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.

 

This slideshow requires JavaScript.

 

The Blog

You’ve reached the blog of Jodilyn Owen, Licensed Midwife and Certified Professional Midwife.

Planning or considering a homebirth?  Get the book today!

You can learn all about midwifery care, professional topics, and options that come up during pregnancy and birth here.  Enjoy and be sure to send me your questions or comments or contact me if you’d like to talk further.

 

GBS Prevention

Read the long article

See the Infographics up-close

This post examines the role of preventative health care in the inhibition of Group B Streptococcus (GBS) infection.  It uses the term “mother” for simplicity’s sake although babies have all kinds of parents who identify in all kinds of ways and all are welcome here.

Let’s break down the long article:

Infections resulting from GBS  can be life-threatening to a newborn.  All pregnant moms are offered a test which detects this bacteria around 36 weeks of pregnancy.  If found, it can be treated through the use of IV antibiotics during labor, which significantly reduces the rate of infection and resulting meningitis and/or sepsis in newborns. While this article does not focus on the treatment of women who test positive, it does promote prevention, which improves the overall health of both mom and baby through the use of probiotics taken orally throughout the pregnancy.  These come in tiny capsules or a liquid packed with powerful lactobaccili (among other gut-friendly bacterium) that usually cost between five and twenty dollars per bottle or package).  It’s a small price to pay for so many amazing benefits.  As a midwife, I often pay for them for clients because of the massive health benefits of these supplements to every mom and baby, including avoiding a host of obstetric complications that would increase risks to mom and baby and often require transfers out of my care.  Great midwifery promotes the intrinsic health of mother and baby through programs like this which lend greatly to positive birth outcomes.

Let’s explore just some of the many benefits:

The Mother

Take a look at what the microbiota is if you aren’t already familiar with it.  The use of probiotics promotes this system that does a bit of everything good in the body including prevent the over-colonization of “bad” bacteria like GBS.  It also happens to prevent diabetes and keep your mood even.  It exists in the mouth, gut, and vagina of the mom and the placenta (and some studies found evidence in the fetal gut as well).

Over the course of pregnancy, the levels of good bacteria in the microbiota change.  By the time you give birth, you have an over-growth of lactobacilli which ensures that your baby will get exposure to this important “good” bacteria during vaginal birth.  When the system is supported right it will also prevent yeast infections, and keep the bacteria that cause UTIs and GBS in check.

The Baby

Impaired levels of probiotics have been correlated to preterm birth.   They are correlated because “bad” bacteria like GBS and candida (yeast) cause cellular damage to the cervix.  It loses its integrity and is not able to hold in the pregnancy as long as it should.  There are dramatic consequences for being born too early—the March of Dimes was founded because of babies born too early or too small.

When mothers take probiotics, they are found in the placenta and fetal gut and stay with the baby after birth to help regulate the baby’s microbiota.  That’s profound!!  You can help your baby synthesize vitamins and amino acids, regulate immune function, have smoother transitions between emotional states, and get a balanced healthy start just by taking probiotics during pregnancy.  After pregnancy, breast milk takes over the important function of populating the baby’s microbiota with everything it needs.

What Matters

  • Take probiotics throughout pregnancy to help keep your body hostile to “bad” bacteria and to strengthen the integrity of your tissue (muscles and skin included), especially uterine tissue like the cervix (and to boost your immune system, keep your mood even, etc., etc., and etc.!)
  • If you are planning a VBAC this winds up mattering a lot. Infections like candida and GBS can wear down the tissue that you are relying on to keep the scarred area strong and healthy.  Take a full dose of 4 probiotic capsules per day for your entire pregnancy.  I have supported an extremely high percentage of VBACing moms in my practice and this statement is NOT a judgment about your scar.  It is part of a recipe that will contribute to your overall success.  Check out this article for more ideas from the VBAC playbook or contact me to discuss further.
  • Have a vaginal, antibiotic free birth for maximum exposure to lactobacilli
  • Ask your provider ahead of time about swabbing your vaginal tract during labor prior to any antibiotics if you need them for any reason (including a planned or unplanned cesarean birth)
  • Regardless of how you deliver your baby, spend time skin to skin with her or him. Allow them to touch your breasts and arm pits with their hands.  You have lactobacilli on your skin that they will benefit from
  • Breastmilk feeds babies and promotes the growth of healthy bacteria in baby’s own microbiota, boosting their immune system and setting them up for good health
  • Babies born to a mom who had to take antibiotics or who were born by cesarean or who drink formula exclusively or as a supplement can all be given oral probiotics. They are available with a dropper or can be mixed into breast milk or formula and given through a bottle or made into a paste (just break open a capsule and add one drop of water at a time, mixing with your finger) and applied to mom’s nipples which is both soothing and healthy for the breast

