Decisions, decisions...

Breastfeed? Bottle feed (hey, it's organic)?

I almost feel bad posting this juxtaposition. It's like shooting fish in a barrel.


Report from Our Bodies, Ourselves co-author booksigning in Albuquerque...

I had the privilege of hearing Judy Norsigian speak last night at Bookworks about the newest book from the Boston Women's Health Collective, Our Bodies, Ourselves: Pregnancy and Birth. It was wonderful to hear someone who really gets it and is right on the political frontlines of birth in America speak about how limited women's choices are really becoming and the crises we are facing. I found it very compelling that she has observed far more fear surrounding pregnancy and birth than there even was 5 or 6 years ago. To counteract the negative messages women are hearing from each other and the media, the book focuses on giving women the confidence they need to reclaim this feminine rite of passage with an emphasis on evidence based practice. And obviously, this leads to the midwifery model of care. Birth centers are closing left and right, obstetricians are denying certified nurse midwives the right to practice in certain hospitals because of perceived "turf wars" and the well-being of women and babies is left on the sidelines in highly charged, financially fueled debate in the medical community.

I bought the book and can't wait to read it. Because of hearing Judy speak, I am now motivated to do the following. And don't worry, I will share my progress with our loyal blog-readers.

  • Write letters to St. Joseph's hospital in Santa Fe and start a letter-writing campaign if there isn't one going already to fight the ban on midwives there. St. Joseph's is the only hospital in Santa Fe, so although New Mexico has a long, proud tradition of midwifery care with some of the best birth outcomes in the country, women of Santa Fe are forced into choosing homebirth if they want access to midwifery care. Find out what the story is in your area, and do the same! I'll be pressuring Elizabeth to write similar letters to the hospitals of Austin who also deny women the choice of midwifery care.

  • Read the chapter about nitrous oxide used for pain relief in Our Bodies, Ourselves:Pregnancy and Birth and get educated about this topic. I've heard things about this in passing when reading British writer Sheila Kitzinger's book, but I hadn't realized the real issues behind it. There have been no studies showing any risk to mother or baby when nitrous oxide is used during labor, and yet women of the U.S. have zero access to this less invasive pain relief option. Why? No anesthesiologists necessary. Birth choices have GOT to stop being limited in this country based on profit! The well-being of mothers and babies should not be sacrified in the name of money. You can start here and here to learn more.

  • Learn more about healthcare reform options. Judy strongly favors a single-payer system and in fact feels that no major strides of progress will be made for childbirth in America until such a system comes about. And in fact, all the Western countries who have more midwifery care and thus better outcomes for mothers and babies across the board than the U.S., have a single payer system. She recommends reading A Second Opinion by Dr. Arnold Relman and passing it along to any physician you know who will read it, because the pressure for change needs to come from doctors. This will certainly be making my goodreads list.
  • Let everyone I know (that means you!) that Our Bodies, Our Blog accepts material from any and all writers about current issues in women's health policy and that they just might link to your article. I'm really hoping eventually we can earn a coveted spot on their list of linked blogs!

The VBAC debate was also discussed in the context of women being more and more frequently denied even the opportunity to choose whether to have a VBAC or not because of VBAC bans in hospitals, as well as the need for more celebrity homebirthers! The talk was really insightful and informative and I would encourage anyone who has the opportunity to go see her while she is on the book tour.


Get a Job!

Everyone at a birth needs to be employed.

No, that doesn't mean that only birth professionals should be there (sorry, Auntie May, you've gotta go!), but from my experiences as a doula, I've come to believe that anyone who's not contributing something is likely to be keeping things from progressing as they should. Too many women allow unwanted visitors to this rare and marvelous experience -- which can have consequences ranging from an annoyed birther to a stalled labor, and all that that entails.

Before inviting someone to attend your birth, consider:
- What energy does this person bring to a situation?
- Can s/he handle intense situations calmly?
- What can s/he do to help me/my partner/my children during this time?
- Do I actually want this person at my birth, or do I feel I should want them?
- Do this person want to attend my birth? Will they feel they can say no if I ask them to attend?
- Am I comfortable with this person seeing me naked? In pain?

Birth is not a spectator sport. But that doesn't mean you shouldn't have a room full of people, if that's what makes you feel safe, warm, and loved. Just think about the roles everyone in that room can play. Don't be shy about assigning duties to everyone from your doula to your mother-in-law. Remember, people are also more likely to get flustered during a long or intense labor if they don't have something to do -- they will likely be glad to know what's expected of them!

