Thursday, March 19, 2015

Why Midwives Matter

Every once in awhile I notice that someone has downloaded the "Home Birth Reasons" document I wrote up way back before Daisy was born, to set forth some of the thinking behind our decision to have her born at home. I keep thinking I ought to update that document, as it was all still hypothetical then, and the subsequent four births at home have given me new insights into why some of us make that choice. And, I guess I'm a little bolder about discussing it now than I once was. But I didn't get around to writing anything until I got asked to speak at the graduation gala for the Midwives College of Utah on the topic of "Why Midwives Matter." It was really enjoyable to have a reason to think these things over again; to ponder what it is that I am so drawn to about birth and midwifery; and to attempt to set forth my thoughts in a comprehensible form. I'm posting the text and slides from my talk below.

I hasten to state, as I often have before, that I hope no one will mistake my enthusiasm for proselytizing—or, worse, for disdain toward those whose circumstances and wishes surrounding birth are different from mine. I feel strongly that in an ideal world, mothers would have some choice about how they give birth, but those choices can and should vary just as personalities and situations vary. This is an explication of personal experience, and perhaps a plea for mutual understanding; no more.

*****

Why midwives matter

The anticipation of birth is often used as a symbol that shows the triumph of life over despair and entropy. Gerard Manley Hopkins used it this way in a poem1 that first laments the modern world's lack of connection with nature and the spiritual, but then reminds us that amid darkness and alienation there is always hope for spiritual renewal. Hopkins uses the image of a mother bird, waiting, watching, and protecting potential life, to convey this hope. He writes:

"Generations have trod, have trod, have trod; 
And all is seared with trade; bleared, smeared with toil; 
And wears man’s smudge and shares man’s smell: the soil 
Is bare now, nor can foot feel, being shod.
Yet for all this, nature is never spent; 
There lives the dearest freshness deep down things; 
And though the last lights off the black West went 
Oh, morning, at the brown brink eastward, springs— 
Because the Holy Ghost over the bent 
World broods with warm breast and with ah! bright wings."

To me, midwives embody this brightness and this watchful hope. The midwife's work is to stay steady through uncertainty and darkness, leading the way through it to light and rebirth. There are many ways that midwives matter to women, to society, and to the world at large, but though I've read and become convinced of many of those matters of public policy, I'm not an expert, and there are other, better, sources for that. So instead, I want to talk more personally about how midwives have brought life and light to me.

When I was 37 weeks into my first pregnancy, I became suddenly uncertain about the obstetricians I'd been seeing. This OB/GYN clinic was busy, efficient, and impersonal, and I was afraid they might not respect my wishes for an unmedicated birth. So I called around and found a group of CNMs that would accept me. Though I didn't ever get to know my midwife well, she was supportive during my labor, and I was grateful to have made the switch. There were aspects of this birth I found less than ideal: the sudden increase in difficulty after having my water artificially broken, the way I had to lie on my back to push, the hurried cutting of the cord and my excessive bleeding that made me pass out in the bathroom. But though I didn't know which of those things I could have avoided, my midwife was a comforting presence in the hospital. And of course, at the end of it all I had perfect little baby Abraham.

A few years later, after taking a hypnobirthing class from a different midwife, my husband Sam and I both felt better-prepared for our second birth experience, and I was more ready to be assertive in stating my preferences. Again, though, when it came time to push, I was put into a lying-down position that made things very difficult.
This baby, Sebastian, was posterior and his hand was up by his face as he came out, and the cord was looped around his neck a couple times. The attending nurses, perhaps unaware of how alarming they sounded, were yelling out scary-sounding medical terms like, "We've got a nucal hand!" and "The heart rate is dropping!" and telling me to push harder, or stop pushing.  Sam and my midwife spoke calmly in my ears, trying to counteract the panicky feeling from the nurses; telling me it was okay, I could push when I was ready, I was doing a fine job. That feeling of being trusted, at least by someone, and the preparation I'd had through hypnobirthing, mattered to me greatly during that birth.

My third child, Malachi, was born six minutes after we reached the hospital. I changed into a hospital gown, knelt backwards on the bed, and pushed him out as the hall nurses came running in, frantic and shouting commands. Then they took him away and banged him on the side with a little hammer while I said over and over, "Is it a boy? Did someone say it's a boy?"