Some disclaimers and information of note

  • The recommendations in this article are not designed to cheat a test but to actually improve the health of the mother, the integrity of the cervix, and the health of the placenta, fetus and newborn
  • Taking probiotics is not a guarantee of avoiding GBS or other complications related to imbalanced or missing gut flora. Talk with your provider about nutritional measures you can take to support your over-all health.  No amount of probiotics or exercise can undo the effects of a diet high in sugar and processed foods
  • Do get tested between 35 and 37 weeks for GBS. If you still test positive after a sustained period of time taking probiotics, eating a diet low in processed sugars and carbs, and rich in food that looks like it was alive, the colonization is highly likely to be one that needs antibiotic treatment. A pregnant woman who tests positive for group B strep bacteria and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby with group B strep disease. If a pregnant woman who tests positive for group B strep bacteria does not get antibiotics at the time of labor, her baby has a 1 in 200 chance of developing group B strep disease.
  • If GBS is found in your Urine during pregnancy, antibiotics can eliminate or greatly reduce the high colonization. Take probiotics at the same time as you take antibiotics and for the rest of your pregnancy.  The CDC recommends that anyone with GBS in their urine at any point during their pregnancy receive antibiotics during labor
  • Please discuss this information with your provider and work together to find a solution that is right for you. If your provider does not have time to discuss this or other preventative measures with you, there are plenty that will and I highly recommend you shop for the one who will serve you best

Capture

You can see the source for these infographics and get an up-close view by clicking here

Share your thoughts on preventative health care during pregnancy and your comments and questions below!

Additional Resources

Microbiota/Microbiome and Pregnancy/Birth/Breastfeeding

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943946/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464665/

https://www.amazon.com/Your-Babys-Microbiome-Critical-Breastfeeding/dp/1603586954

https://www.amazon.com/Microbiome-Effect-Affects-Future-Health/dp/178066270X/ref=sr_1_2?s=books&ie=UTF8&qid=1490123008&sr=1-2

Preterm Birth

http://www.marchofdimes.org/complications/premature-babies.aspx

Group B Strep Disease

https://www.groupbstrepinternational.org/

GBS Infographics

Read the Short-winded blog post

Read the full article

Read The Notes

microbiome changes of pregnancy

PMC full text:Front Microbiol. 2016; 7: 1031. Published online 2016 Jul 14. doi:  10.3389/ fmicb.2016.01031

microbiome changes at birth and feeding

PMC full text:Front Microbiol. 2016; 7: 1031. Published online 2016 Jul 14. doi:  10.3389/ fmicb.2016.01031

GBS Prevention: The Real Deal (an article)

The stakes are high. With all of the science supporting the idea that we can impact outcomes through simple and inexpensive measures, we cannot disregard the first and best options we have to address a disease. And especially where that prevention, aimed at reducing illness for the baby will also dramatically improve the health of the mother.

This is a long article y’all and way past the normal blog length acceptable in the blogosphere….however, you’ll find all of the background information, standards of care, reasoning for examining a new model and solutions for dramatically improving the health of mother and baby long after the relatively brief moment of pregnancy and birth have passed. This model is the real deal.  It provides preventative, protective, and health sustaining treatment for all instead of treating a disease process when symptoms become present in some.  I hope you enjoy the ideas and look forward to your thoughts and input.

