Bridging the Gap Between Community Birth and Hospital Birth with Jodilyn Owen and Arya Pretlow

Discover the intricate dance of midwifery care and the empowering role of patients in healthcare through the expert eyes of Jodilyn Owen, LM, CPM, and Arya Pretlow, MSN, CNM, IBCLC, C-IYAT. For those curious about the meticulous qualifications behind safe home or birth center deliveries and the scenarios that necessitate a hospital transfer, this episode is a treasure trove of insights. We cut through the common myths surrounding non-hospital births, celebrating the proactive, data-driven approaches that characterize midwifery, and the vital collaboration with obstetricians. Meanwhile, the conversation also turns to the dedication of labor and delivery nurses who, despite the challenges of being understaffed and the emotional toll of the job, tirelessly prioritize the wellbeing of mothers and babies.

Step into the world of maternity care, where patient autonomy is nurtured and the resilience of healthcare providers shines bright. We examine the pressures new nurses face and the wisdom of experienced professionals in creating a personalized birth experience. This episode underscores the importance of encouraging patients to voice their needs, further highlighting the role of healthcare professionals in facilitating a birth experience that honors the physiological processes of labor. It's a heartfelt homage to those who navigate the high-stakes environment of hospitals, striving to maintain patient-centered care amidst a myriad of challenges.

Wrapping up, we delve into the transformative impact of collaborative care models, which bridge the gap between midwives and healthcare systems. Whether you're a healthcare professional or a first-time parent seeking guidance, join us on this exploration of birth environments and the profound respect for life that midwives bring to every delivery. Our conversation aims to connect you to a community that values every aspect of the birthing process and inspire collective efforts to improve maternity care for all.

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Transcript

Speaker 1: 0:29

Hello, today I have with me Jody Lynn Owen, lm, cpm, and returning to the show is Aria Pretlow, msn, cnm, ibclc and all the other past and future acronyms that I will put in the show notes. Both Jody Lynn and Aria are midwives, which is a profession that specializes in what is known as the perinatal year, which includes the pre-pregnancy, pregnancy and six weeks postpartum. Jody Lynn, in particular, specializes in community-based clinics through strategic partnerships and health systems. She focuses on bridging gaps in health care and the delivery of health care services for all. She is also the co-author of the Essential Home Birth Guide. Today, jody Lynn and Aria will be discussing the qualifications to be able to safely deliver at a birth center or at home and the reasons that would require a pregnant person to change to a hospital birth. Jody Lynn and Aria, thank you so much for joining me.

Speaker 1: 1:26

So happy to be here. Thank you for having me. Yeah, thank you. I am excited because, having only worked in the hospital setting, I always wonder what it might look like to have delivered at home or to even fathom that and just kind of the thought process of meeting all of those qualifications. And I feel like I am not alone in that, because most OBGYNs that I work with feel like a home birth or state that they think a home birth or a birth center birth is inherently unsafe and I feel like I want to challenge that and figure out where we might be able to work together and meet in the middle and plug people into where they belong.

Speaker 2: 2:12

So could you all enlighten me. I want to give a plug to my licensed midwife, certified professional midwife colleagues, in that they are the experts of low risk, normal birth, and we have to keep in mind that there is a difference in worldview for lack of a better word between people trained as medical doctors, even from those of us trained as nursing professionals. Right, like the nurse, process is not the same as the MD perspective, is not the same as the midwifery model of care, and so we look at constantly assessing is this still normal by like agreed upon standards of normal physiologic pregnancy and markers for health? Is it still low risk, again based on agreed upon standards of care? And we look at this is normal until it isn't and I remember learning in midwifery school and nurse midwifery school in the medical model it is never normal except retrospectively, after it has happened.

Speaker 2: 3:31

They might say that was a normal low risk delivery. But we look at it as this is currently normal and low risk. It has the potential to remain that way and we are going to continue to assess for warning signs because none of us wants to have to transfer an emergency, but also, until there's a warning sign, it's still normal and low risk. Yeah, I agree. So that's the first thing is like a fundamental difference in the perspective of are we assessing in the moment and making that call, or are we withholding that assessment until afterwards and then saying that was quote, unquote, normal?

Speaker 1: 4:10

Yeah, there's a lot of the mindset of preventing an emergency.

Speaker 3: 4:14

Yeah, we're not even interested in preventing emergencies. We're interested in preventing anybody from being outside of the care they need all of the time. There's a certain vigilance that comes with this work. We're both acting on presumption of health and presumption of capability. We trust babies to show us when they're not well, and I think one of the there was a couple of things you said that really kind of lit up in my brain. One of them is that there's a presumption in by license midwives that the people who are pregnant know their bodies and know their babies and that if we give them the space and access to communicate what they know, they will.

Speaker 3: 4:56

So in the hospital system and in this sort of standard medical system which I will try very hard not to disparage it's not what I'm after and it's not what I'm about. We're really close with very hardworking OBs who listen hard to their patients and who respond beautifully, but there's a lot of data system-wide that that doesn't always work, and one of the advantages of being where I am is that I have a lot of time and I have an expectation of access and communication. One of the things that our patients sign is that they accept responsibility to communicate with their providers. That's not something you sign when you go into OB care. You don't have to accept responsibility to communicate. But what we do in those visits we have hour-long visits and what we do over and over and over again is build confidence in the person that they will be heard, they will be believed, be believed and they will be responded to and that they know their body best and they know their baby best. And there's lots of data to back that up. There's a lot of data that says somebody who calls and says I don't feel my baby moving quite like they normally do, it's one of the most accurate predictors that something isn't right. And our job outside of the hospital is to pay attention to all of the little data points and there are a lot of little data points, but there's still data points and then to act long before we're looking at an emergency. I don't even really remember the last time I transferred because of an emergency.

Speaker 3: 6:34

The reason we transfer people into care prenatally or during their pregnancy or postpartum is because we're seeing something happen that we're concerned about and in the very best world we have OBs around us and nurse midwives around us in hospital systems that we can call and say this is what I'm seeing. Here's my three data points. And they will say send them over. And they don't blink. And the challenge right now, of course, is the stress on the healthcare system. So we'll make those calls and they'll say we wish we could help you, but our first appointment is three months after her due date. So that's for real and that makes everything feel very difficult for everybody.

