The Other Cost of Crises Pregnancy Centers

This week’s ruling by California’s Supreme Court that crises pregnancy centers can omit information from their counseling of pregnant women has many well documented outcomes. The primary goals of these centers are to deter women from accessing abortion care and to restrict their rights to autonomous reproductive healthcare decisions. In cities like the one I am living in there are enormous billboards, bus signs, and benches covered in ads for these centers. They read, “Don’t harm your baby! We can help!”, “Free Ultrasounds!”, and “Free Prenatal counseling, we will help you with your decision.” Women are lured to these centers through promises of seemingly unbiased guidance and support. These centers have been found guilty of, and defend their right to omit information about the availability of birth control and access to abortion care (including Plan B medication). They have proudly affirmed that they often tell women they are further along in pregnancy than they are. This helps convince women that they are not eligible for an abortion. It also causes them to imagine a fetus that is more like a baby than a few cells to make it emotionally harder to decide to terminate.

What no one talks about is what happens next if a woman decides to keep her baby. As a midwife in the South I have received these women into care many weeks after their first visit to one of these clinics. Most of them receive regular prenatal care from the clinics. However:

  • If they miss any appointments, they are kicked out of care and left to fend for themselves.
  • Sometimes they do not want to relinquish their baby for adoption through the clinic agency and they are harassed and pursued by agency representatives who prey on their vulnerability and try to shame them into submission.
  • Sometimes women come to a place where they embrace the idea of motherhood and want to do all they can to prepare and learn about birth and parenting. Their newfound power is threatening to the relationship with the crises center and they are pushed away from resources.
  • Sometimes they are violently ill from the pregnancy and ignored completely as long they remain pregnant. Their health really does not matter as long as the vessel of their body continues to carry the pregnancy.

I’m sure somebody out there has documented all of the pathways these pregnancies and women can take—they are varied and many, with complexities and layers we dissect and maneuver through with individuals who wind up in our care. I have sat in stunned silence on my own after these visits many times because the level of depravity and lack of compassion that rises up from these centers and the staff and providers who work in them is frankly unfathomable. It is a lifetime movie gone horribly terribly wrong but it’s no movie—these are very real lives with very real consequences.

What I never heard about, and I wager very few have considered, is this scenario: A woman goes to a clinic for a free ultrasound and prenatal assessment. She may or may not have ever considered abortion. She may be happy about the pregnancy or ambivalent or miserable. She arrives at the crises clinic not knowing the date of her last menstrual period. They do an ultrasound, give her a due date and print out an image for her to take home. They put the little black and white photo into a small white envelope with illustrations of a real baby, looking happy and fat and healthy, surrounded by blue and pink ribbons.

These are the questions we must ask:

  • Is the due date they gave her accurate or is it based on dating that will ensure she will not receive access to abortion care in her area?
  • Is the image they give her of her own baby or one who is more developed than the one she carries?
  • Do they explain how she can access Medicaid, social services, housing, job training, or food for herself and her baby or do they only share resources that exist in their clinic and lead to adoption by a family that pays hefty fees to that same agency?
  • What do we need to unwind to discover her true wishes? She comes to us over-exposed to the subtle and brutal art of shame, devaluing, and tinkered religious ideology all driven straight into her most vulnerable fears and emotions.

I know no one has ever come into our office from this care knowing what resources they have the right to access. Most don’t know they can easily sign up for Medicaid which will guarantee them perinatal healthcare at a variety of locations. I don’t know which clinics give the right dates and which give falsified dates.

But here’s what I want to share in this post: When the only ultrasound a woman has gives her a certain due date, and she does not know when her last period was, that is the only and best information we have to work with. Keep in mind that when a woman comes in late to care with no known date of her last menstrual period and no early ultrasound, we do an ultrasound and measurement of fundal height immediately and work off of that information. A baby who measures 33 weeks by ultrasound and fundal height will be approached as a 33 week old baby. A baby who measures 33 weeks when the early crises clinic ultrasound says it should measure 37 will not. For that baby, with a prior early ultrasound who measures small for that date, here is what we wonder:

  • Why is this baby so small?
  • Why isn’t this baby growing as it should be?
  • How long can we afford to keep this baby inside to try to prove interval growth before we are compromising it?
  • Can we prevent harm from intrauterine growth retardation or another syndrome, disorder, or anomaly by causing an early delivery?
  • Will we cause harm by causing an early delivery of a normal healthy 33 or 34-week-old fetus who would have done perfectly had it been allowed to stay inside and finish growing for a few more weeks?

There is no easy answer to these questions. We use technology to try to measure and assess the actual size of the baby, the flow of blood from the placenta to the baby, anything that is measurable, is measured. But all of our measurements are relative to the first and best known date of any pregnancy. Normal and abnormal interval growth can vary by just enough to give no good answers. We do the best we can. We use all of the power in the maternal-fetal medicine world to try to make the right decision. Sometimes we will get it right, and sometimes we will get it all wrong.

From the March of Dimes:

  • The average cost of a NICU stay for each baby born too early is $55,000. The average cost of a hospital stay for a normal birth is just over $4,000.
  • Babies born too early are at high risk for disabilities and developmental delays including physical, thinking, communicating, social and self-help skills.
  • Day-to-day life for the parent(s) and family is completely disrupted during and after the NICU stay as they navigate interventions and attend appointments and therapies.
  • Parent(s) spend hours in the NICU, and then at therapies, away from their other children and often lose their jobs.
  • The NICU stay can last for months, and often the facility is located miles from home.
  • There is tremendous emotional, physical, and financial stress with premature birth

Families deserve access to healthcare information, research, and guidance that leads to shared-decision making with their provider. The presentation of options that utilize provider skills and local resources to best serve a patient’s needs for their life is a fundamental right.

The cost of lying to patients is high in all directions—for negligent prenatal care, for the delivery of shame as a tool of coercion, for leading a woman to believe that there is help and then abandoning her if she asks questions or changes her mind, for the mother who is induced for a too-small baby who was really just fine but now faces a life of developmental challenges. Frankly the cost of stress to the multitude of providers who gather around a woman and her unborn baby struggling to make the right decisions with bad information is high, too. Yet these clinics are never held to account for those costs. And now the government has decided that they should be encouraged to carry on and pursue their right to lie which supersedes the rights of the mother and the baby to the truth and of society to the health of its most vulnerable people. Money and power are on the side of these clinics, but justice is not. It is one more unjust and unnecessary barrier for those most at risk for adverse outcomes.

