Harvest Midwifery

A Midwife's Baggage

6/1/2023

"It’s dark by the river when it’s night in the forest,

And if you walk this path alone, you will get close to no rest.

Keep some baggage by the door, you never know when they will call you,

And if you’ve walked this path before, you will say a little prayer, take a little light to guide you."

“Alabama Midwife"
Song by Kate MacLeod

In honor of Jill, an incredibly strong mother

The call phone rings, sleep recedes
Answer hushed, try not to disturb
Throw on clothes, creep down stairs,
Flick on lights, grab the baggage,
heavier than preferred.

Miles apart, both midwives pack
Their cars in duplicate,
Each enough to stand alone,
Intended to be together, yet
ready just in case.

Baggage is unpacked, organized,
Touch brings memory of use,
The watching begins: quiet, unobtrusive,
Always with prayer for wisdom and
insight to serve well.

Labor blossoms with patience-
Power, passage, passenger, psyche-
Orchestrated to a climax where
Mother is transformed as
her babe emerges.

Many times the baggage remains
As heavy at departure
As upon arrival.
But other days ...
Watchful eyes spy a need,
Listening ears hear a call for help,
Agile hands sift through supplies,
utilizing tools appropriate.

Today the baggage contents-
Combined with inspiration, intelligence, intuition-
Sufficed for safe passage.
Never taken for granted, prayers are lifted
with profound gratitude.

Upon departure, the heavy baggage
Is no longer so.
Realization sets in.
All is needful, despite being
heavier than preferred.

© 2023 Chloe Raum. All rights reserved.

Transforming the Culture of Birth

5/5/2019

For the mother, childbirth is designed to be a transformative process. Traditionally, childbirth was a pivotal rite of passage. The natural process transforms a previously self-centered woman into an empowered warrior ready to protect and nourish her new child. A woman learns what it means to surrender to forces she cannot control, and to sacrifice her wants and desires for the good of her child.

What is important is that it is her transformation. You cannot force a woman to be transformed in this way any more than you can force a caterpillar to become a butterfly. The most that can be done to promote the best outcome is to understand what is vital to the transformation and to meet those needs. For a caterpillar, this means ample nourishment, access to the right environment, and protection from predators. For a woman, it is the same.

When the needs are met, a woman has the best chance of having a healthy outcome for herself and her child. A mother who is transformed emerges from her birth with a growing confidence in her ability to face the future challenges that will come on her mothering journey. Those who witness this transformation develop a newfound respect and awe of the mother. Witnessing her transformation helps them to embark on their own transformation into parenthood.

The word midwife is literally translated “with woman.” No conditions should be placed upon this definition. A midwife recognizes the range of normalcy in birth. She is intimately familiar with the appearance of transformation; she either observes its unfolding, or is acutely aware of the lack thereof. Too often discussions surrounding issues of scope of midwifery practice focus on artificially constraining which women “qualify” to receive midwifery care, and which women are "risked out" of midwifery care. This is fundamental error. All women need and deserve access to midwife-led care! In fact, the women who are at “higher risk” need midwifery care even more than women who are “low risk.” They might also require obstetric care, and this should never be an “either/or” scenario, but a “both/and” situation instead. Yes, there are times when obstetric care is absolutely essential to promote the best physical outcome for mother and baby. What our culture has yet to rediscover is that midwifery care is absolutely essential for the optimal mental health and transformation of a woman into a mother.

The relationship of trust that is formed between a woman and her midwife is a key element of midwifery care. Within the context of this relationship, the midwife is able to assess the woman’s current state (nutritionally, emotionally, relationally) and provide individualized education and resources to help position the woman for her best possible outcome. One fruit of this relationship is the trust that a woman forms with her midwife. It is this trust that allows the midwife to gently lead a woman into making good choices for herself and her baby. This is important because learning to make good choices is essential to the mother’s transformational work. It cannot happen if a caregiver only offers one option, or coerces the woman to choose what the caregiver prefers, or threatens that the woman’s insurance will not pay for her healthcare if she goes against medical advice, or if a caregiver obtains a judicial mandate to force a woman to submit to a particular procedure. When the mother chooses, she accepts the responsibility of her choice. When the caregiver or the government limits or forces her decision, is it any wonder that it becomes very difficult for a woman to accept responsibility for her outcome?