Here are some suggestions for jobs you can give your support team:
- Birth photographer or videographer
- Caterer (keep you and the rest of the team fed and hydrated)
- Massage therapist
- Doula
- Babysitter/Kids' doula (keep the kids occupied or help them understand what's going on)
- Gopher
- Reporter (keep a log of the event and write a beautiful birth story!)
- Birth tub maintenance technician
- Clean-up crew (homebirth)
- Mediator with medical staff (hospital birth)
- Hand holder (perfect for someone with a warm presence that you just want to be there for you)

I've started teaching childbirth preparation, and this is something I've covered with both my classes. It seems to be well-received, though I'm sure I'll step on someone's toes with it eventually. What do you think, gentle readers?

Yet Another Celebrity Homebirther

Melora Hardin, who plays Jan on The Office, talks about her home births, extended breastfeeding, and attachment parenting here.

I really love what she has to say about nursing both of her girls until they were 2 1/2:
I was adamant about not having to feel like I had to cover up when I was out feeding my child. We see plenty of violence in this country, and if you can't deal with a woman feeding her child, then look the other way.

She is fabulous!


Birth Spool Interview: Pamela Hines-Powell

It's our first interview!

Pamela Hines-Powell is a midwife practicing in Salem, Oregon. Her blog PamAMidwife is some of our very favorite reading here at the Birth Spool (and check out the archives here). She writes extensively about contemporary birth and "unlearning midwifery."

Pam's hands-off philosophy distinguishes her not just from the modern obstetrical world but from many other midwives as well. Her belief in the power and safety of birth inspires and humbles us.

Here's Pam:

When did you know you wanted to be a midwife?

Some people discuss midwifery as a "calling" - certainly any person in their right mind would not choose midwifery for its glamour, income, or regular schedule! In my case, it definitely felt like a calling, but I fought it tooth and nail. It started with my daughter's interventive hospital birth in 1994, which led me to become a doula. The question regarding becoming a midwife kept coming around and I kept stifling it. I think I was on the edge of knowing that my entire world would change should I take this path, and that was really scary in many ways. I eventually took a step forward and all the doors opened easily from that point on.

What educational path did you follow to become a midwife?
As a product of this culture, I believed that a "good" education came from a formal classroom environment. I have since changed my thinking on this, though it's a common misconception with midwifery (and learning in general). I started midwifery school in 1996, with a solid Anatomy & Physiology course and then midwifery studies in 1997. I ended my classroom education in 2000 and completed a four year apprenticeship in 2001.

How long have you been practicing? How many births have you attended?
I have had my own primary practice since the end of 2000. In that time I have attended about 200 births, with another 100 or so in my apprenticeship.

What are your other passions?
I love music, knitting, cleaning my house, and sleep!

Who are your midwifery mentors?
The most important mentors in my midwifery life are Michel Odent, Sarah Buckley, Gloria Lemay, Sarah Wickham, Laura Shanley, and Gail Hart. These people have influenced my beliefs and practice greatly.

You’re stuck on a desert island with one midwifery book – what do you want it to be? [Elizabeth is watching too much Lost and needs to stop thinking about the Island's obstetrical issues quite so much.]
Oh boy. Would I want a midwifery book on a deserted island? Guess I could always say one of Anne Frye's tomes which would keep me reading until I'm rescued - even if that is years away.
Any of Michel Odent's books or Sarah Buckley's Gentle Birth Gentle Mothering would be a first choice for birth-related reads. But really, I would take Middlesex by Jeffery Eugenides if I was deserted on an island!

What was your own experience giving birth like, and how did it influence you?
When I first found out I was pregnant in 1993 we didn't have medical insurance. I don't know where the exposure came from, but I called a local homebirth midwife about cost and services. I never set up an interview with her because soon after we obtained insurance and birth in the hospital would only cost us a small co-pay. I realize that at that time I thought homebirth was for people who didn't have insurance, but I have no comprehension how the concept of 'midwife' and 'homebirth' came into my thinking at all.

My daughter's birth was pretty typical. Paying too much attention to early labor contractions, arrived too soon to the hospital, Pitocin augmentation, pushing on my back, and a deep third degree episiotomy. This birth left me feeling hopeless and wounded. I started researching birth trauma and came to the idea of doulas. The first birth I attended as a doula was a homebirth - it was deeply healing for my soul.