A question just crossed my mind and I will close with it: What would happen to our maternal child outcomes if all of the resources being poured into these clinics, all of the concern, time of staff and providers, and faith-based communities was instead poured into the delivery of services designed to promote the good health of these women regardless of what their decision might be about their pregnancy and future?

Community-Based Midwives and Hospital Systems: A Case for Partnership (The Notes)

These notes are extracted from This Article

  • A set of good vitals and an uncomplicated medical history are not remedies for social inequities or lifelong lack of access to healthcare education and navigation, or accessible, timely, effective, and therapeutic interventions.
  • When a patient presents with a medical complication, a midwife can identify it and ensure access to appropriate care if she has access to those who would provide it.
  • The midwifery model of care recognizes that technical improvements in healthcare delivery are irrelevant without addressing the places where unjust and deeply impactful social determinants of health drive the patient’s life experiences.
  • This work [of midwifery care] results in trusting connections between patient and midwife. Indeed, at the time that hospital staff or a physician meets the patient, she may be experiencing a very real grief over the potential change in relationship with her provider and hopes for a unique and well-planned birth experience.
  • No one anticipates that the nurse or physician standing before them will do harm, but how likely is it that they will see you as an ally in their care when you take a stance of juxtaposition and even mockery of the one provider who has ever truly listened to, heard, and understood them?
  • Ignoring or belittling the midwife or any community-based provider for accessing those resources will make them hesitant to enter into the system in the future.  It is this behavior that pushes midwives to move patients further away from safe and timely interventions.
  • However, the ideals of community-based hospitals, so richly developed in many places, is to open the doors and welcome what the community brings, and to share the fullness of knowledge and technology from a place that recognizes the humanity of each patient and the irreducible needs of each person with whom it interacts.
  • …at all points of intersection [of the preventative and therapeutic pathways of care] patient health improves when they can easily step from one to the other as is appropriate for their needs.
  • We know that the impact of technical interventions is effective and wonderful but it is reliant on hospital policies that make these interventions accessible to the community.
  • If we can look together beyond the responsibility of the hospital to the community and financial interest in receiving midwifery patients, here are some ideas that lead to beneficence [see article suggestions]
  • Joining efforts to achieve the common goals of good health and easy, timely access to healthcare resources can only lead to improved outcomes and the development of a model that can truly serve the consumers and the providers in our community.

Community-Based Midwives and Hospital Systems: A Case for Partnership

Click Here to read just the notes from this article

Community-based midwives are held to particular and sometimes unjustifiable standards by the healthcare community.  They are under tremendous pressure to have perfect outcomes while serving the same communities who face the disparities that lead to premature birth, infant mortality, and maternal morbidities experienced so often in the hospital system.  Wanting or needing access to technology and resources is often seen as a failure of the midwife or as a nuisance to the system, even when those same resources which can prevent the same outcomes are distributed in medical care in an effective and timely manner.

The methods and standards by which Midwives determine that a patient is “safe for midwifery care” are not protective against these needs or outcomes.  A set of good vitals and an uncomplicated medical history are not remedies for social inequities or lifelong lack of access to healthcare education and navigation, or accessible, timely, and effective therapeutic interventions.  When well-networked, midwives can be a leverage point for patients to receive guided access to the larger healthcare system.  There they can receive the interventions and medical support necessary to achieve positive outcomes.  In other words, when a patient presents with a medical complication, a midwife can identify it and ensure access to appropriate care if she has access to those who would provide it.

Failure of a patient to stay healthy enough to remain under the sole care of her midwife, or to qualify for an out-of-hospital birth is often seen as both a shame on the patient who could not achieve optimal health or reach her birth goals, and shameful of the midwife.  Midwifery consumers work hard to address their health concerns, and there are times when all of the lifestyle interventions, guidance and education cannot overcome lifelong health disparities. We work hard to prepare for labor and birth and the most common reason we transfer during labor is for a patient who is just tired and needs an epidural, a nap, and will wake up and push her baby out just fine.  This is normal and reasonable and there is no shame in it—either for the patient, who is equally deserving of pain relief and rest as a patient who planned a hospital birth nor for the midwife who supported the efforts and goals of a family.

In community-based midwifery care we use the continuity of carer model, with hour long prenatal visits.  Three-quarters of this time is used to address healthcare prevention, education, and social support.  The midwifery model of care recognizes that technical improvements in healthcare delivery are irrelevant without addressing the places where unjust and deeply impactful emotional and social determinants drive the experience of a patient’s life.  These are the soil in which the patient is growing from and nurturing both herself and her pregnancy in.  These are the hardships, griefs, and burdens of absorbing the responsibilities of her family and community.  These are the anxieties over how to achieve perfection or avoid failure at every turn.  And these are the sheer terror for many due to the likelihood of their pregnancy resulting in their death or the death of their child simply because of the color of their skin.  This is intensive work, achieved on a platform of preventative healthcare that views each mother as vested in her own health and capable of change. It recognizes that she needs access to resources too long withheld and hidden from her until this point and it provides those freely.  This work results in trusting connections between patient and midwife.  Indeed, at the time that hospital staff or a physician meets the patient, she may be experiencing a very real grief over the potential change in this relationship with her provider and hopes for a unique and well-planned birth experience.

When a risk factor develops that requires entry into the hospital system, the patient has an acute sense that they must relinquish emotional and physical safety in healthcare.  This may very well be a contradiction from the midwife’s perspective because we are in the hospital due to a physical safety issue at the direction of the midwife because of her clinical judgment.  However, statistically speaking, every parent this patient knows who has lost a baby was in the hospital when that baby died or had a hospital birth.  Every mother they know who died or was harmed during childbirth was in a hospital when that event occurred.  While these events have been normalized in a broad sense, it is impossible to mitigate the very real fears that arise from personal exposure.  Every social message about the safety, especially of being a black pregnant patient, has taught them that their odds are not very good.  Every cell in their body and that most powerful function of our minds, the implicit memory, brings on a full red-alert for them in that space.  No one anticipates that the nurse or physician standing before them will do harm, but how likely is it that they will see you as an ally in their care when you take a stance of juxtaposition and even mockery of the one provider who has ever truly listened to, heard, and understood them?

