are healthy and the current hospital/obstetrical system works just fine.” This is the same thing one might comment about industrialized farming: yes, it’s expensive and requires vast amounts of chemicals and monitoring, but it has produced a marvelous amount of cheap, abundant food. And why bother preserving wilderness places? Most people never even visit a wilderness and survive quite well in human-mediated environments. Aldo Leopold and John Muir have provided me with answers to those questions in their wilderness philosophies. Wilderness advocate John Muir advanced a utilitarian case for wilderness common to 20th century ecology—that wilderness should be preserved as a place where natural processes continue to function unimpaired. Several decades later, Leopold argued for “Wilderness as a Land Laboratory” (River 1941). He acknowledges the recreational value of wilderness, but argues that it has even greater scientific value as a control for ecological health. In order to determine what is truly natural or healthy for a biotic system—a “base-datum of normality” (288)—he proposes studying wilderness as controls in comparative studies of used and unused land. Wilderness areas are perfect examples of healthy organisms that have a “capacity for internal self-renewal known as health” (287).

This control argument could be a powerful rationale for preserving homebirth and midwifery. One could argue that very few institutional care providers know what undisturbed birth looks like. When the vast majority of women birth in an unfamiliar location, receive some form of pain medications, are tied to IV lines and monitors, and receive artificial hormones during labor, very few caregivers have ever seen a truly physiological or biodynamic birth. (This has been called “natural” or “normal” birth, but those terms are quite problematic, as natural birth has become associated with the lack of pain medications, and recently has come to mean anything but a cesarean section.) It would seem logical to argue that in order to understand pathology, one must first understand physiology. This is not to say that homebirths are automatically free of any external influences. As Brigitte Jordan shows in her anthropological investigation of birth cultures, Birth in Four Cultures, birth can never be culture-free. However, some birth cultures do promote more physiological experiences than others. The key to determining which practices disturb physiology or upset biodynamism is to compare the birth (or a biotic community) against Karr’s criteria: ability to realize its inherent potential, stability, capacity for self-repair when disturbed, and minimal external support. This is a question Cronon addresses in Changes in the Land. He argues that Native Americans used and changed the land, but that there was a qualitative difference between Native American and European American land use. Native American land use was infinitely sustainable and preserved biodiversity, while European land use patterns quickly deteriorated biotic diversity and soil health.

Michel Odent points out that our ultimate priority shouldn’t be to transform certain farming techniques or birth practices, but to ensure the future of our civilization. He notes that industrialized farming and childbirth both show a “weakened ecological instinct” that impairs our capacity to love. How does this occur in childbirth specifically? He explains that until recently, a woman couldn’t become a mother without releasing a complex cocktail of “love hormones” (including oxytocin and prolactin) at the time of birth. However, industrialized childbirth has disrupted the normal flow of birth hormones. When anesthesia, narcotics, artificial hormones, cesarean surgery, or immediate separation of the mother and baby are present, the mother’s hormonal system is altered and usually the level of hormones released diminishes significantly. Odent is concerned with the long-term implications of any practice that disturbs these vital love hormones, because certain birth practices have been linked to higher rates of autism (induction of labor), suicide (surgical birth, asphyxiation at birth), and anorexia nervosa (presence of a cephalohematoma at birth). (A collection of studies documenting these associations are available through the Primal Health database.) All of these disorders are what Odent terms an “impaired capacity to love”—oneself, others, or nature. Aggressiveness towards non-human life, including the land, is a symptom of that impaired capacity. He concludes that “the current industrialization of childbirth should become the main preoccupation of those interested in the future of humanity” (137-38). Odent is not the only person I have read who insists that our relationship to our bodies and to the earth is connected. In chapter 7 of Unsettling America, “The Body and the Earth,” Wendell Berry argues that there should be a profound resemblance between our treatment of our bodies and of the earth; you can’t simultaneously devalue the body and value the soil.

A final useful concept I have gained from my environmental studies is that of humility and restraint in the face of the unknown. In his book You Can’t Eat GNP: Economics as if Ecology Mattered (2000), Eric Davidson argues that it’s silly to replace something that already works well with something that’s technologically complex and enormously expensive. He comments:

Technology is unlikely to find substitutes for these essential services provided by forests....Simply keep the climate from changing rapidly and keep the forests in good health, and we will have a proven natural ‘technology’ that we know will provide what we need. Start tinkering by replacing forests with new, unproven technologies, and we take a giant risk that is unnecessary and imprudent.

