Thursday, May 5, 2011

Happy International Day of the Midwife!

When a woman becomes pregnant, she is already beginning to grow. It's not her belly that starts to poke out immediately, but her mind and heart that begin to stretch. To integrate the first glimmer of knowledge that she is pregnant requires a huge shift in consciousness. "Oh my God. I am pregnant. I am one of those pregnant women. I'm going to have a baby. My body is amazing. But will I get very sick? Will I be able to give birth? How will my life change? I am PREGNANT! I am so amazed...and confused...and terrified...and joyful...and ambivalent...and profoundly moved." Some or all of these thoughts and emotions will surge through a woman and she will already be making the necessary opening of all channels that motherhood requires.

Dealing with all these new thoughts and feelings, it is pretty normal for arrangements for labour and delivery to not be first and foremost on the mother's mind for at least the first few weeks in as she battled with issues like what to eat without throwing up, and how to get in a nap. Everyone is different, but just integrating the knowledge of being pregnant is a large adjustment in and of itself. Most women, if they have never gotten pregnant with the intent of having a baby before, don't really know what options are available to them in terms of prenatal/postnatal care and birthing.

In Montreal, you have three options. Well, there are more, but here are the main ones: You can have an obstetrician care for you (which is the norm), a family doctor who specializes in maternity care (both types of doctors tend to births in hospitals), or a midwife. Midwifery care is covered by Medicare here in Quebec, as is medical care. Midwives tend to healthy pregnant women and normal births primarily in free standing Birth Houses in which there are no medical practitioners present, though women can be shipped to the nearest hospital easily enough if a problem arises. Midwives also attend births at the woman's home if the woman wants and the situation is deemed appropriate. They also occasionally do so at the hospital, though it doesn't seem to be the norm unless there is a reason for the mom to be there, like a minor pregnancy concern or a transport. If a woman has a complicated pregnancy, or she knows she wants to have an epidural for pain relief in labour, she normally won't be having a midwife tend to her. There are not really enough resources to pull midwives away from their traditional role of helping women have their babies naturally outside the hospital, so those who know they want a medicalized birth (births with epidurals being medicalized births) or those who are found to have complications or higher risk situations will need to seek out doctor care.

In many other places where midwifery is practiced, midwives are often part of the hospital staff. While this has its benefits in many ways for the consumer (access to the hospital environment and drugs/technology etc. they may want) and the midwife (shift hours, responsibility easily shifted to an obstetrician, etc.), it definitely does change the essence of midwifery a lot, which could be seen as a disadvantage.

Midwives here from my observations tend to keep it more traditional, and work with those families who have their hearts set on natural births outside of a medicalized setting. Yes, some of you may be thinking that women should always be able to have their cake and eat it too: the lovely hour long prenatal sessions with a midwife, the one on one care during labour, gentle hands receiving a baby in whatever position the mom wants or in a big tub, hushed tones, uninterrupted skin to skin...AND perhaps pain relief to take the edge off with all the equipment and MDs waiting on the sidelines. And fair enough, it's certainly not wrong to want what looks like the very best of both worlds. But it's rarely done like that here. Rare and precious midwifery resources tend to be given for the most part to those committed to the intention of birthing naturally. For those women who want that well deserved nurturing attention as well as have enough concern about the challenges that could come up in labour to warrant wanting to give birth in a hospital with access to doctors and epidurals, doulas normally fulfill the nurturing role while doctors and nurses maintain a clinical role.

So back to our freshly pregnant woman. With the pregnancy test showing a big old plus sign, the first thought on her mind is not usually who she's going to have receive her baby at the time of birth. It's not really until she starts reading or talking to friends and allowing ideas to gel in her mind as to how she wants her birth to be that she starts to think midwifery care might be thing for her. Yet, despite the huge consumer desire for midwifery care in Quebec, unless she calls with that damp pee stick still in hand, chances are, unless she has already birthed with a midwife previously, she will be put on a waiting list for care at the Birth House. A LONG waiting list. Women are often shocked, when the time finally rolls around for them to start making arrangements for their prenatal care (or, after having received the typical 3 minute prenatal examination from her doctor and trying to ask questions to the OBs back, which can be seen flying out the door as they are completely overworked and need to move on to the next patient, a woman realizes she rightfully wants some more time and attention) to find that their option to experience midwifery care has long since gone.

