Why Choose a Midwife in Massachusetts?

Here is a fantastic video that wraps up so succinctly all the reasons why Massachusetts MUST pass a midwifery bill. This isn't about women craving an indulgent birth experience, but it is about giving pregnant women choices about their bodies, their babies, and their health.

Don't Push The River...It Flows By Itself

A beautiful blog post by Lindsay, who poetically describes how she discovered her own strength and the "vastness of her spirit."

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Women Must Be Informed, Political Collaborators in Their Own Care

Dr. Tiller's clinic in Witchita, KS, one of the few in the country that provides late-term abortions, is closing. With his murder, in addition to wiping out the life of a husband and father, the anti-choice movement has taken away women's access to critical, necessary services. And while the current political make-up shows that the anti-choice movement cannot overturn Roe v. Wade, Dr. Tiller's death is a reminder that all it takes is a sniper to reduce our choices even further. And since OB-GYN's aren't racing to provide abortion services at the risk of their own lives, Dr. Tiller's practice may not ever be replaced.

When I'm not a doula, I work as an abortion counselor. Although most of the women I meet with are between 4 and 7 weeks pregnant, the clinic where I work provides abortion services up until the 23rd week of pregnancy, which is the legal limit of abortion care in the state of Massachusetts.

Your reaction may be visceral, no doubt. At 23 weeks, abortion can be extremely difficult to understand or justify, and it is not uncommon to shake your head and say "I have a real problem with that," even if you are pro-choice. It is tempting, if not comforting, to separate yourself from a woman who would make this choice by assuming that she must be a monster. And I'll be honest and say that once I sat down with a woman who seemingly had no feelings about having an abortion in her 23rd week of pregnancy. It chilled me, her apparent lack of feeling. But many more times than just once, I have sat down with couples who are heartbroken: a routine ultrasound in the 20th week discovers massive deformities; an amniocentesis details profound genetic abnormalities that at are incompatible with all but the briefest of life, and suffering is certain; a doppler at 22 weeks returns no heartbeat, reducing a wanted and cherished baby into a diagnosis of fetal demise. And sometimes, due to the time it takes to run tests, or to the human inconsistencies of those who administer those tests, or the varying reliability of technology, a pregnant woman in those situations can be beyond 23 weeks. And so what do we do in the state of Massachusetts? We tell her she can deliver her dead, deformed, or doomed baby in a labor and delivery unit of a hospital -- which is as monstrous as it sounds -- or we recommend she travel immediately to one of the few clinics in the United States that can terminate her pregnancy. And with the death of Dr. Tiller and the closing of his clinic, there is now one less place where a woman in this delicate and devastating situation can go for care that is humane and treats her with dignity.

And on the other end of pregnancy, women are also losing choices in childbirth. In my line of work, I hear many birth stories from women, and the majority of them have the same eerie arc: first, induction; second, confinement to a bed; third, bone-crushing pain; finally, forced pushing while lying on their backs. Statistically, more than 30% of those stories end in c-section, and these are in pregnancies that had been normal, low-risk, and healthy. It's also the basic formula for reality birth shows on cable TV, where birth is boiled down to a medical event that skirts death practically every time.

VBACs are becoming harder to access, despite evidence that indicates that VBAC is lower risk than repeat C-section. Providers, among both OB's and L&D nurses, have attended fewer and fewer low-risk, healthy childbirths that are purposefully unmedicated and without interventions. What results over time is that if a laboring woman wants a natural birth, she could go to a hospital and have no medical professionals with the experience or willingness to support her desires. Birth centers are losing funding, and homebirth is either criminalized or unregulated in half of the US. In the other half of the country, the standards of care that do govern it are so limiting that its practice is nearly impossible but for a few renegade midwives who are essentially providing care without the benefit of professional support in case of a true obstetric emergency. Healthy women who could experience the normal physiological process of birth are beholden to the artificial constructs of time, liability, and television drama. The art of childbirth, and the choices that encourage birth as a safe, non-medical event, are being lost.

Unless we have a vision that is greater than the arguments of pro-life vs. pro-choice, homebirth vs. hospital, natural birth vs. epidural, we will lose what is truly at stake at the heart of these issues: choices. The quality of women's health care is dependent upon choices and access to qualified care providers, and women must expect no less than to be informed, political collaborators in their own care.