He provides several examples of already available technologies and the proposed “improved” solutions: forest watersheds that purify water, versus pumped and purified groundwater; forests’ beneficial effects on climate to regulate temperature and rainfall, versus giant space shields orbiting over the earth (92). Aldo Leopold likewise recommends caution in the face of the unknown: “If the biota, in the course of aeons, has built something we like but do not understand, then who but a fool would discard seemingly useless parts? To keep every cog and wheel is the first precaution of intelligent tinkering” (Quoted in Davidson 167). I wish to conclude with a quote from the famous Dutch obstetrician G. J. Kloosterman, who was an ardent supporter of midwifery and homebirth:

Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference will only detract from the optimal character. The only thing required from the bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine--nil nocere [do no harm].

Works Cited:

• Bass, Rick. The Ninemile Wolves. Mariner Books, 2003.
• Berry, Wendell. The unsettling of America: Culture & agriculture. San Francisco: Sierra Club Books, 1977.
• Cohen, Michael P. The pathless way: John Muir and American wilderness. Madison, Wis.: University of Wisconsin Press, 1984.
• Cronon, William. Changes in the land: Indians, colonists, and the ecology of New England. New York: Hill and Wang, 1983.
• Davidson, Eric A. You can't eat GNP: Economics as if ecology mattered. Cambridge, MA: Perseus, 2000.
• Davis-Floyd, Robbie. Birth as an American Rite of Passage. Berkeley: University of California Press, 1992.
• Grumbine, R. Edward. Ghost bears: Exploring the biodiversity crisis. Washington, D.C.: Island Press, 1992.
• Joan Iverson Nassauer, ed. Placing Nature: Culture and Landscape Ecology. Island Press, 1997.
• Jordan, Brigitte. Birth in Four Cultures: A Crosscultural Investigation of Childbirth in Yucatan, Holland, Sweden, and the United States. Montreal, Canada: Eden Press Women’s Publications, 1978.
• Kloosterman, G. J., “Universal Aspects of Birth: Human Birth as a Socio-psychosomatic Paradigm,” Journal of Psychosomatic Obstetrics and Gynecology 1, no. 1 (1982): 35-41.
• Leopold, Aldo, The river of the mother of God and other essays. Madison, Wis.: University of Wisconsin Press, 1991.
• Leopold, Aldo. A Sand County almanac; and, Sketches here and there. New York: Oxford University Press, 1968.
• O’Brien, Dan. Buffalo for the Broken Heart: Restoring Life to a Black Hills Ranch. Random House, 2001.
• Odent, Michel. The Farmer and the Obstetrician. London: Free Association Books, 2002.

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The root of my worries

I've been corresponding with my friend Jenne from Descent into Motherhood about my desires for this upcoming birth. We are both seeing a midwife and trying to decide what role we wish them to play in our upcoming births. She wrote to me yesterday something that perfectly sums up the root of my concerns:

Have you thought of it as a control issue? You have had an experience where you were totally in control, autonomous, and making your own decisions. And now it sounds with this particular midwife, you are going to have to give some of that decision making power to her because there will be things that she may not budge on. It's important to you that you are alone in the room, and she may not allow that to happen. Not only does that feel like your power is being taken from you, you may fear that her presence will alter your ability to birth in some way. I think I'm projecting my feelings on to you but I know that it's that reason that I would be uncomfortable with having a midwife. Maybe it's just what you've described to me about this particular midwife. Tell me if I'm wrong on that and I'll be quiet. My fears with having a midwife present are two-fold: I don't trust her to not take control of a situation in a way that overrides my autonomy. That of course is at the root of what I didn't like about my birth experience with my son and led me to consider a UC. I hated having to fight for the responsibility to make my own choices when I could choose to not have to face that fight at all.

My core concerns center on autonomy and control--not control of the birth process itself, but control of my surroundings and those people around me. It's important that I can totally relax during labor and not worry about any externals. For me, I accomplish that through careful planning and control over my birth environment. In a way, I seek to control some things before labor so that I can give up control when labor begins.

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Working through some conflicted feelings

This pregnancy has been marked by a series of conflicting feelings about what I want for the birth. Zari’s unassisted birth was fantastic and really could not have been improved upon. I also felt strongly drawn to having an unassisted pregnancy and birth with her. While I of course had some doubts, fears, and hesitations along the way—doesn’t every pregnant woman at some point?—I just knew that an unassisted birth was what was right, what I needed to go through.