When a proper relationship of trust is established, a midwife can tell a woman when she needs referral or transfer for obstetric care. The midwife can help the woman to see the need and to make a good decision. She can go with the woman to provide continuity of care and continue to meet the woman’s emotional needs. A highly interventive obstetric birth can still be—and for sake of mother and baby, it should be—a transformational birth. Being a midwife is not about fighting over who gets to catch the baby or who gets more money from an insurance company. It is about transforming a woman into a mother while seeking the best outcomes possible.

The hundred-year experiment of stripping women away from their community midwives has resulted in generations of untransformed women, walking wounded with physical or mental scars, who sometimes struggle to confidently chart their course through motherhood. For humankind to not merely survive, but to thrive, this must end. Scope of practice details belong to birthing women and the midwives who serve them. It is appropriate to uphold evidence-based practice, where the integration of the best research evidence, clinical expertise, and the mother’s needs inform her. Women deserve access to midwives who are trusted to utilize their education, experience and intuition to guide the woman to the appropriate care for her individual situation.

The work here, in our state, has barely begun. What remains to be done is much more than any one person can do. What I personally will be able to contribute will be a drop in the bucket compared to the need. The transformation of our birthing culture will be slow, much slower than desired. The demand for midwifery services will outpace the number of families who can be served. I know that there is a great sense of urgency for those who are expecting new babies, and I am saddened that the passage of a law cannot quickly translate into a midwife for every mother.

Today on the International Day of the Midwife, I honor those who have gone before me, those who have educated me, those who were “with woman” as I gave birth to my children, and those who feel the call to serve their sisters in the oldest profession since creation.

Claudia Stood in the Gap

9/6/2014

09/25/09 ~ Claudia and I walking during my labor.

One year ago, as I was working to "birth" this website for my practice on the mainland, a quarter of the world away a dear friend and mentor Claudia Brown CNM drew her last breath.

Claudia graciously welcomed me into her practice Home Birth Kaua'i and attended the home birth of my son in Kalaheo. Her generosity was legendary as she shared her time, her home, and her life with not only family and friends, but the clients she served. Everyone was welcomed into Claudia's ohana.

Five years ago, I had just met Claudia when I transcribed my "Standing in the Gap" essay into a Facebook note a few weeks before giving birth to my third child. At the time the essay was written, it was not a reflection of who I was, but upon the midwife characteristics that I would spend the rest of my life striving to become. The essay reflected the statistical outcomes from the CPM 2000 study published in the British Medical Journal in 2005.

I didn't know five years ago if Claudia was a "standing in the gap" kind of midwife or not, but I intended to find out. What I discovered was a person who was always open to learning something new. Claudia sought to bring out the best in those around her and greatly encouraged me on my midwifery journey. It was an honor to "stand in the gap" with her to provide the Midwives Model of Care to the women of Kauai. Rest in peace, dear friend.

Standing in the Gap
Reflections after Labor Day ~ September 6, 2008
by Chloe Raum

I stand in the gap.

The gap between midwives whose clients have a vaginal birth rate of 96%, and a medical culture where the majority of births in the United States result in a vaginal birth rate of 67% that continues to erode each year.

Natural childbirth doesn't appeal to everyone, because of the fear that is so pervasive in our culture. Fear of pain. Fear of injury. Fear of death. Fear of being sued. Women in our culture are encouraged to take advantage of all the tools that the obstetric profession has to offer. Even better, your insurance will probably pay for every penny of it! Tired of being pregnant? Sure, you can be induced a little early! If your baby has trouble breathing because he wasn't quite ready to be born, we'll just keep him away from you in our NICU. Afraid to feel pain? No problem, our anesthesiologist can help! Not sure you want to risk the uncertainty of laboring at all? Elective cesareans seem to be all the rage now (at least in the media).