If you are already worried I am going to recommend against treating GBS+ moms you can take a quick look at these important notes.

Looking for an upclose of those infographics?

Looking for a short-winded version of this article?

The Issue

Over colonization of the bacteria Group B Streptococcus (GBS) can cause a life threatening infection in newborns.  Most expecting families hear about this at the 36 week visit when they are asked to consent to a test for this bacteria.  If found, antibiotics are delivered through an IV during labor which greatly reduces the baby’s chance of exposure.  Many midwives share the fact that this bacterium is transient and can come and go so the test may be unreliable.  They may offer alternative treatments and discuss the low odds of babies who are exposed actually getting sick in an effort to consider antibiotic over-exposure.  Some providers might scare the living daylights out of their patients with images of weak, mewing infants suffering from high fevers and a very difficult disease to treat in an effort to ensure treatment is given.  Neither is wrong.  On one end the use of antibiotics reduces bacterial diversity in both mother and baby and can cause resistance to antibiotics later in life.  On the other end is the prospect of a disease where the only option once infection sets in is antibiotics and sometimes they are not enough to save the life of a sick newborn.  The cost to a newborn who experiences GBS disease is extraordinary.  The cost to a family who has a seriously ill baby or who lose a baby is immeasurable.  This disease starts with the presence of normal bacteria, progresses to an overgrowth of those bacteria, which progresses to exposure and then transfer and then a normal or a sick newborn.  Every baby at the start of pregnancy is looking a road that might lead to a GBS infection.  So one must ask, is there an answer that might keep babies safely at the start of that road with no progression on the continuum?  This article seeks to look at one answer that gives each baby a high chance of avoiding the long walk towards infection.

The Platform

I would like to reframe how we view testing and treatment of GBS and look at front-line prevention as first-line treatment.  This is to say that medical providers are trained to diagnose and treat, but as the keeper of your and your baby’s body (or your client’s or patient’s for providers), prevention is actual medicine.  The stakes are high.  With all of the science supporting the idea that we can impact outcomes through simple and inexpensive measures, we cannot disregard the first and best options we have to address a disease process.  And especially where that prevention, aimed at reducing illness for the baby will also dramatically improve the health of the mother. Our checklist for GBS management and testing in pregnancy should be:

  1. Recommend quality probiotics high in lactobacilli at first encounter, 1 cap 3-4 times daily
  2. Swab as normal between 35-37 weeks
  3. If antibiotics are given in labor advise to start probiotics as soon as possible.

The Mother

There are hundreds of articles available that help explain and define the microbiome, but in short each of us has a unique microbial population that includes bacteria, archaea, fungi, and viruses.  This whole system is referred to as the microbiota and is located in the mouth, gut, vagina, and placenta.  It is responsible to:

  • Digest and absorb nutrients
  • Synthesize vitamins and amino acids
  • Prevent pathogenic colonization (this is important to our discussion of GBS)
  • Regulate immune function
  • Modulate hormone release in the gastro-intestinal tract which for example helps prevent diabetes
  • Regulates mood and behavior through production of serotonin

(Kristensen et al. Genome Med. 2016; 8:52)

From this short list, one can easily see the massive importance of working right from the start of pregnancy (or long before, ideally) on balancing the microbiota in order to achieve optimal health in the mother.  Additionally, the changes in a healthy microbiota that occur from the first to the third trimester are dramatic and much needed for the health of mother and baby.  While the baby is often the focus of GBS discussions, the mother is a worthy and whole person, deserving of high regard for all that she is and does.  She is far too often viewed merely as a vessel we must sustain until she delivers the human baby who is the real focus of pregnancy and birth.  I have seen first-hand over and over again that when we take excellent physical and emotional care of the mother, the baby thrives.    Even in high risk pregnancies, carrying a baby does not supersede a woman’s autonomy over her own body, her needs, or her desire to be heard, felt, and understood.   It’s an archaic rite of passage that we feel compelled to remind her that, “it’s not about her anymore.”  It is deeply, deeply about her.  It is deeply, deeply about baby.  It is deeply, deeply about how they are together, and how they are separate.  The mother provides the building blocks of the placenta through her well-being.  The baby relies on that placenta for his or her well-being.  The baby experiences the hormones of the mother’s emotional states and learns from the patterns of stress and recovery she teaches during pregnancy.   A mother’s mental health has long term effects on both her and baby.  The question is, how can we promote the optimal physical and mental health of both?  How can we prevent disease for both?

