Midwives of the Revolution

Explorations, analysis, and reflections on women's health, midwifery, and politics from a feminist, marxist lens


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Reflections on Birth and Immediate Postpartum Life

Well, this is now six months late…but I’m a new mom! And a full-time working nurse-midwife! I’m finally ready to dust off the keyboard and start blogging again! So, to kick it off, here’s a post I started right after the transformative experience of welcoming my baby into the world and finally polished off this week. It was fresh when the birth smells were deliciously enveloping my newborn, and fun to revisit now. Enjoy.

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My daughter is now just over a week old. The heat of late summer has broken,  and the kids are back in school at the elementary school across the street. Her umbilical cord stump has just detached, and my bottom and other muscles are gradually returning to normal. I’m generally following the advice I so emphatically dish to my patients: sleep when baby sleeps. Now, I’m taking a breather and making note of what this whole birth thing was like.

Empowerment: I made labor and birth affirmations so I could hear my own midwife voice assuring me during challenging times. My partner drew on this principle several times during labor a few times by asking what I would say to a patient at that phase, when needing reassurance or guidance.

One of the inspirations I had in the week before birth was to make myself affirmations to look at when things got hard during labor. I had been thinking of turning to my friends who had had natural or home births and asking for advice I could use to prepare. While I did receive some good advice (both solicited and not) from such sources, it started to feel strange to me — after all, I’ve attended dozens of births as a student and as a certified nurse-midwife: I know what to expect! Granted, many of the births I’ve attended since beginning professional practice have been in a highly medicalized environment, and few of my patients choose unmedicated birth — fewer have the resources for prepared childbirth.

Yet, I knew the chief thing for me to be successful was not just hearing positive birth stories — and I have read and viewed many — and connecting with the friends and family who were there at my Blessingway, provided beads for my labor necklace, or who were lighting candles for me both near and across the country during my labor. Even having the best labor team possible — which I was fortunate to have — was not a guarantee that I would be okay. No, what I needed more than anything was to be able to hear it from the most authoritative voice I know, my own from my heart as a midwife and my own strength as a woman. For what good is a labor team if the mama isn’t the most willing and capable member?

Though I didn’t look too consciously at the pictures I created, they helped promote a good birth environment — my support team would recite the mantras I had written: Ya mero! Fierce mamas believe in you! You are going to get huge! Yes, yes you can. Trust your body, and so on…And more than anything, I was grateful for the opportunity to make them in the days I was “overdue” and making my nest and heart ready for my baby.

The days after birth, I kept reliving the experience. I was so exhausted and overwhelmed with love and sore in ways I never thought possible. Tears would flow every time I remembered how I felt when my little girl was wet and warm and just screaming her little head off, fresh out of the birth canal on my chest. I had heard and taught women about the “baby blues” on countless postpartum rounds. This was more like a spiritual high, of connection that nourished the parts of me that had been longing for this moment of readiness for years.

I also woke up this week in a panic, realizing that I am probably at high risk for postpartum depression. So I called up my doula, who had mentioned that she does placenta encapsulation, and I ordered up an edible form of the afterbirth to ward off the very real possibility of falling prey to the dark side of new mama life.

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Tree of life: placenta print

I had been hearing about placenta encapsulation for a few years, and knew it hadn’t been studied much. Searches in scientific literatures brings up little of substance, mostly concluding that more research needs to be done. But I also knew that loads of mamas and midwives swore by its powers. I had been planning to plant the placenta in the garden, but when I had a major panic thinking of returning to a very challenging work environment just 10 weeks after the birth, I thought why not give this a chance? Most mammals eat their placentas (seemingly more for survival reasons relating to evading predators), and the power of the oxytocin and progesterone gave me hope it would do more good than harm to try it out. So my lovely doula came over and picked up the placenta a couple days after the birth, and generously returned two days later with a beautiful jar of the capsules and extra home-made herbalist goodies.

In spite of my fears of impending depression, I mostly can’t help but think about how lucky I am to have experienced the birth I did, and how well this network of birth and postpartum support is setting up my little family for a bounty of love, patience, and joy. I had one of the most highly skilled midwives in my area at my birth, who worked with me through a fairly long labor and helped me achieve a normal birth. In almost any hospital, I am certain I would not have had such a nice outcome. Being denied freedom to move and oral nourishment, while being strapped into continuous monitors, I imagine my baby and I would have become very stressed, and a surgical birth would have likely ensued.