We know that once the sympathetic system is activated in this way, people become hyper-alert to whatever is in their realm of focus.  This tunnel-vision is most often directed towards hospital staff—the nurses and doctors who she interacts with in triage before she regains access to a state in which she is ready to learn, engage, and process information.  These are basic principles applicable across many fields of medicine, and even more so when there is a sense of needing to protect one’s baby.

In the instant that you are introduced to the patient, she will see your response to her decision to use midwifery care, she will note how you greet or ignore her midwife, and she will read a thousand cues from your actions and responses.  How you treat the patient for her choices and the midwife for asking for an evaluation or intervention matters.  Her body will decide very quickly:  Fight, Flight, or Rest.  Can you ensure that she is never alone and has her partner or midwife with her at all points during care—especially those first few moments when she is most susceptible to panic?  These first interactions set the table for the rest of the patient stay and experience.

Midwives have extensive training and evaluate ongoing data sets from blood work, ultrasounds, clinic visits, and interactions over many weeks or months of care. She is in your hospital because she wants to be—because you are a resource and have access to resources her patient needs.  Like any community-based or rural provider, she relies on you, on hospital staff, systems, and technology to be there when her patients need it.  Ignoring or belittling the midwife or any community-based provider for accessing those resources will make them hesitant to enter into the system in the future.  It is this behavior that pushes midwives to move patients further away from safe and timely interventions.

The burden of community-based hospitals is to receive what the community brings and to provide basic medical care.  However, the ideals of community-based hospitals, so richly developed in many places, is to open the doors and welcome what the community brings, and to share the fullness of knowledge and technology from a place that recognizes the humanity of each patient and the irreducible needs of each person with whom it interacts.

The work of community-based midwives exists on the preventative pathway of maternal child healthcare.  The work of hospitals and obstetrics is on the therapeutic pathway of maternal child healthcare.  There are many opportunities for these pathways to cross, and at all points of intersection patient health improves when they can easily step from one to the other as is appropriate for their needs.

Midwives and the families and communities we serve are your families and your communities.  We share the work of seeking health and access to healthcare for all people.  We know that the impact of technical interventions is effective and wonderful but it is reliant on hospital policies that make these interventions accessible to the community.

We understand that relationships between community-based healthcare providers like midwives can be seen through a transactional lens—and if so, then view the midwives as great business.  They rarely bring a patient who does not require interactions and interventions that are highly billable and great for the bottom line.  We must address the scarcity mindset—that somehow allowing midwives to access resources will play a role in the diminishing of patient numbers for the hospital.  The number of patients that midwives see is negligible to larger healthcare institutions.  As stated, the patients midwives do bring in for care will typically increase the hospital census and income.  While this is a very low-level view of the potential relationship between the hospital and community-based midwives, it is very real and just fine to rely on.

If we can look together beyond the responsibility of the hospital to the community and financial interest in receiving midwifery patients, here are some ideas that lead to beneficence:

  • You receive patients every day who arrive in labor, screaming and incoherent, possibly drug-addicted. You have no history, no labs, no ultrasounds and no idea who that patient is.  You follow your guidelines and do the best you can for them.  Midwifery patients arrive with loads of documentation.  They come in with labs, ultrasounds, a known history, and notes about how this patient learns best and the stressors and norms of their lives.  That is a lot to work from! Use your guidelines and do the best you can for them, too.
  • Greet patients warmly regardless of where they arrive from. Use simple statements that have been shown to be effective in other teaching hospitals, “I’m so glad you are here today.  I see you were receiving your care from a midwife so this might all be new to you.  I want to assure you we are going to do our best for you today” or “I see you were in the middle of a planned homebirth.  I’m sorry that didn’t go as you wanted it to.  We are going to do the best we can for you here today”.
  • Greet the midwife with kindness—she will expect you to take the lead. She has decided based on clinical information or a concern that this patient is safer with access to you and the resources that you have. Talking to her about your thoughts and plans (when it is not an emergency) or being inclusive will help foster good will with the patient and out in the community
  • Adapt policies to allow consulting, referring, partnership and education for community-based physicians to include midwifery-led clinics. Seek community rotations in midwifery clinics for your residents.  Learning from and with each other allows providers to get to know each other and deconstruct ideas of “other” so common from both sides to this relationship.
  • Provide credentialing for Nurse Midwives who operate in community-based clinics so that they can follow patients and manage care for those that want to plan or are in need of a hospital birth

Joining efforts to achieve the common goals of good health and easy, timely access to healthcare resources can only lead to improved outcomes and the development of a model that can truly serve the consumers and the providers in our community. To learn more about midwives in your area, and to find out how your institution can ensure easy access to resources for the community, contact your local midwifery-led clinic or midwives association.

 

 

Access in Healthcare

I have several posts written that haven’t been posted.  This is partly due to me trying to find my space in this new space, and partly because as we learn about and settle into a new practice in a new community, there is not much time for editing.  This article is from March of 2018 and examines our model of care through the lens of one of our programs, group prenatal care.  This program and many of the classes that spin off of requests made in the group, are open to all families, even if they are not in our care.  If you are in Memphis and want to join us for a program or come into care, please contact me.

As a community-based midwife I have been drawn to, pulled, and stewed in the places where midwifery and public health come together like a heated 32-beat tango.  Connected, dependent, free-spirited in nature yet grounded in science, this form of perinatal healthcare is my deepest heart’s work.  In Seattle our clinic, situated in the heart of a medically underserved neighborhood, was founded with the basic premise that we could reimagine healthcare.  The families, colleagues, health systems, and communities that participate in the care are committed to this mindset or to providing space within a more rigid system where we can explore the outer bounds of our ideas.  That organization continues to evolve and stretch into places and ways of being present for families and communities that astound me.  There are other midwifery-led clinics innovating and serving their communities around the US. Midwives are busy people, working through the wee hours trying to make a dent in maternal and infant health outcomes. In Memphis I am again working in an environment where that element of possibility leads us forward and exposes innovations as they naturally arise from our efforts to meet the needs of the families we serve.