Speaker 3: 7:15

And the other thing that I think we have to think about safety. And what does safety mean to people? How would you define safety? And there's a perception of safety. There's absolute safety and there's relative safety. And for many communities, the perception of safety in the hospital and the absolute safety in the hospital that's being measured now quite regularly. It's just not there. So we have part of what we're dealing with is a lot of people who are terrified of the hospital. They don't really qualify for an out of hospital birth, but they are so afraid of the hospital and they have seen their sisters and their aunties and their best friends get harmed in that system. And it's not always that somebody dies. There's a lot. There's way too much death in this country in maternal and child health, but sometimes it's just the way that people are treated and it's just so demeaning and so demoralizing. And making it through that process, I think, is part of the challenge that the healthcare system is facing right now. We just have to do better for people.

Speaker 1: 8:18

Yeah, I agree with all of that. Even when we are trying to do our best in the healthcare setting, the reasons that you brought up are what make it challenging the rushing people through labor because we have people on hold that are having medical induction scheduled, that maybe their medical reason isn't as urgent or emergent as this other medical reason and latherin's repeat. So, yeah, it's very frustrating. And then to have to practice in that way when you have somebody quote unquote taking up a bed who maybe came in in natural labor and has slowed down but wants to go natural, and then you have this person on hold because this person came in in labor and qualified to stay, and then what do you do from there? You try to encourage that person to speed their labor along so that they no longer take up a bed or don't push because we have to go back to an emergency C section. But you're complete and plus two hang on.

Speaker 3: 9:09

It's sort of a birth at the hospital. The OR, those are intentional but they happen. Patient education pieces I've ever heard and I've been at a lot of births in the hospital, and she said to the patient I want you to know that we're all here doing our JOB's, as to get caught up in what our bosses are telling us to do and the pressure we feel from our colleagues to move quickly and get things done. But this is your birth and what you need is important and you can stop us by telling us what you need. And I thought it was just one of the most breathtaking sentences because she acknowledged the tip of working in that space and reactivated the voice of the patient and made a promise to her in that moment I'm going to listen to you and we'll slow down if you need us to slow down Slow. So birth is slow and I think that's you know.

Speaker 3: 10:03

It's slow and there's great physiological pauses in labor that happen and they're just real.

Speaker 3: 10:09

So part of the reason that somebody will, we get a lot of people who've had a prior hospital birth, who were in, and when we tell them, you know, tell us more about that. What are you thinking about? Can you describe what you're looking for? They do mention what you just said, which is they had a feeling that they were being pushed along and they want more space and they want to be with their family and it's a really big day for them. It's the last day of their pregnancy, but it's a really big day, it's a really important day and they want to be in it.

Speaker 1: 10:47

Yeah, I agree with all of that and that's how I feel as well.

Speaker 1: 10:51

And I just want to throw out there that when you are a new nurse on labor and delivery and trying to do all the things and trying to navigate the pressure from your colleagues and trying to wrap your head around this thought process that everything is an emergency and everything is high risk until it's not especially if you're at a high risk center it's really really hard to step back and have that attitude that you just mentioned from that nurse, and so it's important that patients know that that's what their nurse hopes to say one day.

Speaker 1: 11:21

If you have a new nurse that's rather green or seems stressed out that day, but that is the truth we can slow down. When you say that's what you need, it's the more experienced nurses playing defense like oh, I didn't go up on the pit because of meh, meh, meh, meh, meh, meh, meh, just because you know that that is where your patient is at, that the patient is adequate, that the labor is moving along and everything's fine and you don't need to go up on the pit just because and you don't need to do the interventions, just because this is what a normal labor looks like and we are. Yes, we are concerned about the patients coming in, but it is a balance of taking care of that person that is right in front of you versus thinking about the people that might be coming in. So everyone is encouraged to feel empowered to speak up when they need to.

Speaker 2: 12:08

I think that with more experienced nurses you also have the benefit of a degree of gravitas amongst the providers, right?

Speaker 2: 12:16

So if a nurse with whom the MDs and the CNMs are familiar and they're like, oh yeah, that nurse, I rely on that nurse, I trust that nurse, we have been in many, many, many, many bursts together and so, okay, I you know, maybe that provider would have preferred that something got moved along for any number of reasons, who knows what. But they fundamentally trust the professional judgment of that nurse and that nurse then feels also empowered to behave in the autonomous manner that her license I'm saying her, because most of us are hers but that their license affords them. And I think, in my experience at least and observation, a newer nurse does not yet feel that not only confidence, but you literally do not feel that you are an autonomous provider in the hospital system. And so, even though you're trained that way and taught that way, when you get in practice there's a lot of hierarchy and it's it's a lot of feeling like you got to somehow prove yourself, even though you don't know what the benchmark is.

Speaker 2: 13:25

So, how do you, how do you prove when you don't know what? What's the rubric?

Speaker 1: 13:29

Well, the benchmark is suddenly you have all the magic tricks that the providers are like oh, she's going to use her woo woo and make that baby cry Right, which really was a birth ball, yeah, and just weird positions.

Speaker 2: 15:23

It actually was literally holding the person's hand and being nice to them. That's magic. But you have to have the time and space right. You can't have two other people on pit and be like I'm in here holding this person's hand because you've got high risk patients now, and so also there's that right, Like with all the staffing shortages and the turnover, frequently you're going to have more newer nurses than experienced nurses, because the rigors of the profession also injure us physically and otherwise. It is not sustainable for a lifetime profession. Yeah, that is true. I mean, there are unicorns and we've worked with them, right, but like I don't know how she does that Since she was like 20. I don't, I don't know.

Speaker 1: 16:11

I'm thinking of a certain 69 year old nurse that's talking.

Speaker 2: 16:14

Right, All the props I love and I'm like dude, I don't know how you.

Speaker 3: 16:18

I think that's one of the things also when you look at you know out of hospital, birth and what's so hard to fathom, and I've worked with a lot of obese who never knew what. They just thought it was this you know people dancing in skirts and howling at the moon or something. You know that.