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Great Videos on OPTIONS in childbirth

Virgina’s Birth Matters video contest is conjuring up creative juices — and giving us fantastic ways to let people know that there are MANY options to how you birth a child!! Here is Part One of South Coast Midwifery’s video, and when that’s done, you can watch Part Two. Southcoast Midwifery is in California, where it seems all of my midwifery books are based! Massachusetts will get there!

–maria
(this has been cross-posted on the Massachusetts Friends of Midwives blog)

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Is it REALLY about the epidural?

When I tell people I'm a doula, one of the responses I get is a shake of the head, coupled with "Nah, I go for the drugs!" Or "Why should I experience pain if I don't need to?"

I loved this entry from the blog "Empowering Birth." What woman wouldn't want to walk away from her non-medicated birth experience with the sense that now she can accomplish anything in the world? What woman wouldn't want that feeling from ANYTHING? What mother wouldn't want that feeling for her daughter? The craving for this experience is what motivated me to have my third child with midwives at a birth center.

But as I delve deeper into the world of birth -- as a mother who has had three wildly different birth experiences, as a doula who has attended many births, and as an aspiring midwife -- I dare to say that it is NOT about whether a laboring mom gets an epidural. Pain is subjective. What one woman can tolerate for 24 hours, another may not be able to tolerate for 24 minutes. Is one woman stronger than the other? Is one woman's birth better than the other? A woman's body has the ability to grow and birth a child. There is, in fact, nothing more natural than that act of creation and birth, epidural or drug free, at home or in a hospital. Witnessing a birth is a phenomenal, powerful experience no matter how the birth happened and what circumstances led to its unfolding.

Because I am a trained mental health clinician, I know that people have all kinds of experiences and make very different decisions than someone else would in the exact same circumstance. None of it is up for judgment, and as a birth professional with a background in mental health, I'm very cautious about even the mildest suggestion that a woman who chooses an epidural is less-than or that the babies had a less-than birth. In fact, I'm very cautious about the suggestion that a woman who chooses an elective, first-time cesarean is less-than.

My birth passion is more focused on freedom of choices. Is a pregnant or laboring woman making a decision about her baby's birth out of fear? Does she have the supportive people she needs to form a circle around her? Is she making an informed decision about her body, which decades of trends and popular culture have taught her to dislike and distrust, if not abuse? Natural childbirth is not only about the epidural. It is about our culture; our love and reliance of technology over our instincts. It is about our need to control a normal, healthy process that should be allowed to take its own path and power and time, and intervening only when it is medically necessary. It is about a culture that focuses on liability and lost income or productivity more than the intangibles, like faith and trust.

Actually, I think that the last thing natural childbirth is about is that epidural. It is about all that is normal about birth. That we don't know when it will begin, nor do we know how long it will take. It can surprise us, and yet if we can remain watchful while still being patient and respectful of the process, it will reveal itself as all that it is meant to be.

The Nature of Nature

As a doula, I have seen a million natural birth videos, showing women with glowing, ecstatic faces. Their births are peaceful and gentle, transcendent. Or the stories are of Homeric journeys, women whose bellies are their body armor, and in the mist of a new morning after a long, dark night, rise triumphantly. Women who cry out, "I never knew I had such strength!"

I engage in a fair amount of childbirth education with clients. While I worry about the woman whose idea of birth comes from reality TV or prime time dramas made for entertainment purposes, I worry equally about the woman who has only watched videos that promise her either bliss or empowerment -- in exchange, all she has to do is birth naturally. I do emphatically believe in the revolutionary idea that childbirth is not something we should be taught to fear; but as birth professionals it is critical that while we educate women to trust their bodies and trust the process of birth, we should also remember that the uninterrupted process of birth can be full of surprises. Nature - responsible for crystal streams, painted mountains, and skies spotted with sparkling jewels - is also responsible for hurricanes and gale-force winds.

As a pregnant woman anticipating my 3rd labor, I made all the right choices for a natural birth: I got prenatal care from midwives, chose a birth center instead of a hospital, and shook my head when well-meaning friends suggested that it was time for an induction as I got more uncomfortable. I was determined it was going to happen naturally, and it did. But my labor was naturally precipitous, and if I were to compare it to something in nature, it would be a riptide.