Out-of-hospital midwifery clients are not just lucky, do not have superior pelvises or grow consistently smaller babies. However, many of them do receive a different quality of prenatal care. They are attended in labor by midwives trained with a different set of skills. They are enveloped in an atmosphere that has a more flexible understanding of the range of "normal." This results in a dramatic difference in outcomes. Not different mortality outcomes ... maternal and infant death rates are consistent for healthy women attended by skilled caregivers in either hospital or out-of-hospital settings. But the differences in medical interventions, along with their associated complications, are staggering.

The mothers who find themselves in the gap are those who just didn't fit the textbook expectations of pregnancy or labor. Here is the mother whose due date is uncertain. Here is the mother who is pregnant more than 40 weeks. Here is the mother whose water breaks and her labor doesn't immediately kick in. Here is the mother with the posterior baby who doesn't progress in labor unless someone helps her to find a way to get the baby turned. Here is the mother who needs the comfort of laboring in a birth pool to cope. Here is the mother with the unexpected breech presentation. Here is the mother with the sexual abuse history who needs to resolve that pain before she can birth her baby. Here is the mother with twins who needs lots of additional nutritional counseling to have an adequate diet to carry two babies to term. Here is the mother who wants to have a vaginal birth after a cesarean.

What is amazing is that 67% of mothers continue to birth vaginally regardless of where they are, or how they're treated. More often that not, the human body will still function despite the roadblocks set in its way. For those mothers, having the personalized attention of midwifery care would have just been the icing on the cake. She would have enjoyed the extra counseling and education that is possible when each prenatal visit is an hour long. She would have had direct access to her midwife any time throughout her pregnancy. She wouldn't have seen new faces when the shift changed during labor. Perhaps she might have had an intact perineum instead of a tear or episiotomy. Her follow-up postpartum care would have come to her at home. She would have been attended by someone who knows how to help nearly all of her clients be successful in breastfeeding. She would have the confidence from "climbing her personal Mt. Everest" that will serve her well during the future challenges of motherhood.

For the mothers in the gap, midwifery care is even more vital. It can mean getting a troubled labor back on track. It can be allowing the parents full access to information on risks and benefits and allowing them to make uncoerced decisions. It can be a midwife's skill in monitoring labor with her whole being instead of relying on a machine that goes "ping." It can be assessing a need for additional medical intervention and gently counseling the mother to understand why this birth needs to be different from her ideal. It can be helping her to understand that which is understandable and to accept that which is incomprehensible.

Future mothers, do your homework. Look at the statistics of your prospective birth attendant and setting. Educate yourself about birth and the trade-off of risks. If you're fine with a one-in-three chance of having your baby cut out of your belly, you might be satisfied with mainstream medical care. But if you'd rather drop that risk to one-in-twenty-five, perhaps you'd better check out your alternatives. You might have to drive to another state, or pay more out of pocket. Some women find it worth going the extra mile. Others do not. It is your decision to make and I respect your right and responsibility to make it.

For myself, I am a midwife and have been called to stand in the gap. I feel it is my debt to society. At the birth of my first child, I was given a precious gift by my two midwives who stood in the gap with me. Because of their training and experience, I was able to avoid a primary cesarean section and have my baby safely and naturally. I succeeded with breastfeeding. I learned about good nutrition and my whole family is healthier for it. If I can help to bridge the gap for even just one mother and help her avoid an unnecessary cesarean section, then I have succeeded. How life unfolds at the beginning is that important. Natural childbirth may be the hardest physical work a woman ever accomplishes. Fortunately, the reality is that with the right caregiver and setting, natural childbirth is overwhelmingly achievable and one of the most rewarding endeavors a mother will ever undertake.