Since even before deciding I wanted to be a midwife, I knew home birth would be for me, and now having done it, I feel so strong and powerful as a mama, but also even more convinced of the importance of preserving normal, natural birth. At no point would drugs have helped my labor. At every point, my preparation and support team — my mother, partner, doula, and the midwife assistant — helped me more than any drugs normally administered during labor could. Every laboring woman deserves this type of set-up. How much better for me and my baby (therefore also for public health) that neither of us was too stressed physically during labor, so that we could have such a good, non-interventive birth?!

I know that not every laboring person desires unmedicated birth, but if given the tools and support, it seems many more might at least feel they could make that choice. It seems likely that this could be so helpful in lowering our national rates of surgical births, now more than a staggering one third of all births.

Yet birth is only the beginning. After bringing new life into the world, you have to keep sustaining it! And protecting it for many years!

People have asked me how pregnancy, and now how birth, has changed me as a midwife, but I think that piece, the postpartum and parenting piece has been the most humbling as a women’s healthcare provider. Now, I have pushed this baby out into the world, and now I am responsible for her. I am lucky that I have experience with babies and that I feel so confident in caring for her after this magical birth experience. But if it weren’t for my mother staying with us the first week, the meal train organized by other parent friends, and living in a supportive community, I don’t know I would feel capable of doing hardly anything this week! And I have mamas I care for who have hardly any such support — single mamas, teenage mamas, and mamas with unhelpful or unavailable families. It hardly makes sense to leave new moms alone as a society to figure out recovery from birth and caring for a vulnerable newborn baby.

And then there’s breastfeeding! What a major

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Image borrowed from Rachel Epp Buller’s book cover Have Milk Will Travel

commitment! And I knew it was something I wanted to do, and in fact had literally had dreams about for years. But then doing it is another thing all together. So far, so good. I love how it feels to snuggle this little person and I love how cool it is that my body is making the only food she needs now. I also love how my midwife and doula prepared me to deal with the pain in my nipples the first few days, with ointment, exposing them to air, and the homeopathic medicine. But again, how humbling to have worked with dozens of women to initiate the process immediately postpartum, and then realize how hard it is in real life to keep it up, all hours of the day and night. And a crying newborn. How much patience and calm it takes to keep on loving and caring for a needy newborn. No wonder, with such little support from friends, family, and healthcare providers, so few women in this country actually do commit to breastfeeding for any length of time.

I guess that’s it. Just sharing my thoughts on being a new and breastfeeding mama of a beautiful baby girl that I’m head over heels in love with! And of being a transformed midwife with a new appreciation for birth, the yoni, midwives, doulas, and mothers of all kind everywhere and of every time.

 


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Healing to the test?

In this day of Common Core and mandatory ACTs for high school graduation, it should not be surprising that patients are obsessed about getting all the lab tests they can to make sure “everything is alright.” Luckily, unlike my teacher friends being measured by their students’ test results, my patients’ performance on tests or other health measures does not directly impact my pay or job standing. But this preoccupation with testing does impact  how I work.

What tests matter?

Don’t get me wrong. The miracles of modern medicine include such wonderful innovations as cultures and blood tests for herpes, liquid based pap and HPV tests, vaginitis cultures, gonorrhea and chlamydia DNA tests, and sophisticated tests for syphilis and HIV. You don’t have to just rely on the patient’s history and the exam findings to make a diagnosis when such tests are available. I am ever so grateful to have these tests, as I like to compare my clinical diagnosis to the test findings to learn more about what I’m seeing, especially as a new provider. And duh, there are many infections and diseases you can’t diagnose from an exam alone, like HIV.

Someone that has high risk sexual practices, like multiple sex partners or a non-monogamous partner, or who doesn’t practice safer sex with new partners needs to be screened. Luckily, our scientist friends over at CDC have figured out based on evidence that such folks should be screened for common STIs even if they don’t have symptoms, based on such risk factors. In a healthy clinic environment, we can educate patients about what health practices put them at risk and for which screening is indicated. We can point to evidence based guidelines to shape our practices, and we can counsel patients about what we recommend they get screened for. We can also educate patients on reducing risk and promote prevention.

It’s also usually indicated to offer HIV testing to all patients at least annually and three months following a positive test for other sexually transmitted infections like gonorrhea, chlamydia, trichomoniasis, or herpes.

