Unassisted Childbirth

I wrote this post about ten years ago ... nothing much has changed in the system, but we are seeing a growing number of women choosing to birth outside the medical system.

Back in the good old days, when I was a subsistence farmer in paradise, I had a friend who told me her birth story. This was before I started working with birth, but not before I had already started studying and learning, and listening to women's stories.

 

Friends Sharing Birth Stories

My friend's first baby had been a breech who did not want to get her head down. The policy at that time in Italy, as in many places, was to deliver breech babies by cesarean section, especially if the woman was a primipara.

So, my friend had a c-section, and she did not feel good about that birth at all. She thought that it was probably possible to give birth to a breech baby vaginally, and she felt pushed into making a decision that did not feel right to her. She decided she didn't want to go back to the hospital again to give birth.

She became pregnant again, and decided to stay at home this time and give birth on her own terms. She looked for a homebirth midwife but at that time in Italy they were a rare breed, especially if you were living in the hills as all us organic subsistence farmers did. She prepared by reading about natural birth, and she made sure she had methergine in the house - they always had it on hand for the goats.

Labor started and she sent her husband and child out for the day. She didn't want her daughter present for what she knew was going to be an intense and possibly scary event.
This was before cell phones, and they didn't have a phone, so he planned to come back around suppertime. She labored on her own and late in the afternoon, gave birth to a healthy baby.
"Were you scared?"
"Yes, I really wanted to have someone else around. I remember when I started pushing, and I felt a cervical lip, and I gently pushed it out of the way - I really wanted someone to be there with me. But I knew everything would be okay - I had a feeling. And if it wasn't ok, then it wasn't. I did it my way."

There is a growing movement that promotes unassisted childbirth as a way to regain control over your own birth, and there are many valid reasons for not wanting anyone at all from outside your circle of family and loved ones to be present at the birth of your child. It is, after all, a natural event, more like lovemaking than like a medical procedure. The presence of a stranger, even a well-liked one, can change and disturb the process. Midwives can be regulated by laws that perhaps don't agree with a woman's perception of how she wants her birth to proceed. 

I often get calls from women who are planning to give birth without attendants. They want information, or they want to find someone to be a "fly on the wall" - who can be there "just in case". Most of these women are women who have not been able to find a registered midwife - either they didn't call early enough, or they live in the wrong area, or they are considered too high risk for a homebirth. They don't really want an unassisted birth, but they are committed to not wanting to go to the hospital unless they really have to, so they are left with unassisted birth as their only option. Because we Canadians are used to free health care, cost is also a consideration. Unregistered midwives charge around $2000 for prenatal, birth, and postpartum care (that works out to about $10.73 an hour, in case you're wondering). Many women do not feel that this amount is an option, and, again, make the choice to give birth "unassisted".

I firmly believe in a woman's right to choose what's best for her body, and for her life. If a woman chooses to give birth on her own, or just with her partner, or her sister, in her own home, then power to her! She is making an adult choice, and she is accepting responsibility. But I do feel sad when women want to have the care of a midwife and cannot.

No woman should have to give birth on her own if she doesn't want to. Midwifery care should be available, really available, to any woman. Homebirth should be an option for us all. Unassisted homebirth is only one option, but it should be an option that is actively chosen and not decided on for lack of other plans. Equally, hospital birth is only one option. Health women carrying healthy babies should not have to go to the hospital to give birth unless they actively want to. Informed choice should be a reality - it should be informed, that is, women should educate themselves and each other, and they should ask for informtaion from their care providers. And choice should be a real choice with real options - unassisted, home birth, midwifery care, hospital birth.

Let's work together to bring the woman and child back to the center of maternity care!

Midwifery and Bullshit

 

These are not midwifery tools, but they could be. 

I have started offering prenatal support and consultation to women who are looking to give birth in an autonomous way. Several of these women are being followed, or have been followed, by registered midwives here in Canada. I've also spoken to a few practising midwives in this country, and I believe our midwifery establishment is in crisis.

We were an unusual country. Midwifery was illegal in all of our provinces and territories until the 1990's, when provinces started to recognize that it would be useful to register and educate midwives in the medical model. During the twenty years from the 1970's until midwifery was legitimized and regulated, midwives worked illegally to assist mothers at home, and there were a few midwives who were charged with practising medicine without a license. 

During the 1990's, midwifery became regulated and legitimized in several provinces. Midwifery education programs were developed and offered in universities across the country. These programs were very hard to get accepted into, and required a formal academic background over life experience. Most of the original lay midwives who had been practising illegally before legislation were "grandmothered" in to the Colleges of Midwives, but the applicants who were accepted into the programs were generally younger and obviously less experienced. 