Addressing gut-flora health will absolutely improve the fundamental health of the mother and therefore the health of the placenta and the baby.  During the third trimester levels of lactobacilli naturally rise and even over-grow to ensure exposure for the baby while protecting against bacterial and viral infections in the vaginal tract.  This entire system is its own natural pharmacy when supported correctly.

The Baby

Several studies suggest that impaired levels of probiotics in the vagina correlate with preterm birth.  This is because of the cellular damage that an abundance of harmful bacteria can cause to the strength and integrity of the cervix.  This includes yeast infections and GBS infections as well as STI’s.  Babies born too early or too small are at risk for a number of poor outcomes, including being three times as likely to die within the first year of life than a baby born at term.  You can read more about the effects of preterm birth here.

In her talk entitled “No Guts, No Glory: The Microbiome in Diabetes,” Meghan Jardine, M.S., M.B.A., R.D., L.D., D.D.E. notes that the critical shapers of gut biology are:

  • Natural delivery
  • Breast milk fed babies have probiotics
  • Formula fed babies have reduced/missing probiotics
  • By the time the child is 3 years old the gut composition is established
  • Over time, our environment continues to change our microbiota

A well designed 2012 study showed that taking probiotics during pregnancy affected the placenta and fetal gut and even the regulation of the infant’s microbiota. (Rautava S, Collado MC, Salminen S, Isolauri E. Neonatology. 2012; 102(3):178-84.)  Exposure also seems to correlate with reduced allergic diseases like eczema.

Mode of Birth and Feeding

Exposure to probiotics taken orally by the mother can be seen in the placenta and meconium of the fetus during pregnancy.  That said, the two most important factors found to shape the infant gut microbiota are mode of birth (vaginal vs cesarean) and feeding (breastmilk vs formula).

The overgrowth of lactobacilli in the vagina provides essential exposure for the baby to lactobacilli during vaginal births.  Babies do not get this exposure during a cesarean birth.  Many hospitals are swabbing mom’s vaginal area prior to cesarean birth in order to be able to transfer lactobacilli from the mom to the baby.  (Dominguez-Bello MG, et al. JC Nat Med. 2016 Mar; 22(3):250-3.) Be sure to swab well before the administration of any antibiotics given prior to surgery.  Exposing baby to the skin of the mother under her breasts and armpits during skin to skin time and breastfeeding over the first months of life help increase exposure. Additionally, babies born by cesarean who are breastfed should receive oral probiotics for the first four months of life.

The most abundant organisms in breast-fed infant guts are not the same as those found in formula-fed babies (Balmer SE, Wharton BA. Arch Dis Child. 1989 Dec; 64(12):1672-7.)  Breastmilk has elements which promote and nourish healthy bacteria in the baby’s gut.  Breastmilk feeds both the baby and the bacteria.  Babies who are formula fed should receive probiotics orally to help promote the growth of a healthy microbiota.