What’s your favorite part of being a midwife? Least favorite?
My favorite part of midwifery is the challenges it has brought up in my personal life and awareness. Midwifery has really pushed me beyond my comfort zone many times - it's a lot like labor! Just when I think I have myself figured out, there's something else that comes up and pushes me further. I also enjoy the families that I am on this journey with and I love those new babies!

My least favorite is the inability to be sure of my schedule. Always being on-call is hard when you want to go out of town with friends or family. Birthdays and holidays have been interrupted by births or other client care. It never fails that if I stay up too late and crawl into bed exhausted, I will be called to a birth soon after I fall asleep.

What is your role as a midwife?
I see myself as a consultant, really. I have specific knowledge and skills that come in to play when there is a need, but this knowledge does not make me an expert on any particular motherbaby. Clients hire me for this knowledge in the rare instance that it is needed; they also hire me because of my resources and exposure to information in our community. I try to approach every client as a new version of care... each family chooses what they want done in the scope of their prenatal care (no blood pressure checks, no doppler, no testing), their birth, and postpartum. Customizing care allows me to meet the specific needs of each family without taking anything away from their experience. I trust that my clients have a stronger attachment to their health and the health of their baby than I do - and I stand by them in all their varied choices and requests.

What does being a midwife mean to you?
To me, being a midwife is a very intimate role in the childbearing journey. Because we have much more connection with women than doctors achieve, we are entrusted with more. Once a woman lets down her guard with me as a midwife, it is my job to hold that trust and respect. Midwives impact the birth experience in positive and negative ways... it is up to each midwife to separate her needs and desires from that of her client. Being a midwife offers lessons in self-reflection and huge personal growth opportunities. If I don't see those opportunities for change within myself, I am of no use to any of my clients.

Do you think birthing at home makes a difference for a mother? What about her baby?
It definitely makes a difference. We would never expect a woman to have an orgasm in a public place with strangers waiting for her climax. Yet, somehow, there is a thought that women should feel safe enough and private enough to birth in the hospital. The hormones of labor and birth mimic those involved in orgasm. If we really viewed childbirth as a sexual experience then perhaps more women would birth at home.

A woman who has safety, privacy, intimacy, and love will birth her baby easier than a woman who is under the judgmental gaze of the clock and a waiting staff. Being in her own environment offers her the familiarity of her intimate space, thereby reducing any sort of new brain (neocortex) activity (it's much easier to fall asleep in our own homes than in someone else's). In her home a woman's perception of pain is different, her feeling of control is different, and her process of labor and birth is different than in the hospital. At a hospital, there are rigorous protocols that allow for a very small window of, if any, personal desires on the part of the mother. Each woman in the hospital is another number, needing to allow certain standard procedures and interventions to be a "good" patient and "progress."

Since the baby is within the mother, they are a unit that I do not separate into two categories. If the mother's labor is hindered by observation, lack of privacy, or medications, the baby is affected. Babies need the hormones that the mother is releasing to create their own hormonal cocktail. These hormones ensure a safe trip for both of them and continue through the immediate postpartum transition to help with bonding and attachment.

What do you consider “high risk” and how do you handle those clients? Do you attend breeches, VBACs?
In my opinion, high risk applies to the obvious: complete placenta previa, pre-eclampsia, HELLP syndrome, premature births, etc. I do attend breeches, twins, and VBACs in my practice. Above all else, I can recommend that someone seek care elsewhere for their birth, but the risk that I apply to births isn't the same risk that a family may choose. For instance, I could feel fine with a labor starting at 35 weeks, but the woman in labor may not feel the same way. There are allowances on both sides and I do my best to stand up for and support the family's choice regarding continuing care.

What are the biggest challenges you face as a midwife? That midwives face in general?
The biggest risk to all midwives right now is the push to license all homebirth midwives. Mandatory licensure changes the face of midwifery - what we can and cannot do. It puts a woman's choice in the hands of a legislature, which is something I am opposed to. It also means that if a midwife chooses not to become licensed she faces criminalization. I'm strongly against criminalization of midwives. It seems that we're damned either way - in a state where midwives are illegal and being actively prosecuted, licensing seems like a logical way to end the legal battles and fear. Putting the state government (and often, the medical model) in charge of something like midwifery is risky business - the voices that make up the licensing rules and overseeing board are not always midwife friendly. It's not an easy situation to discuss with people, particularly because I live in a great state for midwifery. Oregon has only had voluntary licensure for homebirth midwives. No midwives are prosecuted in Oregon for practicing, licensed or not.