There are women whose birth stories have them, somehow, scanning the ocean in search of the crest of the wave, and once found, they ride it, shifting their weight here and there so that they don't fall if they begin to lose their balance. The sea water is spraying them in the face, and the mix of salt and perspiration on their skin is invigorating, affirming. And then there are other women in the riptide who are like me. I didn't fight it. I didn't navigate it. I didn't negotiate with it in any way. For weeks I have struggled with the mental picture of me being knocked down by a single wave; but I am starting to see that a woman's strength in birth is also in the letting go and allowing herself to tumble fearlessly with the current, never losing sight of the belief that, when the energy of the tide is through, she will find herself upright again on the shore.

High-Tech vs. High-Touch Maternity Care

Please click on the title above to read a simple, straightforward summary about the benefits to keeping interventions low in childbirth, from Consumer Reports -- a fairly benign publication that reaches out to a wide segment of people, not just alternative health or alternative birth populations!

In the Company of Midwives

2AM, January 25 (Sunday)
My 7 year old is sleeping beside me. Last temperature check was 102F. We are both tossing and turning, keeping each other awake. I feel a slight, quick gush in my underwear and go to the bathroom, anxious that my water has broken. But it is blood, bright red like a period, and some of it thick.

My husband is sleeping in the 7 year old's bed, which is downstairs beside the 4 year old's bed. I wake him up to tell him what is happening; he doesn't tell me for a few days that this frightened him.

But I'd seen blood before in this pregnancy. I already knew what came next. Call the midwife on call, go to triage - which is in the hospital, and not the Birth Center where I was aiming to give birth when the time came - be placed on an external fetal monitor for an hour or so, and then go home because the baby is fine, I am fine. The blood is a mystery, but then it goes away. And so it went, just like that. During the whole thing, while waiting for the midwife on call to call me back, while waiting for the cab, while in the cab going to the hospital, I have a contraction or two. Nothing big, nothing regular.

8PM, same day. Same thing.
My dear friend comes to put my kids to bed, and this time my husband comes with me. Bleeding stops, the baby is fine, fine, fine; the midwife on call acknowledges the continuing mystery, cautions me with specific instructions on when to return, then says I can go home. We are heading out the door, jackets on, when the attending OB says no. She says I should stay overnight for continuous fetal monitoring, but adds "If I could make you do what I really want you to do, I'd induce you now." She says, despite the baby being fine, despite my not having any pain, despite the bleeding which has again stopped, despite the absence of any immediate certain problem, "What's the point in being pregnant anymore? You are already full-term." I know if I stay, even if the baby continues to be fine throughout the night, that in the morning I will be faced with induction. She says if I insist on going home, I must sign a waiver that I have signed out Against Medical Advice.

The problem she is concerned about - that the midwives and I and she are all concerned about - is that my placenta is abrupting. The midwives have cared for me with due diligence. And even though it cannot be ruled out with 100% certainty, this would be an atypical presentation of abruption. I am a good patient; I follow instructions well, and I am not unreasonable. I just want to go home and let labor start on its own, and I know it will soon. The OB states frankly that I'm probably not abrupting, but because she cannot guarantee it, she'd rather keep me close by. She states that sometimes if abruption happens it maybe can happen really quickly. I appreciate that she wants to keep me safe, but I also feel that in the absence of any other symptoms, normal birth prevails. She is pretty and young with eyeglasses that are trendy but not so funky as to undermine her authority. She says "You're also over 35. Statistically you are at high risk for many problems."

I sign out AMA.

1AM, January 26 (Monday)
Bleeding again. I am a good patient; I follow instructions well, and I am not unreasonable. I return to the hospital and settle in for the night, fetal monitors belted to my belly. I know I will not be leaving this hospital again, not with this baby still inside my body. I know I will be induced by morning.

8:30AM, same day
It is a new morning. I never hear from the OB again, but the shifts have changed, and now my midwife is on duty. She sits beside me and holds my hand to tell me gently that she's sorry, but I can't give birth at the Birth Center anymore. It's easy to let that go, as my big concern is with induction. I am having contractions, but if they come regularly, they are mild and barely a distraction. Conversely, if they are strong and require my full attention, they last only 30 seconds. Meanwhile, the bleeding has not subsided like it has every time before. In fact, though it is not a hemorrhage, perhaps it is even slightly increasing.