When I was a graduate student in Iowa and trying to conceive my first child, I was working as a doula and apprenticing with a direct-entry midwife. After we moved to Illinois, I started assisting a home birth CNM at prenatal visits and births occurring in my area. This pregnancy, I am living in a new state and for the first time in several years, I am not a part of the local midwifery community. This is part of the reason that I felt the need to initiate care with a home birth midwife here; I no longer had access to midwifery care, advice, or skills except through a formal, paying midwife-client relationship. There are a few things that I want access to: during pregnancy, I like checking my hemoglobin levels early in pregnancy and again around 28 weeks to be sure that my blood volume has expanded adequately (hemoglobin levels should drop by the 28-week check; if they are stable or rising, that is cause for concern). I want someone to check me for tears after the birth, suture/Dermabond if necessary, and to do bloodwork in case I want a Rhogam shot. While I could in theory go to a hospital for those postpartum services, it would be extremely disruptive and kind of pointless to get in the car hours after having a home birth!

I also find myself wanting the option of having skilled assistance during labor for certain rare emergency situations: shoulder dystocia primarily, and to a lesser degree rapid postpartum hemorrhage or the baby needing resuscitation (the latter is the least worrisome to me, even though it is probably the most common of the three scenarios I listed, since I am trained in neonatal resuscitation). This wasn’t as much of a concern during my first pregnancy, but I find it weighing more heavily on my mind this time. I suspect it’s because, now that I have a child of my own, the idea of losing a baby is no longer an abstraction to me. I wouldn’t say at all that I was simply being callous or naïve the first time around, just that the possibility of losing a child is more palpable to me now.

I was happy to learn that a home birth midwife lived only 20 miles away from our new house—the closest I have ever lived to a home birth provider in many years. Although I could pay out-of-pocket for a midwife, I was quite happy to find that she was a CNM who could accept my insurance. This means that instead of paying $3,600 for her global fee, my out-of-pocket expenses are around $1,000 ($500 for the deductible and another $500 for the 20% co-pay). Labwork and birth pool rental are additional; she rents out heated, jetted Spa-In-A-Box pools, but I won’t need that now that I have a free La Bassine.

I met with the midwife early on in my pregnancy to talk about what I was looking for and figure out if she would work for me. I talked about my first birth and how I was looking for a hands-off midwife who would respect my need for privacy. I had a few specifics I quizzed her about: was she willing to not listen to heart tones at all? (No; she’d like to listen every 30 minutes. But otherwise she is fine staying out of the room while I am laboring.) Was she willing to stay in another room during the actual birth? (No, she’d prefer to be in the room as the baby is being born to keep an eye on possible problems). I am actually quite fine with having heart tones checked. I understand from a midwife’s perspective why it is important to listen. If I am inviting a midwife to the birth, she does need to have a way to know if the baby is responding well to labor.

The second point is more of a stickler for me, and it’s been on my mind a lot recently. I feel very strongly about keeping the “birth bubble” intact in the immediate postpartum period. Even many home birth midwives tend to do a lot of stuff right after the birth: putting a hat on the baby, rubbing it gently with towels, speaking with the mother, suctioning the baby’s nose and mouth, taking a full set of vitals every few minutes (baby’s heart rate & respiration rate, mom’s blood pressure, etc), feeling if the placenta has detached, etc. While these activities are not terribly interventive in the grand scheme of things—after all, baby is usually still in the mother’s arms—they do “wake the mother” and take her away from that critical time in which her primary task, physiologically speaking, is to produce high levels of oxytocin to help the uterus clamp down efficiently, the placenta to detach cleanly and completely, and thus prevent a postpartum hemorrhage. In Michel Odent’s article “The First Hour Following Birth: Don’t Wake the Mother!”, he explains how midwives ought to behave in the immediate postpartum period:

They first make sure the room is warm enough. During the third stage women never complain that it is too hot. If they are shivering, it means the place is not warm enough. In the case of a homebirth, the only important tool to prepare is a transportable heater that can be plugged in any place and at any time and can be used to warm blankets or towels. Their other goal is to make sure the mother is not distracted at all while looking at the baby’s eyes and feeling contact with the baby’s skin. There are countless avoidable ways of distracting mother and baby at that stage. The mother can be distracted because she feels observed or guided, because somebody is talking, because the birth attendant wants to cut the cord before the delivery of the placenta, because the telephone rings, or because a light is suddenly switched on, etc. At that stage, after a birth in physiological conditions, the mother is still in a particular state of consciousness, as if "on another planet." Her neocortex is still more or less at rest. The watchword should be, "Don’t wake up the mother!"