What do you predict will be the culture of birth in our country over the next 20 years? Will we ever get to a place of trusting birth?
It will have to take some huge steps towards a no-fault malpractice atmosphere and, quite possibly, socialized medicine. If we look at the countries with the best outcomes and highest rates of midwife-attended births, they are countries that have socialized medicine. If our healthcare stays privately funded then we will likely not see an improvement towards more gentle birth. I imagine that in the next ten years we are probably going to see a cesarean rate that is above 80%.

What makes your style of care different from a physician? A hospital midwife? Other home birth midwives?

I believe in women. I trust that with the attachment to their babies they have the strongest, most honest voice in choices. It's not fair to have created a relationship with a provider only to have them doubt your process and coerce you into something that you don't want because of protocols or rules. The fear of litigation is tremendous not only in hospital-based providers but also with homebirth midwives. There are a lot of "what if" stories that come into play when you talk to midwives about unhindered birth. My fear isn't in getting reamed by the system. My fear is not standing up for a woman's choice in birth. I am hired by my clients, I am not in control of their decisions.

I want to be shown that something is beneficial to motherbaby before I incorporate it into my practice. UK Midwife Sarah Wickham has a great quote:
Whether or not we do things like this as a regular part of our personal practice, why do we feel we need research evidence to support the argument for not intervening? In a model of midwifery that assumes normality, I would assume that midwives would need to see evidence that something is useful before incorporating it into their practice, not the other way around. Have we become that uncomfortable with the physiology and normality of birth that we would rather intervene than not? Are we so fearful of litigation that we feel we need to “do” rather than “be with”? And are these practices really so ingrained in us that we feel compelled to continue them on a routine basis unless – or until - they can be proven unhelpful?

This quote encompasses exactly what I believe about care in pregnancy and birth. I work hard to bring evidence to my clients so they can make the best decisions for the course of their care. The fear around stepping out into what is right is big. If we all step out together then things change, right? The time is perfect for homebirth midwives to let go of some of those old obstetric rituals and beliefs that keep women from coming into their own power.

What advice do you have for women who plan to become midwives?
Take it slow, don't rush it. If your heart is telling you to take care of your young children, put midwifery aside for awhile. Read, read, read, even if you're not actively planning on apprenticing anytime soon. New information and research comes out every day... stay on top of what is being said, being done, being learned. If you're meant to be a midwife then you will eventually be one. Pushing the goal of becoming a midwife is a lot like pushing a slow labor - it's painful and the end result can often end up being far different than what we wanted. Honor the path - sometimes we learn more on the becoming than we do the being.

Do you have an idea of what would comprise the ultimate education/knowledge for a CPM?
No, no, no. It has to be personally defined. We are not all the same, nor do we all learn the same. I cannot even begin to speculate what this would look like or have to encompass for it to be "ultimate". Each family, each community, has a different need. If we all are trained the same and think the same and practice the same, where is the midwife for people who want something different for their birth?

Since you live in a voluntary licensure state, you have written about why a midwife would choose not to be licensed. Do you see value in licensure in any circumstances? What certifications/licenses/etc. would you support, if any?
I'm still working on this one myself. I'm not sure if I have a black and white stance on it, but I do feel strongly about midwives being criminalized - in legal and illegal states. I would hope that every legislative effort to legalize midwives begins with a process that includes voluntary licensure.

Oregon and Utah are the only states that currently offer voluntary licensure of midwives. Idaho is in the process of trying to pass legislation for voluntary licensure, though midwives have been legal in that state for awhile. It is true that it's much easier to pass legislation for voluntary licensure in states where it is not downright illegal to practice, but I still think that the first legal step should always attempt to be voluntary.

If a state has mandatory licensure, midwives still run the risk of being prosecuted - either by not following state protocols or not being licensed (usually because they don't agree with or will not abide by the protocols). So in essence, even if you're 'legal' or 'licensed', you can still run the risk of prosecution just for supporting a family that chooses to go against state protocols. As a midwife, what my clients choose to do for their care and birth far exceeds any rules given to me by a state bureaucracy. If I lose my license because of standing by a family's choice then my integrity, as far as I'm concerned, is still intact.