That was the first birth where I thought, "Hey, I did that myself." I was so surprised that I had known what to do without anyone telling me—and that the pushing had been so much easier when I could position myself the way I wanted! I felt like one of those African women you hear about who squats down and gives birth in the fields and then picks her baby up and keeps on working. Later, when we got the hospital bills—thousands and thousands of dollars for no one attending the birth, no medication, and one night in the hospital room during which I tried to sleep while the nurses woke me up to check my vital signs every hour —Sam and I began to wonder if there was a better way. I began to research home birth. For Malachi's birth, I suppose midwives mattered to me mostly because of their absence. It was the speed and cost of this unassisted hospital birth that made it even occur to us to look for other options.2

Sam and I researched the idea of home birth the way we made most decisions: with a strong emphasis on rationality and fact-finding. I read everything I could find on the subject, positive or negative. If a study was referenced, I read through the study itself to see if the methodology was sound and convincing. I told Sam what I learned, and we made spreadsheets of pros and cons, ranking different considerations for their relative importance to us.

As I studied, though my appreciation for the advances in modern medicine remained unchanged, I became less likely to believe someone's assertions simply by virtue of their M.D. or their insistence that "safety comes first." I realized that differing viewpoints about what was "safe," or how many trade-offs to make in pursuit of safety,3 existed even among doctors, and that no one else was actually as good at determining our family's needs and priorities as we were ourselves! It wasn't that I had lost respect for the medical/technological model of care, but more that I was no longer willing to endow it with a godlike omniscience that really, it had never deserved.  

I learned that the midwifery model of care, with its emphasis on families, maternal choice, and wellness—and for all its reputation of new-age hippie spiritualism—was very evidence-based and, in fact, had a strong rational component to go along with its touchy-feely reputation. I knew it wouldn't be the right choice for all women, but it certainly wasn't an irresponsible choice. Thus, through these discoveries, I found myself changed in many ways going into the next pregnancy—a little less worried about what people might think, and more willing to consider things out of the mainstream.

When I was expecting our fourth baby, I interviewed a few different midwives before meeting Cathy Larson. I knew immediately that she was the right choice for us. I respected her experience and her intellect, but we also connected on a spiritual level, and I felt from our first meeting that she would be interested in not just me as a client, but me as a person. This impression was soon tested after I went for an ultrasound and was told I had placenta previa. Cathy told me optimistically that the placenta will sometimes shift position, but the ultrasound technician said that with the placenta this low, he hadn't yet seen a case where it moved enough.

Without saying anything to anyone else, Sam and I prayed about what to do next, and both of us felt that everything would be okay. When I told Cathy of our desire to go ahead with plans for the home birth, she showed total trust in our feelings. She informed me of the various possibilities and outcomes and expressed confidence that as this baby's mother, I would know the right way to proceed. In fact, she seemed a lot more sure of that than I was myself!  

During that pregnancy I felt supported and listened to as never before. Cathy talked to Sebby's monkey at prenatal visits, she put her hands on my belly and said hello to the baby before finding the heartbeat, she lit candles and I lay on a bed instead of an exam table. I marveled at how calm and peaceful I felt, in spite of the uncertainty about the placenta previa.

When we went in a few weeks before birth for one more ultrasound, what surprised me was not that the placenta had moved, but how inevitable that outcome felt. It still felt miraculous, and we were full of gratitude, but in the past I hadn't been used to trusting my own intuition, and it felt good to have it confirmed in such a tangible way.

My fourth birth was like a gift from start to finish: a peaceful day of quiet labor, a bike ride, trailing my fingers in the water as Sam rowed us around the lake in a canoe, fields of sunflowers, a rising flock of blackbirds into an orange sky. Cathy and Briana were there when the moon came up, staying just involved enough, as Sam and I labored in our own lamplit bedroom, and through that quiet night. 

As the sky grew pink over the mountains, Sam and I breathing in that sunrise together, our little girl, Daisy, slipped out into the peaceful world. She stared up at me with her bright clear eyes, a kind of knowing, steady gaze I'd never seen from our other babies, who were always squinting and bleary from the eye ointment the hospital required as a matter of course. The house was suddenly a holy place, and I realized something: I'd come to home birth for all the logical, practical reasons, ready to defy the stereotypes and proclaim the utter rationality of this choice—but in the end, it was the spirituality, the intangibles, that made the most difference of all. 