Speaker 3: 16:33

That was the different intense and intense and candles and, you know, bringing in. I think one of the things that I found effective in that communication and just education around what is midwifery and what is out of hospital birth is I bring in all my bags and I open them all up and they'll always be like Tony, look at it, it's a hospital in a bag and it is. It's. Every single thing that is in the L and D room is at a home birth. We have. We have all of the resuscitative equipment and IVs and oxygen and everything other than an OR. We do not have an OR and we do not have an anesthesiologist, although I have one that continually begs me to come to a home birth to do an epidural. But we know that that's not safe or possible, but he just really wants to help. He just really believes in the thing. So still in my adulthood, when I would walk into a hospital room and into labor and delivery room and it looked like a hospital room, you could see the medical equipment. Now everything is tucked away in cupboards and where I'm sitting down, the birth center is like that Everything's tucked away in cupboards but it's all there All the medication, all the antihemorrhagics, all of the things that we need are here, instruments that have been autoclaved, all of it. So we have all of the same instruments and supplies. So then you start to ask what is the difference? And the main difference in terms of communicating around safety is that we do not have an operating room down the hall, and I think that the number of times that hospital-based births you see somebody needing to be run down the hall, it's high. So that's what people and you only really need one to have it stick in your craw and think I never would do this without an OR. And that's where our expertise comes in. Our expertise is prevention and our expertise is paying close attention and I think one of those things that you talk about as a nurse in the hospital, where the demands on your time are so heavy, you're so heavily engaged in all of the things around the patient care and outside of the hospital we don't have a pressure system like that. It's slower.

Speaker 3: 18:40

To say it's one to one is almost an understatement, because you really are with this family through almost all their whole labor and we don't go to the sleep room, we don't go to do clinic. I mean, I've done that in the birth centers. Sometimes we'll pop over, but even rarely, because I just want my brain on what's happening. We don't leave them, we're theirs, we're their champion. And if you can imagine if your healthcare provider was the person when you lean back, they have their hands on your back, they're going to catch you, you can lean into them and they will support you. You can look into their eyes and be afraid in a moment and have them look at you and tell you I know, I know, I know what you're feeling, it's normal, you're okay and you are not alone. And that kind of care is extraordinary. And even the very best nurses that I've worked with in the hospital aren't really allowed to engage in that kind of care. And the best doctors, I think nobody goes to medical school to run around a hospital like a chicken with their head cut off. Nobody, everybody goes to medical or nursing school.

Speaker 3: 19:54

I would think most people let's say some people probably go for the power, but most people the vast majority of healthcare providers you will ever meet got into that profession because they saw themselves contributing to the health and well-being and comfort of another human through using skills, education, talent, time, ideas that they would learn in school and be able to bring into their community or bring into the hospital room or bring into the lives of another person and then they can't enact that, they can't manifest it and it is washed out of them deeply carefully, systematically scrubbed out of them so that by the time they are holding license they don't really resemble who they were in the beginning. And we have to do so much work to unwind providers and let them see their space and availability and time to be able to do what you meant to do. Now that you have this license, this education, this power, you can bring this to your community and that is what midwives do. We don't work in that system. We have certainly have a hierarchy in this world. I don't think we are free from eating our young and all that kind of stuff. But there's a lot more leeway if you are really bent on being a provider who acts from kindness, who approaches people as if they matter and who believes what people want is crucial to their health and to their health story, and that is really different than being in that system. So there's sort of this duality of your question of who qualifies for out of hospital birth and part of it is that you have to entirely reimagine the providers that that person is with. And if you take the best doctors and the best nurses and you set them free, that's who they're with. It's, it's the best people, but they're allowed to be their best selves. We want you to follow guidelines you got to follow guidelines but we want you to think, and you know I've been in at Burson hospitals where sometimes Birthing mom would say, oh, I really just want to try and do this without medicine, and a nurse would throw her hands in the air Ah, I came to work for a reason.

Speaker 3: 22:17

Today we get to do it. We're really gonna do something special. And that idea of engaging with somebody in a physiological way, working through something that is physiologically normal, healthy, robust. If you, I always tell people, put on your vagina goggles and walk around any major city. Most of us it's changing now, but most of us arrived through a vagina. Most of us survived the process of allowing somebody to arrive through a vagina and most of us survived that process Over the history of all of time. And then our job is to be really highly, highly trained to make sure that if something isn't right At any point, we don't wait, we don't blink. There's no ego. We're going to our friends, we're gonna take good care of us in the hospital. There's not an adversarial relationship. We have to work for each other, be for each other, and then the whole system works.

Speaker 1: 23:12

Yeah, I really like how you described the scrubbing of the actual motives of healthcare providers, because I feel like even the new nurses that I Train, or people that change specialty, hoping that labor and delivery is the place where I can be that person, and Then receive a rude awakening when they realize that they cannot have that time For that relationship that they want to build with that person and they they can't have the time to make the birth as special as they wanted to. We can still make it special. It's just a skill set, trying to sit it into that tiny little sliver of time, trying to, and I just I want to. There's a couple things that come up for me.

Speaker 1: 23:57

First of all, the sheer level of documentation that has to happen in the hospital setting. I am spending most of my time clicking buttons and not helping the patient, and I have to click those buttons because if I don't click the buttons then if something happens and I didn't click the button, then I lose my license and that's just the ugliness of what we experience in the hospital setting. And so when you have somebody sign the consent saying that they are taking responsibility To communicate, that is a huge part of what's missing in the hospital setting. We absolve people of partnering with their own physiology when they walk into the hospital, because it is assumed that the provider is the one telling them how this works. And the other thing is that even when you go into the room, you know and you want to be a part of that natural birth or just really hold that patient's hand, you have that first experience where you're in there and you get stuck and your other patient needs you, or the charge nurse is saying you have another admission, or you know you're gonna cover someone's lunch or whatever it is, and then suddenly that service that you wanted to provide, that Relationship that you wanted to engage in, becomes something negative in the eyes of everybody else on the team. Because we are Working as I mean, we're working as a team, but it's a very short staffed team, no matter how you slice it. Even when we're optimally staffed, based on a one standards, it's not the same as the one-to-one that you would get with a midwife and a doula that is there, with the midwife and your Family and all of those people that can help support you. It's just not the same.

Speaker 1: 25:29

And so when you have that first experience, when you are trying to be that person for that, that patient that is birthing, and you suddenly have to rip away that care that you were hoping to provide, that you had promised to provide. The shame and the sadness in the Hurt for both you and that patient is something that can never be forgotten. And so then what nurses tend to do is they just dig deeper into that documentation process, into the team quote-unquote mentality. Where I'm not serving my patient, I'm serving the floor, I'm serving my co-workers, I am working to keep everybody here safe, and that's it. That's all you have.

Speaker 1: 26:09

And so if you manage to be in this profession for longer than a couple of years Because most of the time that's the number if you manage to be a nurse in labor and delivery for the long haul and you start to learn how to provide those services and to get in there and have that short-term relationship where you are being that person for that patient momentarily, it can get beat down and then come back every single time and Still be that person in that room. If you become that magical unicorn you know it's it's still not the same, it's still not enough. It is still not what you would get in a home birth where you have that one-on-one person that has gotten to know you for your entire Pregnancy and will be there after and everything, you get that person for 12 hours. If that, because of the teamwork that we have, you might lose that person. And who knows when that's gonna happen, because maybe the other patient is delivering and you lose that person that you had that bond with and suddenly Everything is just, you know, thrown up in the air. And that's not to say that there's not going to be another spectacular human being that walks in the room.