Birth is a consumer issue, obviously. What can consumers do to change maternity care in the US?
Educate others, listen to women's stories, tell your story. Again, there are so many factors that play into the current attitudes around birth that even a consumer drive may not be enough to really change it alone. Women need to hear stories of personal empowerment through birth. All women hear is how scary and dangerous birth is. There needs to be more public voices telling women the truth about birth.

What advice do you have for pregnant mothers?
Don't overthink birth. It's not a final test that you cram for. What you need to know to birth is what you already have inside you and no amount of breathing patterns or practicing relaxation can change that inner knowledge. Listen to your body and work on gaining back the intuition that so many of us are taught to ignore. Our biggest job when pregnant is reversing the brainwashed ideas and lies about pregnancy, birth and mothering.

I know you’ve read Navelgazing Midwife’s latest post about the competency of CNMs vs. CPMs/LMs. Do you agree that nurse midwives are inherently better equipped to handle the unpredictable nature of birth? [Here is a link to that post, which has since been edited.]
Definitely not. Nurse-midwives by definition are great at hospital births. They prescribe and administer medications and procedures that work best in the safety confines of a hospital. Being a great hospital-based midwife does not mean that one is automatically a great homebirth midwife. Just as I could never walk into a hospital and assume to have knowledge about the systems there, hospital-based providers have to undergo a sort of reprogramming when attending home birth, including learning different skills.

I'm not really sure what sort of skills Barb thinks that she and other homebirth midwives should have - I don't prescribe birth control pills for women, I don't do colposcopies, I don't deal with breast lumps. I have some knowledge about them but feel these things are beyond my scope of practice - and my clients deserve a provider to refer to that does have a multitude of experience dealing with these issues firsthand. Even if I gained the knowledge, would I really use it that much? Perhaps that is the reason why it is so tricky: once given this knowledge and skills is a midwife more apt to apply it to every one of her clients? Is she more willing to be interventive because she has certain skills now? (Many naturopathic physicians in Oregon attend homebirths with a vacuum extractor!) If there are things I want to know more about or how to handle, nurse-midwifery school wouldn't be my first course of action, for sure. I don’t think I could complete nurse-midwifery school and come out with the same ideas about life and birth.

Tell us about your idea of an absolutely perfect birth culture. Where do midwives, nurses and doctors fit in? How is the care for low risk and higher risk women different? How is it the same? What are the roles of doulas and childbirth educators?
Ideally, I'd love to see women have options.

For hospital births: I believe that OB/Gyns are first and foremost surgeons (some I've talked to have admitted the same). If we're giving normal birth to surgeons then there will be a higher rate of surgery. (Which coincides with what I commented on above re: extended training outside the scope of practice/location... if skills, procedures, and rituals are learned then it's much harder to keep them from being applied across the board.) I'd much rather see OB/Gyns put to good use by overseeing high risk and surgical births. I would imagine that not too many Ob/Gyns would disagree - the struggle between keeping clinic hours, attending births and having a family of their own would ease considerably.

In hospital-based situations, I would love to see nurse-midwives as the standard of care for normal and low-risk women (though reframing what we consider 'high risk' is a necessary part of this process). I would also like women who birth in the hospital to receive at least one in-home visit before and after birth - as any midwife will tell you, in-home visits offer a distinct view of a woman's socioeconomic issues, her healthcare needs, etc. These nurses, or other professional, could offer women who are at higher risk resources and information about services in the community. Most hospital-based providers have no idea what their patient's home lives or needs are outside of clinical care. Having providers that really practiced evidence-based care would change the hospital environment towards a more positive direction.

For home births: I would love to see midwifery and homebirth as an option for every woman in every community. Currently, there are few options for a midwifery education if you do not have financial resources. This limits midwifery to women of a certain race, class, and area of the country. In essence, if you're middle to upper middle class white woman then going into midwifery could be an option for you. If you do not have these resources, and do not want to attain heavy debt along the way, then your community will not be served by homebirth midwifery. Midwifery training and midwifery access is very race and class biased. Most issues within the attachment parenting movement are racially, economically, and culturally biased - they're practices that are frequently carried out by a rather homogenous group of people.

