What the Unassisted Childbirth Movement Means for Birth Providers

I met with a good friend and midwifery colleague for lunch this week. It was great to see her. We had worked together in my former midwifery practice for almost three years before I left in June. She was about halfway through her intrapartum rotation with us as a student on my first day as a new midwife, so when she started in the practice just shy of a year after I did, we quickly became friends. That’s the hard part about leaving. The great part is that when you get together again, you spend less time groaning about your work situation (though that is definitely allowed) and more time talking about the things that interest you: life, love, work, whatever.

Rani brought a really funky looking alt-birth magazine that she wanted to show me because she thought I might be interested in getting a subscription. While I was flipping through it, she mentioned that one of the articles was about unassisted birth and how it really upset her. Given the constraints of our lunch, I wasn’t able to read the article, but we did end up having a lively discussion about unassisted birth and why some women choose it.

Let’s face it, the idea of giving birth unassisted, with no skilled caregiver in attendance, gives the vast majority of obstetrical care providers of all stripes chest pain and would send the large majority of women running for the nearest hospital and camping out there during their last trimester. When women do not have access to prenatal care and skilled birth attendants, maternal and infant mortality and morbidity are high. Postpartum hemorrhage and complications of obstructed labor including, but not limited to, infection, obstetrical fistula and fetal death are at their highest rates in parts of the world where women do not have access to skilled care providers. So why is there an entire movement of women (albeit small), largely here in the US, choosing to provide their own prenatal care and deliver their babies unassisted?

Some would say that this ‘keep your hands off my body’ mentality is a distinctly American one. We Americans have always been known for our feisty, independent spirits. But in this case, that is not the answer. When reading posts about unassisted childbirth on the internet via blogs and message boards, it seems that the majority of these women are not first-time mothers. They have had one or more children within our medical system (and I used the term system lightly) and have come away so dissatisfied that they have opted to go it alone. The fact that they have chosen the inherently more dangerous route for both themselves and their babies after careful examination of the evidence and their own experience is a massive failure for every person providing care to women.

Maternal morbidity in American hospitals is high. Skyrocketing cesarean section rates, providers who still perform routine episiotomy without patient consent, ‘the husband stitch’ (don’t get me started), have many of us shaking our heads at the state of things wondering how loud we have to shout to make change. Yet these things are happening with alarming frequency and causing women who feel they have no other choice to seek out alternatives to ‘standard’ care.

Some women choose home birth with a qualified midwife, a fantastic option for the majority of women who want it. Some choose a birth center whether in or out of the hospital, while others simply try finding a new hospital or a different kind of skilled care provider. Unfortunately, these are not always viable options. Too many women do not have access to a handful of different hospitals in their town or an obstetrical care provider on every other block. Some women have had a cesarean birth in the only hospital they have any kind of access to and are told they must have another cesarean birth because the hospital does not allow VBACs. So what is that woman’s choice? She can refuse repeat c-section, yes, that’s true. But in a hospital that doesn’t allow them, I can almost guarantee you that she will not be treated respectfully by the people who are supposed to be caring for her. She will be coerced at every turn by everyone to have a surgical birth. So what does she do? Perhaps she looks for a homebirth midwife. But there is likely not going to be one in her area thanks to a shortage of obstetrical providers of all types, and if there is one, they may not feel comfortable with attending a VBAC out of the hospital. Or even worse, home birth might be illegal in her state. So what does she do? She chooses to give birth at home unassisted.

One may ask about women who labor alone at home and come in crowning or give birth on the way to the hospital, and I am always the first to argue that these births (when full term) rarely have bad outcomes. But: 1) these are generally women who have received prenatal care, and 2) are in the hospital or their midwife had arrived at their home for the most risky part of childbirth: third stage. Delivery of the placenta is the time that most postpartum hemorrhages occur, and without treatment, they are deadly.

A leading cause of maternal death worldwide, ACOG estimates that approximately one woman dies of PPH every four minutes around the world equaling around 140,000 deaths per year. PPH prevention, recognition and quick treatment are absolutely essential, and someone giving birth with no skilled attendant is likely to be missing at least one of the three key pieces to that puzzle.

Not all the women choosing to give birth this way are running from repeat c-sections. Many are simply running from the interventions that have made labor more difficult, the experience unpleasant, and are often unproven in their benefits. Not to mention, for the mother seeking an un-medicated labor, the L&D nurse and/or obstetrician who get angry when she declines an epidural and desires to be mobile in labor. The mobile laboring woman needs constant care. You can’t just strap her to the monitor, turn the TV on for her and tell her to call if the pump starts beeping. You have to check for fetal heart tones periodically and talk to her. She needs support. Given that in a ‘typical’ labor with an epidural, none of the medical staff spend more than five minutes at a time at her bedside until it is time to push, one can see how this could color the attitude of the person providing said care. For some women, that is fine. It is the experience they want. No pain, no strangers unless needed. But for most, this is an incredibly vulnerable time and whether she is anesthetized or experiencing the full throes of labor, she needs to be cared for.

Many women (rightly) feel that they have not been cared for in labor. How many times have I been asked both as a staff midwife and as an RN, “When is my doctor coming?” and had to answer “Probably when you are seven or eight centimeters.” These are not words that women want to hear, though many have learned to accept it, and there are many, many amazing L&D nurses out there who fill that gap and take beautiful care of the families entrusted to them. Unfortunately, there are many who will get snippy if you don’t take that epidural because they don’t want to hear you moan, or they are tired, or they are having a bad day. And most women do not have the option to walk out and go somewhere else.