Pamela Hines-Powell has written about this as well (and I interviewed her more in depth about what she does/does not do at births for my dissertation). Immediately postpartum, her default routine—what she does unless the mother requests otherwise—is to stay silent, out of the mother’s line of vision, and quietly observe the mother and baby from several feet away. No one but the parents touches the baby for the first hour or so after the birth. The midwives only step in to assist or interact once the mother initiates contact (barring, of course, an emergency situation). For example, here are a few of her common birth & postpartum practices, taken from a longer post about her midwife identity crisis:

• Routine vaginal exams - during labor or prenatally. It’s not uncommon for us to never touch a woman’s vagina - or even see her vulva - until the baby is crowning (if we can see it) or afterwards when looking for tears/lacerations.
• I’m not going to do perineal massage or even support of the perineum (some women with land births like to have some rectal counterpressure) as baby is being born…but I’m not likely to do anything at all during second stage in water births…blame it on me trying to protect my back and not wanting my shirt wet, but really it’s because the mother does it all on her own - and she knows best.
• I do not - nor does my wonderful assistant - usually touch the baby for a good hour or so after the birth. No routine checking the heart rate - we look and observe tone and respiratory effort. Only if that is in question will we come closer and do vitals or listen to heart rate.
• I typically do not do much face to face labor support, breathing reminders or talk women through labor contractions other than a very occasional gentle reminder of why she is doing this or that her body is working so well with her baby. If a woman needs more than that, I’m there, but my default is to stay in the background and support women to find their own way of laboring (and they have a tendency to breathe pretty well without instruction, too!) .
  

I have found myself fretting unproductively (since I haven’t had the chance to actually talk these things over with the midwife yet) about whether or not I would be able to have an undisturbed labor, birth, and especially third stage with a midwife present in the room. It’s this fruitless feedback loop of worry and anxiety that has been weighing heavily on me. On the one hand, I have had an unassisted birth and can’t really see how it could be improved upon. On the other hand, I have felt a need this time around to have access to a midwife, and I need to respect that as much as I listened to my need to have an unassisted pregnancy and birth with Zari. How can I reconcile my desire for an undisturbed birth with the presence of outsiders at my labor, when even having my own husband in the room felt distracting to me, made me feel self-conscious, like I was being watched, like how it feels when someone reads over your shoulder?

I talked over these things at length yesterday with my good friend Jen, who has experience both giving birth and attending births. She had her first baby in a birth center, her second at home with a CNM, and her third unassisted, with a midwife hired as a photographer. She is also apprenticing with a home birth midwife, so has seen birth from the other end of things, so to speak, including several more complicated/complex births. At the end of our conversation, she suggested that I, or this new baby, might need something that this midwife can offer. Perhaps my task this time is to learn how to move past my fears about having a midwife and to embrace this pregnancy and this birth journey for what it needs to be, rather than always comparing it against Zari’s pregnancy and birth. I think she was very wise to say this. Maybe there’s something unexpected that will arise during this pregnancy or birth that is spurring me to seek midwifery care. Maybe I need to learn how to let people into my life and accept assistance. I am a very independent, self-reliant person, and I always want to do things by myself. I have already proven that I can give birth alone, that I can do it all without assistance. Perhaps I don’t need go through that particular rite of passage this time.

I am eager to talk through these issues with the midwife the next time we meet, since I need to move beyond the unproductive anxiety that I have been feeling. I don’t like that this pregnancy has been so dominated by these unsettled concerns. Now that my birth is drawing nearer, I need to turn my emotional and mental energy in a more positive, productive direction, towards creating the birth that I desire rather than worry that it might not work out the right way. I know that my concerns are minor in the grand scheme of things—you know, compared to people dying of AIDS or extreme poverty or domestic violence or whatever—but they are still real and important to me.

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Conference downloads on sale

All downloads from AAMI's 2008 Trust Birth Conference and the Helping Hands Conference are on sale through the end of December. This is a fantastic way to listen to speakers you've always wanted to hear. Some of the ones I'd really like to get:

• Heather Cushman-Dowdee (aka Hathor the Cow Goddess, aka Mama-Is): Telling Our Stories
• Pamela Hines-Powell: More of Them, Less of Me
• Why Women Stay Home Alone: Panel Discussion (I was on this and would like to have a recording of it for dissertation/book writing purposes).
  