It was not that my other births had lacked holiness. Quite the contrary. As Ida Darragh said, 4

"At the moment of birth, there is [always] a rare and brief glimpse of the connection between this world and another, of before and after, of mortal and immortal, of spiritual and physical, of known and unknown.”
But here in my own home, where I was truly myself and truly free, my eyes were opened to the sacredness in a way that the distractions of the hospital had prevented. I felt that, rather than simply glimpsing the intersection of heaven and earth, we had invited and welcomed it, and were allowed to stay and drink it in for a time. Of all the miracles of Daisy's birth, that feeling was perhaps the most miraculous thing of all.

Even if that had been my last or only birth, I would have felt forever changed by it. But I want to address the idea I've sometimes heard, that we risk overemphasizing the birth experience when we discuss how transformative it can be. This may be an important day, this argument goes, but it is just one day, a day that will fade with time, and that the baby remembers nothing of. Surely the days and years to follow are much more important, so why elevate the birth to such a position? Of course, there is truth in this: all births are unique, women have different goals and seek different things from birth, and even a negative birth experience doesn't mean the baby or the mother is less transformed. My hospital births were as important to me, in their own ways, as was this first home birth, where I sought a more active role and a more involved midwife. But because I have now seen both, I strongly believe that there is value in seeking out more meaning through birth, and in making empowered choices rather than accepting passively the default options. 

When I have run marathons, I realize that race day is not everything, and that the way I race doesn't negate my training before or afterwards—but knowing the physical commitment and the mental fortitude required, few people would say, "Why are you making such a big deal of this? It's just one day in your life." They would realize that the race is important to me for reasons larger than the finite and physical. And indeed, the marathons I have run have left me changed in ways that went beyond just "getting into shape." Birth, because of its position between two worlds, is inherently significant—and so I think a deliberate, intentionally chosen birth has even more of a chance to inform, and transform, a family, far beyond the hours where labor is literally talking place.

To illustrate, I will tell you briefly of my three births that followed that first home birth. 
Before my fifth birth, I labored with contractions that neither stopped (so I could rest) nor intensified (so I could progress), for nearly five days. I was alternately exhausted, terrified, discouraged, and confused, unsure why this was happening or what it meant. While I felt like I was wandering, only half-real, through a world of mist and shadows, Sam and Cathy kept me anchored. They were full of strength and optimism, full of trust in me and my body, infusing me with a calm I no longer felt for myself. There were no ultimatums or lectures, but simply the peaceful path of confidence they made for me, a safe trail that I could follow as I made my way through the uncertainty and self-doubt. 

And once I had reached the end of that path, I became aware of how much beauty there had been in those days of preparatory labor. Because I had been allowed to experience an entire spectrum, rather than rushed through it or pushed to choose a quicker path, I felt grateful and transformed by where I had been. And the bond I felt with baby Juniper, who made that long journey with me, was deep and strong from the very start. I felt, as one author put it, the "sense of autonomy [which] culminates after birth in an embodied sense of power."5

As when Cathy had trusted my intuition in the last birth, she trusted my body during this birth, and her confidence built and bolstered my own. That "embodied sense of power" has carried through to my mothering and my decision-making in all aspects of life. That is what the care of a midwife meant to me.

My sixth pregnancy went to 41 weeks, and though I was trying to be open to the baby's timing and not attach too much significance to the due date, I still felt discouraged. It was Cathy's calm and matter-of-fact suggestion that I could choose to view this extra time as a gift that helped me change my viewpoint. I found gratitude and peace during that long week, and when the birth process began, I knew the timing was exactly right. The labor progressed quickly, and before Cathy arrived, I remember Sam's hands on my back, and him saying with total calm, "You're getting really close." Cathy walked in just in time to catch baby Marigold bare-handed as I knelt in the empty birthing pool. Sam's confidence and my increased patience—these were gifts from a midwife that mattered, long after the birth itself was over.

Three weeks ago, I started the journey through labor again. And in spite of the things I've learned and the ways I've grown in confidence since my first birth, I've found that babies always have the capacity to surprise you, and birth never becomes routine. And so after a pregnancy where the baby remained somewhat mysterious to me, and a labor that seemed to break all the conventions I'd come to expect, my midwives gave me another gift of love and trust, encouraging me follow my body's instincts and reassuring me of their confidence, in spite of the non-textbook way the labor seemed to be progressing. 

