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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

 

Postpartum Hemorrhage Management for the out of hospital midwife

Atul Gawande’s beautiful book The Checklist Manifesto easily applies to all of us out of hospital midwives. Check that link out–it’s the audio format because I know you are driving several hours per day between carpool and pick-ups and drop-offs and client visits and the grocery store and the gym. And back to the grocery store for whatever you forgot on the first trip.

Why does this book matter to us?  Why do these ideas matter to us? I can hear your midwife brains roaring about how we intuit our way through our practice–even obstetric emergencies–and we do it better and more efficiently than an entire team of OBs, neonatologists, and resuscitation teams designed just for, well, obstetric emergencies and resuscitation. You’re right, we carry a lot of the capacity of the combined powers of these teams in our personhood. We do so out of necessity. Because we are fortunate to spend most of our time in observation, but we are trained for the times where we must act and resolve obstetric emergencies in the out of hospital setting. ALSO is a training course originally designed for family practice docs to learn to manage obstetric emergencies through the use of team work and checklists in the form of mnemonics. I took this course way back and was the only midwife present with about 200 residents and practicing physicians. It was a terrifying 3 days and I learned the management of obstetric emergencies in hospitals–then adapted what I had learned to the out of hospital setting for use in my own practice. To say it has served me well over the years is an extreme understatement. So I was thrilled to see that I could re-up my certification this year at the end of a recent midwifery conference. I am happy to say the course is now extraordinarily well adapted to my learning style and actual practice. I highly recommend it or attending Expect the Unexpected, BEST, or one of the other specific courses designed for managing obstetric emergencies.

When it comes to emergencies, there have been many studies (many! Pubmed search “safety checklist and get reading!) that we should pay attention to. Studies show that outlining steps, having someone in charge of reading the steps, and making sure they are followed really matters when it comes to outcomes.

Who is your team?  In the space of an out of hospital obstetric emergency, every adult human in the room and building is a part of your team.

I’ll be posting additional sheets like this one—they are from our practice and not universally perfect.  Take it and make it your own, let it inspire you to have clear easy to read information for every kind of emergency you drill for.  Use it, adapt it, make it work for you.

This sheet is a simple tool to help you navigate through a postpartum hemorrhage–a common maternal morbidity in high resource countries that is trending upward. By acting promptly, hitting each step, and using your best skills along the way you greatly improve the chances that you will stop it long before it causes the need for a transfer. And for that rare mom that will require the entire run of our storehouse and hospital support to boot, by completing these tasks and documenting them you can help ensure a smooth transfer of services.

Please note this is designed for states where midwives have access to legend drugs and carry them as a regular tool in their birth kit. It does not address the use of herbs or other measures employed in states where medications are not available for use or low resource settings. I would love to hear what you are doing in those places–let us know in the comments below!

Click Here for the PDF

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Inuit or I Knew It

This is a post about the profession of midwifery. It is a bit of a window into our world—all are welcome to read and give feedback, leave your comments below! Somebody give me a little CPR—this is my first post with one space after each “.” It feels cramped! It’s a new world, blogosphere!

Midwives are often viewed as mystical. We are touted as having been “called” to this work, perceived or harassed as wise women, seers, or my errgmmm least fave of all time, “hippies” which I think implies just really earthy and soul-driven. I can’t speak for all midwives–I am fresh off of a conference of a few hundred of us and can speak only so far as to say that there is a huge variety of the kind of people and types of practices in our field today. Leadership in some locals is very state focused and in others very nationally or globally or village focused. I could go on and on but here’s the best way of explaining it. When you meet an Engineer in Washington, or Tennessee, or Australia, or Uganda, or China you’re hiring someone with the basic kind of education that each of their counterparts has. Their experience, bias, and framework will be individualized for the geography, setting, and environment they work in as well as the one they grew up in. Same goes for educators, lawyers, and yes, even us midwives. And for the record, most educators, engineers, civil servants, and even lawyers I know felt drawn to their profession, so I don’t think that sets us apart in any meaningful way. We’re just people trying to get paid to do what we love.

Our profession overall is shifting–with many of us dedicated to maintaining an apprenticeship based model, self-regulated in practice, and outside the mainstream health systems. There is a newer model blooming, responsive to the pressures of technology and societal norms in education, standards of practice, and accountability. It is designing itself to function as an innate and integrated part of the healthcare system in the US as midwifery does in so many places globally. Those of us working in this model are engaged in legislative efforts, systems change, policy-building, education reform, and standardization. These midwives will be seen as educated (many with a Master’s degree in science), working in professional settings like community-based clinics, birth centers, and hospitals. They might wear scrubs every day or some will wear the clothes they’ve always worn because they believe that scrubs can create a sense of power differential and are committed to health care in partnership in all ways—starting with the perception of power. Some of those in street clothes will exude power and some in scrubs will create an art of shared-decision making. Most midwives will fall somewhere along the spectrum of this vast continuum and move up and down it over the course of their day, year, and career. I’m not here to tell you what’s right or wrong for you as a midwife or which midwife a consumer should absolutely pick. My opinion is that there is a mother for every midwife and I suspect we will always have a midwife for every mother.