Over and over again, wherever I am, I am taught a singular lesson about imagination and healthcare.  I am taught to follow my commitment to seek the strength and health of families I serve, even when it is not arranged as we are told it should be. When I first learned about labor I understood it to come in phases and stages which one neatly progresses through.  My doula certification required rote memorization of these steps, the signs of each one, and how to provide physical and emotional comfort and support for the pregnant person through labor and birth.  Yet I did not attend my first birth as a trained doula.  I sat in a small hospital birthing center with my brother and sister-in-law while they labored and birthed my nephew.  It was not my response to the phases and stages that provided her comfort.  It was my presence and attunement with her and my brother, my faith in her abilities, my interest in seeing my brother become a father from a place of strength, and my keen sense of wanting her to have a meaningful and timeless experience that mattered.  This experience was the first of many that taught me to look at pregnancy, birth, and early parenting as equally whole, layered, complex, and varied as the mothers and fathers I served. As equally needful of a response that understood both the expected norms and the reality and potential of the person in front of me.  I have witnessed alchemy a thousand and thousand times.  A shifting, morphing, and transforming moment.  Sometimes it is in prenatal care when a connection is made, sometimes during labor when the power of contractions takes a mother away from us and she retreats to a private universe, sometimes when she breathes her first breath as a mother to her baby now here, warm in her arms.

The science of pregnancy and birth is remarkable.  It allows us to support, aid, and even rescue mothers and babies every day.  As providers what do we have to learn from but the tools we are given?  Our books, our lectures, our machines that keep us moving in linear phases and stages through expected norms.  Those great teachers of mine gave and continue to give me command of the skills I need to care for families safely during their perinatal year.  But those other great teachers—the mothers, the fathers, the babies—they have informed me too.  From them I learned that the work I feel pulled to—this creation of micro-systems where families don’t just survive but really thrive and come into their fullness does not exist or occur in a linear progression.  It lives in the expansive reaches of our imagination.

It lives in discarding programs and services that always meet the needs of a linear and ordered system but rarely the true needs of the people in it. 

For many years I have run models of group pregnancy and postpartum care.  I have tested and tried curricula written by organizations committed to improving maternal and infant outcomes.  They have demonstrated success in these important areas.  The organizations that designed them have a lot of rules—so many people need to be present, they all need to be pregnant within about the same gestational age, they are assigned topics and facilitated, there is required attendance at a specified number of groups, they replace the individual visits with the midwife or doctor.  This makes perfect sense if we are trying to facilitate a group that teaches to the phases and stages of pregnancy and birth.  It makes perfect sense if we read any of the text books.  They all highlight “expected changes at this time” by trimester.  Naturally, we group pregnant people together who are the same gestational age experiencing the same changes.  We can conveniently teach to these issues and this does provide a kind of comfort—knowing that you are not alone in your changes and learning to adapt to them.  However, I have never been able to exactly stick to the prescription or the curriculum.  Usually because someone wants to participate but for work or life or financial reasons they can only get to a group that is running at a certain time.

Not the group they are slotted to, but to the group that is accessible when they can access it.

People arrive to group care full of ideas, needs, and questions that are totally unrelated to any prescribed content.  So what if the curriculum is the content of their lives in that moment? Ours is.

Now buckle up, I’ve said this before but let’s discover what it means:

When it comes to maternal and infant health,

there are only no answers if all of the answers are “no”.

If you are running a community-based clinic which fundamentally believes in access to care and services, you say yes a lot.  You say yes when the curriculum says no. You say yes when it means someone is going to skip a phase or jump over half of the progression.  You say yes when someone can come tonight but not again for six months.  You say yes when someone has never shown up but wants to sit in group now.  You say yes when a grandmother-to-be shows up with her pregnant child to explore this new model of care.  You say yes when a patient calls and tells you their car won’t start and they are out of money and they need a ride—even when it means the group will wait an extra five minutes to start. You say yes when a new mom shows up because she was lonely and knew that there was a prenatal group today.  You say yes because connection is the remedy for isolation and prevents depression, and her mental health matters.  You say yes because her presence there teaches the expecting mothers about what it looks like to care for a baby over the course of two hours in ways you could never script.  You say yes because someone else, maybe even someone else’s grandmother will hold and rock and walk that baby and tell her what a good job she’s doing.  You say yes because there are not limits on your imagination and you don’t see the people who come into care as limited, as broken, as needy, as powerless.  Your system does not rely on anything that resembles a normal healthcare delivery experience.  Why should it?  You are unbound so you are allowed to follow the dictates of the moment, the needs of the individual, the kindness that needs to manifest from your own heart.  And you are unbound so you can think with curiosity about the clinical presentation of disease, disorder, and dysfunction.  You are unbound so you can think about prevention and isolating a remedy that leads to health and not merely symptom management.

You can accomplish all of this in deep partnership with patients, clients, and their family members. 

And here’s what I’ve learned from saying yes.  As a provider, it is no toll on me to do so.  I don’t mean to be romantic about it–this is hard work.  It is also a remedy, a boon, and a manifestation of my humanity.  The people I work with feel the same way.  They are fanned out all over the city right now as you’re reading this bringing food, giving rides, sitting and listening, available, and present.  And in this example, of group prenatal care that evolves into group perinatal, parenting, god-parenting, and grand-parenting care, each person present feels their experience reflected in the shifting, morphing, and transforming moments of others.

We are learners and teachers, we are wise and vested and new and afraid.  We see where we are going, we feel where we have come from, we sit where we are.

We recognize the suffering and joy in others and freely bestow and receive compassion in that space.  This is a platform for health.  This is our platform for healthcare.  And this is one reason why I believe families in our care emerge with health outcomes that do not reflect the societal norms even though they have extraordinary life stressors. They are at risk for all of the risks, yet they very rarely manifest any of them.  This form of midwifery exists at the intersection of love and justice and healthcare.  It is not about leveraging the cost of healthcare, though it costs less. It is not about the birth. It is about good and even robust physical, emotional, and mental health where the right kind of birth in the right place for each family is the natural outcome of a platform where every idea has the potential to become a solution and every person is worthy of our best yes.