Why isn’t it all about the test though?

I know why we’re all obsessed about getting tested for everything. It’s widely promoted as the be all and end all of healthcare. And it probably has a lot to do with the fact that lab testing companies make money every time providers order tests. They have put a lot of work into convincing the healthcare world that tests are better than anything for most diagnoses. This contributes to the the move away from physical examination as an essential skill in health provision. How many times have you been to see a physician for care and they have not laid hands on you at all? Not listened to your heart, lungs, and bowel sounds, not measured your abdominal girth, not palpated your tummy, not inspected your legs or feet? I hear frequently from friends that their doctors don’t even touch them.

We have been trained to think that the test says everything. And when it comes to women’s health, our bodies are so often the site of something wrong, something that could be wrong, and we want that test that says “everything is alright.” But we are not test subjects, we are human bodies. I hate that my patients think they need to hold themselves up to be examined like that: alright or not alright based on a test. Even if a physical exam appears to be normal or not normal, there are also other elements of the clinic visit to be taken into consideration — the patient’s history or symptomatology, for instance. Technology cannot replace the wise hands or critical thinking skills of an experienced practitioner.

Then what is it all about?

Heart disease is the number one killer of women in the United States. It drives me crazy that I have many patients who are not at risk for gonorrhea and chlamydia, who don’t even get bacterial vaginosis, but demand to be tested for these infections as though the results to those tests will be the major determinant of whether or not “everything is alright” for them. The far bigger impact on their health is not something that may or may not be wrong specifically with their vaginas but that they have sedentary lives, eat no fruits and vegetables, and eat a ton of fast food and junk food. Somewhere down the line, when they begin to develop diabetes or high blood pressure, there will be tests they can demand, and those tests may reveal whether or not everything is alright. Maybe everything is “alright” until the tests say otherwise. Maybe these test-hungry patients are trying to buy time until there will be a simple solution like a blood pressure pill or diabetes medicine to take, something far less complicated than trying to change a lifestyle when there’s nothing “wrong” except for…well, their whole lifestyle. And who can blame them? Pretty much nothing about how this society is organized facilitates healthy lifestyles for any but the few, and that’s why we are mostly an unhealthy society. If it were easy to be healthy, most of us would be.

What is it all about? Making the clinic a welcoming environment in which the normal and healthy are celebrated and explained, and the provider and patient can be partners in moving toward healthier habits and reducing risks. Demystifying the office visit and the technology we sometimes use to aid our assessments. Patiently explaining. And hopefully winning patients’ trust to lean on the exam and not just the tests.


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“There are so many places in the world with no healthcare–how could our patients have all this access but not show up?”

This is a common refrain from my collaborating physician, a woman who has worked in this community for decades and whose spirit betrays her lack of ability to maintain empathy. I’m not sure what she had to begin with, but now it is worn pretty bare.

It was hard to imagine those first few weeks. It can’t be that bad, I thought. Most people probably have some level of interest in taking care of our health, have some buy-in. Especially pregnant patients, right?

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Every week, there are patients who show up toward the end of pregnancy, realizing it’s time to have the baby, having not been in prenatal care for months, maybe at all. They know they need to get the baby out. But they didn’t come in for their second trimester anemia follow-up, the anatomy scan ultrasound, the diabetes screen. They didn’t necessarily take their prenatal vitamins and likely haven’t been eating healthy. Maybe they were smoking weed or drinking or having high risk sex. They don’t know if the baby is going appropriately or if the baby is “okay,” but they come in…they come in.

Everyone I work with, even those who have been working in this community for years, still seems surprised that our patients don’t reverence prenatal care the way they did, or the way they think everyone should. “I went for every one of my prenatal appointments, I took my vitamins, I showed up, why can’t these people?”

“These people.”

And it’s true. In the narrowest sense, all pregnant patients in my state can get prenatal  care. For undocumented mamas, it can be more difficult. No public health clinic is going to turn you away, that I know of. And for our patients, getting insured, getting Medicaid, is possible. Not saying the state doesn’t make you jump through hoops that may at times be humiliating and exhausting, but in theory pregnant women at least can get insured. But at least there is some assurance that the state will cover the cost of your care. It’s free!

And then there is coming in.