Speaker 1: 27:15

Because, honestly, when you look at the places where in the hospital, where they say that they get the best care, where we have the highest Patient satisfaction, most of the time it is labor and delivery, but that is all relative to what it could be and Unfortunately we do not have the resources, we're not given the what we need to make that happen, like on so many levels, like physical resources. You know, do we have clean pads to give to this patient? We don't have time. We have. We may have three patients on pitosa and even though that's really unsafe, we may not have had lunch that day. We may, guys, this is every day. I mean, this is three days a week for us. This is our entire career, so how many times are we going without lunch and those kinds of things when you have someone that's that beaten down and going through that and they're still coming to work every day? It's not the same. It's not the same service that they can provide.

Speaker 3: 28:05

This is number one why I tell all of my patients to bring a treat to their nurse, like something in your bag. Any box of frangoments, whatever it is. Give you, give a little, we spring oranges.

Speaker 1: 28:16

Thank you. Yes, something sweet, but also healthy. That's not going to make us Don't know.

Speaker 3: 28:21

Yeah, I've had lots of nurses as Patients. I had this bizarre run where I had an inordinate amount of doctors and nurses as patients and the nurses all said they were there because they didn't trust the doctors, and the doctors all said that they were there because they didn't trust the nurses, so they were all choosing out of hospital births, and I would like if you all could just get together and combine your resources and get activated to solve these problems. They would be amazing. Yeah, there's something I want to say is that when you talk about team and we think about who's the team and I know that there's pregnant people Listening to this podcast right now this is what I want to say right now they are growing and feeding and nourishing and nurturing their baby with nobody's permission. They didn't come to prenatal visit where I said you're allowed to feed your baby now, or you're allowed to grow the baby, or Please let your placenta continue to develop. I affirm it's okay, you can do that.

Speaker 3: 29:14

The main team in this story is the parent and the baby and their relationship with each other and the Perfection to which they engage with each other and are for each other all the time, every night, every day, 24-7, from the moment of conception, and then they come into care and we start talking and using language that divides them and we start Saying things like, oh, only your baby would do this, your baby's not cooperating with this, or why can't you know All of the language there? That's just built into the system and people just you see them like Sinking under that language, and we have resident physicians that rotate with us and when they're in visits, I always teach them two things because of what you just said, and its nurses can do the same thing. There's ways to ask one or two questions that light people up and make them feel that you believe they are an expert in something and that Gives you credit in their eyes, instead of acting like we're the ones who can solve all the problems and we're the ones who have this Idea of responsibility. It's not something we give to people. It's something that is taken from them in most healthcare systems. But they arrive with responsibility For themselves and their babies and then we slowly suck it away from them until they believe they can't do anything without Somebody saying yes, I'm allowing you to get up and use the bathroom Whatever it can be something that I'll allow you to have a drink of water, things like that. Well, we intuitively have been drinking water and using the bathroom our whole lives when we needed to and all of a sudden, for this one day, all of that disappears and what I teach the residents is that, during labor, to say, tell me about your baby.

Speaker 3: 30:50

And then just be quiet. People will talk for half Hour because babies have schedules, they have wake schedules, they have sleep schedules, they like to play, they like Somebody's voice, they love this song, they love this, they love that. People will tell you a bunch and Right after the baby is born, when you go in and do that new-born exam Maybe it's been a couple hours Tell me about your baby, what do you notice? And just be quiet. Because they will have observed and gotten to know their own baby exquisitely. In the first moments and the first moments after birth, babies arrive ready to engage and ready to play and Ready to be a part of our world, and parents notice them and Just activating them as experts and just listening. It takes two minutes, literally two minutes. So when you do have three patients, if you have two minutes, one of the best things you can do is just ask them Tell me about your baby. You're the expert, you know this one and it changes everything. I love that. Yeah, we don't have to be perfect, right, and I think we, you know, outside the hospital, we're not perfect either. We just have more time to make up from from the things that we we wish, that we we could or we want to. But the other thing is that we start talking like this and people get goo goo gaga. I mean that care, get me over there.

Speaker 3: 32:01

And I think one of the things we wanted to talk about today was this idea of Well, who can come to this care and exploring wherever you live and starting to call some midwives and you go and meet them and you talk with them if you have a chronic health condition. There's most chronic health conditions rule you out of being safer out of hospital care Hypertension, uncontrolled diabetes, insulin, controlled diabetes. We can care for people who have diet control diabetes or Metformin controlled diabetes in Washington state, but is that the best place are? You know? We we don't know. So we follow the baby and we want to see how that baby is growing and make sure that the best guess that we have About the size of that baby is going to be safe for out of hospital care, because the other thing we don't have here is Vacuums or forceps. So we you know we all have to train to use them, but we don't have them here and we never use them and you wouldn't want to midwife using. So I think like just Knowing that if there's a chronic health condition, if there's something going on that makes it difficult for you to get to visit, so you need limited prenatal care.

Speaker 3: 33:07

Midwifery out of hospital birth care is safest with full course of care and we have all the time people walking into the birth center with no care and then we help them get what they need and navigate into the system the best we can. So there's so many things that can come up during pregnancy that disqualify people for care. But the way to discover that is to start talking with midwives about your own health history and and your own goals and your own expectations for your birth and to know that Physiological birth is really different than birth in the hospital. The pain is different, the process is different, the timing is different. It's different when you've spent nine months preparing for birth and you go into birth Confident, you walk in like a boss and I've worked, you know in the part of the world where there was no fear around birth, where girls are at the births of their big sisters and their cousins and their aunties and other women in the neighborhood. So by the time they arrive to birth, they've seen it, they know it's possible, it's shorter, it's faster, it's, it's it, I don't know that it's easier. They still have to labor and they still have to birth. But birthing without fear which is the name of a book, of course, but birthing without fear is a really different experience.

