There will be an ongoing chat every Thursday at 9pm EST on twitter using the #studentmidwife hashtag. Come join, lurk, and listen to the newest wave of midwives.

This will be centered on out-of-hospital birth assisting and midwifery, though all student midwives are welcome to participate.

As a birth worker, I have found it interesting how much of my time we spend with our pregnant clients prenatally and postpartum going over the most basic mechanisms of birth, birth control, and self-care of the reproductive system. As a practice, we see ourselves as facilitators and mythbusters, and we merely help families reach for and find the best options for them.

First-time parents seem to have a great deal of fear surrounding the childbirth process and mystery surrounding their conception. With the myths and the pain and the romanticizing of birth seen in the media and perpetuated through tired stereotypes, I can’t blame them – but I can blame our educational system.

I have described the cartilage and ligaments of the pelvic girdle and the role of the hormone relaxin. I have pushed stuffed babies through my preceptor’s model pelvis, showing the final rotation of the baby in the descent through the pelvis just before birth. I have illustrated breech birth, posterior birth, shown pictures of what a placenta looks like and described to women where their organs go when a full-term uterus is taking up all their abdominal space.

I argue that these are basic, BASIC pieces of information that we are withholding from our children in our impotence in de-politicizing birth. There are approximately 6,000,000 (yes, six million) pregnancies each year in the United States, counting for over 4 million live births. Think about that. These women and men are mostly going in with no knowledge of basic nutrition for pregnancy, basic physiology of how that baby is going to come out, basic knowledge of breastfeeding… and we expect a 7 minute (if with an OB) or 15 minute (with a CNM)* prenatal exam once a month to cover all these topics?

We are either naive or delusional.

There should be nothing political about preparing American children for pregnancy and birth: the truth is that most Americans will become parents at some point in their life. We are doing these future parents an incredible disservice and feeding into the “doctor-worship” that in part creates our heavily litigious society. We create a situation where they either have the wherewithal to educate themselves or they abdicate responsibility to “experts.” We all know what happens when those experts disappoint or when the outcome is not what was assured.

Contraception and abortion aside, family planning and method of birth aside, we owe it to our children to reevaluate their sex education. What do our children go into their sexually active lives believing about conception, birth, and pregnancy? I argue that this is the responsibility of our educational system, though since it is doing such an inadequate job, it falls to parents to fill in the blanks. There are basics, beyond “the birds and the bees,” beyond the basic mechanisms of intercourse, that should be taught.

• The normal cycle of female fertility. Not the “rhythm method” of 28 days that is commonly referred to, but accurate signs of fertility (cervical mucous, cervical height and openness, and basal temperature).
• The basics of implantation and early pregnancy, as it relates to environmental toxins and also intended pregnancy. A basic knowledge of toxins and how they affect the embryo is essential in making a connection in these kids’ minds between their bodies and wellness. We should also be covering basic signs of early pregnancy – how many teens didn’t find out until 2+ months of gestation?
• The basics of nutrition. This is a life skill that is sorely lacking in our children’s health curriculum. It is relegated to the sidelines, to a one semester class grouped with many other “health” topics. These are the building blocks for future children and for healthy adult lives, and shouldn’t be ignored.
• The physiology of birth and lactation. How are full-term, normal babies born? How does a baby with a 14″ head fit through a 10cm hole? How is milk produced? What are the success and failure rates of common obstetrical interventions? What are their risks? These are questions that we get all the time from grown adults.
• Basic self-care. The importance of breast exams, Pap smears, prostate exams for men.

Some of these are covered currently, but many are not. I feel like even if they were covered well, I would still spend a lot of time re-explaining. Retention rates are different for everyone and education is not always consistent. However, I think this would help reduce the culture of fear that has sprung up around birth. In truth, the media is currently creating our culture of birth and raising our children. Are we content with that? I hope not.

Comprehensive sex education doesn’t have to be political and can do our children and our culture a great service. We should make this a priority, especially with healthcare in shambles and our children’s generation probably being the first in history to have a lower life expectancy than their parents. This isn’t about politics or religion – this is about the health of the American family.

