I’m a midwife. I’m also a woman of reproductive age and I have a lot of friends that want to have babies; to make them, adopt them, foster them, and squeeze their chubby little cheeks. I also have friends who don’t want them but end up with them, pregnant all the same. Or who do want them but struggle to conceive. Or are ambivalent about wanting them. The audience for this post is mostly people who are trying/want to be pregnant, which I know isn’t for everyone.
I consider myself a non-intrusive personality and on the subject of birthing, I (usually) only speak when spoken to. Each person’s journey is so personal and I only like to offer my opinion when I’m asked for it. Most women who are trying to become or are pregnant receive plenty of unsolicited advice. That doesn’t mean it is easy for me to sit back and zip-my-lips all the time. I, of course, have some opinions that are informed from my 11 years as a birth worker: four as a Labor and Delivery nurse and seven as a certified nurse-midwife. So these are my thoughts, as I would share them over coffee (yes, you can still drink it!) with a good friend who is considering or newly pregnant. This is, obviously, not actual medical advice. You’ll need your own healthcare provider for that! But it is an abbreviated version of what I’d like to tell my friends, should they be interested.
FIRST THINGS FIRST, WHAT DO YOU WANT?
Do you want to deliver in your house and get into bed after you give birth? Does having an operating room just down the hall make you feel more comfortable or less secure? Will it drive you crazy being around computers, monitors, hooked up to an IV-drip? There are so many things to consider in making your decision about whom you would like your care provider to be and the setting you would prefer to deliver.
You can’t always control where you birth, whom you birth with, or the outcome of that birth, just like you can’t control what kind of child you will have. The perfect intro to parenting. But you can bring a lot of thought and intention to how you would like it to go and make choices that are in line with your values and desires.
DELIVERING OUT OF THE HOSPITAL
Delivering out of the hospital has a lower rate of cesarean section, assisted vaginal delivery (vacuum or forceps) and lower induction rates. The rate of neonatal death is higher, but for both in and out of hospital delivery it is overall very low. Check out this study for more details.
Most women who deliver out of the hospital will deliver with a midwife. Most women who deliver outside of the hospital will have a choice about the position they give birth in; standing, squatting, side-lying, in the tub—it is most likely up to you.
At home: If you deliver at home, it is overwhelmingly likely that you will either choose a CNM or CPM to be the provider at your birth (see definitions below). If you are a low-risk woman, having a low-risk pregnancy, and prefer low-intervention, this could be a great option for you.
Things you can have at home: A healthcare provider skilled in labor and delivery management, who can perform immediate newborn and maternal resuscitation if needed. The comfort of you own home- you can labor anywhere you want, eat as you wish, even pee in your own toilet. It is quite likely that you will know your midwife, or there will be a small group of midwives who will attend your care.
Things you can not have at home: Immediate access to an operating room, epidural or IV pain management, advanced resuscitative measures for a newborn or the mother.
At a birth center: If you prefer the low intervention of a home birth, but either don’t have access to a home you feel comfortable birthing in, or don’t want to clean up the mess afterwards, you may prefer to be in a birth center. Birth centers are generally peaceful spaces, with the family unit in mind. They often have comfortable beds, good access to hydrotherapy, and everything on site that you need for a safe out of hospital birth.
Things you can have at a birth center: Mostly the same things you can have at home. While a birth center may seem safer to some people, the services they can offer in terms of pain-management and resuscitation are usually very similar to a home birth. However, they may be accredited by the AABC, which means they meet some criteria for safety. This can be a helpful tool in evaluating sites, since there is no equivalent for researching midwives who might attend your birth at home.
Things you can not have at a birth center: Same as a home birth.
DELIVERING IN THE HOSPITAL:
You can chose to deliver in the hospital with a CNM or an MD. If you deliver with a midwife, you will likely have more choice over the position you are in while you are delivering, the lighting of the room, etc. If you deliver with an MD it is more likely that you will be in a bed, with your legs in stir-ups, with a bright light on in the room. This is not always the case. I’ve helped usher in babies alongside MDs where we lay side by side on the floor under a squatting mother. But any midwife, or MD for that matter, will tell you that this is the exception and not the norm.
Midwives (which in the hospital will be a CNM) If you are a low-risk woman, the midwifery model of care has been shown to be equal to if not better than the mainstream obstetric model of care. I’m a midwife so of course this is biased, but the Cochrane review agrees with me. As midwives, we are trained in providing high quality, low-intervention care for normal birth and recognizing when it is not normal and sending you along to an OBGYN or MFM specialist.
OBGYN doctors (and some Family Medicine MDs) are well-trained in pregnancy complications and obstetric emergencies. So if you’re having one of those things, then that is who you want. But if you are not having one of those things, and things are normal, it is better to have a specialist in normal—a midwife.
