Claudia Stood in the Gap

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.

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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.