* 1% of births in the US are at home with midwives, so it is a safe assumption that most women are seeing either a hospital OB or CNM practice, with the above typical appointment times.

Anyone who knows me knows that I am a huge fan of unencumbered, un-messed-with, unmedicated childbirth.  I will sing the praises of my homebirth to anyone who will sit still long enough to listen, and I frequently caution pregnant women on the interventions that they are likely to encounter in the hospital. This philosophy has allied me pretty firmly in the “natural childbirth movement” camp, especially since declaring my intentions to become a homebirth midwife.

People within the NCB movement often seem shocked to hear that my first child was born by cesarean, and I frequently hear “Aren’t you glad you know better now?”

I’m sorry… what?

For my first birth, I was at a freestanding birth center with CNMs completely devoted to birth as a normal event. Their cesarean rate was below 10%. I took a Bradley course. I spent the first 12+hrs of birth laboring at home, the next 24 upright or in the water, before transferring to the hospital for pain relief and another 10hrs of labor. Tell me what part of that would have changed with more knowledge?

No, don’t. Because frankly, my experience and choices aren’t the point. The point is this disturbing trend among NCB advocates of assuming a few things about women who have had a child (or children) by cesarean.

So let me debunk some common myths within the NCB movement re: moms who had cesareans.

We are not all ignorant. We are not all victims of the big, bad system that is out to control your uteri, lambs led to slaughter, or victims of coercion. We are women who had home birth and birth center transfers, women who had trustworthy providers, informed consent, and done “everything right.” We are just as informed and educated as those of you who sailed through uncomplicated births or fought for challenging ones.

We did not all have unnecessary cesareans. We are women with true obstetrical emergencies – Bandl’s rings and dangerous dystocias. We are women who decided that our cesarean was safer than attempting a vaginal breech with a provider who has never seen one. We are women who, completely informed to the risks we were undertaking, decided after days of stalled labor that we could be better mothers to our children by choosing to end labor in surgical birth. We are women who chose elective surgery because it was what we felt gave us the best control over our birth.

Having a cesarean isn’t “the easy way out.” Anyone who has had one and dealt with the pain of adhesions, nursing a baby who repeatedly kicks your fresh scar, the numbness that can last for years, and the difficulty of simple tasks – carrying your baby and going up stairs – can testify to this. Hell, anyone who has fought for a VBAC can attest to this. Whether you never felt a contraction or were in labor for days, cesarean birth is never easy.

Cesarean birth is birth. A mother is born. A baby is born. By suggesting otherwise, you only reveal your bias and your ignorance. Suggesting that a mother shouldn’t use the phrase “give birth” because she didn’t push out a baby is ludicrous and a personal insult that does nothing but reveal your insecurity and does nothing to educate. Just don’t go there.

We do not all regret our cesareans. A cesarean can be a liberating, empowering, family-centered event. Do not assume there is grief attached to surgical birth, for that is frequently not the case. Sub-statement: do not try to attach grief to a cesarean birth that isn’t there. You don’t have the right to tell a mother that she should regret something.

Being pro natural childbirth does not make you anti-cesarean. Let me repeat that. BEING PRO NATURAL CHILDBIRTH DOES NOT MAKE YOU ANTI-CESAREAN. Cesareans save lives sometimes. Cesareans can be the best, least-risky way to give birth sometimes. As natural childbirth advocates, we are pro-CHOICE. We are pro-informed consent. We are pro-eliminating unnecessary risk. Just like we trust our bodies to birth, we trust women, armed with unbiased information, to be able to make the best choices for themselves. We resented having our choices taken from us in the system – why then would we take the choice away from women on the other end? The ability to choose natural birth and its risk package means the ability to choose cesarean and its risks. PERIOD.

These assumptions are ugly, and show ignorance within the NCB movement. These assumptions once again take the choice out of women’s hands – the choice to feel how we feel about our births, however they happened. Have your opinions in private, but show respect and maturity and know when to STFU and listen.