Midwives were and are in great demand. The supply is very limited, partly because of the restrictions that competitive educational options and limited employment options mean for anyone who is drawn to the practice. Provincial governments in Canada have succeeded in effectively reducing the number of potential practising midwives, either with restrictive educational possibilities, or by limiting the ways that midwives can practice.

Because of the lack of registered midwives, and because the available midwives were practising in the medical model, several women over the years in various provinces in Canada chose to give birth either unassisted or with Traditional Birth Companions. As well, midwives trained in the US or elsewhere started offering their services as midwives and attended women at home. This was risky, because with the creation of a College of Midwives, anyone offering restricted practices under the provincial midwifery acts could be (and were!) prosecuted by the provincial College of Midwives. So far, this has happened in B.C., Saskatchewan, and Quebec. 

The pandemic of 2020 changed the face of birth. Women who were hiring doulas to accompany them to their hospital births found that the hospital authorities had full power to limit the number of people present, and doulas were left at home in front of their phones, providing encouragement, support and continuity of care from afar (Hats off, shout out, Kudos to all you doulas out there!!!). Home birth was restricted or banned in some areas, and midwives were given even more rules and regulations they had to practice under. 

Hospitals were seen, rightly so, as places for sick people (hmmmm, isn't that what they always were?). A few women, certainly a larger number than in 2019, decided that they would give birth on their own. Others decided that they would continue with midwifery care and fill in the gaps with the council and support of other practitioners.

Here is a little account of what is wrong with midwifery today, gleaned from conversations I have had with women seeking answers, and why I believe it has gone wrong:

• Newborn mothers and babies do not need immediate testing. They need skin-to-skin togetherness, if the immediate indications of their health is good.
• Newborns do not have to latch on the breast like a champion within the first half hour of life. Again, they need skin-to-skin togetherness. Mother will need to eat and drink. Attendants should stick around with gentle attention.
• If you say that you will offer a woman attendance at her home, and you visit her home and bring equipment and preparations ... she is not going to hear your quid pro quos and fine fine print at the bottom of your conversations. She will be deeply disappointed when you tell her that (for whatever reason, that has to do with YOUR infrastructure and organization of lack thereof) she cannot after all birth in the comfort of her own home.
• Women over 40 are not inherently dangerous. They can carry a baby to term and do not need extra testing or worrying conversations about how risky their pregnancy is. That's why she chose you, a midwife, so they wouldn't have to be bullied.
• Midwives have to learn to keep their faces pleasant. So many women have let me know that they got really scared when they saw a young midwife look at their lady parts with horror/fear on their face. A vulva or a newborn's head can look wildly psychedelic, but usually is no reason for alarm.
• The word "should" doesn't belong in your vocabulary if you are attending a birthing woman. 

Women now, a small percentage but nevertheless a percentage, are choosing to give birth at home autonomously instead of seeking the attendance of a midwife or a physician. This fact makes me sad. Why? Because I believe that every woman deserves a safe and sacred place in which to birth her child. Some women want to birth in the hospital. That birth should be as respected and loved as a birth that takes place at home surrounded by a circle of women. Some women want to birth at home, and these women deserve respectful, kind, reliable, and legal midwifery care. 

There is work to be done!!!

Trickle Down?

Let's face it ... good stuff doesn't trickle down. You have to work really hard to get the good things in life to the people who deserve them: shelter, medical care, food, clean clothes, and all of those things that many of us take for granted.

In the last ten days, I have had over ten requests from women who desperately need maternity care. I can only provide them with free doula care, from the volunteers who donate their time to Montreal Birth Companions. Some of these volunteers are students, some are experienced doulas.  But doulas don't provide medical care, and most of these women have not had prenatal care, so they are at risk for worse outcomes than the generally healthy population of our fair city.

I was called at 2:30 in the morning last week by a doula, frantic with worry. She had been called by one of our clients who was bleeding heavily. I told the doula to call 911 immediately. She did so and mother and baby survived.

Several times over the past week I have been juggling available doulas to accompany one of the MBC mothers who was laboring and needed companionship. Doulas are people too, some are on vacation, some are pregnant, most have other jobs.

I assisted at a birth where the midwives were unable to provide the mother with effective care postpartum. I was at another birth with a baby who became ill after birth. I got another call from a doula whose client was bleeding after giving birth, and the midwives had not made it to the house on time.