There is, of course, a wide variety of reasons patients don’t come in until midway through the second, or even until late in the third, trimester to establish care or to pick up where they left off after the initial dating ultrasound. I can’t pretend to understand all that goes on outside the clinic, in my patients’ lives, but I can say that moralizing about patients not showing up doesn’t actually help get them in the door or make them feel welcomed when they do show up.

No, this isn’t a rural community in subsaharan Africa, where there isn’t modern medicine. Oh, here, we have it all! We are in the heart of a wealthy American city!

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…A wealthy city in which fifty public elementary schools were just closed, almost all in black and brown neighborhoods; in which the majority of my patients only ever see white faces in their health clinics, maybe their kids’ schools, and in blue uniforms; in which there are few grocery stores and terrible transportation systems in the neighborhoods that are majority people of color; where in some areas youth are tracked into the criminal injustice system and in others, they are offered the world.

When the City doesn’t really give a shit about you, doesn’t value your basic human needs, let alone your higher aspirations…why would you necessarily adhere to the proscribed regimen of care for the baby you are carrying?

And even in these terrible circumstances, most of our patients are active participants in their care — they show up, get excited each time they hear the baby’s heartbeat, they worry when anything isn’t normal, they ask great questions about their bodies and the life growing inside of them.

But just as you can’t compare yourself, who did everything “right” when you were pregnant, to the few patients that don’t show up for care, you also cannot compare these “delinquent” patients to those mamas in the (other) third world who would be so grateful to have access to the kind of care that our patients take for granted.

And what if your managed care Medicaid company has you tied to your primary care provider at a clinic where every time you meet with the doctor, you feel like she doesn’t have time for you, doesn’t explain where your cervix is, doesn’t follow up on your look of bewilderment with a simple question about how she can help you understand?

I might not keep showing up either.

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It is frustrating and scary as hell to be a prenatal care provider in those situations. When you accept a pregnant patient into your care so late, you just don’t know what you’re going to get. Intrauterine growth restriction? Fetal alcohol syndrome? Uncontrolled gestational diabetes? Preterm labor? You feel like you’re scrambling to catch up, to find out what is going on physiologically, with the pregnancy, and what motivates the woman carrying the pregnancy. You worry she might expect everything to go perfectly, while it appears she hasn’t done her part to reduce risk, since you haven’t seen her for so much of her pregnancy. You might become the type of provider you swore you’d never become. You might not even recognize yourself after years of seeing the same social problems reflected in the faces of your beautiful young patients.

Until we fight for and win from the system quality affordable housing, excellent free public education, decriminalization of our youth and of blackness, safe and affordable food and water, expansive mass transit, and a single payer health care system, the circumstances under which we utilize any and all of these basic human needs will be less than ideal. And so will our provision of such care and services.

I look forward to working in healthcare in which women’s and children’s lives will be truly valued, and in which we will collectively trust, not scrutinize–but also, enhance–women’s decisions and lives.

For now, I am grateful for having a worldview that helps me find empathy alongside righteous rage against the system. I’m grateful for education that gave me the tools to provide evidence based care, so I can continue working to do my best for patients as they show up in my clinic, whenever they’re at in the lifecycle. I’m grateful for lunchtime office yoga or forest preserve walks that preserve my sanity. And I’m grateful for intersectional (anti-racist, anti-sexist, environmental justice approach) social and economic movements in the city, country, and world, that can make things better inside and outside the clinic walls. Because good lord, things need to get better, soon.


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“[Knock on wood]…So if I got pregnant and you took care of me, you would come to my house for the delivery?”

#1 myth about midwives:

We only/always attend birth at home.

So…more on this later. But (for better or worse) the vast majority of midwives (particularly nurse-midwives) in the US attend births in the hospital–including me. We can take care of low risk pregnant women — meaning, we need to consult or co-manage your care with a physician if you have an issue like gestational (or pre-existing) diabetes, hypertension in pregnancy, twins/multiples pregnancy, preterm birth, or need an instrument (vacuum or forceps) or surgical (c-section) birth. Otherwise, we are all yours for the normal stuff!  

One day, women will be healthier, birth will be less risky for many women, we will have single payer or nationalized healthcare, and birth can again commonly take place in the home, for women who want it. And then or perhaps before that day (but when I have lots more experience under my belt), I will attend home birth. Until then, my nurse-midwife sisters (and a few brothers!) will take care of you in the clinic/office for your gynecology and prenatal care needs and in the hospital or out of hospital birth center when you need to deliver your baby.