Why are we losing this small, but vitally important population of women? Because we are not meeting their needs. Basta. That’s the end of the story. We must change that and strive to meet the needs of every pregnant and laboring woman to the best of our ability. Yes, I’ve heard and lived the lawsuit argument. There is not an obstetrical provider out there who doesn’t practice with the black cloud of our lawsuit-happy culture over their heads. It’s hard. Every move you make, you make and document, trying to be sure that you dot all of your i’s and cross all of your t’s in the event that you receive a summons 15 years down the line. That’s the reality of our culture and that too has to change.

Somehow, we need to remember, culturally, that nothing in life is guaranteed, especially childbearing. Having babies has always been risky. Labor can develop complications. Babies are not always born perfect, and if they are, may still develop problems later on in their childhood. So yes, recognition of risk by everyone is absolutely necessary, but so too is the need to take care of mothers and babies who have catastrophic events and require a high level of extensive care for months or years. Health care reform is here, like it or not, and we can all raise a voice to be sure that sufficient care is provided so that lawsuits don’t have to be threatened for things that are no one’s fault, and more good obstetrical providers will stay in practice for longer periods of time. I recall reading that the average time an OB/GYN spends practicing obstetrics during their entire career is 10 years. That is a shame and really needs to change. We are facing a shortage of OB/GYN providers of all stripes and we need to keep the ones we have who want to continue practicing, but who are all too often burnt out by the perceived risks.

Health care reimbursement is also dropping, and providers are countering that by seeing more patients in a day than is safe. I don’t care who you are, you shouldn’t be seeing 50 patients in an 8 hour day. Not only can your care not be in any way thorough, the patient will leave your office not feeling cared for, which, in my opinion, is a key factor in lawsuits. People who feel they can talk to their care provider and will be listened to, who feel that things have been explained to them sufficiently, and feel empowered to make good choices are less likely to sue. We all need to work together to figure out how to maintain, or, in many cases, reestablish relationships with the people in our care.

We need to grab hold of these consumers who are choosing what is almost always the less-safe option and ask them what we can do to bring them back in. Do we need to recruit a homebirth midwife to their area and have that midwife feel supported by the obstetrical community? Do we need to allow VBACs at the local hospital? Allow her to refuse an intervention such as continuous electronic fetal monitoring and not feel harassed by staff? Do we need to not withhold nutrition from her as she labors? How about offer her more valid medical options for pain relief other than ineffective narcotics or total sensation blocking epidurals? (Nitrous Oxide aka Gas and Air, anyone?) The answer to all of these is a resounding YES. Of course, there will always be counterculture, and women will choose to give birth unassisted, but I think fewer would make that choice if they truly felt that they would be supported in the choices they made for their health and that of their unborn child. They have their own best interest at heart, and it’s time that we did too.

Have you chosen an unassisted birth? I would love to hear from you. The whys and wherefores really interest me as both a provider of women’s healthcare and public heath junkie.

Today is the 4th anniversary of passing my boards and being a Certified Nurse-Midwife. It’s hard to believe: part of me still feels so new, and the other part feels like I have been doing this forever. Since beginning my training, I have been fortunate enough to observe midwifery in many settings and have been even more lucky to have 232 babies born into my hands.

This post is for the new crop of midwifery students beginning their clinical training this semester. I am far enough out of school to have a fair amount of precepting experience, but near enough to my graduation to remember the nerves and worries and stresses of being a student. I hope I can offer some words here that will prepare you for what is to come and alleviate some of your fears.

First: You don’t have to know everything! Yes, be prepared. Practice your hand skills. Make sure you can do leopolds, measure a fundal height, find a cervix both with a speculum and your fingers. Know how to take a good history on a blank sheet of paper without pre-printed notes, and most importantly, know how to do a physical exam from head to toe without missing any steps.

That’s basics. Seems like a lot to be labeled “first,” but if you can do that, the harder stuff won’t seem quite so difficult.

Second: There is one thing you should know about midwives: 99% of us love teaching, which is why we work in teaching practices. Think two, three, four times before labeling your midwife preceptor ‘too difficult’ or ‘mean’ or ‘hates to teach.’ Ask yourself why she might seem that way.

As midwives, families entrust us with not only their lives, but with the lives of their unborn children. That’s a huge responsibility. You had better know what you are doing to be entrusted with that.  You want the families you care for to trust you, to feel that they can come to you with questions or concerns, just as you want them to be open with you and not withhold information, so that you can provide the proper care. Trust is a two way street. You need to have the knowledge and convey that to them, so that they will feel comfortable entrusting you with their care

Your midwife preceptor wants to be sure that you are adequately prepared to do this. Skills are learned by doing, knowledge is gained by study. If  your preceptor asks you a pointed question and you don’t know the answer, DON’T PANIC. You don’t have to know everything. You are a student. Heck, even as a midwife you aren’t necessarily going to know every piece of information you need. The skill needed here is to know where to get the information you need. I cannot tell you how important this is. Know how to use resources such as up-to-date, or pubmed, and your textbooks! If you don’t know the answer, the correct response is always: “I don’t know, but I will look it up and tell you what I’ve found.”

Third: It is possible that your midwife-preceptor is having a bad day. This does happen from time to time, and for that, we apologize. I, personally, try not to let that effect my teaching, but I’m human, as is every other preceptor out there and our moods sometimes get the better of us. Please, give us another session before passing judgement.

Fourth: Enjoy the learning experience! Midwifery school is hard, but so awesome. Get excited about everything you learn, even if you think you will never use something, find a way to tuck it away, it will come in handy at some point. You are embarking on an amazing journey. Keep your chin up. Try not to get overly stressed out. Smile! Tears have their place, but if you know you are prone to them, learn how to deal with stress so that they don’t pop up at the first hard question you are asked. Do yoga. Learn to knit. Take up kickboxing. Whatever helps you find your zen.

Most importantly, know where to find what you need and keep and open mind. We are excited to have you in the profession and want you to be excited to be here too!