There came a moment in the midst of the labor, as there always does, when the task ahead seemed too daunting, and the words came to my head, "I can't do it. It's too difficult, I can't go on." But even as I formed this thought I knew it was the wrong thing to say, so I cried out instead, "Please, help me!" And almost before I had the words out, I felt an almost tangible wave of love and strength from the circle of people around me—Sam, my midwives, my children. There was a whole roomful of voices—coming, it seemed, from many more people than were actually present—calling out, "You're doing it. You're strong. We're with you. We love you." And as I pushed through that small eternity, in and out of time at once, I felt their love flowing through me, giving me the literal strength to continue.

When at last I sat holding sweet baby Theodore, my midwives told me about how he had come: breech, with his feet falling out and then his body, his little arms and at last his head. We talked over all the little mysteries that were suddenly clear to us, and Sam told me how funny it had looked to see him dangling out feet first like that, and my girls giggled, "Baby Teddy! Why were you backwards?" I had a strong conviction that all was well, everything was as it should be. And I realized, again, how grateful I was to be cared for by these strong midwives, who believed in my instincts and theirs, who trusted me so much more deeply than a liability or a medical release form could capture, who brought to an unexpected situation their gifts of calm and love instead of knee-jerk reactions and panic. Women who were prepared for complication, and thus not ruled by it, and who had not just knowledge, but also wisdom and patience.

The Polish poet Czeslaw Milosz wrote a poem which affirms the possibility of the miraculous, even in our modern and disbelieving world. It's called "On Angels."6 He writes:

All was taken away from you: white dresses,
wings, even existence.
Yet I believe you,
messengers.

There, where the world is turned inside out,
a heavy fabric embroidered with stars and beasts,
you stroll, inspecting the trustworthy seams.

Short is your stay here:
now and then at a matinal hour, if the sky is clear,
in a melody repeated by a bird,
or in the smell of apples at close of day
when the light makes the orchards magic.

I have heard [your] voice many a time when asleep
and, what is strange, I understood more or less
an order or an appeal in an unearthly tongue:

day draws near
another one
do what you can."

In my association with midwives, and at that sacred intersection of earth and heaven, I have come as close to angels as perhaps I ever will in this life. I have seen how the work of a midwife, in both the small and the large things, is indeed the work of helping "day draw near"—of "doing what we can." Ultimately, it is the work of delivering life and light to a dark world. I hope that there will always be midwives, watching over that crossroads with "warm breast, and with ah! Bright wings.


1 "God's Grandeur," Gerard Manley Hopkins, 1918.
2 I always feel like someone is going to think it's crass to mention money when talking about the advantages of midwives—like you're putting a price on the mother's and baby's lives. But as I studied, I found that it wasn't so simple (see this, for example). First of all, there wasn't really a correlation between spending more and saving lives. In fact, for most pregnancies, having fewer of the expensive interventions during childbirth actually seemed to lead to better outcomes. And as economist Thomas Sowell points out, "[We often hear] the pious statement that "if it saves just one life, it is worth whatever it costs. People say things like that when they want to puff themselves up as caring or when they want to win votes from those who don't bother to think through what they are saying. In real life, nobody acts on that principle. People don't give up boating, skiing, or rock climbing, even though they know that many people lose their lives in these recreational activities every year. You probably wouldn't buy a newspaper that was fireproof, because it would cost too much, even though [any non fire-proof] paper…could catch fire and end up burning down your home with you in it." In a reality with limited resources, it would be irresponsible NOT to consider the different ways of best allocating those resources, and childbirth is no different. Spending lots of money for a technology-heavy birth does not eliminate risk, but simply shifts which types of risks you are willing to face. Conversely, choosing a home birth may mean families give up certain types of benefits in exchange for other benefits they consider more important.
3 For another good discussion of this principle, see this post: http://www.freerangekids.com/how-safe-is-safe-enough-for-playground-surfaces/
4 "What Matters to Women, Matters to Midwives:13 Essentials." From Into These Hands, Wisdom from Midwives, published by Spirituality and Health Books. 2011.
5 Mainstreaming Midwives: the politics of Change. Edited by Robbie Davis-Floyd and Christine Barbara Johnson. 2006.
6 "On Angels," Czeslaw Milosz.

8 comments:

  1. It is for this purpose, being witness to light, that I am a midwife. Thank you, Marilyn, for your trust.

    ReplyDelete
  2. When I was first married, I had friends who did home birth - this was nearly 40 years ago, and I believe their first babies were born without even a mid-wife. They just decided to do it themselves. I thought it was a lovely idea, but when I was pregnant myself, I heard too many stories about people having complications and not being able to get the baby to the hospital in time to save it.