MFM doctors are an excellent choice for high-risk pregnancies because that is what they are trained to do. They are specialist MDs who may work together with a CNM, an OBGYN or FM MD, or you may only see the MFM doctor, depending on your needs and their recommendation. Again, an excellent choice for women with high-risk pregnancies.
Why choose a hospital: Some people feel way more comfortable being in a hospital, or maybe your partner or family feels more comfortable if you are in a hospital. Or you need to deliver in a hospital. Therefore, you should deliver in a hospital.
Are all hospitals created equal? No. Every hospital has their own protocols and their own culture. Across the U.S., in hospital c/s rates range from around 10%-70%. This is very likely a reflection of the culture of the hospital—what do those whom work at that hospital consider as normal and abnormal? Is it in keeping with current guidelines?
Things I would want to know about any hospital I was delivering at (ok, I would actually probably ask a lot more, but these are the things that would be deal breakers for me):
- What is the c/s rate? If it is over %20 for low-risk pregnancies, deal breaker.
- Do they utilize intermittent monitoring and with what frequency? If they don’t use it, the chances you are tied to a monitoring machine and can’t walk easily go up, as do the chances you will end up delivering by c/s. If they use only continuous monitoring, deal-breaker.
- Will they ‘allow’ you to eat or drink during labor? If the answer is no, deal-breaker.
ALREADY PREGNANT? TRYING TO GET PREGNANT?
Now that you have some idea of whom you might want to birth your child with, and where you might want to do so, some thoughts if you’re considering pregnancy or are already pregnant:
Infertility: I can’t talk about pregnancy without acknowledging what can sometimes be a painful road to becoming pregnant. What I want to say about this is that you are not alone. If you are trying to become pregnant, 85% percent of couples (these studies are done on heterosexual couples) will become pregnant within a year. Which means the other 15% percent are not getting pregnant, due to known or unknown causes, and that is painful. On average 20% of pregnancies result in a miscarriage, also a relatively unknown statistic. While this can be ‘normal’ it doesn’t diminish the pain, the waiting, the hope, the darkness. It is really normal for both partners to process the journey to parenthood differently, as well as the losses along the journey. If you can afford it, I always recommend to add a therapist or counselor on this journey.
Diet: I’m afraid to even write about diet because there are a million opinions out there and a long list of dos/don’t that I’m not going to get into. I often have people ask questions about the supplements, shakes, adjusted diets that they are on and if they are safe and should continue. So this is my broad stroke general advice. You should eat a lot of fruits and vegetables. You should avoid processed/salted food as much as possible, just like you should when you are not pregnant. It is generally accepted medical knowledge that fatty dairy, red meats, fried foods, and lots of sugar are not good for us ever. So the same goes for pregnancy. Also, most women avoid fruits and vegetables like the plague in early pregnancy and only eat bland carbs. This often causes some terror about the nutrition of their body and their baby. But hey, everyone is doing it and we’re all hanging in there.
Exercise: Move your body! Hopefully you’re moving it before you are pregnant but if not and you want to start when you are pregnant you should. If you never ran before should you train for a marathon? Probably not. But there is a lot of space in between those two things and most of it is fine for you to do. If yoga is your jam, or running, or swimming, keep at it. If you feel like you physically can’t do it anymore, then you shouldn’t do it. You’re welcome.
Age: As a culture, we continue to delay childbearing until we feel more established in our careers, travels and partnerships. Is this bad? Maybe yes, maybe no. It is true that the risks of becoming pregnant, staying pregnant, having complications in pregnancy and birthing can all increase as our age increases. Ouch. But for many of those things, the increases are incremental and there can be some ways to decrease your risk or to receive assistance in becoming pregnant. Becoming pregnant and having a kids can sometimes seem like a statistical odds game that we are all trying to play just right. For me, the bottom line is more about being aware that there are some increased risks but also being aware that having a child you are not ready for carries a lot of risks too. So the time isn’t right until it is right for you. I think that is a pretty Western viewpoint but I am admittedly a Westerner, so there you go.
Mental health: Back to what I have come to call my evangelism for mental health care. I don’t know many women who are NOT dealing with some level of angst, anxiety, concern, depression, severe depression or panic in their lives. In our culture of planning and control, the journey to parenthood can often turn everything we have known upside down. This line is over-used but so good: If your blood-pressure is high, you don’t hesitate to go to the doctor. If your mental health is not doing well, why not seek out the same healthcare you deserve? Sometimes the answer is money, finding someone you can trust, making the appointment, actually going to the appointment. These are all legitimate concerns. Another good thing to talk to your healthcare provider about is if they have recommendations or even someone in their office; as the women’s health community realizes how important mental health is to a healthy pregnancy, many clinics are incorporating mental health providers into their clinics.