We know statistically that midwife attended out-of-hospital-births for low risk women are generally safe. They are as safe as(and some would definitely argue even safer) than doctor attended hospital births. And we know women WANT midwifery care. Oh, do they want it. As a doula such a large percentage of my clients receive default care in a hospital with a doctor they may like but chances are will never see at their births. They had wanted so much to get into the Birth House and give birth naturally, yet, like the VAST majority of women who want this care, just couldn't get in. Sure, I can provide the warm fuzzy and individualized emotional care women usually need to feel confident about their birthing selves, but as I have said in past blogs, I don't have control over the environment. While my presence definitely helps to reduce unwanted and often unnecessary interventions, it's not the same for those who didn't really want to be in the hospital anyway. In fact, from having vast amounts of hospital birth attending experience, I can say that those women who just don't feel right in a hospital but feel they have to be there anyway without any other choice, there is definitely a huge emotional, and thus often physical impact upon the birth. If a woman walks into a hospital holding my hand tightly and bursts into tears when she gets there because it's simply not where she feels safe and right (I so know that feeling...when I was a 22 year old pregnant girl I walked into the hospital I had planned to give birth at and walked out with all my sphincters in "PROTECT" mode, with the vow, "NO NO NO" on my lips), I don't expect an easy birthing. Challenging births can definitely be a direct result of a woman not being where she feels safest, and I don't care who tells me that's just hocus pokus. So if a woman's birth can be made longer and more painful and perhaps more complicated by not being in an environment that supports her psychological and emotional needs as well as the basic clinical stuff, we are creating problems, not just succeeding in preventing them by having most women birth in a hospital.

So where does that leave women? Well, if they're really determined to birth outside of a hospital and cannot find any licensed midwives around, some will look for traditional birth attendants, usually midwives who are trained in other areas of the world (and some have extensive training...more than they would even get here through the university training route) but not practicing within the Quebec system, to tend to them in birth. This service is extremely difficult to find, there are extremely few resources, and in the end most women don't want to do make this choice as they are afraid of being on the "down low". The resources for this service, which a client would have to pay out of pocket for, are terribly few because honestly, if something went wrong during the birth and you were caught out as the birth attendant "practicing medicine without a licence", well, you could into huge trouble. This is to protect women from bad and dangerous care (and bad care unfortunately does sometimes happen in these situations, though usually most of the women assuming this role know well what they're doing). Understandably, many legal midwives don't much like unregulated birth attendants either, as any blips on the radar can reflect badly on their profession and hurt what they have been fighting for for years. So it is the extremely rare and dedicated bird with a passion to tend to women where they want to be tended to in their place of choice as opposed to standing back and accepting that women should be happy with the shabby "default" route our government forces us into, who will attend home births illegally. Her belief in the rights of men, women, and babies to start their lives together in the environment of their choice usually overrides her fear of getting caught out by "the establishment" who has deemed to dictate where this very private affair must happen. These are women who are taking a huge personal risk of potential fines and/or jail time if found out, especially if something goes wrong during or after birth. In spite of the concerns, backlash, criticism, and arguments the powers that be have against the role of the underground midwife, I must say I fiercely admire the spirit and bravery of one who stands up for family and choice in this way at great personal risk. If not for some of my midwives working "underground" at the time they tended to me, I would not be the empowered birther I was, nor would I be doing what I do today. So a "Happy Midwives Day" goes out to ALL of you, the ones in the shadows as well as the ones in the light.

Another choice some women pursue is to give birth unassisted. The very rare couple will feel okay with this choice, but some people feel so strongly about not being in a hospital to have a baby, and simply cannot accept that they have to go there because the government refuses to meet the desperate consumer need for more midwives, that they will do so. Some even feel that the midwifery care they are receiving is too limited by governmental and medical dictates. There is also the choice to birth somewhere else other than Quebec if possible...perhaps even drive to The Farm to have your homebirth of a breech or twins with one of the Farm midwives if that's what you want to do. Most would not know about or fathom these as reasonable options, thus leaving them with the "default". Please realize I'm not saying default in terms of all hospital birthing being default. If this is where you feel safe and want to be you should be there, and I will follow you happily. It's the default for the women who don't want to be there because they cannot get a midwife or aren't happy with the midwifery care they may be receiving.

We simply cannot be okay in a society which says to around 70% of women who want the care of a sage femme, "No, Madame, we don't have a midwife for you. They are all booked up. Live with it. Yes, statistics say their care is safer. Yes, they are incredibly cost effective for our overburdened medical system. Yes, we know how you feel about having to birth in a hospital with a doctor when you are healthy and wanting things a certain way. And by the way, if you choose any other alternative to what we say, you put people at risk of going to jail for your selfish desires. We don't really make changes in the interest of birthing women and their partners and babies without massive and constant pressure on us exerted by the likes of you, and even then, change is gonna be slow, because quite frankly, you're not really a primary concern. And neither are midwives." On this Day of the Midwife, I want you all to really think about how medieval this is, and explore how it makes you feel to know that birthing choices, birth being such an important, profound, and personal event in a family's life, are being dictated and limited. The Witch Hunts have not really ended. There is still not enough healing here for all those terrible past transgressions against women and their midwives, and these transgressions that continue today. Whatever your opinion of midwifery care in Quebec is, the fact that choice for women is so drastically limited in the realm of something sacred that belongs to us should pique your concern.