Personal Thoughts on Postdates

2/7/2014

With my first pregnancy, I had a due date of January 3. I knew my mother had a history of going late, but you know that was way back when dates were a little less certain. And I knew that term pregnancy usually averages between 38-42 weeks and that it's more common for first-timers to be late than early. However, none of that information persuaded me to refrain from shouting my due date from the rooftop to anyone who would hear.

Then I went past my due date, and the questions began. Suddenly everyone was concerned about me being overdue. It wasn't so much the immediate family; they did fine, mostly because we'd been having these discussions for most of nine months. It was everyone else. Well-meaning friends and folks from church or work calling, emailing, and random folks in the grocery store all asking the same questions, and me growing weary of patiently explaining the answers over and over again.

When are you due? Well, that would be over a week ago. Yes, I'm ready for the baby to arrive, but no, I'm not feeling miserable, why should I be? I'm sleeping fine, thank you, except for getting up 2-3 times to pee. What are you having? A BABY (hopefully of the human variety, not a beluga whale or a porcupine) and no, we didn't want an ultrasound to see the sex. Why wouldn't you want to know? Because we like to be surprised! How big did the ultrasound say your baby is? I didn't have an ultrasound. Third trimester ultrasounds can be off by 1 to 2 lbs in either direction. How many mothers do you know who were scared into induction or even a scheduled cesarean because their baby was supposed to be too big and then it turned out not to be? When are they going to induce you? They're NOT. Period. Babies come when they're ready when a mother is experiencing a healthy pregnancy. Who is your OB? Who on earth would let you go this long? I don't have an OB anymore. She fired me from her practice in my fourth month. But I do have two terrific midwives. Midwives have a much better track record with helping mothers to stay healthy and make it to term.

Are you really planning to have the baby at home? That is the current plan. Aren't you scared it will hurt? I expect it will, but I think I'll be able to work with labor better if I can eat, drink, and soak in a warm bath instead of being starved and harpooned to an uncomfortable bed by IVs, fetal monitors, and catheters. How will you be able to live with yourself if your baby dies from a complication because you weren't in the hospital? The same way I'd have to live with myself if my baby dies from iatrogenic causes in the hospital. Research shows that the infant mortality rates for healthy mothers planning homebirth with skilled attendants versus hospital births are comparable. Babies can still die (mothers too, for that matter) sometimes from the same causes regardless of setting and sometimes from different causes. For every intended home-born baby that might have been saved with immediate access to hospital resources, I expect there is also a hospital-born baby who died due to the side effects of routine medical intervention in the hospital model of care.

By forty-one weeks even the healthiest and happiest pregnant woman can become violent if asked the same questions over and over again. I grew weary of trying to educate the world. The pinnacle of my frustration was on the Sunday morning when I valiantly went to church, only to find that my friend (due 2 weeks after me) was at the hospital because her water had broken that morning. An older gentleman looked at me and said, "What are you doing here?" I know he meant well, but that was not encouraging. It was all I could do to contain my frustration as I snapped back, "I'm here to worship God, what are YOU doing here?!?" Thankfully my first baby arrived at 2:30am on that Wednesday before I had to deal with the moral dilemma of "forsaking the assembly" versus maintaining my hold on sanity. Weighing in at 8 lbs, he was the smallest of my babies and the latest at 41 weeks and 6 days.

When I found myself pregnant again, I took a different approach. I decided to have a "due month" instead of a due date. My due month was July. This drove most everyone crazy. I refused to give the church secretary my due date to be printed in the church bulletin. But she kept pestering me, so finally I told her that if she had to have a date, to feel free to use the last day of July, but that was not my due date. Mentally I was expecting that this baby would be just as late as my first; in fact, I was counting on it. When she decided to arrive only two days late instead of thirteen, I felt really, really gypped! I had not quite completed my to-do list yet. Oh well, babies come when they are ready and she was 8 lbs, 14 oz. In retrospect I was glad she didn't have an additional eleven days to pack on more fluff!