My midwife explains the reasons why induction is warranted, and I believe her, not only because she has seen me more than a dozen times through the course of this normal and healthy pregnancy, but because she is presenting me with induction options. She has not dictated my care, then placed orders with a nurse and disappeared. She has remained sitting beside my bed and holding my hand, and she explains each choice to me, knowing what my hopes and preferences have been for this labor. In fact, when my husband walks in to the room, she explains it all a second time, for his benefit. Contractions are still coming, but they remain inconsistent. So we choose a course of action together, my midwife, husband, and I, one that will allow me to have as normal a birth as possible.

11AM, same day
Somehow, I missed breakfast. I cannot go into labor on an empty stomach, and clear fluids certainly will not sustain me through the workout that is childbirth. My midwife orders me a lunch. She takes heat from the Attending OB. "She's not in active labor," she tells him, which is the hospital policy. "She's not in any labor at all, and she's hungry."

12:30PM, same day
There is a delay in the induction. Pharmacy hasn't delivered the drugs yet, and there are some patients in triage who need evaluation. I eat - plentifully. I put my fork down, push the tray away, and suddenly a force wraps itself around my mid-section. I close my eyes and breathe through it, and it keeps on going. A minute and a half goes by before the contraction lets go of me. The room is suddenly as hot as July, and I feel another one coming. I stand up, hold on to my husband, let my knees go weak and try to relax every single muscle in my body so that my uterus is the only muscle efforting. Another minute and a half goes by. My eyes are closed, and I hear my midwife enter the room. There is a small space between the surges of contractions, and just as I feel another one coming upon me, she says it. She says it for me, because the contractions have taken all my breath, and I can no longer talk. She says, "You're in labor, Maria. Let's cancel that induction. This is all you."

Same day, some time after 12:30PM and before 1:47PM
I take my face away from where I have buried it in my husband's neck, regain my stance and say calmly "I can do this," while catching my breath. My husband holds me and tightens his arms around me, telling me silently that he believes me. I hear my midwife's affirmation, "You can do this, Maria."

1:47PM, January 26 (Monday)
My daughter is born. Official time from start of labor to birth is 1 hour and 17 minutes. She is caught by my midwife, who later writes in the chart:
NSVD
It stands for Normal Spontaneous Vaginal Delivery.

Precipitous Labor

"pre cip' i tous: adj. Like a precipice; extremely steep; abrupt or ill-considered. "


That is the definition found in the 2nd edition of the American Heritage Dictionary. Medically, a precipitous labor is a labor that results in a birth in 3 hours or less. We all have seen on the news the story of a woman whose baby was born in a car en route to the hospital, or whose kindergartener knew enough of his numbers to call 9-1-1. Like many doulas, I have a precipitous labor clause in my contract to ensure I get paid, even if I miss the birth. I suppose many of us, if we attend enough births, will experience (or miss experiencing, even) a preciptious labor or two -- but for the most part we wouldn't bet on it, and wouldn't want to.

Just over 2 weeks ago, I gave birth in an hour and 17 minutes. I have a friend who said that she had a quick labor, too, and then she described how she pushed for just 20 minutes. She had obvious pride in her birth story, so I didn't tell her that her labor wasn't anything even close to mine. My labor was rapid. Like, really rapid. Like at 12:30PM, I was eating lunch and chatting with my husband, and then by 1:47PM there was a baby in the room. The dictionary definition of "precipitous" is far more accurate than the medical definition; my labor was like being thrown off a very steep cliff with no chute, and I free fell all the way until my daughter exploded out of my body.

A goal of natural childbirth requires values clarification, a real sense of why you want to birth naturally: do you believe in normal birth, and that in the absence of true medical necessity, there is no need to intervene with its process? Do you believe in your own primal strength? Or do you want your strength challenged? I've even had a client flat out say she was so terrified of needles that in fact an epidural was far more frightening than unmedicated childbirth. Natural labor also requires planning and practice; in other words, lots and lots of fore thought. And all my plans were tossed out the window - there was no time to collect myself, no time to process, and I had to use only what remained: my instinct - to breathe and keep the air moving through my body; my husband - whom I held on to for dear life as he supported my weight and helped me rock and sway through this deft force of nature, and my midwife - who, despite the collective surprise of everyone in the birth room at such a swift and decisive labor, entirely believed as I did that nothing was ever wrong, and there was nothing to be afraid of.