• Rachel Correa: Stella's Life and Stillbirth

If I had to choose only one, it would be, hands down, Rachel Correa's talk about the stillbirth of her first baby. I can't even try to describe it so I will just say listen to it yourself. While she was speaking--about the stillbirth of her daughter Stella, about other parents of stillborn children, about her three other children's births--she showed photographs of these births and babies, of her family, of her grieving and healing process. If you buy this download, I'd recommend contacting Rachel about obtaining a copy of her Powerpoint to go along with her talk. I have no idea if she'd be willing to share the pictures, but I think the presentation is not complete without the images. She used my laptop during the presentation, so I am lucky to still have the slideshow on my computer.

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Q&A with Carla Hartley

Carla Hartley, founder and director of the Ancient Art Midwifery Institute, gave me permission to repost this recent email correspondence.

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Dear Carla,

I am really confused by the unassisted birth movement within your midwifery study course. Why do we study all of this stuff to be educated midwives and right along side of this tell moms to just trust birth and have no one there?

Thanks for any time you can take to answer this for me.

Here is where I am coming from:

A: My course is really really really hard. It is comprehensive because I want midwives to KNOW more, so they are comfortable doing less. I saw a lot of midwives meddling with birth because many of them did not know enough to recognize variations of normal. Their education was based on EXPERIENCE only. Now in my grandmother’s day, experience was enough because it was NOT fear-laden. Birth was, as Sheila Kitzinger says, domestic, part of life. The experience of most of the midwives I had any contact with in my early days was based on fear. They did not start going to births because they believed in birth, so much as they wanted to help women avoid the hospital. Yet their lack of knowledge and trust of the birthing process meant that a LOT of women who started out at home ended up in the hospital anyway.

I recognized early on that because I had studied sooooooooooo much before I started apprenticing, things that panicked experienced midwives did not at all panic me. I understood the physiology. I knew that there were many possible birth scenarios that were NORMAL. I also saw that clients almost always depended on the midwife's knowledge and trusted her opinion on almost everything. That made me uncomfortable. One of the things that I believe people gain having a home birth is a sense of their own ability to make decisions about their children. If we as midwives don’t leave families CHANGED then I think we have missed a great opportunity to affect society in a very positive way. MUCH of what my students do is client education and the constant reminder that parents are their own authorities and the rest of us (doctors, midwives, doulas, childbirth educators) are merely paid consultants. Once that resonates with a couple, and they accept the responsibility that comes with authority, they change. They believe in their ability to make good decisions. That is HUGE!

B. I trust birth. Birth is inherently safe. Messing with it in any way compromises safety. It is an innate biological capability for most women to grow a baby and then EJECT a baby with no help from anyone. Midwives are NOT the guardians of normal birth. Birth is normal with or without midwives. But what midwives should be doing is acting as the guardian of the mother and baby's space, so they can do what they were made to do. Most women want that--but some don't. They just want to be in their own little world with no intrusion. That doesn't mean that birth is any less safe.

Midwives know a lot of things that can go wrong. That is why I think we do have to study and prepare to an extreme degree. We have to be sure that we don't CAUSE anything to go wrong. I think much of what we do has the potential to cause problems. I don't have time today to list those but they start with what we say, our own body language, what we wear (I hate scrubs in a home birth) and the things we think we have to measure, poke and prod.

Have you read my blog and the TrustBirth.com site? I trust birth—not birth attendants—for if you only trust birth that is attended then you really don't trust birth at all. You trust the attendant. And then you start over. Who? Doctor, surgeon, CNM, CPM, SIM*? And it goes on and on....NO, the truth is that women and their babies are quite capable for the most part to do it without anyone. Most women who chose home birth want a midwife and my goal is to help there be MORE midwives for them to choose from and midwives who are truly WITH WOMAN midwives and not birth managers.

I don't want to insult you in any way and I am glad to have the opportunity to help you understand what seems to many a real mystery but look at what you said in your post to me:

"Why do we study all of this stuff to be educated midwives and right along side of this tell moms to just trust birth and have no one there?"