If you aren’t the woman giving birth – STFU. Listen.

If you weren’t in the room and don’t know every detail – STFU. Listen.

If you think cesarean moms are victims of ignorance – STFU. Listen.

If you think that since 1 in 3 births are by cesarean, that gives you the right to assume someone’s cesarean was unnecessary – STFU. Listen.

If you feel the need to “enlighten” women who are choosing cesarean birth – STFU. Listen.

Until you have laid on that table yourself, having made that choice – STFU. Listen.

Nobody has the right to judge in the natural childbirth movement or elsewhere. There is no room for people in this movement who want to negate women’s choices and experiences, whatever they are. Women will tell YOU how they feel and whether it was right for them. Get a clue. Take the hint. Support women in their choices, help them find the resources *they* want, bust myths. Women are smart. Empower them.

And learn when to STFU and listen.

Obstetrician (OB) – This is the most popular and mainstream option in my area. Obstetricians (and perinatologists for very high-risk births) provide the pinnacle of expertise on complications and abnormalities during birth. They almost exclusively practice in hospitals, though rarely some are known to provide births at home though this is outside normative OB training and generally reflects a personal philosophy rather than a professionally-motivated one. They are MDs or DOs, so they have been through a course of school that is approximately 4 years of medical school, 4 years of residency, and are licensed in their state of practice and have passed the American Board of Obstetrics and Gynecology certification exam. They are qualified surgeons, and are the only providers qualified to provide a cesarean or care over a heavily-managed birth with additional complications. Some are also familiar with un-managed birth (birth with no drugs or interventions), but many are not, as it is not a required part of their training.

Some links: American Congress of Obstetricians and Gynecologists

Certified Nurse Midwife (CNM/CM) – This is a certification that has quite a bit of flexibility. CNMs are nurses, so have been through nursing school and have a bachelor’s degree plus specialized courses in midwifery. They are certified nationally and on the state level as nurses and midwives and CNMs have recognized licensure in all 50 states. Beginning soon, nurse midwives will be required to attain a Masters’ Degree in midwifery. They are trained in both managed and un-managed birth, to assist high-risk and independently care for low-risk birth, in the use of technology and not using technology to assist birth, and usually practice according to the community in which they work. Many CNMs work under OBs in hospitals and some have their own practices in hospitals or birthing centers. Other CNMs are found throughout the homebirth community, though this is not a required part of their training. CNMs are allowed a differing amount of autonomy depending on the state in which they practice. Some can only work under the auspices of OBs (which may yield more medicalized care) and others are allowed more self-guided care (which will depend on the midwife).

Some links: American College of Nurse Midwives, American Midwifery Certification Board

Certified Professional Midwife (CPM) – This is a certification for non-nurse midwives. CPMs are only trained for low-risk home or birth center births. CPMs do not have hospital privileges in any of the 50 states and are licensed, certified, or registered in 24 states. Check your state’s laws about the legality of CPMs here, but know that even if they are illegal, there are CPMs practicing in all 50 states. These midwives are trained through many paths, mainly with an apprenticeship with a currently practicing midwife (CPM or CNM). After their apprenticeship, this competency-based certification requires them to prove their skills to a qualified educator and then take a certifying test. They must re-certify every 3 years to maintain their certification. CPMs do not use the technology to manage birth that is available in hospitals, though they do carry basic equipment to monitor mother and baby (blood pressure cuff, fetascope/doppler, stethoscope, etc) and all must maintain current CPR and NNR (neonatal resuscitation) certification. In the case of complications or the need for interventions to labor, a CPM will transfer care to a hospital and to a CNM or OB. The CPM is the only midwifery certification that requires homebirth experience.

Some links: North American Registry of Midwives, The Big Push for Midwives

(Both CNMs and CPMs fall under the purvey of MANA, the Midwives Alliance of North America. This is an umbrella organization dedicated to the benefits of The Midwifery Model of Care and establishes core competencies for all midwives.)