Speaker 3: 34:20

When you are allowed to like this, it's a squizzic cocktail of hormones that is in your body and that cocktail is allowed to do what it does. It protects us and it moves us through Laboring and birthing in a totally different way than when people have their hands inside our bodies and there's machines beeping at us and people who we don't know coming in and out. When the burden is on the provider to be the person who is your continuity. That's very different than the burden being on you, being continuity for 10 providers. You're in relationship-based care. You've developed trust, you've developed a sense of who you are in relation to this provider and how you might be activated in this birth to succeed. And you know what, any moment, if you say, hey, whoops, this not for me, I really just want an epidural, that person's gonna be like, okay, let's go, that's fine, you're allowed to. Unless there's a head in my hands, we can go. Yeah, at which point?

Speaker 2: 35:21

I love that relationship-based care is such a huge difference and I think even in what I have seen in CNM, training is oftentimes, if you're gonna be in a hospital-based practice, you're gonna be in a multi midwife practice, and while we still may follow the midwifery model of care effectively, we now have to follow the same kind of rules as far as what are those awful things that they figure out how whether you're fiscally working right, rvu.

Speaker 1: 35:51

Straping ratios Q&A. Every hospital has a different one. All the awful things yeah.

Speaker 2: 35:59

So you still might have a different midwife seeing you at every visit and Not know which one's gonna be on call, because they have a call schedule Right when you go into birth. And so, even though you're still gonna have that overall midwifery model and approach, it's in order to function in a hospital setting for for the provider. The setup of the whole clinic experience is much more similar to Kind of a standard OB office than it is to an out-of-hospital based provider office.

Speaker 1: 36:34

Well, plus, you have a OBGYN overseeing, so anytime the OBGYN gets uncomfortable.

Speaker 2: 36:39

You mean, like in the hospital in general, yeah, and not to mention all the nurses who I love us, and also, oh my god, just keep your eyes on your strip for a little while. Like, is that a diesel? I don't know, let's find out. Right, I know, like, why, like, wow, there were. There were a couple things that came to mind in the last minutes of conversation that I wanted to bring up, but there's a beautiful book called breath becomes air, and the was written by Paul Kellen nithi, and so he was like a young neurosurgeon resident on the verge of finishing when he was diagnosed with brain cancer and Much of the book so he passes away. The book was finished posthumously.

Speaker 2: 37:21

The book is about his process of coming to terms with his own humanity as a provider, now that he is a patient, and really dissecting the ways in which the process of becoming a healthcare provider Dehumanizes us, and then, of course, we not intentionally to some extent dehumanize our patients, because that's part of the Psychological work. That sort of has to happen in order to do the work that we do, in order to operate on someone's brain. You probably have to just think of it as a brain and not as. Oh my god, there's a whole person in consciousness and all of the things I don't know. Our new brain surgery, and that, I think, is very similar.

Speaker 2: 38:06

We were talking about just the dehumanization of nurses, right, and I joke that Only. It's not actually funny. The nursing diet is basically the starvation diet. We talk about working three twelve hour shifts. It's never only 12 hours. You also have your commute and it's not like you work three on four off or even one on one off, right. So in a seven-day week you might actually work five or six shifts, depending on how things just get scheduled over the course of a two-week scheduling period. So you're hungry, you're thirsty, you're ridiculously stressed, you're under all the pressure from all the directions and that's not a way to set people up to care with a capital C. It's. It sets us up to survive and to focus on the survival of our patients. And but that's also like baseline, right. It's like, of course, everyone wants a healthy parent and a healthy baby. That, like we shouldn't even have to say that. That's just yes, but it can be so much more than that. But we also need healthy environments to support that process, and that includes the environment in which the Support staff, all of the licensed providers supporting that family and the environment in which we're working, and I Haven't seen yet that hospitals have figured out how to do that and the other thing.

Speaker 2: 39:28

So I trained as an LM before Nursing school. So when I showed up as a new nurse and thankfully got like labor and delivery, when I was trying to figure out what kind of job to apply for as a nurse, I knew I needed to work as a nurse for a year before I could apply for frontier nursing University CNN program. That's their rule. I was like, okay, I just Need to meet this requirement In a way that I can actually Survive, put maybe even thrive, who knows right.

Speaker 2: 39:58

So a dear friend from midwifery school was like because I was thinking maybe, maybe it's the emergency department, maybe what I need is just something that's like it's just quick. I knew I didn't want meds. Her like I feel like it needs to be either all about the women or all about the babies, didn't really want peas, I didn't know what to do with myself and she was like so sweet, it was such a lovely thing to say. She was like I think that you know you really have to protect your midwife heart and Maybe emergency department is not the place to do that. But what none of us could fathom was the degree to which a labor and delivery unit destroys your midwife heart and Because you can't function as a midwife In the way that I was trained in that environment and I remember my preceptor because I was in like the new grad fellowship program, right, my preceptor was so frustrated with me because I wanted to spend time with the patients.

Speaker 2: 40:50

I was like I don't care about how you get that out of that machine, I'll figure it out, but what I?

Speaker 2: 40:56

We have this person here who needs us and I want relationship. I got into midwifery for the relationships and she was like I know that you are frustrated and when you have all of these Logistics down and you can Admit a person within 20 minutes instead of an hour because you actually ask them all of the questions and listen to their answers, dare you, when you can actually, I know when you can do all of these things to make you a functional member of the team not including the family, right, but like the professional team then you can start having relationships with the patients again. And so then when I got to that point, I suppose some might argue. I never really got to that point because I was still actually asking all of the questions and all the answers, taking a long time. To admit people, I would spend most of my time. I don't know if you remember I hardly was at the nurses station because I wanted to be in the rooms with the people.

Speaker 2: 41:55

But you have the skills to do so, and then I would come, I did, and I would come out, though, and the attitude that I would encounter from my fellow nurses who didn't have those skills or that interest, was that I must be a slow, dumb nurse because I'm in the room forever.

Speaker 2: 42:11

But actually I was in the room providing midwifery care, not CNN care, not OB care, but that relationship I was in, there being the L&D nurse that they hoped they would get, because there is still this idea that like I don't need a doula, I'm going to have an L&D nurse. Like they get their very own special nurse to put in their pocket. And we know that's not what happens when you get there, but I feel like the general public doesn't know that still. And so I was engaged in that relationship with the capital R and that caring with the capital C and doing all the nursing obligations and all the systems and pushing all the buttons, but trying to actually connect with people in the short amount of time that I had with them, because that's the part that I needed in order to maintain any sense of self, frankly, and certainly professional self.

Speaker 2: 43:08

It was really really hard, very, very frustrating and very interesting to me that tension between the attitudes just based on, again, my entree to this work was as a community midwife. Right, like you hang out in their living room hanging out with their mom and their mother-in-law who's cooking some big food to share with everybody, and you're having meals, and then you're checking on them and you're hanging out with them and they're telling you stories between contractions and you're walking up and down the hallways. You just are in their space, welcomed into their home. It's an incredible honor and one that I miss.