I am left with the sense that I didn't so much give birth as I did give way to birth, and I am feeling far more humbled by nature than I am empowered or heroic. My "precipitous" labor certainly was "abrupt", though not "ill-considered," and yet, in the end, just as it was meant to be.

Fence-Sitting

I told a good friend that, unexpectedly, I was pregnant. She said to me, "But you work as a doula. You are surrounded by pregnant women and newborn babies all the time. It's not that surprising that you're pregnant!" Another good friend's response was "You also work as a counselor in an abortion clinic. You know how these things happen -- how could you be surprised that you're pregnant?"

So that's what it's like sitting on a fence. My husband and I agreed not to make any decisions right then and there, and gave ourselves permission to ride a rollercoaster of emotions, come to any number of decisions, and then change them again until we finally settled on something that felt right.

A fellow doula offered her congratulations, saying "What a gift it is to go through a 3rd pregnancy, knowing all that you know about childbirth." And true, if I chose to continue the pregnancy, I had a plan for my prenatal care and very definite goals for my labor and birth. But the truth is symmetrical; I also knew every step of the abortion procedure. I knew exactly where to go, nothing to eat or drink after midnight until after my procedure was done, and that I needed to ask for an anti-nausea agent in my IV sedation. I knew that the doctor would write words on my medical report to indicate that the procedure was complete, and the likely words would be "fetal parts", "villi", "sac" or "POC," which stands for Products of Conception.

This is actually my 4th pregnancy, as I had a miscarriage between my two daughters. The gravity of the loss I felt at that time took me by surprise. I grieved as if someone had died, and I was barely 7 weeks at the time. Ironically, four years later, here I was waiting to be 7 weeks, so that if I were to terminate, there would be less likelihood of complication. But unlike my miscarriage, this time I had a choice, and I had never felt such ambivalence. I didn't want to bring another child into the lives of my daughters just because I was afraid to have an abortion. How was it that I could offer support and smiles and reassurance to dozens of women who make that choice every week?

I do occasionally sit with ambivalent women at the clinic. Women who take more than 20 minutes to fill out a single registration form, women whom we see through our security cameras sitting in the car long after they've shut off the engine. When I talk with them in counseling, I tell them that it is one thing to consider abortion, to look it up online, to make the appointment. But it is a different thing altogether to show up, to sit in the waiting room with a dozen other women who are there for the very same reason, and then actually go through with it. Some of them, especially if they are very early in the pregnancy, I counsel to go home, (I always wish I could open the front doors and shout out to the protesters, "Letting one go!") because a 1st trimester procedure can be done up to 14 weeks into the pregnancy. Because she has the time, I suggest she talk to her friends, garner the support she needs, and then if she returns, I assure her it will be easier. I imagined myself as the patient with any of my fellow counselors sitting in the room with me, explaining to me all that I already knew. And in my mind I could see them sending me home, and with a kind smile, saying "Maria, you are not ready to make this decision today."

Nine weeks into my pregnancy, I had my first prenatal appointment with a midwife. I chose not to share with her that my pregnancy was due to an act of carelessness. I also didn't disclose that abortion was still an option (which makes me feel silly in hindsight, as I rarely sit down with a woman at the abortion clinic who is voluntarily terminating her pregnancy despite having begun prenatal care). Nine weeks was also when I began spotting. I had been spotting for a few days by the time I saw her.

She sent me for an ultrasound, and I remembered my previous pregnancy loss. I wondered if maybe God was punishing me. For getting pregnant so thoughtlessly and then responding with indecision, my penance would be miscarriage, and then my husband and I would never, ever, ever take a chance again. I would continue my thriving doula career, coaching women through childbirth and breastfeeding, knowing that I would never again be a laboring or nursing mother, because we would never again let an accident like that happen. I lay on the exam table in radiology, the technician rolled the transducer over my belly, and there it was: a tadpole with a little flashing light, a heartbeat. I cried through the rest of the exam, which I hadn't done years before when the ultrasound had shown no heartbeat. I felt relief that I wouldn't have to experience that again, the bleeding, the clots, the pain that wrapped around my waist from back to front - the labor of a miscarriage. And though it would be a while yet before I would feel a rush of attachment for the image on the screen, I knew that my third journey into motherhood had already begun.