Lay Midwife (LM, DEM, other non-certified designations) – These designations are for all other midwives who attend births but are not regulated or certified by an overarching national organization. Their skills vary and their training varies. These midwives only do home births. Talk to each individual midwife about her experience and training and what she carries with her at births and her standards for prenatal care.

Unassisted prenatal or unassisted childbirth (UP/UC) – This acronym refers to people who prefer to be their own prenatal or childbirth care providers. The care and expertise will differ depending on your own wants, needs, and abilities. Some people decide to have parallel care for prenatals with one of the above providers and then birth on their own and others decide to take on all their care on their own.

These five forms of prenatal care are your basic choices for childbirth care. Not all of these choices are equally safe for every individual, but your individual circumstances will determine which choice is the best for you and your family. Do your research, understand your own unique risks, and choose a provider that you feel will best be able to serve you. Remember: YOU are the best gauge for appropriate care for your family.

As always, remember to interview your provider before you decide on them. You have the right to the type of care you feel is best for you and that means the right to consent or not consent to any provider who is presented to you throughout your care. Found a CNM that you love but you don’t like her birth assistant? You have the right to not consent to her being at your birth or prenatals. Make sure that you choose your care providers and their staff carefully, as these are the people who will be caring for you in one of your most vulnerable times.

Happy birthing!

I wanted to let you all know that I filed my withdrawal with IHM this evening, effective immediately. The decision ended up being that I am still pursuing the CPM certification, but I will be doing it through the Portfolio Evaluation Process (PEP) instead of a school. This should allow me the flexibility I need at this point in my family’s life to fulfill my most important commitments (to them and to my religion) and then add another member to my family come February. I should be updating soon with some new goals, because this blog just got a lot more important to keeping me accountable to this path.

Your newly rogue apprenticing midwife,

Sara

Don’t you want to give your baby the best you can possibly give her?

Breast is best!

Organic food is the best start for baby’s health.

Get the best prenatal vitamins. Your nutrition is important!

How many times have we heard the tired, worn-out mantra of BEST BEST BEST? Yes, of course some things are “the best.” We live in a world with so few neutrals that we cannot help but prioritize which “bests” we can give our children and which bests we can give ourselves.

Eew, that word. PRIORITIES. It’s become an ugly word – a word that we have started to throw around as an insult, as a term that lets us judge others as inferior and misguided. We have started to use the word as an excuse for bad behavior.

Forget that. Priorities are a good thing. A mature thing. We cannot do everything, for ourselves, for our children, for others. If we try to do everything, something will give or everything will end up half-assed.

Let me repeat that.

WE CANNOT DO EVERYTHING.

You cannot be the best worker AND be the best stay-at-home parent to your children. Sometimes, you have to sacrifice having a parent at home in order to put food on the table. You have to choose which is more important, because when it comes to that deadline on your daughter’s birthday, working overtime, having money for food or health benefits, or being at every event for your child, something will have to give. Right now, this society is NOT geared towards these two things being compatible. It should be, but that’s a whole different blog post.

Breast isn’t always best. If breastfeeding means that your child is always hungry, you are always panicking about supply and taking medications that make you miserable, and your marriage is falling apart from the stress of it all, breast isn’t best. I said it. If using formula means that you are better parents, able to enjoy your children and this journey of parenting, and able to cope with getting up in the morning, then use formula and say a prayer of thanks that we live in a society where formula is a good enough option when breastfeeding can’t or doesn’t work.

It’s really ok if you don’t buy organic foods. Buy organic when you can, and concentrate on feeding your family in a way that teaches them to nourish their body with food that is good for them. Getting Amy’s Organic Frozen Lasagna teaches a far different lesson than making lasagna out of commercial but homemade produce. Especially when it comes to food choices, our children will see and do what we do. Do we want our kids eating processed convenience foods or learning that cooking and nourishing your body, even when we have to buy commercial, is important?

Now for the catch.

Yeah, you thought that this was an apologist post, didn’t you? Most posts about “it’s ok if you don’t…” end here, with the cry of “Don’t let mama guilt get to you! Be confident! You’re doing great!” Not this one.