Speaker 3: 43:48

There's something about that. We talk a lot about territory, terrain and environment, which are concepts that have been studied really well by the UK midwives, where midwifery is normal, but understanding how territory, terrain and environment impact a birthing person and impact their team. So when you're in the hospital, I'll tell people bring one thing that's so bizarre that it makes everybody stop and ask you what's that? You know? A picture, a family photo? That's just crazy. Or put a picture of your cat or some stuffed animal that you lost, something that humanizes you and stops people and say, oh, tell you, what is that on your table there and you get to tell a little story about your home. It brings people into your worldview.

Speaker 3: 44:34

And for us, where we are at the birth center and we do our clinic visits in the same rooms that people birth in. So when we're sitting in there, I'll tell them. You know, when we're preparing for birth, I'll say you know you're going to come in here. All the furniture moves, the art comes off the wall. You can hang up whatever you want. You're going to make this room your space. You use it like a hotel room. You're definitely still on our floors, but you have to work so hard to make this room, you know, look and feel and as much as possible smell like you, because that's where your sort of innate comfort comes from, is a sense that this is my environment. And I said nobody's going to walk through the door like we own the place. We knock and say you know, is it okay, unless you're pushing or something going on that we need to run in. But that's really where we're in there most of the time, and when we're not, everybody's really respectful. You'll never have something happen like I've seen in the hospital, where the person who is responsible for checking the thermometer, the temperature on the little mini fridges in the rooms, just walks in while someone's pushing and it's like that's his job. So he's just like in and out, students in and out, providers in and out, somebody in and out, in and out, in and out. There's none of that. So you're not disrupted and we know that safe physiological birth relies on you disrupting yourself and not other people disrupting you.

Speaker 3: 45:57

So even when people need something in labor, we prepare them ahead of time. If you see a straw in your face, it's because we think you need more liquid. But we'll rarely say to you do you want something to drink what would you like? And here's a list. We do that all ahead of time. But if you ever look up and you say I need something to drink, talk as much as you want.

Speaker 3: 46:16

That's not disruptive to your process. What's disruptive is all of us coming in and like, oh, just move, like that, oh, I just need to do this. So I just need to hear that. We tell them ahead of time we're going to listen to the baby every half hour and this is how we do it. You never move. We move to you, and my hardest patients are nurses who are in labor labor way and then they move their bodies every time they see us to make it easier for us and how much we have to work with them in that moment. No matter how much we do ahead of time to tell them don't move, you keep doing what you're doing. We do bendy, twisty yoga moves to get to be able to hear the baby and get the Doppler there. So that's just a very different quality of interaction.

Speaker 3: 46:57

And I do want to say there's something about what, aria, I think I mean I've told you this to your face, but I'll tell you now on this podcast that there's something about being a licensed midwife working in a setting with well, I'll just speak to Aria, because you're very human. That makes me feel safer and better and I can do my job, knowing that the things that we need around because no person is just a pregnant person and we have discovered this quite acutely over the course of your PhD studies that people have so many other things going on. They have anxiety, they have UTIs, they have yeah, I don't know an ache in their elbow. But having a team around us in the birth center where people look up and everything they need is right there and they don't have to traverse these wild pathways between providers, has been a real game changer. And I think when we're looking at, when people are going and looking at birth centers, make sure your whole team is lined up. It's rare to find everybody you need in one birth center or in one midwifery practice, because our scope is really hyper focused. We are highly, highly trained on just that time. I want to be pregnant, I am pregnant, I'm having a baby, I was just pregnant.

Speaker 3: 48:18

But people aren't only that thing and today, in today's world, most especially post COVID, most of the population arrives to pregnancy with a non pregnant challenge or issue or health concern whether that be physical, mental, emotional, it doesn't matter. All of that impacts your pregnancy and being able to access all of that care is really important. But people have to be the authors of their own story. And if it's not set up for you beautifully, like you walk in a place and all the providers you need are right there, then you have to do that work for yourself and you have to expect to advocate along the way for yourself, no matter how much your midwife is like. I want you to have this thing, whether it's like something for your itchy skin, something for your mental health, something for your anemia. I want you to have this. I'm going to write all the referrals. I'm going to bang down all the doors. I can't. As a patient, you have to push into that system and get that care so you can stay safe for your out of hospital birth plans.

Speaker 3: 49:19

There's a lot of work people have to do right now to be present in the health care system and when you are pregnant you can't pretend those things don't exist. We push and we push and we push ourselves through and I'm speaking primarily to the people who identify as women. We push ourselves through in extraordinary ways, past our own health issues, past our own sicknesses, past our own needs for mental health, past our own wants for the things that we want in our lives. So we are serving and working for others, and that is something I wish wasn't true, but it is true. So we have to acknowledge it.

Speaker 3: 49:54

And then we arrive to pregnancy and all those things come crashing down and you have about nine months to get it all taken care of and it takes a long time to get appointments and a long time to get the right kind of provider to help you. And one of the things that I found extraordinary about working with you is that people would come in for their pregnancy and have three other issues and we could put them on an appointment with Ari and Ari knew they're pregnant and we have this time where they're activated in their health and you would level them up in a thousand ways Because you're an amazing health educator and an amazing provider and you would see the whole person there. So midwives and out of hospital birth, I think are safest when we are partnered with people who want to think like us, who look at the world like us, who want people to show up and engage in their health and be activated, to learn and to do more and be more. And you're just learning. And that is also where we get a generational page turn, because this is somebody who's coming in with the story of their mother and their grandmother in their body and they are writing the story for their baby in their body.

Speaker 3: 51:07

But they can write a story. It's not authored and you can change your health and you can change the way that you engage with all of the things in our environment, the way we move and the way we nourish ourselves and the way we connect With others and the way we deal with isolation and loneliness and anxiety. We can change all of that and what I can speak to as a provider who got to see what happened when people could access that care with Aria care I cannot provide. It's not in my scope of practice. It was just a completely different pregnancy outcome. I don't think it matters. Are you with an OB or are you with a midwife? Are you in the hospital or out of the hospital? Use that time in your pregnancy to level yourself up. Find providers who are interested in you and interested in learning about how you want to be in the world and who will help you get there? None of us can do it alone.

Speaker 1: 52:01

Yeah. How do we make the health care system learn that? How do we find more Arias?