Midwifery for All Series

“Midwifery for All is for you—education, support, and exploration of the options for your care.  You can use it to start discussions with your physician or midwife about the kind of care you would like to receive.”

Welcome!

Midwifery for All is intended to highlight some of the areas where fear has built up a tradition of practice that might not be in line with either good science or your needs.  We understand that the greatest risk many face in their pregnancy care is the perspective and bias of providers and the healthcare system.  We are missing out on options for preventative health care simply because of preconceived notions and societal and systemic stigmas about the health of pregnant people.

Read: Size Friendly Pregnancy Care

This causes devastating effects across multiple outcomes–leading to extraordinary emotional and financial costs for families and decimating the healthcare system.  While providers and systems are responsible for the tangled mess we are all in, it is the consumer–people just like you–who can create change by changing our expectations and demands for education-based, preventative healthcare.

We are managing to save a lot of people from the brink of severe conditions during pregnancy.  But it is not enough to save someone from dying. That is a terrible standard of care when so many pregnant people have clear signs and symptoms of needing help long before they need a life saving rescue.

We believe we can prevent almost all of these conditions from progressing to disease through kind attention, education-based care, and skilled and thoughtful provider behavior. You deserve to live in good health, strength, and with all of the energy you need to do what you would like to do each day.

Midwives have the time, space, and skills to address underlying health needs over the course of your pregnancy and life.  In our practice we focus on predictable, preventable, and reversible conditions that start off with just a hint of something not quite right (you know the feeling!) and progress all the way into a diagnosed disease. Our goal is to pay attention to the first hint, your signs and symptoms, and to respond in partnership with you to quickly turn a corner into good health. We don’t wait for pregnancy to start this work–if you are considering your first or subsequent pregnancy, or might want to have a family one day–we can help get you prepared through this same program.

Through this series we dig deep into the issues that so many of us are afraid of when it comes to pregnancy: race, size-friendly care, stress, poverty, preterm births, prior cesarean births, smoking, HIV, and many more.  Check back often as we upload booklets, we will live-link them here.

Midwifery for All is for you—education, support, and exploration of the options for your care.  You can use it to start discussions with your physician or midwife about the kind of care you would like to receive.  It is a tool for pregnancy and birth decision making, and we would love to hear which booklets you enjoyed, what questions you have, and how you are moving forward in your care.

Wishing you the best for healthful and joyful pregnancy, birth, and parenting!

Do you have a topic you would like to see addressed?  Contact Us and let us know!

Size Friendly Pregnancy Care

“The typical experience for people of size with healthcare delivers guilt, shame, and fear as front-line medicine instead of kindness, support, and education.”

Click Here to to Download a PDF of Size Friendly Pregnancy Care.

Scroll down to see the preview.

Our Midwifery for All Series aims to close the gap between what is known by science and what is understood by healthcare professionals, pregnant people, families, and communities.

Click HERE for an introduction to the philosophy of our care and learn why Midwifery for All matters so very much.  Click Here for our favorite resources

Do you have a topic you would like to see addressed?  Contact Us and let us know!

Click Here to to Download a PDF of Size Friendly Pregnancy Care.

Read:  Midwifery for All Series

Read: Midwifery Philosophy 101

 

 

A Layered Question: Midwifery Philosophy 101

“How do we address public health outcomes while caring for one family at a time as if all public health depends on only their outcome?”

Let’s take a look at this multifaceted question:

How does a person navigate the stormy waters of pregnancy healthcare if you are anything other than a 5’7 140lb white, married (to a man) woman who identifies as such, hovering in the middle to upper class?

As you can see we are dealing with multiple layers of the human experience and their effects on pregnancy healthcare: your health before pregnancy even starts, BMI/Obesity, race, sexual and partnership identification, lifestyle choices, and economic status. I hope to address these topics from my midwife-minded perspective in the coming posts, starting here with our general approach and philosophy regarding pregnancy healthcare.

For my friends in the north: I am going to stretch this a little further and choose to add the extraordinary complication of living in the South to this discussion. I did not know, and could not understand, as a northern midwife, that my southern counterparts and the families they serve face challenges far far far (did I say far?!) beyond what we do in the North. I knew of course that things were different but I didn’t really understand.

I have tried 85 times to write about what it’s like to live in a place where faith-based healthcare makes room for providers to decline to mention during prenatal care the option for genetic screening (taking this as one example of dozens). They do not inform patients of these options because their faith (read: the PROVIDER’s faith, not the FAMILY’s faith) does not allow consideration of options that include the termination of a pregnancy under any circumstance. So there is no option for screening given. Not even when a pregnancy poses danger to a woman’s or pregnant person’s life. Not even when that baby will live less than an hour and in terrible agony. Not even when a family would choose to live life with an intensely high medical needs child, or one affected by a genetic anomaly, but wants the opportunity to prepare their home, family, work, and resources to meet their needs. Not even when the mental health of the mother or pregnant person is in jeopardy.

I’ve read charts here with “nuchal translucency” (a screen completed prior to the 14th week) noted at 22 weeks. There’s no such thing!  But this deception is allowed and encouraged….and this is only the tip of the iceberg. Want a tubal ligation but your husband isn’t present to consent?  You may have difficulty accessing this surgical form of family planning in the south. Of important note is that there are providers in these systems who do not practice this way but the system supports those who do. There are four major healthcare systems in this city—three of those with multiple hospitals that support providers who practice faith-based medicine according to the model that the physician’s faith determines your healthcare options.

If you are a person of faith, this might sound nice on the surface, but I would put forth that it is our religious leaders who should help us navigate the decisions we are faced with in our lives. They have training and education that enables counseling and support for our spirituality.  They help us stay aligned with our religious values and belief systems in all areas, including our medical decision-making. Our physicians and providers should offer us healthcare options, discussions, consent, and treatment based on shared-decision making. We are responsible for ensuring we integrate our religious, social, and cultural outlook into our healthcare by engaging all of the systems and people that matter to us in that process. At the same time, many systems are designed to ensure that culturally relevant care is nearly impossible to acheive and it should not be the burden of the consumer to correct this but the burden of each provider, administrator, and system to make it right .