Prevention

As noted in the beginning of this article, prevention of GBS over-colonization should be seen as the first and best method to stop the long walk to full blown GBS disease.  In addition to preventing GBS exposure for babies, we can help maintain healthy microbiota and all of the benefits for mother, placenta, and baby that are the natural outcomes of that system.  In our day-to-day healthcare regimens, we should all be taking probiotics.  Every provider should be recommending probiotics along with a high quality prenatal vitamin at the first visit.  In an early release of data comparing midwifery care to OB care there was a very large difference in the number of patients who tested GBS positive between the two groups.  The numbers are still being teased out but one theory is the normalcy of midwives recommending probiotics to all patients.  (will update when final numbers are published)

The Solution

  • Take a daily form of probiotics (take 1-4 capsules per day) containing anywhere from 10-25 billion units of mixed flora but with high amounts of bacilli noted (available in grocery stores, Super Supplements or the Vitamin Shoppe).
  • Reduce the amount of sugar and refined carbohydrates you eat. GBS is a bacteria that tends to like sugary environments, and seems to colonize where there are not sufficient lactobacilli to keep it at bay.
  • Help keep your vaginal tract acidic and hostile to bacteria by taking probiotics and Azo Cranberry capsules (take one in the morning and one at night). Do not drink cranberry juice as the added sugar causes more harm than the cranberries help.

The Notes

  • The recommendations in this article are not designed to cheat a test but to actually improve the health of the mother, the integrity of the cervix, and the health of the placenta, fetus and newborn
  • Taking probiotics is not a guarantee of avoiding GBS or other complications related to imbalanced or missing gut flora. Talk with your provider about nutritional measures you can take to support your over-all health.  No amount of probiotics or exercise can undo the effects of a diet high in sugar and processed foods
  • Do get tested between 35 and 37 weeks for GBS. If you still test positive after a sustained period of time taking probiotics, eating a diet low in processed sugars and carbs, and rich in food that looks like it was alive, the colonization is highly likely to be one that needs antibiotic treatment. A pregnant woman who tests positive for group B strep bacteria and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby with group B strep disease. If a pregnant woman who tests positive for group B strep bacteria does not get antibiotics at the time of labor, her baby has a 1 in 200 chance of developing group B strep disease.
  • If GBS is found in your Urine during pregnancy, antibiotics can get the high colonization in check. Take probiotics at the same time as you take antibiotics and for the rest of your pregnancy.  The CDC recommends that anyone with GBS in their urine at any point during their pregnancy receive antibiotics during labor
  • Please discuss this information with your provider and work together to find a solution that is right for you. If your provider does not have time to discuss this or other preventative measures with you, there are plenty that will and I highly recommend you shop for the one who will serve you best

Additional Resources

Microbiota/Microbiome and Pregnancy/Birth/Breastfeeding

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943946/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464665/

https://www.amazon.com/Your-Babys-Microbiome-Critical-Breastfeeding/dp/1603586954

https://www.amazon.com/Microbiome-Effect-Affects-Future-Health/dp/178066270X/ref=sr_1_2?s=books&ie=UTF8&qid=1490123008&sr=1-2

Preterm Birth

http://www.marchofdimes.org/complications/premature-babies.aspx

Group B Strep Disease

https://www.groupbstrepinternational.org/

Schedule a Visit Today

Schedule your appointment today. We have availability beyond what is listed on the calendar…

If you are a professional looking to network or meet with Jodilyn, or would like to schedule her to come and talk at your event or school, you can call directly at 901-471-1606 or contact to schedule by email.

If you would like to talk with Jodilyn about midwifery services,  you can call or text (901)471-1606 to schedule a meet and greet.

If you have an urgent question please call 901-685-4063 and follow the instructions on the voicemail.  Your call will be returned within 10 minutes.

Step One:  Meet the Midwife!

Step Two:  Schedule Your Initial Visit

After establishing care you can book your Regular Prenatal Visits online.

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!

What do you imagine?

“…It is a design which rises up the mother as a qualified expert on her body and her baby. That is not to say that she knows everything. All experts get help, advice, and learn from others. So can she, but without relinquishing her role as primary in the relationship with her health…”

Today I attended a breastfeeding research update at a local (I’m now living in Memphis, y’all!) hospital.  The two-hour long program was aimed at providing understanding and context around the recent uproar regarding Sudden Unexpected Postpartum Collapse and best practices for breastfeeding.  Long story short:  keep practicing safe feeding and sleep practices and keep feeding your baby and keep looking for hospitals with the baby-friendly designation.  It matters.