    So I went to an OBGYN. Who was a sweet guy, and in whom I learned to trust. He came in to deliver Gin even though it wasn't his night on call. I had taken Lamaze and was breathing and taking care of things the best I could - no meds. When he finally came, he came in to check me, said "You'll have to keep pushing," then went out to chat with the nurses, leaving me and Guy - all alone - trying to figure out why this was so hard.

    My water had broken in the morning, but nothing had happened - and I went in to the hospital without contractions at five in the evening. No one there to advise me. By eight thirty, I had worked myself to the point of transition - just the two of us. When Gin came, she had a little banana head, she had been squeezed so tightly. (Doesn't seem to have hurt her life), and every blood vessel in my face had exploded - even the ones in my eyes. I was covered by tiny red dots. It had not been peaceful. Not fun. Not holy. And then they stuck me in this recovery room where people were talking loudly about their dates the night before - one bed out of seven in a hall like room with just curtains for privacy.

    Cam's was different. Same doctor, but I knew more. I had a labor of about an hour. His was holy. Till they stuck me in a room with a family that was speaking constantly in another loud, very loud language - with tons of anxious visitors, because something wasn't right. And they had cut me, of course, so I was blood all up my back, and the bathroom was down the hall, and the children, who had continually been peeking at me through the curtains, followed me out into the hall when I had to go down there, staring at me. No one cared about us. I was fine, as far as they were concerned, and the holiness was stolen in noise and institutional confusion. I stayed 12 hours and was out of there.

    Char also had her hand on her head, and I delivered her a far more sensible way, in a far more sensible place - where I had a little room of my own to do it all in, and the children all came. And with Murphy it was even better - but still in an institutional place where they whisk your baby away.

    I think your choice is lovely and holy and sweet - in line with the life you and Sam have built for your family. I am sorry, for my babies, that I hadn't the same experiences. The same faith. The same beautiful soul. Even so. We are alright. And I love being able to share that quiet experience you have offered.

    ReplyDelete
  3. I so appreciated your thoughts at graduation, thank you for sharing!

    ReplyDelete
  4. So perfectly presented and put together! Your own experiences, poetry, etc. etc. Lovely. And, of course, I could ramble many thoughts and wonderings of my own that it provoked, but sometimes . . . I tire of my own thoughts ;) and would prefer to just let these lovely ones stand. Bravo. And so cool that you were asked to speak at this big fancy pants graduation gala business. Such an honor!

    ReplyDelete
  5. Oh, K. I loved reading about your experiences. It's so sad that you were abandoned like that with Ginna—but then, as you said, it all worked out fine. And it nearly always does, I guess. Birth is just an experience it's hard to take the holiness out of. Love you!

    ReplyDelete
  6. Nancy, I *never* tire your thoughts! I did feel honored. Even the name "gala" is such a fancy word, isn't it? :)

    ReplyDelete
  7. It's astounding to me how different my experience with homebirth was from yours. I even had the same midwife and my experience was was so opposite what you experienced. It's a big head scratcher for me. I read all the studies and look at both sides of the story too and have come to the opposite conclusion about the safety and importance of homebirth.
    I look back on the time I was interested in homebirth and when I actually had one and I can't figure out why I thought it mattered so much. Every other day of my child's life is what matters to me now, but back then all my thoughts were focused on that one day, that one experience. My subsequent hospital births have been so much easier, safer, less painful (even without any medication) and just as spiritual.

    Anyway, it's just interesting to me how homebirth can be so important to some people and merely a blip on the radar for others. Or for someone like me, how it can swing from important to totally unimportant all within a few years.

    I'm glad homebirth has worked out for you so well and that you've enjoyed it. I still don't understand why midwives matter, but I'm happy for people like you for whom homebirth obviously brings happiness and joy. It's nice to find a health care provider you really connect with.

    ReplyDelete
    Replies
    1. Holly, you're right that everyone's experiences are so different! I appreciate that more and more as I get older. And as I said in the post, choices about birth can and should vary based on situation and personality. I'm glad we as women have more of those choices now. And really, that we have choices in how to respond and take action "every day of our child's lives" as well. It's wonderful that we don't all have to do things the same way!
      Thanks for your comment.

      Delete