Shortly after the news of my next pregnancy was announced, the inevitable questions of "When are you due?" began again. Luckily we moved to Kaua'i at the beginning of that pregnancy so there weren't any chance encounters with old friends in the grocery store. As I was in the mood to embrace "island time," I decided to merely have a "due season." Autumn ... doesn't that sound like a nice due season? As harvest neared, my belly swelled. Our sweet church family regarded me with wide eyes each time I walked through the door, just a little bigger than before. I just smiled at them all, thumped my belly and declared, "Not ripe yet!" Just before my due date, I taught the first of many childbirth classes with my midwifery partners on the island. And five days past my due date, not "late" but just in his own good time, my third child arrived weighing 9 lbs, 8 oz. His birth was faster and somehow slightly easier than the labor with my second child even though he was my biggest baby.

This week, a midwife colleague from Kaua'i contacted me seeking reassurance, as she was surprised to find herself in the land of postdates. Here were my words to her:

"Before the days of clocks, calendars, and ways of peeking into the womb, there was just day and night, new moon and full moon, and the seasons marked by transitions in the natural world. It was easier to access intuition and to accept mystery. At the root of our calling, we are invited to trust that nature's design is beautiful, intricate and serves a vital purpose. Wisdom comes from observing nature and learning more fully how to interact to support MotherBaby on the journey. Your midwife-mind holds knowledge, but your mother-body is filled with ancient wisdom. Trust yourself."

As a midwife, I am obligated to present expectant mothers with information upon which to base their choices. It is important to share both information upon actual risks that have been observed, and to place that in context with the understanding of normalcy. But I also owe it to mothers to help them embrace the unknown and be reassured that even though no one can promise a particular outcome, I can promise to travel the journey with them.

Considering Term Vaginal Breech Birth

11/20/2013

Recently I have been reviewing the variety of opinions regarding the birth of term babies in breech positions. In my community, the obstetrical standard of care offers routine cesarean section for breech presentation. It is interesting to read ACOG's opinion from 2006, Mode of term singleton breech delivery, and to see the following recommendations:

* The decision regarding the mode of delivery should depend on the experience of the healthcare provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery.

* Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.

A dilemma exists in the US due to the lack of physicians who possess expertise in vaginal breech delivery. A prior ACOG committee opinion from 2001 recommended that vaginal breech births were not appropriate following the publication of the Term Breech Trial in the Lancet in 2000. Many physicians stopped offering vaginal breech delivery as an option for mothers. Medical schools stopped teaching new physicians vaginal breech skills. By the time a follow-up study found the "risk of death or neurodevelopmental delay was no different in the planned cesarean delivery group compared with the planned vaginal delivery group," few physicians remained who were willing to permit a trial of labor for a known breech presentation. Cesarean birth for the term breech baby has become routine, and ACOG states that 86.9% of breech presentations were delivered via cesarean in the year 2002.

Interestingly, ACOG's counterpart in Canada, the SOCG, has taken a stronger stance in support of vaginal breech birth at term. The SOCG now recommends revising their undergraduate and postgraduate training requirements to include theoretical and hands-on vaginal breech skills, and to promote training of current health care providers in those skills as well. In their 2009 clinical practice guidelines titled, Vaginal Delivery of Breech Presentation, labor selection criteria, contraindications, and labor management guidelines are offered. However, most impressive is SOCG's perspective regarding a woman's autonomy and the expectation of how the facility and staff should honor her wishes.

"Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care."

There is a need for true shared decision-making in American maternity care. Health care providers should recognize that their obligation is to offer the patient their experience and evidence regarding term breech birth, and then to allow the mother her right to make an informed decision of either consent or refusal to the provider's recommendation. There is a need for laws to allow for health care providers to document the informed discussion and the mother's decision, without requiring the health care provider to abandon care for her. The time has come to stop pitting the perceived best interests of the baby against those of the mother, and to begin to treat MotherBaby as one, acknowledging that the mother has the right to self-determination about the health care she chooses to receive.