GIVING BIRTH
If I have a midwife do I need a doula? if I have a doula, do I need a midwife? Bless my family, I’ve been a midwife for 7 years and some of them still aren’t sure what I do. So if you are a bit confused too, worry not. A nurse midwife is trained as a healthcare provider, in the family of doctors, nurse practitioners, dentists, etc. A doula is trained as a birth support and advocate; another way of describing a doula would be like a fairy-angel who thinks of everything you thought you did but in fact forgot, or didn’t plan for because sometimes you don’t know what you don’t know, who rubs your back and may help you take a sh*t, who helps you navigate the system when you don’t understand, who will hold pressure on your lower back for hours to ease the pain while your partner snores in the bed, or will teach your partner how to hold pressure to ease the pain if that is what you as a pair want. I often hear people say they don’t want a doula because their partner will do everything, to which I respond that your partner can still do as much as they want but probably this is their first or second birth and they just don’t know all the things. I can’t think of a single person I’ve cared for who felt like the doula was not a valuable asset to their birthing team, no matter the child. They are also the best documented ‘intervention’ at lowering your risk of having a cesarean section. Many communities and hospitals either offer doula care or have discounted pricing too, especially for those in training, so ask around. If there was one thing I could wish for everyone having a baby, it would be to have a doula.
If I have a doula, do I need to go to childbirth education? While of course it is up to you, I think it is a great idea. I think the things you learn in an education class can stimulate great conversation to help you answer some of these questions about what you want and how to position yourself to increase the chance that you’ll receive it. There are now some good online options as well.
ONCE THE BABY IS OUT
There is so much cultural attention, that can border on obsession, about what the pregnant woman should eat, do, attend, how she should prepare, decorate, organize. And then the baby comes. And usually within 24-72 hours you, and perhaps your partner and if you are lucky some family, are alone with that baby in your home. Asking yourself who allowed you to take that baby out of the hospital, what you should do with it, where is the part where you get to sleep, etc?
Postpartum Doula: While my main recommendation is that you should get a doula, my second recommendation is to get a postpartum doula. Many doulas include this type of care in their ‘package’ that you buy. What do they do? They come to your house, where unless you had a home birth it is unlikely any healthcare providers will set foot, and they help you find a rhythm in your own space. Help you interpret the babies clues, maybe give you a moment to shower, or eat, or sleep. They may help you evaluate breastfeeding, so you don’t have to pack up the 47 new gadgets you now have and put them in the car to visit the lactation consultant.
Fourth Trimester: There is a growing mainstream cultural understanding regarding the ‘4th trimester’, the three months after the baby is born. Your baby is small, you are constantly feeding him/her, nobody is sleeping much and hopefully you don’t have to go back to work yet unless you want to but nearly 45% of Americans who work outside the home are returning to work in this timeframe.
Food/Laundry/Toilet etc: I say, if your friends don’t offer to set you up a Meal Train situation, don’t be shy to ask them to! Take advantage of all of the goodwill around you and ask for help. So many people want to help but don’t know how, so don’t be afraid to tell them that what you need is dinner, a clean toilet, clean laundry, a shower, etc. While many friends want to come over and ‘hold the baby’ what you likely need is someone else to help you care for the space you live in so that you can rest, feed your baby, hold your baby, repeat.
RESOURCES I LIKE
- Books:
- Mindful Birthing by Nancy Bardacke
- The Birth Partner by Penny Simkin
- Conquering Infertility by Alice Domar
- Any book written by Ina May
- The Fourth Trimester by Kimberly Ann Johnson
- The Fifth Trimester by Lauren Smith Brody
- Websites:
- Evidence-Based Birth
- Childbirth Connection
- ACNM
- Free prenatal yoga videos
- Yoga Birth Babies
- Apps:
- Expectful, a meditation guide app
- Podcasts:
- The Longest Shortest Days
- Motherbirth
- Common Sense Pregnancy and Parenting
- Yoga Birth Babies
- Miscellaneous
- To find a healthcare provider who has training in caring for people who have experienced sexual assault: Breathe Network
HEALTHCARE PROVIDER DEFINITIONS:
Certified Professional Midwife (CPM) – Independent midwifery practitioner trained in out of hospital birth, meets requirements set forth by NARM.
Certified Nurse-Midwife (CNM) – Trained first as an registered nurse then with a graduate degree (or certificate if you were trained a long time ago), in nurse midwifery. Licensed nationally by the AMCB. There are a couple varied but similar routes to this path. For example, I received my Bachelors of Science in Nursing then my Masters of Science in Nursing with a specialization in midwifery. I am licensed as a Nurse Midwife Nurse Practitioner in the state of Oregon.
Obstetrician and Gynecologist Medical Doctor (OBGYN-MD) – After completion of medical school, OBGYN physicians complete a 4-year residency in obstetrics and gynecology.
Maternal Fetal Medicine Doctor (MFM-MD) – After completing all the same training as OBGYN physicians, MFM physicians complete an additional fellowship, typically 3 more years