I have had several requests over the past few weeks from mothers who cannot find a midwife, who don't want to birth in the hospital, who are looking for an unregistered midwife. Unregistered, underground, or illegal midwives work without any medical backup and if they need to transfer their clients to the hospital, have no standing with the medical staff and are treated either as doulas or as "friends". Unregistered midwives often make calls that are not as effective as they could be - they work on a basis of mutual respect which sometimes can mean taking risks that may be dangerous and unprofessional.

I am seeing the writing on the wall, and it is telling me that we are not taking care of our mothers and babies. I can't always be there to answer the phone when a mother is in need, or a doula, (and rightly so) cannot provide medical care when there is no doctor.

Something must be done! Se non ora, quando?

Freedom For Birth (Web version)

Bad Science, Bad Medicine, Bad Luck

I am actually enraged this morning, and I have been since last night. It's just no good any more to pretend to be kind old Mrs Tiggy Winkle, and watch women being abused over, and over, and over again in our worn out medical system.

A few weeks ago, I witnessed a natural, speedy delivery. The woman was effectively pushing in a supported squat. Enter the doctor, who cannot catch a baby from underneath and pressures the woman to lie down. A small shoulder dystocia develops. Doc pulls on the head like there's no tomorrow and breaks the baby's collar bone.

That same week, a foreign lady let me know that an OB at the same hospital has been charging her $100 cash for each prenatal. Here in Canada, that is ILLEGAL.

She labors beautifully, and is almost delivering, when the doc suggests an episiotomy. This was the one thing, the ONE THING, that my client was terrified of. Luckily, she pushed the baby out with the next contraction.

Move forward, random thoughts: A client was in the hospital for twelve hours. During that time, she saw about ten medical professionals. What do you think the most-asked question was: How are you feeling? Nope. "Do you have any questions?" Nope. "Is there anything you need?" Nope. It was "Have you had any miscarriages or abortions. Well, it's not rocket science to figure out that that may not be the best question to ask a laboring woman for two reason: One, she may not want everyone in the room, including her partner, to know. And, Two, these are painful memories that she may not want to think about.

But yesterday takes the cake.

Lady is being induced, medically necessary induction. Gets put on the pit. She's 2 cm. Then in five hours, she's seven cm! And then two hours later, still seven cm! They are talking AROM, so my client wants me to come to the hospital. Fine.

She's laboring so well, not feeling her contractions at all. I have seen this, infrequently, but I've seen it. The doc wants to AROM, but since she's seven cm, she decides to wait it out.

Finally, in the evening, another physician comes in and checks her. She's two.

Discussion. Justification "your vagina is a funny shape". "She's a good resident so we don't check her results". Even when those results are difficult to believe? Really? Then, a peace offering. You stay here and sleep, we'll start the induction again tomorrow.

Bad Science: why the induction? check your results, and especially check a student's results. Have a look at how you're playing with the insulin and oxytocin.
Bad Bedside manner:  Is it necessary that a woman not eat for days? Is it possible to at least make eye contact with the doula, so that she doesn't feel like shit when she leaves the hospital? Are you going to apologize for your mistakes?
Bad Luck:  How often do iatrogenic errors lead to major consequences?

Where is this all leading? It's not leading to a rise in home births, at least not in Quebec. I was speaking to a midwife yesterday from another country who has witnessed over a thousand births, and she is not certified here and therefore is not practicing. There is no bridging program that effectively allows for CPMs to become certified here in Canada, so we are left with a lack of midwives and an overburdened hospital system where errors frequently can and do happen.

Comments? What are YOU doing to change obstetrical care in your community?

Unassisted Childbirth

Back in the good old days, when I was a subsistence farmer in paradise, I had a friend who told me her birth story. This was before I started working with birth, but not before I had already started studying and learning, and listening to women's stories.

Friends Sharing Birth Stories

 My friend's first baby had been a breech who did not want to get her head down. The policy at that time in Italy, as in many places, was to deliver breech babies by cesarean section, especially if the woman was a primipara.

So, my friend had a c-section, and she did not feel good about that birth at all. She thought that it was probably possible to give birth to a breech baby vaginally, and she felt pushed into making a decision that did not feel right to her. She decided she didn't want to go back to the hospital again to give birth.

She became pregnant again, and decided to stay at home this time and give birth on her own terms. She looked for a homebirth midwife but at that time in Italy they were a rare breed, especially if you were living in the hills as all us organic subsistence farmers did. She prepared by reading about natural birth, and she made sure she had methergine in the house - they always had it on hand for the goats.

Labor started and she sent her husband and child out for the day. She didn't want her daughter present for what she knew was going to be an intense and possibly scary event.
This was before cell phones, and they didn't have a phone, so he planned to come back around suppertime. She labored on her own and late in the afternoon, gave birth to a healthy baby.
"Were you scared?"
"Yes, I really wanted to have someone else around. I remember when I started pushing, and I felt a cervical lip, and I gently pushed it out of the way - I really wanted someone to be there with me. But I knew everything would be okay - I had a feeling. And if it wasn't ok, then it wasn't. I did it my way."