Stuart Fischbein, MD

Even though they are few and far between, it is encouraging to discover birth attendants who continue to provide mothers with vaginal breech birth options. Ina May Gaskin and other Farm midwives are renowned for providing the Midwifery Model of Care to healthy women who travel from other states for a trial of labor with term breech babies. In Atlanta, Dr. Joseph Tate accepts referrals for women seeking a vaginal breech birth in the hospital. Dr. Stuart Fischbein in southern California is a strong believer that collaboration between doctors and midwives provides clients with the best care. He has left his former hospital-based practice to work along side a licensed midwife, and is willing to provide a trial of labor for term breech mothers who are good candidates for a vaginal birth. In this interview with Progressive Parenting's Gena Kirby, Dr. Fischbein discusses the issues surrounding vaginal breech birth and the importance of patients' rights to informed consent and refusal.

Breech presentation is considered by some to be a variation of normal, and for others as a high-risk scenario. Evidence shows that it does carry more risk than vertex presentation and it is vital to address those risks during the informed choice discussion. According to SOCG, even with careful case selection and labor management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. However since long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity, it is reasonable for some women to seek a trial of labor. No suitable candidate should be forced to birth via major abdominal surgery without offering a trial of labor. Neither should a woman be forced into a lower resource birth setting (giving birth out-of-hospital) due to a lack of a higher resource setting permitting a trial of labor.

It is wise for all birth attendants to seek training to facilitate vaginal breech birth because it is not uncommon to experience an unexpected breech presentation. In order for training opportunities to exist, the ability for health care providers to offer safe breech birth options should be revived for the women who would seek them.

Many thanks to Jodie Myers for capturing such lovely video of a home breech birth attended by Dr. Fischbein titled, "Aurora's Birth."

A Gentler Cesarean

11/13/2013

Mothers and babies who receive a surgical birth often have additional challenges to overcome in the early postpartum period. A decision to give birth via major abdominal surgery is never taken lightly, and often occurs as a result of a situation where surgical birth is considered necessary to promote the best outcome for mother and baby. Unexpected cesareans can be very traumatic for a mother whose birth experience quickly diverges from her plan. In a traditional cesarean surgery, mother and baby are separated for most of the "magical hour" after birth which complicates normal bonding and breastfeeding.

Below is a touching video showcasing a Family-Centered Cesarean by Dr. Brad Bootstaylor, a perinatologist on the staff of Intown Midwifery in Atlanta, Georgia.

ImprovingBirth.org has a lovely birth story from another mother who experienced a Family-Centered Cesarean. I look forward to the day that this option is available to all mothers and babies in our country.

Considering the ethics of evidence-based care

9/6/2013

I enjoyed this article from the AMA Journal of Ethics titled, The Difference between Science and Technology in Birth, and appreciated the authors' view on evidence-based care, ethics, and informed consent. It's important to recognize that modern midwifery does not seek a "natural" birth at all costs. Instead, the primary focus is evidence-based care that supports the best health possibilities for the mother and baby.

Low-intervention births are often labeled "natural," something that sounds more foolishly romantic than medically sensible. For this reason, we believe it would be better to think of childbirth not in terms of "natural versus medical" but rather "scientific versus unscientific."

There's a notion, that maternity care should strive to be "scientific" instead of "natural" or "medical." In reality, a safe birth might need to have various components along the continuum between those extremes. Attending births certainly requires a caregiver to know how to act and when to act, but it must include the experience of learning when nonaction is the most beneficial for mother and baby.

Few experiences before medical school prepare a person for what it means to act on the principle “First, do no harm.” In most areas of life, action is more highly valued than nonaction. Yet birth offers an opportunity to appreciate the importance of clinical humility and of living by the motto, “Don’t just do something—stand there.” To be a good doctor means to stand there until you know that intervention is likely to be best for the patient, even when that may be the most harrowing for your own psyche.