Our responsibility doesn’t end at “I had to prioritize against (SAHPing/breastfeeding/organic).” We don’t get to stick our noses out and arrogantly declare ourselves proud that we are prioritizing. We don’t get to manipulate the science surrounding the fact that having a parent at home helps kids with confidence and success, breastfeeding is imminently superior for a baby’s health, or that foods grown without pesticides are simply better for you.

We all, REGARDLESS OF THE CHOICES WE MAKE FOR OURSELVES, have a responsibility to demand higher standards. We have a responsibility to help create a society where every child can grow up with parents who have the time to make a decent living AND be available when their children need them. We need to fight for parental leave and simply to make our society friendlier towards families with children. We need to fight to make good breastfeeding help affordable and easy to find, and make the sight of babies being nursed more commonplace than the sight of a child being bottle-fed. We need to fight to have higher standards for ALL our food and to make sure that every family can afford to eat healthy, whole foods, and have the support and time to make this choice for their families.

We have to face head-on the reality of the society we live in. We have to face the fact that most of those of us who work want to be more available to our children, but we can’t for fear of our job security or losing income that feeds our family. We have to face the fact that most of us who ended up formula feeding did so because we either couldn’t find good support or it just wasn’t working the way we were told it would. We have to face the fact that if we could find the right foods for the right price and have the time to prepare them, we would all be making things from scratch and buying organic, but our budgets and schedules are prohibiting us.

These limitations – security, support, time, energy, knowledge – are all limitations that have become endemically commonplace in our society. I’ll be the one to say it – it’s WRONG. It is wrong to make a parent choose between healthcare or food and being with their children. It’s wrong to make a mother choose formula because she can’t get the help/donor milk/support to breastfeed. It’s wrong to make a family eat food riddled with pesticides or processed foods because they can’t afford better. This is what our society says is “good enough” for us, and it’s not.

Do what you need to do for your families and for your sanity. You can only do so much with such resistance from our society, but your responsibility doesn’t end there. The fight is all of ours, and frankly – if we don’t fight this fight, we are making things harder for our children when it comes their time to prioritize. One thing I never want to pass down to my children is the struggles I had trying to make the best decisions while parenting them.

Dear M and C,

As I evaluated two of the Social/Emotional Health assignments, I was highly disturbed and troubled by them. I found myself putting them off to the end of my deadline, so I spent some time meditating on why they bothered me so much. These are the two assignments, for your reference:

Develop a family-friendly, self-evaluation Social Safety Assessment form.  Include information regarding a woman’s personal safety, family safety, environment, community support and basic needs. 

Based on identified needs on the Social Safety Assessment form, develop a list of non-threatening follow-up questions and referral options, as applicable. 

I did lots of soul-searching and it came down to this: despite the resources available to me in Holistic Midwifery and my past experience with abuse, I do not believe that as a midwife, I am qualified to assess my clients and evaluate whether behavior constitutes as “typical” or “abusive.” I believe that such an assessment form is not only beyond my experience and knowledge to create, but it is beyond my scope of practice as a midwife (I used this page: http://narm.org/faq/cpm-practice-guidelines/ to research my scope of practice as a CPM).

As a midwife, I have certain red flags to look for: for example, the 17 behaviors on p. 301-3 in Holistic Midwifery. I also have my intake forms, which already ask questions about mom & partner’s feelings about their relationship, home life, finances, feelings about the pregnancy, and past abuse. If any of these behaviors raise red flags for me or if I have a gut instinct that abuse is present, I believe that the next step should be referral to a qualified counselor of the client’s choice. I do not believe that it is within my scope of practice to go any further in the assessment, as I am not qualified by reading one small section in a textbook.

Abuse is a serious complication of pregnancy that I believe should always be co-managed by an expert. I believe that it is within my scope to help heal from birth and sex-related abuse by providing that safe space to talk, but I am not a counselor or a therapist. Anyone with past abuse, just like someone with a mental or physical illness, in order for me to serve them safely, must have a relationship with an expert qualified to help them handle said trauma.