There is a growing movement that promotes unassisted childbirth as a way to regain control over your own birth, and there are many valid reasons for not wanting anyone at all from outside your circle of family and loved ones to be present at the birth of your child. It is, after all, a natural event, more like lovemaking than like a medical procedure. The presence of a stranger, even a well-liked one, can change and disturb the process. Midwives can be regulated by laws that perhaps don't agree with a woman's perception of how she wants her birth to proceed. This site provides some interesting information about unassisted childbirth:UC

I often get calls from women who are planning to give birth without attendants. They want information, or they want to find someone to be a "fly on the wall" - who can be there "just in case". Most of these women are women who have not been able to find a registered midwife - either they didn't call early enough, or they live in the wrong area, or they are considered too high risk for a homebirth. They don't really want an unassisted birth, but they are committed to not wanting to go to the hospital unless they really have to, so they are left with unassisted birth as their only option. Because we Canadians are used to free health care, cost is also a consideration. Unregistered midwives charge around $2000 for prenatal, birth, and postpartum care (that works out to about $10.73 an hour, in case you're wondering). Many women do not feel that this amount is an option, and, again, make the choice to give birth "unassisted".

I firmly believe in a woman's right to choose what's best for her body, and for her life. If a woman chooses to give birth on her own, or just with her partner, or her sister, in her own home, then power to her! She is making an adult choice, and she is accepting responsibility. But I do feel sad when women want to have the care of a midwife and cannot.

No woman should have to give birth on her own if she doesn't want to. Midwifery care should be available, really available, to any woman. Homebirth should be an option for us all. Unassisted homebirth is only one option, but it should be an option that is actively chosen and not decided on for lack of other plans. Equally, hospital birth is only one option. Health women carrying healthy babies should not have to go to the hospital to give birth unless they actively want to. Informed choice should be a reality - it should be informed, that is, women should educate themselves and each other, and they should ask for informtaion from their care providers. And choice should be a real choice with real options - unassisted, home birth, midwifery care, hospital birth.

Let's work together to bring the woman and child back to the center of maternity care!

Montreal Doula Training April 15, 2012

I am happy to announce that I have teamed up with Jana from Studio Vie to organize a doula course that will be starting on April 15, 2012.

The program is based on the approach that I have explored in my book, and we will be using the book as our text.

This program is comprised of three levels. Completion of the Level One course will allow the participants to volunteer as doulas for Montreal Birth Companions volunteer doula organization.

Level Two is a continuation and an exploration of themes introduced in Level One. This level will provide doulas with the necessary skills to run a private doula practice.



 Level Three courses are specialized, and they take place in all sorts of interesting places.

We will be going to Cuba together next spring, and this summer we will be exploring storytelling and healing with Lewis Mehl-Madrona, in Italy.

To be accepted into Level Three you need to have attended births as a doula or lay midwife, and you need a strong foundation in self-directed learning.

If you are interested in accompanying me on any or all of these journeys, please let me know. Our courses are filling up fast!

Illegal Midwives part 2

 The bureaucracy in Quebec has decided to remove another hurdle for women who choose to give birth at home without the support of a registered midwife. There aren't enough birthing centers or registered midwives to go 'round, so more and more women are giving birth "unassisted" or with the attendance of an unregistered midwife.

The women who choose to have their babies at home with  "illegal" midwives pay a price: registered midwives are free, paid for by provincial medical insurance. The other midwives charge around two thousand dollars for their services, which is a great deal as it includes sometimes months of prenatal care, personalized and attentive labor and birth attendance, and comprehensive postnatal support.

They also pay with hours of bureaucratic nonsense, when it comes to getting their new baby a birth certificate.
It may be that raggedy old hippies or sneaky foreigners on tourist visas come to mind when you are imagining the women who choose this route. But they are more often highly educated, professional women who are used to doing things "their way" and do not want to go outside their own home to give birth.

I have heard stories of women being threatened with the police and child protective services if they did not present themselves and their hour-old baby at the hospital to do their paperwork.  This new directive is a small fairy step in the right direction:
Quebec bureacracy

Illegal Midwives?

"Illegal" is a word that brings to mind outlaws, bandits, drug runners, hoaxters and jails. I prefer to use the word "underground" when I am talking about the midwives I know who are working outside the (extremely limited) system of registration, colleges,and paperwork that is in place in most of Canada. I joke that they are underground - they'll only assist a woman in an underground parking lot or a basement. Ha ha.