So let's get to the good stuff. I have been blessed in my life to have my four babies born with midwives (okay, one came out before the midwife got there, but not without her sheer great effort to rush). My first midwife was a teeny, gentle lady, but tough as nails. She would hug me before and after appointments, and was so mellow and reassuring about my health, ensuring I was eating well. She was a rock during my challenging posterior birth (my wee one was born face up after around 3 hours of pushing while squatting and moving around). The labour was pretty easy as far as labours go, but the pushing was quite a challenge. She had me get up and belly dance. She helped me stay focused. She never made me venture into fear. And she was tough with me when she needed to be. When, like many first time birthers I called her to my home because I was SURE the sensations I was having indicated the baby was not far off, she checked me, told the heinous news I was 4cm, and stood back as I moaned and groaned about it. For Pete's sake, I was 3cm when I saw her last 18 hours ago (granted, I had only just started labour then). She simply did not enable my fear that I couldn't do this. She looked me in the eye and said, "THAT was latent labour. Now things are changing. This is good." She refused to entertain my "whens" and "whys" and casually went off to take a nap so she could be fresh for the birth, which she looked jauntily confident would happen reasonably soon, leaving me to think that at least one of us thought things were going okay. And sure enough, I was fully dilated about 2 hours later.

My first midwife was not just a midwife to the birth of my first daughter, but to me as a mother, silly little girl that I was. And she honoured me as "Mother", so I owned up to her expectations. Without her presence, strength, and trust in me, I would not have been transformed by birth the same way. She assured me that had I been at the hospital I had originally planned to birth in, I would have had a Cesarean. Not for any fetal distress, but because my kid would have been deemed as "stuck". But out she came. And no tearing to show for it, either. To you, my first midwife, je t'aime. You put me on this path. Bless you.

With my second baby I had a very strong intuition right from the get to that he was a boy, and that he was not going to be a birth that worked out at home. I can't tell you why I felt that, but it was true. Even though the Maison de Naissance was not officially up and running yet with its pilot project to see if midwifery should be legal, I was one of their early customers. I had met my midwife before, who had been a back up to my first midwife. I was pretty confident about giving birth, but I had this niggling feeling. Things were pretty rough in my life at the time. I didn't feel like home was home. There were many concerns about my date. I was given a due date of December 27th by an ultrasound done at what we thought might have been 20 weeks (to also rule out suspected twins). Given my growth, my health, and the fact there were no twins, all the midwives at the centre totally disagreed with this date and pushed up edd by a month. I had never had a period between pregnancies, so I was truly at a loss about when I conceived. And we just didn't trust the ultrasound at that point because it was probably done later in the pregnancy than we thought.

My midwife was stellar. More than anything, she was a huge source of emotional support. She provided me with a lot of counseling prenatally, as I was a bit of an emotional mess at the time. I started having contractions on Hallowe'en, having huge bouts of them that would then periodically stop, making me forget I was close to birth. We were in a bit of a pickle, because I was in the mid 36 week range. Once contractions stuck around and didn't stop anymore, I went to the Maison de Naissance to labour before we were to transport to the hospital, and it was rough. This baby was clearly also posterior, but he was wreaking a lot more havoc than my first star gazer. I was experiencing more pain at 5 cm than I had in transition with my first child, and I stayed there for a long time. My midwife took me to the hospital in her car after a night and day of no visible progress. I cried a little because I had not wanted a hospital birth, but I didn't fuss because that was the way it seemed to have to go down. And I received such a lovely reception. I had just attended a birth with the doctor who was on call 3 weeks before and she took me in her arms and danced with me through some contractions while I cried on her shoulder that I was having a rough time. She took me to a room and suggested she break my waters. I looked to my midwife and she nodded. When it came to any interventions, I had decided just to let her approve or not because I was in too much pain to think about anything else. I made my poor midwife's life difficult with this birth. I was refusing being on the monitor (not because I was not into having my baby heard, I was just in too much pain to sit still)and, though she totally buffered the harshness of the environment from me, nurses blamed her for my labouring my way and my friend told me later they made her cry. Don't get the impression she was not a fierce and badass woman, she was, but because of the grand opening of the Maison de Naissance, I think she was super exhausted and overworked. Yet in spite of that her labour support when I was in the hospital was absolutely present, tireless, and necessary. Whenever I was about to give up, she'd suggest something. I'd balk, but then it would turn out she was right and I felt better. The doctor and the resident were absolutely angelic men I will never forget, and when my face up baby was finally born on November 3rd, they called me a champion. They treated me with the utmost respect. Darn tootin'! These gentlemen, and they truly were gentlemen, made all the difference in how I could have felt about myself and my birth had they chosen to treat me with contempt for being a pain in the ass.