Speaker 2: 52:04

Well, I think it brings up something that's very interesting also, which is thank you so much for all of that. You know I love. This was my dream come true. I wanted to come back to Seattle, work with my LM friends and help them keep their people in scope. And most people don't have a primary care provider anymore. The primary care offices are closing left and right. We can't stay in business because insurance won't pay us and neither will patients. I still have to feed my family, right, like it's a problem. It's a problem in our whole health care system.

Speaker 2: 52:38

So if you don't have a primary care provider and you're pregnant and you let's say something super run of the mill you have herpes, you have, you have genital herpes and you you learn or maybe you already knew that 36 weeks the recommendation is you start some antiviral medication and then the midwife is like who you want to go to for that? And you're like provider right, who, what Right, or or something that's a little bit, maybe easier. You have a UTI, right? Okay, you go to your midwife, she doesn't have. So in this case, like the LM, scope does not include diagnosis and treatment of things other than, like you are pregnant, you are postpartum that the tear is, whatever degree, right? So you have a UTI. This is not rocket science, this is a. You can make a clinical diagnosis on this when it's in your scope, but they're going to run labs Like the person says, it burns when I P and I have increased urgency and all of the things and they are like let's make sure your kidneys are okay and also less than some labs because someone's going to need to treat it and we can save time. So I'm going to send some P. In the meantime, who's your primary care provider? Right, and they either don't have one or they're like they call and they can't get in for three weeks, and you cannot have a UTI for three weeks while you're pregnant. And so it's like, okay, well, you're going to have to go to urgent care.

Speaker 2: 53:56

In COVID times, nobody wants to go to urgent care, and I do not blame them. Like, even in not COVID times, nobody wants to go to urgent care, right, I get it. And when it's like I could, I don't want to go and sit there with a bunch of hacking, coughing people while I'm pregnant. You know, is there anyone who can help? I loved being able to be that person who was like just send them down the hall to me, right? Or you're not even in our practice, that's okay. Send me the records, right, we'll set them up as a new patient just for this visit. I could do a telehealth, I can look at their labs and I can, I can take care of it. That kept that person safe, right, healthy, got them back to healthy quicker than having to enter with that whole situation of getting into urgent care or, you know, heaven forbid, having to go to the emergency department. Like what if you're 38 weeks pregnant and you have a UTI and then it could cause some contractions, right, but maybe you're not actually in labor, you just are dehydrated and irritable and all of the things. But now you're at the hospital and so if you go to the emergency department big with baby, they're going to send you to L and D. It just is the spiral and they're like I, but I I just have a UTI and want it treated. I didn't want to stay here and have my baby, and that is a real fear that people have.

Speaker 2: 55:13

The other thing that I want to connect that to is that the laws governing the scope for licensed midwives and certified professional midwives vary by state, unlike any medical doctors. It varies a little bit for CNNs and CRNAs. Some states still require us to have a supervising physician, others don't. We are independent practice states, so I am in an independent practice state. I will not practice in a state where it is not an independent practice state because I'm fully qualified to do this job independently. But it was only just recently, for example, approved for independent practice in Virginia, right? So you've been there watching that transition from having to have an OB kind of quote unquote supervisor to like no, we're, we're independent and we don't need you to sign off on this. Our ability to provide the care within our scope is equal to your ability to provide care within your scope. So we can all just work together but we don't have to step over each other's feet.

Speaker 2: 56:14

So, with licensed midwives, part of the challenge for anybody listening to this and thinking about maybe what they have experienced as a nurse or a provider in a hospital setting or as a as a pregnant person, is it a much of the attitude in the hospital about home birth and community birth depends on, historically, what is the environment? Also, what? What are the laws around midwifery care outside of a hospital system? Not only does it vary by state, but also historical legacy, and intertwined with that, therefore, are all the isms that ever ism and so there.

Speaker 2: 56:56

There are places like I remember when, when I first came to Virginia, licensed midwifery had only just been legalized and so they didn't have a drug legend, which meant they couldn't carry an administer anti hemorrhagic drugs. So the the three baseline things that you can give someone a shot of pitocin in their thigh to help them stop bleeding, you can put some mesoprostil in the rectum to help them stop bleeding, right, you can. We had tools that in I was trained to use outside of the hospital in Washington because it was already in our scope. I arrived in Virginia and was like what do you mean? You can't give oxygen during resuscitation, that's a drug, and they didn't have a drug legend so they couldn't use it. Their work around was to have a staff RN with standing orders from an OB, and so they would activate that situation, right, and it would be like, okay, I've got standing orders, we're doing an RP, I get to administer the oxygen. Okay, I've got standing orders, they have blood too much, I get to administer the pitocin. I don't understand how you, the midwife, can suture the perineum but can't administer the lidocaine before doing so? Like then, I don't even know how they worked around, just things that like we should all be scratching our heads and shaking our heads because none of it made any sense, whereas at that same time in Washington we had full use of all of those things within certain regulations for out of hospital use. Of course, there's a point at which you're like we've done the things, we got to go, you're still bleeding too much, it's managed for now, but you've lost too much, right, like you need to go be somewhere where they can give you a different level of intervention.

Speaker 2: 58:42

So when we saw transfers from out of hospital birth into the hospital, the thing to keep in mind is frequently, particularly in states where it's not a friendly environment for that kind of transfer, people don't want to transfer. The families themselves don't want to transfer and often will decline the recommendation of the midwife to transfer at this time. And the midwife cannot abandon care, nor can they pack the person in their car and kidnap them to the hospital. The person is still an autonomous adult person making their health care decisions for themselves, and so if finally they acquiesce and decide to transfer, all eyes go to the midwife and what the heck were you doing or not doing that? This train wreck has now arrived and now we have to clean up quote-unquote your mess, and nobody wants to be in that position, professionally or personally.

Speaker 2: 59:44

That midwife may have actually done everything correct, including respecting the patient's autonomy. It wasn't a birth gone bad. It was. I mean, who knows? We can't know. Every story is different, right? But there's more to it than just I told you we need to transfer and you didn't transfer and or I didn't do things that should have been done. It's much more complicated than that and that's partly because the self-selecting Patient population for out-of-hospital birth Tends to already want an out-of-hospital birth because they desire that level of autonomy that they should also have in the hospital. That is the right to have all the time. But there's something magical and Disarming and Depersonalizing that happens when you put on a hospital gown and an ID bracelet that all of a sudden it feels like you don't get a say anymore.