The care options that are here are not healthcare as we know it in the North. For all of you, I know, this post so far will seem frankly unbelievable and unrelatable. The posts linked to below about health and lifestyle choices will seem dated and broad. You are working on terminology, micro-aggressions, systemic racism, and deep systems issues. We are working on basic access and consent issues very much related to the ethics behind Informed Consent and the Nuremberg Code couched in overt racism packed in systemic racism, micro-aggressions, and deep systems issues.

Conversations about lifestyle, access, and health disparities are coming into the light in many corners here. Questions are being asked:  Why is it like this?  Does it have to be like this?  What it would look like if healthcare wasn’t like this?  The midwives here have been advocating and caring for families in all the ways possible—faith based and non-faith based. And even with the two of us new to practice here, there are five of us in or adjacent to the city I’m living in now. Five who are practicing in community-based settings. Five who can create protocols and follow guidelines appropriate to the profession and their community.

We need space for conversation and inquiry here, we need routes for education and change. The South is not some backwards “other”—I am not at all trying to say that the South “needs saving”. I am new here, but I’m right here where this community is at: listening, participating, wondering. Pregnancy, birth, breastfeeding, parenting, general health. These communities are rising up and looking for solutions to the very real barriers they face. I recognize that process. It has a familiar rhythm, grit, and complexity. There is tension, anger, frustration, desperation, and there are large gaps between what is known and what is understood.

For our practice it boils down to this: How do we address public health outcomes while caring for one family at a time as if all public health depends on only their outcome?

I have answered that question many times in posts and articles and interviews.  I stand by my answer.  We must be kind and use our skills to meet people where they are at.  The rest will follow. I am committed to this model of care which leaves room for so much possibility.

I have the great privilege of holding a license to practice midwifery and of being supported by a local, long-standing clinic and non-profit organization that constantly looks to be a partner in community solutions. I have my clinical experience, my willingness to learn and to meet people right where they are at. I have the fundamental belief that kindness matters and that none of us has anything that matters until all of us have access to reach our potential. This awareness and mindset allow me the opportunity to be a part of families’ lives in the very ways midwives have since the earliest days of society.  In the very ways midwives all over the south and indeed the world are a part of healthcare systems, families, and community health.

I have the unique benefit of working with a practice partner who is fierce about identifying solutions and solving problems. She is brilliant, experienced, kind, and unafraid of stepping in to dismantle the hardships families face. We are not looking at pregnancy as an isolated, siloed experience. It exists in the layers and complexities of the lives of the people and families we serve. We are working on a number of projects right now centered around how we acknowledge and prevent non-pregnancy related medical and socially generated pathologies from determining pregnancy outcomes. My practice partner states over and over again that these problems require providers to change their understanding and behaviors,  and stop promoting the false idea that “these women” and “those families” just don’t want good health badly enough.

We believe the barriers that have separated “Self” from “Other” need to fall—we are all of us people just trying our best to give our all and find love, connection, and health in our lives.  We are unique individuals with complex cultures but we share so very much. What if as providers we use our licenses to open up this conversation and create new paths to robust health for all families?  That is the work we are engaged in here in the South. And each micro-community has to find its way in the larger social construct. We want to pull apart the loaded, layered question and answer simply, “yes, I believe in you, your interest and capacity for learning is vast, and together we can find solutions that meet your needs in the right way at the right time for you.”  There is nothing to stop us from applying this philosophy of care to pregnant people of all races, sizes, orientations, cultural backgrounds, and socioeconomic truths.

Next Up:

Midwifery for All Series

Size Friendly Care

 

Dysglycemia in Pregnancy

Scroll down or click here for the slide show and link to the pdf.

Many women come into pregnancy primed for Gestational Diabetes.  This is a disease process which exists on a continuum and with support, guidance, and effort, pregnancy  can be a leverage into optimal health.  This is a very exciting option compared to the standard expectation that one will move from at-risk all the way into a full blown disease which requires multiple finger pokes a day, medication to control, and affects nearly every organ system in both mom and baby as well as their long term health outcomes.  Additionally, nutrition and exercise interventions during pregnancy reduce the likelihood of cesarean section (and you know how I feel about avoiding the primary cesarean and VBACs).

Do not be fooled by common recommendations which allow for a great deal of carbs per meal.  The single most important dietary intervention is the elimination of sugars and carbs with the exception of fresh fruit which is loaded in fiber that provides benefits which far exceed the effects of fructose.  Choose low glycemic load fruits. Increase levels of lean protein and low glycemic load vegetables for filling alternatives to sugars.  Look for glycemic load which represents glucose in a normal serving (the index represents portions much greater than one person can eat). Expect the first 3 days to be the hardest as you teach your body that it can get energy from sources other than sugar-heavy foods.  Cravings will be very strong but can be helped by keeping nourished throughout the day.

During pregnancy it is especially important to provide families with support for these changes until they can take them on as their own.  Failure due to “non-compliance” is usually blamed on the patient but is actually the failure of the provider to work on education and support that is meaningful to the individual and their family in a personalized way.  It is a huge investment of time with dividends in multitudes:  short and long term health for the pregnancy, mother, baby, and family.  If the provider cannot spend the kind of time needed, and does not have a health coach on staff who can–switch providers.

For those diagnosed already with Gestational Diabetes, take a look at lifestyle changes which have been shown to improve outcomes even over medication.  Work with your midwife or doctor to increase lifestyle changes and decrease medication.  If you are at the end of your pregnancy or a new parent–it’s not too late to start.  Breastfeeding longer than six months can also help regulate your insulin resistance and improve outcomes for you.

Click Here to download the PDF of this infographic.  Please submit your questions, comments or ideas for additional content.

 

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5 P’s from the VBAC Playbook: Lessons for Every Pregnancy

These 5 P’s have come to us by way of families who have been down incredibly difficult roads and have emerged wizened. You can use their wisdom to jump into your own best health and birth outcomes.

Parents who have birthed by cesarean often talk about what they didn’t know for their first birth.  By the time we meet, there is normally some recognition that they didn’t know because they didn’t access the information they could have. This is said without judgement of self or other.  We all do the best we can in the moments we have to navigate decisions.  But the list of “I didn’t know…” is a common thread in our prenatal conversations and VBAC support groups.  Every expecting family can use the lessons these families have grown to embrace.