It would be awesome if we could return to the idea that a formal, classroom education isn't the "best" or only type of midwifery education and allow for various routes of learning. I've learned so much in my career from other people and situations outside my formal education. This idea that “if you go to midwifery school and attend a certain number of births (usually quickly at a high-volume, fast-paced site) and viola! you're a midwife!” is hurting women and midwives. It is taking away from the true essence of being a midwife: learning a trade that is not easily found by memorizing words and taking tests, but by fully absorbing, being patient and present while providing women and families with continuity of care that creates an intimate relationship ready for the time of birth.

I think it's also important to look at race and class issues at high-volume birth sites - where middle to upper middle class white women go to 'get numbers', essentially practice their skills on women of color. This is an issue that most people don’t consider inappropriate…why?

In addition, we need MORE homebirth midwives. The more midwives we have, the more exposure this option gets. The more families that are interested, the more variety of midwives we need. Each family comes to homebirth with different paths and ideas - we need midwives that can suit the desires and needs of many different types of families! I'd love for there to be fewer issues around state regulations and more about community standards and peer review. While it may sound ok to say that every midwife MUST do such-and-such, talking to your peers about why your client chose NOT to do it may change the attitudes and atmosphere in the midwifery community in a positive way. There is a lot of backbiting amongst midwives about who is "safe" and who is not - and this usually revolves around being afraid of the laws, rather than supporting families.

What inspired you to start taking a hands-off role in 2nd and 3rd stage labor? What changes have you noticed since you started that approach?
Reading information from the UC community (the cbirth list was awesomely helpful during my apprenticeship and the early years of my practice) and birth writers like Michel Odent planted seeds in my head about how I wanted to practice.

We know too much about the hormones and physiologic process of labor and birth to ignore the science. Why are we still doing things that completely interrupt the process, putting motherbaby at risk? It was this dilemma that somehow pushed me further into putting into practice what I had been reading and hearing for years. I didn't want to be another midwife that did things just because it was routine or "couldn't hurt". I wanted to support the natural process as best I could.

For my practice, it started with having mothers and/or partners catch their own babies. I didn't believe in the idea that I "had to deliver" the head and then the dad could then catch the body. I wanted to dispel the myth that there were some fancy maneuvers or skill involved in catching a baby. Women never questioned their ability to receive their own babies at birth - especially in the water. They just do it. Fathers, on the other hand, were nervous. Once you explain that you just hold your hands out and receive the baby it all becomes clearer. As exciting as it is to catch a baby for me, I would imagine that feeling is a thousand times better when that baby is your baby, a product of your love.

I do not provide perineal massage or other techniques when a woman is pushing - I do not check her cervix to see if she is 'ready to push'. These two thought processes baffle me, knowing what we do about the expulsive efforts involved in pushing. Both are hindrances to the natural, instinctive flow of second stage for most women.

I cannot say that I've seen a higher rate of tears that I've needed to repair than midwives who provide hands-on 'support' during second stage, but I do not have any statistics to offer of either approach between midwives (I am in the process of slowly compiling info like this from my practice!). I rarely suture – I think at last count I had sutured 5 times in a little over 200 births. I feel that over the past couple of years I've changed the way I view tears in general, trusting the body's ability to alleviate pressure in areas that it needs to in order to avoid compromising more sensitive parts of the vagina. This idea that midwives can do all these things during pushing and at birth to prevent tears is not something that I believe in.

It seemed natural to evolve into a more hands-off third stage. Certainly with the birth of the baby the mother must be focused on that being. She is enveloped in a beautiful, blissful bubble that is protecting both her and her baby by creating a rush of beneficial hormones. These hormones will help her uterus contract, release the placenta and minimize bleeding while allowing that important bonding with the new baby that will ensure his/her survival through attachment. The last thing this loving couple needs is someone's hands on her baby, putting a hat or blanket on him, listening to the heart with a stethoscope, etc.

To assess how baby is transitioning, I am aware of baby's tone when he/she is born. It's baby’s tone that will tell us a great deal about how baby is doing - if tone is not great, but not horrible, then giving the baby some time to make the transition on his own is necessary. If some time passes with no improvement, a way to step in and assess while making verbal contact with the mother is key. We tell clients that if they do not see us come up to them or their baby after the birth then everything is fine. The gurgly breathing sounds, the color, etc., are all a normal part of the transition. We talk a lot about honoring that first 15 minutes or so - in more ways than just the attachment. We also discuss the lower risk of hemorrhage and other complications from allowing the first 15 minutes to be quiet and focused on baby. This seems to make sense to couples and they usually welcome it.