The midwife of my second birth helped me to let go of expectations in labour, how to go with the flow, how to release, how to shift my mind, how to relinquish control. She taught me how strong I can be when things are harder than you expect. She fiercely protected my experience within the place I never thought I'd end up, but did it with such non combattiveness I noticed nothing, and because of that, I can honestly say I had a great hospital birth, despite the talk in the nurse's station of what a jerk I was for howling the case room down and not taking the epidural. Sticks and stones. To the midwife of my first son, who taught me how sweet and beautiful the experience of mothering a boy could be when I was a bit scared of having a boy, thank you, thank you, thank you! That birth could have ended up waaaayyyy differently had you allowed me to entertain the looming despair. Much love to you!

My third midwife was very special because she was willing to attend my home birth. This was illegal for her to do especially because she was on staff at Maison de Naissance, so for that dedication to homebirthing women, refusing to have her skills limited by location, she was a saint. She helped me navigate my way through some blood sugar fluctuations I was having, and helped me gain back some of the faith I had lost in the greatness of my birthing body because of my challenging previous birth. We had both pursued the same training in emotional process work, so we had tons to talk about, and I learned so much about how our minds affect our births. We sorted out some of the reasons my last birth may have been hard and helped me to truly open up to the experience and be present for it, no matter what. I believe she created a self fullfilling prophesy letting me know how much easier this birth could go, how I had processed and healed, how I had learned, and how receptive my body could be with that shift to surrender.

Our last visit before my second daughter's birth she looked me in the eye and said, "I have a feeling this will go fast." I held that lightly, as I didn't want to be disappointed if the birth went the same way it had gone before. Well, it did go fast. In fact, it was 43 minutes from the first contraction to the birth, and she didn't make it to catch the baby. But she made it for the placenta. Having had a birth in which I received NO vaginal exams and my water bag remained intact until my daughter's emerging shoulder broke it, nobody received her except my husband and me, and I had no tearing, opened my eyes to clincially hands off birth. To you, my third midwife, thank you and je t'aime. You faciliated such healing and such a reclaimation of power in a way I never imagined. You risked your practice because of your belief in women's choices, and bestowed your gift upon me. You are amazing.

My fourth pregnancy was smooth and easy, a great gift gleaned from all of my experiences. I knew i could weather any kind of birth, older 36 year old mama that I was going to me now, and knew I was powerful no matter what. My fourth midwife could not have been a better match. The agreement was, "I'm there as vigilance and experience, but I will not interfere unless I need to." And I fully trusted that if she was doing something, it was necessary. This helped me to relax fully, knowing there was a strong, competent safety net, a strong, comforting, loving presence, but that my birth was my very own and that I owned it. Having her trust me so deeply was one of the most empowering gifts a birthing woman could ever have. So our prenatals were really about just building up excitement and being thrilled with the normal, and getting really excited about the fact that finally, homebirth was going to be legal. My fouth baby, my sweet little second boy, was among the first handful of babies to be born legally at home in Quebec. My birth was pretty much perfect in every way, and I caught my own baby after 1.5 hours of very gentle labour and maybe 30 minutes of active labour and pushing. Almost six years later, I am still high about it. To you, my fourth midwife, je t'aime. The quality of your presence make my birth sheer and utter joy. How you regarded me helped to make it so. You were there not to help me grow up, but to witness how I had already grown, and to revel in how deeply gorgeous, how spiritually profound birth can truly be, how it can be a woman's greatest expression of ecstasy.

Every one of my midwives was exactly the right one for that phase of my life, and today seems like the right day to express my deepest gratitude for your presences in my childbearing and transformations. You will never just be to me the women who midwifed my births, but the midwives of different phases of growth who have helped me to become the person I am today. Truly, my life may have been very different without each and every one of you. God bless you, ladies.

To midwives everywhere, today I honour you. To Vickie in New Jersey, to Alexis in New Mexico, to Julie in England, to Ina May in Tennessee, to Stephanie in Oregon, to Barb in Cali, to Kersten in Nova Scotia, to Ratine in Madagascar, to the near and dear (Celine, Francoise, ZaZa, Trista, Lise, Fabienne, Marie, Sinclaire, France, my motorcycle Goddess, and,of course, Isabelle) here and everywhere...Love to ya, girls, and to the all male midwives too.