I was struck there (and said so at the end of the program so this is not news to anyone who was there) by the quantity of information, data, charts, opinions, expectations, to-do lists, not to-do lists, etc…that providers are expected to impart on brand new moms.  The best of brains at the best of times has about 5 minutes of capacity and will recall just about three things if you carefully point out that you want them to remember the three things, explain them and review them in short to the point terms.  A postpartum brain will not under any circumstance recall pages of information, diagrams, or lectures albeit usually lovingly given, prior to discharge.  It’s not a mystery why parents and babies suffer from the very things we providers are “teaching”.  The only mystery is that we all keep moving our mouths when all the science tells us that’s probably not the way a pregnant or newly postpartum mother will learn.

Let’s shift the paradigm.  Let’s ask questions, listen, and contextualize the information that matters to each family.  Let’s sit down on the bed or in the rocking chair (rocking is notoriously good for you–among other benefits it releases endorphins– so this is a win-win, you’ll come away from the conversation feeling calmer and more energized) and talk with moms ask moms questions and listen to their responses.  How do you imagine feeding your baby when you get home?  Where will you sit?  Where will you rest?  Where is your baby while you’re resting?  Who is around you?  What kind of items are near you?  What kind of questions do you have?

As you can see–the conversation that will unfold out of her idea about what being a mother means to her will give lots of opportunity to get into all of the items on your checklist but most likely she will actually bring them up herself!  Does it cost more?  More than what?  Healthcare costs drop when patient-provider conversation increases.  Does it take longer? Longer than if we teach her to pay attention to her own sense of wonder, knowledge, and ability to ask questions and find a willing and engaged healthcare provider?

Take a moment, take a breath, people feel good when they feel heard.

Nurses often talk about the pressure related to the patient ratings they receive–this is very real and very terrifying in terms of job security.  If you want those high marks you can get them by listening and responding to the woman or family in front of you with kindness and more listening.  That is human nature, it is biology and physics at play in the world and you can rely on it to bring you higher job satisfaction and moms and dads and babies a healthier postpartum experience where they can really engage in the process of learning about each other, from each other, with you as their support system.  That is participatory medicine at it’s best. That is the true meaning of patient-centered care.  It is a design which rises up the mother as a qualified expert on her body and her baby.  That is not to say that she knows everything.  All experts get help, advice, and learn from others.  That’s most likely exactly how they got to be experts. So can she, but without relinquishing her role as primary in the relationship with her health.

Can you imagine the outcomes in a world where we ask new mothers what they imagine and provide healthcare education that is timely, relevant, and meaningful to them?   Do you remember what you imagined about yourself as a mother or father?  Did you get support to grow you in that work?  Do you want to learn more about how to be this kind of provider?  Share your story!

 

 

Social Justice & Midwifery

…It recognizes the social determinants of health and addresses mothers without guilt, shame, or fear. It recognizes the need of every human being to be heard, understood, and felt in their healthcare. It sees the starting point as unique for each family and conforms to the goals and desires of the families in care. Midwives operate outside the larger healthcare system but as partners with it. We offer care on your terms, never requiring you to miss work or leave your children to come to an appointment…

Midwifery meets families where they are at.  It crosses socio-economic lines while providing the same high quality, individualized care for all.  It recognizes the social determinants of health and addresses mothers without guilt, shame, or fear.  It recognizes the need of every human being to be heard, understood, and felt in their healthcare.  It sees the starting point as unique for each family and conforms to the goals and desires of the families in care.  Midwives operate outside the larger healthcare system but as partners with it.  We offer care on individualized terms, never requiring a parent to miss work or leave children to come to an appointment.  It is a family affair and everyone will have a role and purpose in the progression of pregnancy, birth, and the early time together.  Midwives bring parents and babies together–they are seen as one.  The language and behavior of your midwife will reflect this paradigm.  Partners are welcome and learn how to feel where baby is, listen to the heart beat and develop support that works best for them.