The effects? I've noticed fewer hemorrhages and more happy clients. My current apprentice got me off the thinking that every baby had to be to the breast within the first half hour. If we allow that bubble to stay intact, the baby and mother do what they need to do. Babies may not latch on right away, but they mouth the nipple and look at their mothers, which is just as beneficial for both of them. There is plenty of time for technique once she changes her attention to the outside world and things get more settled.

How do your clients react when you tell them how hands-off you are?
A few are concerned - and it usually has to do with a misunderstanding. I'm not going to stand aside and watch them hemorrhage. I'm not going to withhold support when they need it. I think the main discussions happen around the normal physiological process of labor and birth - and how I am there to be the midwife that their family needs. My role at birth changes with each family. Once we discuss their visions, their ideas and the ability to ask for what they want, people are typically fine. I am really adaptable based on what my clients want... I want a relationship built on mutual trust long before the birth so things flow smoothly and easily during that time.

I find that many people hire me specifically for my flexibility and ideas about birth. My clients are usually not the type that wants a midwife to tell them how to breathe during labor, what to do about prenatal testing, or how to feed their babies. I want my relationship with clients to be one based on equality. They have innate knowledge about their bodies and babies and I hope that I honor that knowledge above everything else I see clinically.

When was the last time you caught a baby?
It's been over a year - and it was for a client having her tenth baby and her fourth homebirth with me. But normally if anyone is going to catch a baby that isn't a family member it will be my apprentice. So there are some situations in which we do receive babies into our own hands, but not often.

What role can doulas and childbirth educators take in promoting trust of birth?
I think that doulas have gotten into the trap of doing a lot at births. Part of this is the fault of the training - all these tools, tricks, and techniques are taught and while they all have their place, many doulas want to use all of them at each birth. I think that a reasonable goal for doulas is offering support mostly for partners - and encouraging the partners with their knowledge. In the end, it would be nice if the mother felt as if the father or partner completely supported her and did all these great things rather than the doula alone.

I also think that there is a misconception that if you have a doula you'll have a birth with fewer interventions or medications. Doulas are up against too many obstacles to even think about guaranteeing that their presence will lower the rates of intervention at hospital births. If women need a doula to protect them from their care provider or birth location then they need to seriously re-evaluate where they're giving birth and with whom.

Childbirth educators also face huge obstacles. The biggest job of a childbirth educator is to help deprogram this culture and their brainwashing about birth. I feel for childbirth educators and doulas: the job that the public expects from them is momentous amidst the medicalization of childbirth. There are so many women out there that desire a natural (unmedicated) birth in a hospital setting, two things that are completely at odds with each other.

I think that exposing women to normal, unhindered birth visually as often as possible is so important. Pregnant women in general enjoy watching birth videos - if the images offer realistic, but normal views on birth, things might start to change. I would love it if all women could be exposed to unassisted childbirth stories and images... somehow the idea of an attended homebirth doesn't seem as radical when they're shown something more on the fringe. We'd also see women who felt drawn to unassisted birth have a visual, concrete example of others who have taken that path and hopefully give them direction towards their ideal birth.

Of course, all of this is dependent upon the birthworkers' own view of birth. We cannot teach women about birth trust unless we believe it with all of our heart.

What does the unassisted birth movement have to teach midwives?
What doesn't it have to teach midwives? I owe a great deal of my education and continued growth as a woman and midwife to the unassisted birth community. I'm not sure why the UC movement threatens so many midwives. We give a lot of lip service to women who birth with an attendant at home as "taking full responsibility" for their births when the act of hiring a midwife implies that both the midwife and the mother together share responsibility. Women who birth at home unattended assume full responsibility for their choices and often choose to do so because of this fact alone. As midwives we need to be aware of how just our mere presence can change a woman's labor or birth in positive and negative ways, something that I don't think many people even think about. Reading unassisted birth stories can provide midwives and midwifery students clear perspectives on what women really want and need in birth.

A UK midwife once said that they see unassisted births all the time - births where the baby is born without assistance of the midwife. She pointed out that what we call 'unassisted' here in the US is really "unattended" births. If we as midwives could really examine who we are at births, why we decide to do the things we do, and what affect that could have on the motherbaby, we might start to see more "unassisted" births.