Doesn't that sound a LOT like what docs believe about birth? Doctors don't own birth. Midwives don't own birth. Just because you study and sacrifice and put yourself in debt to become a midwife or doctor does not mean you own a woman's experience. It also does not mean that you are necessary. (OUCH!) Women and babies know how, if we will step back and let them. And we understand that our job is to serve them.

And I don't like the word "support" here because she is not a table we are holding up. I like "SERVE" because I think that is what midwives—well, everyone involved in birth—should be doing. SERVING.

In that framework—servant, consultant—it is quite possible to be a midwife who trusts birth and trust the woman and her baby. It is possible to be a midwife whose client calls AFTER the birth and says it just never occurred to me to call you, that the midwife would not be offended.

My very first official paying clients decided a couple months before the birth that they were going to DIY, as we called it back then, because I was uncomfortable about something I thought might present a problem. I was a rookie and was ultra cautious. Not afraid; I just wanted them to know that there could be a problem. After talking about it for a while they came to see me and said, “Carla, we are going to let you off the hook. We know you are concerned, but we really are not. So we are not going to call you when labor starts.” I cried. They said, “Oh no, don't be sad. You helped us realize that birth is safe and that few things go wrong if you don't mess with. You encouraged us to listen to our own instincts about birth and we know everything is going to be fine.. But YOU don't. And we understand that and we don't want to put you in a position of being concerned. We will call you when the baby is born and you can come see for yourself that we were right!!!!”

I quickly corrected them that my tears were not of rejection but absolute humble appreciation for what they were telling me. Just because I did not go to the birth (I went a few hours after) did not mean I did not serve them well as their midwife. I did not have to be the one to catch the baby. I did not have to watch or guard a perineum in order for her to have a baby without tearing. I helped them believe in themselves and THEIR ability to parent this child before, during and after birth. I did good! In my dictionary, I WAS their midwife.

If this doesn't answer your questions, please, please feel free to write again or call me. I am honored that you asked, actually. I do not see my job helping women become midwives and also supporting women who want to have their babies alone as a contradiction in any way because of what I believe that midwifery should be in the first place.

Carla Hartley

*SIM (Self-Identified Midwife) is a term used (often derogatorily) to describe midwives who choose not to become certified through a professional organization.

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If I were looking for a midwife...

Sage Femme would be a great fit for me. Read about her practice style on her recent post Midwife Identity Crisis. Too bad we live several thousand miles apart!!

The midwife I apprenticed with before I moved has started doing more of these kinds of births. Here's a brief description from an email conversation we had about two years ago:

My midwifery partner and I have done a few births this summer in which the parents did not want to be bothered with at all...no heart tones, no vag checks, etc. OK...so that's what we did. Many first time moms, too. When mom was getting away from herself and feeling out of control, I would go over to the tub, get to eye level with her and tell her she was strong and powerful, and that this is normal. She is doing fine. Then I would give her a drink (Dad, too) and give her a cool cloth...then back to couch! Same when baby was out...mom caught her own baby and sat back w/Dad to admire their son. We checked that baby was breathing without difficulty and pinking up, Mom didn't look too bloody, so we retreated to the couch again until they called us to get out of the water.

We need more midwives like you!

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Hats off!

Ever wondered why we put hats on newborn babies? Is it really necessary? Are there risks in doing so?

Read this midwife's response to why she doesn't put hats on newborns.

Of particular note is her last paragraph. By striving to keep the "birth bubble" intact immediately after a birth (having the mother pick up her own baby, no hats, no bulb syringes, staying out of eyesight of the parents, no talking to parents after the birth), she has noted these changes:

I've had a huge decline in hemorrhage. The transition feels more peaceful, more gentle and more aware for all involved. I find myself more often moved to tears by being able to sit back and observe the entire scene instead of being on edge looking for something wrong. I think the babies prefer it, as well. :)

Michel Odent explains why distracting a mother right after birth predisposes her to postpartum hemorrhage:

It is after the birth of the baby and before the delivery of the placenta that women have the capacity to reach the highest possible peak of oxytocin. As in any other circumstances (for example sexual intercourse or lactation) the release of oxytocin is highly dependent on environmental factors. It is easier if the place is very warm (so that the level of hormones of the adrenaline family is as low as possible). It is also easier if the mother has nothing else to do than to look at the baby’s eyes and to feel contact with the baby’s skin, without any distraction.

Oxytocin is the hormone that causes uterine contractions. Anti-hemorrhagic drugs (Pitocin, Methergine) are made from synthetic oxytocin.

Hats off to hands-off midwives and doctors!

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