“Preventing the Primary C-Section” is a phrase used in research that demonstrates the fallout from a first birth that falls into the 20-60 percent of all American births (depending on where you live) that end in an operative delivery.  Some cesareans are necessary, this is not an article slamming those of us who’ve had surgical births.  Regardless of origin, the data clearly shows that we tend to struggle with a host of problems as a result of that surgery. These extend well beyond the first baby and can have severe impact on the health of future pregnancies. (As a midwife who has cared for many, many VBACing moms, the data collected does not reflect the emotional and mental health implications, which is a whole other book we want to write book we need to write, or maybe just a blog post–check back frequently).

The American College of Obstetricians and Gynecologists put out a consensus statement called, “Safe Prevention of the Primary Cesarean Delivery” in which they state:

A large population-based study from Canada found that the risk of severe maternal morbidities––defined as hemorrhage that requires hysterectomy or transfusion, uterine rupture, anesthetic complications, shock, cardiac arrest, acute renal failure, assisted ventilation, venous thromboembolism, major infection, or in-hospital wound disruption or hematoma––was increased threefold for cesarean delivery as compared with vaginal delivery (2.7% versus 0.9%, respectively).  (source) There also are concerns regarding the long-term risks associated with cesarean delivery, particularly those associated with subsequent pregnancies. The incidence of placental abnormalities, such as placenta previa, in future pregnancies increases with each subsequent cesarean delivery, from 1% with one prior cesarean delivery to almost 3% with three or more prior cesarean deliveries. In addition, an increasing number of prior cesareans is associated with the morbidity of placental previa: after three cesarean deliveries, the risk that a placenta previa will be complicated by placenta accreta is nearly 40%.  (source)

The most important moment of your pregnancy might be right now.  Did you just skim that last paragraph–assuming that these things won’t happen to you?  Take a deep breath, exhale, and know that with some preparation and education the one single thing during your pregnancy or birth that you can be assured of is that nothing in your birth experience happened because you made the choice not to face it, grapple with it, ask questions about it, become educated and engaged with your provider about it.  Take a step into becoming a highly informed consumer.  It is your right.  Pregnancy and birth are the first links in a long and multi-string chain of decisions and consequences that you will make for yourself as a parent and for your baby.  Approach with curiosity, flexibility, and a mindset that you can learn all you need to know.  Sink into the idea and the belief that you can rely on that knowledge along with your inner wisdom to forge your way into parenthood. Don’t relinquish your power by standing by, looking the other way, or ignoring the questions and ideas in your mind.

So let’s get to it.   The explanation with these is intended as a starting point for you to begin your exploration of the options–if you have questions ask them!! Ask people you know and trust, read books that are evidence based or thoughtful and inclusive.  There is no one answer that is right for everyone and your answers might change as your pregnancy progresses.  That’s normal, act on your education and knowledge!  Don’t be afraid to ask in the comments and we can identify some resources together.

The 5 P’s that can help Prevent that Primary Cesarean birth:

Place
I know, this is not the first item you might expect to find on this list.  But for planning your birth, you need to work backwards.  The place you want to birth determines what kind of provider and even specifically which provider you can choose.  Hospital, Birth Center, Home birth?  Where do you imagine yourself when you meet your baby?  Who is around you?  What does it sound like?  If you are unfamiliar with out of hospital birth options, take a gander at this great book for a stress-free introduction to it all.  If it is a hospital, take a look at their cesarean section rate.  A huge percentage of your birth will be impacted by where you are and the system at work there.  In a hospital the protocols and procedures generally determine the way that a provider acts.  If the hospital has high rates of intervention you should expect that to effect your experience.  Some would argue that certain hospitals have high rates because they see high risk patients.  Guess what?  We believe what we will see long before we actually see it.  If the experience is that women fall apart and need saving during labor, one might ask how much of the beliefs and behaviors affect outcomes for all women who birth there. It is not born of neglect or bad intention, but we know what we know what we know what we know.  And we do, what we know.
Model of Care
Your provider has been trained in a specific way–and they have adapted their training and developed their own style.  There’s no way to know what you’re getting until you ask.  Typically speaking you can get all of the same tests and screens from and OB or a midwife (nurse or licensed).  The focus of care differs with each provider–the time, approach to education, resource-sharing, and commitment to shared-decision making will all vary.  What do you want?  Go and meet with a few different providers who offer births at the location of your choosing.  The right fit will be clear after three interviews for most families.
Participate
Not to ring a bell too many times in one blog post.  You can go back and read why it is so important to take active, intentional steps to become a highly informed consumer.  If you don’t hesitate to ask what comes on the turkey sandwich and tell them what you like and don’t like at a restaurant, you certainly need not hesitate to ask what to expect from your care, state your needs as they arise, and switch providers if something is not working well, or you get an impending sense of discomfort.  Read, gather, discuss, bring your ideas to your visits, ask all the questions, tell all the ideas you have–it all matters so so much.  Taking the step into your strength as an informed consumer will change your life.  It will also show you if you have a provider who will engage with you on mutual terms.  This is not about fighting or being obstinate, it is about learning and engaging in the learning process with a person who should be a great teacher for you.
Prevent
Your pregnancy is a time to set up the environment of your body for optimal health.  A lot of people approach chronic conditions during pregnancy with the mindset that if we can just “get through this time” we can work on it after the baby.  But you are laying the brickwork for how you feel everyday.  You don’t have to suffer.  You don’t have to greet your baby in anything less than vigorous good health–find a provider who will approach you as a whole person and a mother, not just a vessel that needs to stay together just enough to support the life of your baby.  You are your baby’s health–the chances are that if you don’t feel well, the placenta isn’t going to get the life support it needs to do what it is designed to do for all the days your baby needs it.  You are the soil, sun, and water of your baby’s growing physical and mental health.  Rich in nutrients, full of energy, and supported with just enough of all of the building blocks–not too much or too little, you can grow a healthy, full term baby.
Predict
A provider who pays attention to you and the messages your body is giving will better offer care that answers the prediction of what might happen next.  This can be long-term:  something in your health you want to work on that you feel is at a tipping point.  Labs that come back that can be corrected before they get out of control.  Or it can be short term.  A provider who knows you will believe you and act immediately if you have a sign or symptom that is a red flag.  A provider who knows you knows your family health history and will work closely with you to see into the future and offer solutions and resources to support you in writing the health story you want for your and your baby’s life.
The more healthcare consumers approach their healthcare as consumers with consumer rights the more providers feel like this applies to them. 
These 5 P’s have come to us by way of families who have been down incredibly difficult roads and have emerged wizened.  Families can use their wisdom to jump into your own best health and birth outcomes.
What have your best moments been as a healthcare consumer?  What advice would you give other families as they prepare for pregnancy and birth?