I’m an evolving human being and my sense of where I am and where I want to be in my career has evolved as well. If you’ve hired me or worked with me or read anything I’ve written you can probably figure out where I fall in. You can always ask me if you want to, I’m open about my views on all this evolution in our profession.

But wait, what’s all this got to do with intuition?  I want to recap a great discussion I had many years ago which taught me one of the most valuable lessons of my professional and personal life. I admit to being one of these people who pops light bulbs in my vicinity on the regular (literally). Need a watch killed?  I’m your girl. Unsure about dating a certain someone?  Gimme 5 or 6 minutes tops and I’ll have them read. I don’t know why I do these things…I’m not always right and my willingness to participate in the world by thinking and feeling my way through has gotten me into some trouble but overall, over time it has served me just fine. For a long time people called me “intuitive”. I could “sense” things about people, or the course of events. But here’s what a very seasoned midwife laid out for me. I promise you know her and you think she’s a hippy.  She might be!  And she’s a smart, savvy, well-studied, educated and engaged learner also. She pays attention. I called her to review a difficult case I had. As I recalled the care and birth of this mother I said, “I knew that xyz was coming”. She asked me, “Jodilyn, how did you know that?”  ” I just knew it–I sensed it–I…”  “Intuited it?” She asked me in a rather forceful manner. “I suppose so. Yes, I guess that is what one would call it. I intuited it.”

She proceeded to walk me back through incident, and had me identify, step by step what I saw, smelled, heard, noticed, thought of, and did. As I did so I built a profound stack of scientific evidence that, when put together, would undeniably lead to this outcome. According to every text book ever written since the beginning of obstetric text books. “So you see,” she chirped pleasantly, “you didn’t intuit anything. That’s crap. It’s an undersale of your knowledge and abilities. You have three dozen pieces of proof for your diagnosis and you don’t need anybody’s permission to know that you were right.” Three dozen pieces of proof. She was right. I did. I knew my stuff and I knew where this mom was headed and that she needed intervention. I took the right steps and got her into the care she needed in time and just as I saw coming, she had extreme need of high level intervention. But at the time, I couldn’t explain to the doctors how I knew what I knew. Forget them, I couldn’t explain it to the family, or even to myself.

After that incident, I began to peel apart my “sense of things” and force myself into a tedious exercise. Doulas are usually massively equipped with this “sense of things” skill–walking into a room to find a laboring mother, her partner, family, providers, and nurse. Each with their own emotional experience, needs, goals, desires, and fears. The music is on and people are having side conversations. The room smells like a lot of bodily fluid (often the depth of those smells is a sign itself of how far along labor has progressed) and a lot of sterilization chemicals. In an instant that doula sizes up the room, the tone, the interactions, the body language, the mother’s noises and movements, who is holding stress in what parts of their bodies, the tension, the love, the energy, the gaps in energy, who is driving the intention in the space. Then, she matches all of that up against what she knows are the mother’s wishes, hopes, worries, fears, and dreams. And she meets every single person in that room exactly where they are with hardly a word. She seamlessly integrates and harnesses the parts and pieces needed for the family that is relying on her. It isn’t long before everyone–provider, nurse, family–everyone is in love with her. They all feel seen and understood by this woman. And that was how I trained my brain for years and years and hundreds and hundreds of births before midwifery.

My mentor set me on the path to train my brain to quantify all of the dozens if not hundreds of data points along the way that were my teachers and to let myself be informed primarily in bullet points instead of feels. At first this process gave me tremendous headaches. It was a slowing down that took discipline and discomfort. I had to stop seeing myself in one way, and open up to myself in this whole new dimension–smart, savvy, educated, knowledgeable, prepared, and capable.

I remember the first time I took a mom to a physician because of the same condition as the one that started me on this path moving from Intuit to I knew It. The physician asked me, what are you seeing that leads you to believe this?  I said here’s what I know and why I know it. I believe you are here to help this mom but I know what she needs and that’s why I’m calling. And I gave her my list of evidence. And she agreed. And mom and baby were healthy and fine because I identified a simple physiological disruption long before it ever got a chance to manifest as a diagnosable pathology.

Now I’m old (which I enjoy!) and I’ve embraced not needing anyone’s permission to know that what I see–labs, signs, symptoms, constellations of symptoms, are of great import and can make a real difference in the health of a family I am working with. I happily consult colleagues, teachers, and mentors and work with them to hear fresh ideas, consider possibilities, and to build a care plan.

But I needed the intervention of a surprising midwife to find my way. It taught me to stay waaaayyyy open to what all midwives have to offer, to trust that even if it’s not how I practice, or we don’t share cultural, social, or especially here in the south, religious ground, we share the work of mothers, babies, pregnant people, families, and ourselves. How do you Intuit? How do you Knew It?  How do you seek the knowledge and wisdom of others to help inform you as you grow and learn?  How can you leave space for others to practice in a way that is genuine to them and continue to be yourself? What pieces would you want us all to pay attention to?

 

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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