What are some of the major and subtle effects of the changes you’ve made in your practice on mothers and newborns?

I can only really speak about the changes that have affected me. I have clients who appreciate being able to control their experience, but I don't know how much more details I could really provide than that.

For me as a woman, seeing birth work in these ways has given me tremendous faith in nature and our perfect design. Through the changes I’ve made, I actually observe births from a very different perspective... rather than being anxious when the baby comes, jumping around to do so many different things, I sit and watch. I'm aware of things, but I'm not expecting them. I am much more moved by the emotional experience of birth now than I was before I made these changes. Whereas before I would rarely feel myself getting emotional at births, I now find myself tearing up a majority of the time. Birth is so awe-inspiring, but also so ordinary. We're mammals... this is what we do.

Do mothers who trust themselves to birth trust themselves to mother? Are their babies and toddlers different in any way?
I definitely think so, but maybe I'm being too simplistic. I know that when a mother is offered the opportunity to make her own choices regarding her prenatal and birth care she seems to gain a certain level of strength that carries over into other parts of her parenting. When a couple works together during labor and births their baby essentially on their own, the foundation for parenting has been set. Together they birthed this baby - and the unity they have created at birth carries over into their parenting.

I'm not sure if their babies or toddlers are actually different in personality, but surely a less anxious, more grounded mother will help foster a more secure attachment with her baby, right?

How do we teach our children to trust birth when they, like us, are growing up in a culture of fear surrounding birth?
The first obvious, huge hurdle is to trust birth ourselves as parents. We have to re-learn what we've originally been told about birth and our bodies. Talking about birth in very normal terms is important - so is teaching our children to question what they are told, even when the information comes from us. Keeping bodily functions and health out in the open is something I found beneficial in parenting my own daughter, who is almost 14. Through my work in childbirth, her exposure to information (videos, books) and even attending some births with me, she has definitely formed her own view about birth. She still maintains that when she is pregnant, she wants an unassisted birth, with no midwife, and will call me only when she needs something. This is not because I have told her how to think; it's based on what she has been exposed to and how she feels about her body as a female in our culture.

Do you feel that trusting birth extends to trusting other physiological functions as well, like death? How can we apply trusting birth to other scenarios in our lives?
Birth and death are very similar in our culture - they are feared and they happen behind closed doors in a hospital. Speaking to a hospice care worker at a family member's death, I realized just how similar birth and dying at home are. Midwives for coming into or going out of life do the same thing: they provide options for resources, choices in care, and support. They ease pain, they offer comfort.

Trusting birth means trusting the divine nature of our body. That belief carries over into every other part of our world in terms of body image and healthcare. It affects how we deal with other healthcare providers, what course of action we take when we're ill and what type of preventative care we employ.

Is there a place for doulas at a homebirth with a midwife who trusts birth and an unhindered 2nd/3rd stage?
I don't really have any opinion one way or another regarding doulas at homebirths. My only requirement is that the woman wants the doula there and they've discussed the type of labor/birth care they want from the doula and from me. Whether or not I would want a doula at a birth isn't really important, because the decision and ability to have one should rest with the laboring mother only.

What would happen to birth statistics overall if our entire culture had a radical shift to trusting birth? Which complications would decline the most?
We'd see a more reasonable rate of maternal and infant health overall, of course. I think we'd even change some ideas that could really benefit women who are high-risk or babies that are born premature (like delayed cord clamping, more kangaroo care, increased efforts for breastfeeding, etc). The biggest decline would be cesarean sections, as we would expect, but I honestly think we'd see a lower epidural rate and more active births. In turn, we would naturally see a rise in breastfeeding and helpful breastfeeding support within communities (as opposed to paid lactation consultants).

If as a society we began to truly trust birth and were able to rely on our mothers and sisters for reliable, empowering birth information, would there be less need for professional childbirth educators and doulas?
Yes, yes, yes, yes, of course. The outside information that a woman really needs to birth her baby is small. She has all the information that she requires already within her when she is pregnant. The only obstacle is overcoming the lies that we're taught about how faulty our bodies are - once this is shifted, the door is wide open for a woman to discover her own path to birthing her baby. Each woman is different and each way of laboring varied. Honoring that and treating birth in a very no-nonsense sort of way will help women find their own journey.