The Link between Justice and Health

…Our health is the launching pad which allows us to reach our full potential. Healthcare that actually improves health, protects access to the opportunity to participate in the economic, social, political, and personal lives of an individual’s community and world…

If you are new to the idea that health, healthcare, and justice are linked:  here is the fundamental reason we all need access to high quality healthcare:

Our health is the launching pad which allows us to reach our full potential.  Healthcare that actually improves health, protects access to the opportunity to participate in the economic, social, political, and personal lives of an individual’s community and world.

Beyond this, there are of course complicated, systemic and overt drivers that prevent communities from participating in the political, social, economic, and personal lives of their community and world.  I am not here to say that those aren’t  real, impactful and destabilizing for the individual.  But without health, those determinants play second fiddle.  With health, the engagement of identifying problems and solutions becomes a discussion and a possibility from within a community.

In today’s world where inflammation, insulin resistance and adrenal dysfunction are deeply tied to each other and the way we–or whether or not we manage to–integrate and recover from stress, this is more true than ever before.

Let’s look together at a dramatic example:  Before I knew to offer education for this, I watched immigrant women who had arrived in America in the year prior to their pregnancy, continue to eat the same diet they had in their home country with one exception.  The ingredients were American.  The flour refined and void of the fiber naturally found in the food they grew up eating.  These women disintegrated before my eyes and their health became almost exactly like the health of most women coming from whole lifetimes of American poverty and the “typical” American diet.  In fact, the occurrence of maternal child outcomes taking a nosedive within the first generation of arrival in America has been well documented, though not well explained. How is it possible that women arrive from developing, or even war-torn nations and their health declines?!

The women I saw developed persistent fatigue which made work a complete drag and engaging with their family a lost art.  Mostly, when asked, they ascribed it to the difficulty of being away from family.  But their sense of their vigor and their actual blood glucose levels told a different story.  Interestingly no one blamed pregnancy–they had all grown up where pregnancy was viewed as a normal, active, and healthy time in a woman’s life.

During a home visit, one of the families cooked us dinner and it was there that as I chatted in the kitchen with the mom while she prepared the food that I saw what I came to demonstrate in my practice as the one of the Real Culprits.  With guidance to find imported flours–and to eliminate the processed American foods–blood glucose levels returned to normal.  The extra belly fat melted away as the muscles could once again absorb the insulin being delivered by the pancreas instead of creating a toxic and hostile environment from which each woman was supposed to work full time, care for her family, establish herself in a new home with all of the stress that moving brings, and support the activities at her church or community center (or both).  This food was not so slowly and ever so surely poisoning these women and their babies, who often grew so big that despite well supported labor and best practices, were born by cesarean section at alarming rates.  This was true for first time moms who naturally carry a higher risk of cesarean birth, but also for 2nd, 3rd, and 4th time moms who had healthy vaginal births as part of their health history.

I combine catered education about nutrition with stress reduction strategies at each prenatal visit for every family.  Have a mom bring in a picture of her pantry if you can’t do a home visit.  Frame it is a starting point, not a place to drip shame, fear, and humiliation into her life.  Let’s learn together–have her teach you about her life, her stress, her nutrition, her loves.  Rich or poor, immigrant or 4th generation American. Everyone receives education that meets them where they are at and responds to their life in that moment.

One of the more important maternal/child health results of addressing these deep needs of mothers is that babies grew to be the right size for their mother’s body.  That is a reduction in healthcare costs in the tens of thousands per mother/baby. It reduces so many immeasurable personal costs and so very many short and long term healthcare costs.  A healthcare actuary could have some good solid fun with seeing the numbers all the way through.  It lends to the potential for each baby to be born to a mom ready to mother physically and engage mentally, because they feel good, they feel energized, they feel like themselves.  Even in a foreign country.  Even with a minimum wage job when they are actually qualified mathematicians, accountants, doctors, or teachers.  Even when they miss their family and are learning a new language. Even when they want to somehow muster the  capacity to attend night school to learn a new trade or earn a new certificate so that they can move into a life of opportunity for themselves and their children. 

**an interlude for all of you now fuming advocates from the world of the threat of a big baby  = cesarean birth.  Let me save you from skipping the rest of this article so you can leave an inflamed comment.  This is not that.  These babies are at real risk–their pancreas having been tested and pushed beyond its limits while en utero, they develop a lot of brown fat around the cheeks and shoulders, and are usually 1-4 pounds heavier than mom’s other babies.  These are not the robust babies who could have been born vaginally if mom had providers who knew to use positioning and time to aid in a healthy birth.  They look very, very different than a baby who is just born a big healthy baby.  None of those babies are included in this observation** [also, I love you for the work you do educating mothers about how to use their bodies to birth their babies and demanding that providers get with the program written so many thousands of years ago]

Back to the blog…

The model of healthcare delivery I offer is wrapped in listening and free from standard time constraints.  And still, I almost missed it.  It took listening, observing, and participation in the lives of the families I serve to find this connection.  It took nothing at all for me to apply the lesson to every pregnant woman who came through the door.

If we want to use our privilege as healthcare providers to launch families onto a platform where they can begin to see that opportunity funded by energy, vitality, and good health is different than opportunity funded by the massive domino effects of refined foods and stress without recovery–the disability of diabetes, cardiovascular failure, endocrine implosions, adrenal fatigue–well, we are in the perfect position to do so.

What do you do to offer healthcare that promotes justice?  Do you want to learn more about offering this kind of healthcare?  Are you a healthcare consumer who has or has not received personalized care?  Share your story!