Midwives are welcoming to all, provide care that is relevant to the life and needs of each family, and is truly dedicated to partnering with families as they explore, develop knowledge, and make decisions in their healthcare.

Midwives are trained in all obstetrical emergencies and have finely-tuned skills to address them if and when they arise.  Yet, midwives practice from a place that trusts women’s bodies and babies as real experts in this process of pregnancy and birth.  Women have been carrying and birthing children since the beginning of humanity, and for nearly all of that time other women have learned the art and science of supporting their physical and emotional health to acheive excellent outcomes in all communities across the world.

Midwifery is…

…Early, Often and Easy to Access appointments.
On time, every time, all the time you need.
Your midwife is your midwife, you’ll see her at each visit…

  • Preconception Counseling
    • Timing your pregnancy
    • Understanding your cycle
    • Your health, your baby’s health
    • Stress and Recovery Plan
    • Choosing a provider
  • Prenatal Care
    • Early, Often and Easy to Access appointments
    • On time, every time, all the time you need
    • Your midwife is your midwife, you’ll see her at each visit
    • All screens and tests offered (blood work, testing, ultrasounds)
    • Shared, education-based decision making
    • Appointments in the clinic, your home, or place of work
    • Appointments on evenings or weekends
    • Evidence-based, individualized care for all
    • Visits once per month (or more as needed) until week 32, then visits at week 34, 36, 38, 39, 40, 41
    • Monthly phone check-ins between appointments
  • Birth
    • At your home or in the birth center, or a planned hospital birth with a physician
    • Attended by your midwife and her team that you will have spent time with prenatally
    • Midwife brings all equipment, supplies, and medication to your birth.  This includes fetal monitor, IV fluids, oxygen, sterile instruments, and suturing equipment
    • Midwife stays at your home until mother and baby are stable and fed and demonstrate comfort with her leaving (usually 4-6 hours)
    • Family stays in birth center until mother and baby are stable and fed and demonstrate comfort with her leaving (usually 4-6 hours)
  • Postpartum
    • Newborn screens, birth certificates
    • Home visits on days 1, 3, 5, and 7 (more often if needed)
    • Clinic visits on weeks 2, 4, and 6 for mom and baby
    • Referrals for pediatric care and well woman care

 

This slideshow requires JavaScript.

Midwifery Holds

…The midwife defends this paradigm at all points in care while bringing to the table complete knowledge of perinatal care for mother and baby and highly refined skills for the prenatal care, birth, and postpartum time…

12aa1

The essence of midwifery is that there is a space created on the family’s terms in which midwife, parents, siblings, and baby work together to develop and promote the primary role that each family plays in the pregnancy.  Baby grows to perfection without permission from any outside sources.  The midwife recognizes the baby as a unique individual that is on a journey of her own long before the day of birth.  The midwife comes to the mother and baby to celebrate this process.  To use skills and knowledge to promote their best health.  To share her vision for maternal-child health and to deliver the resources needed to accomplish this for each family.

The goals of the midwife are:

  • To ensure that each mother and family hold their baby for the first time and meet them from a place of physical and emotional health.
  • That parents go on to hold their babies from a place of wisdom and strength that comes with the transition into parenthood.
  • That families are reassured that, as Donald Winnicot taught us

When you hold your baby you are doing something of importance…what happens in your arms is a little part in the way in which you give a good foundation for the mental health of this new member of the community…You are a specialist in this particular matter of care of your own children. (paraphrased)

The midwife defends this paradigm at all points in care while bringing to the table complete knowledge of perinatal care for mother and baby and highly refined skills for the prenatal care, birth, and postpartum time.

Midwives launch parents who recognize the value of their own knowledge and abilities.  When the day comes to part, they leave care in vigorous strength and health with access to resources that can be used to build a future of good health for their families.

How has your healthcare become a catalyst for your health?

{read on: But what exactly, is midwifery care?}