I have no reservations on discontinuing care to clients who refuse the care of an expert in their trauma, because I truly believe that their safety during pregnancy, birth, and the postpartum period is at risk. I also believe that not referring any flags that come up on initial intake to counseling services, therapy, or pastoral care for qualified assessment is medical neglect, tantamount to finding cancer on an x-ray and not referring to an oncologist because “it’s not bad enough for referral.”

I also believe that Anne Frye’s description and explanation of abuse in Holistic Midwifery is incomplete at best and inaccurate at worst, though that is probably a discussion for another time.

I will not be creating a Social Safety Assessment form and follow-up questions per the assignment for the reasons stated above. I fully expect to receive an “incomplete assignment” for these two assignments, but cannot in good conscience create a form that I believe is beyond my scope of practice.

I look forward to seeing you next weekend for the skills seminar!

Yours,

Sara Eiser

This being me, I reasoned that a small town had to have a homebirth midwife, and a small town with secrets of the paranormal variety must have a homebirth midwife who saw many of those secrets. Enter Eula Bujeau, a Louisiana transplant who finds herself a midwife to some strange characters. I hope you enjoy the story for something a bit lighter.

The Wolf Moon

(Yes, I'm nursing Nomi in this picture...)

I’ve found that my life has themes. Each season, each year… distinct time periods where G-d draws my focus to one facet of my life in particular. I have blogged this winter about trying to find balance in my life. I am a busy, blessed woman and have found that in undertaking this midwifery journey, I am changing my life quite a bit. This is helping me to re-prioritize but also highlighting the shortcomings and excesses of my life.

This winter it was balance and prioritizing and this spring is family. Not family like my parents and my children and my husband, but created family – those people who have become part of my life through circumstance and shared interests and location. My synagogue, my friends, my colleagues. I am renewing my commitment to them and finding a place of deeper love for them.

I have been privileged enough to become an apprentice under fantastic midwives, Anni and Paula and their assistant (also a training midwife) Deanna, along with two of my other classmates from IHM, Aza and Carla. Anni and Paula, in speaking to all of us about our training, highlighted the importance of family and guarding the time that we have with our loves. They told us that no matter what, we were the guardians of our families. Birth will go on with or without us, but the moments that we have with our families only happen once.

Carla, Aza, and I all have small children and husbands and friends that need us, and it’s refreshing to have midwives who value our other commitments. There were children at our meeting, toys, an iPad playing Kipper, cell phones being checked for updates on family… and there was talk about the family that the six of us women were becoming. Anni and Paula made it clear that Deanna had become part of their family and for this to work out, we would as well.

I was amazed at the strong, diverse group we were. Age, race, religion, location, dietary restrictions, education… but it didn’t seem to matter. We found shared connections in a love of Wegmans groceries, kissing boo-boos, and food that was kosher and vegan and just plain yummy. Husband stories, children stories, birth stories; squirrel watching out Anni’s huge picture windows and a love for sitting in a circle and talking and eating together. There was laughter and the love of a family while we sat there on a shag carpet, watching Anni knit, me eat, and the kids play. While we talked about midwifery and family and anything else.

I’m learning the value of a village – you cannot raise a child without that support, and you cannot grow a midwife without it. I’m excited to be creating that kind of community – that kind of family – with these six women. Anni, Paula, Deanna, Carla, Aza, and I will be supporting each other, teaching each other, guiding and loving each other through this whole process of growing more midwives. I’m excited to get to know my new family – excited for their children and their lives and their loves to become a part of mine. I’m honored to be a part of this practice with these women.

This spring, I’m working on loving and honoring both of my families – my family by blood and my family by circumstance and shared interest. This is part of the balancing act of a calling that is timeless and tireless. I am limited and birth is not. I have to guard myself because midwifery is (as Anni stated) a jealous lover and I don’t want to give up my other loves for it.

I’ve reached no conclusions, but I’m glad that I will have women who are looking out for me and for my family as well. I am happy and supported and am already being put to work with my first prenatal observation on Saturday as a brand new member of a family of women who support women in their choices surrounding birth.

Gotta relax.