In fact, the women working outside the system are not allowed to assume the title of midwife or sage-femme, which is why many of them describe themselves as birth attendants or even as birth activists. The Montreal Gazette's story about this phenomenon presents some bare facts and portrays a sympathetic, sensible woman who has chosen to assist women who would otherwise be giving birth in a hospital with a doula, or alone at home. Not so say that giving birth with a doula isn't the choice that most women ultimately make. The doula's job is often a difficult one, because of this. She has to straddle compromises that are often unbearable to watch.

"Brave" and "courage" are often words I hear about the women who choose to give birth at home with a qualified, if "illegal", attendant (or "stupid" and "selfish"). But I think a woman is much braver who knows exactly the kind of treatment she may receive in a hospital, after she has already had an unnecessary cesarean section, and chooses to go back into that environment with a doula at her side, in the hopes that she will be able to give birth with dignity and autonomy.

The sad thing is, birth shouldn't have to be about bravery, about ego, about choices, the law, surgery, or drugs.Here is an excerpt from my upcoming book:

The other day I was at a birth. My client was a third-time mother and she didn’t want to be in the hospital for too long, but her previous two births had not been that short. So as she kept in touch during the day I agreed that she didn’t have to rush to the hospital. It was mid-morning when she decided to go, after having a bath and making sure her kids were settled. When the doctor examined her, she was almost ready to give birth. The birth proceeded very quickly, and afterwards, the obstetrician said “Oh, ladies like you will put me out of business!”

I would like to be put out of business. I would like the system to change so much that the privately hired doula is a thing of the past. Certainly, there will always be women who do not have anyone to accompany them at their birth, and for these situations we will have the volunteer doula associations that already exist today. My vision is one of most women giving birth at home, with full medical back-up available to them if needed. Midwives would provide prenatal care and accompany the laboring women through labor and birth. They would assist with the postpartum period and help the new mother adjust to life with a new baby. If there were problems, the midwives would refer the woman to a doctor, who may in turn refer her to a specialist, an obstetrician. Full emergency support would be in place for the rare occasion that it is needed, so that the midwife would know that she is covered in the case of an emergency.

The women who chose to give birth in the hospital, in my dream world, would be there because of clear medical or social need. The hospital birthing centers would provide specialized medical care for the few women who need it. Occasionally, there would be a woman who needs the extra emotional support of a doula, but the doula would be well-integrated into the hospital system and would be on call in these situations. Sometimes a woman would want to give birth away from home, and she could go to an independent birthing center which, again, would be fully supported in case of a medical emergency.

I do not believe that this vision is so far off in the future, or that it is out of our reach. For now, however, our reality is that most women in the developed world are giving birth in hospitals, and many of these hospitals have different philosophies about birth than many of the patients they are there to serve. In Canada, the philosophy of any hospital must be to provide the best care for the greatest number of people. This may translate into an epidural for every woman, especially if there are not enough nurses to support women individually. In the USA, hospitals are run as profit-making enterprises, so the word philosophy may not apply. We do know, however, that cesarean section rates are skyrocketing, and that the general consensus is that a national rate of about 15% may be optimum. Personally, I believe that the rate for emergency cesarean sections can be held to 5% without putting the mothers or babies at risk.

The doula is the interface between the birthing community and the medical establishment. This puts us in a difficult position. I have spoken to  women who thought that I would leave them to give birth alone if they decided to take an epidural (this is beyond cruel). I have been yelled at by a physician who thought I had removed an intravenous drip (the nurse hadn’t had time to put it in). I have been looked upon as a knight in shining armor (I don’t even like horseback riding) by women who had not yet understood that the birth work is done by the birthing woman.

I have also been thanked and cherished by hundreds of women who have been happy to have me by their side as they go through the experience of giving birth. My task, our task as doulas, and in a bigger sense, our task as human beings in the 21^st century, is to “humanize” birth. To me, that means affirming that all of us are different, and that we all have needs, desires, and histories, that cannot and should not be judged. 

I fully support those women who choose to give birth at home, who choose to assist others at home, and who choose to follow a different path. My only condition, however, is that birth attendants keep their egos, their pride, and their ambitions out of the birthing room, and indeed, out of the process. That way, knowledge of the craft can be the highest priority, assessments can be made honestly, and difficult decisions are not clouded by personal needs.

Two of the most famous midwives, Shifra and Puah, were "illegal"; they disobeyed the Pharoah of Egypt to assist women at home ... power to the women who follow in their footsteps! May we merit to be midwives to a better way of giving birth.