Speaker 2: 1:00:35

So, depending on how those kind of experiences with transfer etc, etc. Goes, what people who work in hospitals see coming in are the worst case scenarios. You don't see the 99 other out of a hundred births in the last three years that that midwife had. You don't see all the ones that didn't have anything go wrong because they didn't need your services and so it isn't that your end of one doesn't count as a representation of what birth outside of a hospital setting is like. You didn't get to see the others that, yeah, sometimes they're tense, sometimes there's a lot, sometimes their butter births it's all the same variety, but most of the time they didn't need your services and so you don't get to see the wide variety of experience that happens outside of a hospital.

Speaker 2: 1:01:25

And when you think, well, if this is what arrives, then this is what is going on outside our doors, then of course, as a healthcare professional, you're like that's crazy talk, because if all out of hospital birth were like that, I would agree with you that that's crazy talk. But the truth of the matter is it's not, and we have not only personal experience but also there's good data that shows that, especially when we subtract the not Intended to be out of hospital births, you have to subtract all the ones that their plan was the hospital all along. We can't count that in with all the people who planned and prepared for an out of hospital birth. The numbers are good.

Speaker 3: 1:02:03

Generally, yeah, the numbers are really good. And the other thing are you, when you talk about that idea of agency and Person who recognizes the importance of their own autonomy Through this process and they still want support, they still want education, they still want healthcare, but they want agency over decision-making and I would say the vast majority of the time that does lead to these incredible Outcomes so I had some questions from someone that has never experienced an out of hospital birth.

Speaker 1: 1:02:35

I've never attended or had a birth on my own. How do you plan for all of the Possibilities other than having that hospital in a bag?

Speaker 3: 1:02:44

Yeah, the same way that you do in the hospital and really the same way. We have checklists and we have equipment and we have carts. So in the burst and we have carts at the home birth, we have containers that come out of the bag and we make a cart, basically, and we have a checklist about what needs to be On there and what items need to be stopped and what medications need to be there, and everything is Orchestrated around how you smoothly move through that space. We do like quarterly drills. We just did a drill where we kind of brought up some of the questions that are easier to solve in the hospital, where patients in a bed and you know the best emergency Emergency management, everybody in that room knows exactly where they're supposed to be and your toes are on somebody else's toes While you're solving a problem, but you know your roles and your responsibilities and it gets solved and we have the same thing. We have roles, we have responsibilities, we have sims where we practice who's doing what and where the only thing is we don't have a reliable hospital bed where a patient is laying down on the bed. So it's, it's really a lot of talking we just talked through about like we have.

Speaker 3: 1:03:50

We do water births a lot people. People be laboring in the water or even birthing in the water. And If we have to get somebody out of the tub quickly, how do we get them out and then put them on the? We make a little landing pad on the floor with blankets and checks, pads and a pillow, or onto the bed if there's time, and how do we place them so that everybody has the most access to what we need access to, so that we have somebody who can place an IV in, somebody who can manage a hemorrhage or whatever is going on with the baby If the baby needs resuscitation. So we do all the training with the Mostly with family practice docs, like we'll do.

Speaker 3: 1:04:24

The. Also training will do all of our training. Every nrp and CPR class I take, there's always nurses and doctors in there. We do it all together. We're learning the same things. The only difference is that there's no button in our room. We don't get to push a button and a whole resuscitation team shows up. We're the button. So sometimes when it happens, I'm like on the button here it goes.

Speaker 3: 1:04:43

But I've trained, I've trained and I've trained and I've trained and I've trained for these things so that when we do need them which is rare that we need them, but when we do we are really ready to go. And Part of that includes how we activate EMS. Part of that includes that I was just talking with an OB at the hospital across the street about Our emergency, how we can work together during an emergency to make sure that everything is facilitated really smoothly. So there's a lot of communication that goes on. We have to know how to instruct EMS because, for example, a critical event with the heart, a cardiovascular event, is treated really differently by EMS when there is a baby in the body, then when there's not, and they're used to showing up on the scene and solving a problem and then going, but with it. In the case of obstetric critical care, we actually just go and we do our, do all the things you know how to do, which probably nobody wants to hear all that but we do all of those items and on the way, because you have to solve the problem in the OR if it's really a critical emergency. So we just drilled on, like how to give orders to EMS, about to override what they are exquisitely trained to do, but they got to be overridden and so some of that stuff where all of a sudden we have to put on our our bossy voice and do all the things in to manage an emergency.

Speaker 3: 1:06:06

And then you know, I always tell people if there's an emergency, I get really calm. But you'll hear something you never heard from me before and I can't replicate it, which is the way that I will communicate with you and doulas that I've worked with that many, many births who've seen me in that space, they know it like like that and a bit that's her like. They just know okay, and then they get hyper attentive and they listen really carefully and everybody becomes part of the team when we're dealing with something that is urgent. But we have all the medications handy, we have everything we need Close by and we just handle it. And if we can handle it all here, we handle it all here and the vast majority of the time we actually do.

Speaker 3: 1:06:46

And then the question is the follow-up. And you know, just if it was something with the baby, what is the follow-up that's required, just physiologically for the baby to be observed? And if there's follow-up that's needed for Somebody who's blood too much, then we just go across the street or we go to the hospital that's nearby and Ask for help. And the other thing that we have is a really nice program with one of the hospitals for people who have Hypertensive episodes during labor or postpartum so that they have really quick, easy access to the care there and they have a huge program For hypertension. So we're part of that program and we've saved a number of lives by having those programs in place and by working really hard to establish and maintain those relationships and by working with doctors who understand every now and then they're gonna see somebody where it's like Everything went sideways and it's one person out of a thousand that they'll see like that and they don't judge us. They just ask how can we help? How can we? What do you need? This? It looks really difficult. Here's the things we would want different next time. But it's later, it's not in the moment. Nobody's screaming each other. We have good relationships and we can approach each other later and say here's what went well, here's what we wish we could change, how can we do this together again next time differently? And we just work together. We're learning together. We believe in each other as learners and that process is really important to the midwives and it winds up being very important to the patients, even though they don't see that side of it.

Speaker 3: 1:08:12

When you go in and there's lots of places where you can look up questions to ask when I'm interviewing my midwife, well, one of those main questions should be how are your relationships with the doctors near us or closest to us? If we're rural, how is it for you? Are you supported? And if they're not, and you feel called towards Advocacy and go be an advocate and your parent, you have a huge voice in how the system works and how we can ask providers to show up and you can go to an OB. You can go to your Legislature, your legislator, and say I want change in the system, I want it to be a different story for People like me who are having babies. I want these systems to work better. I want midwives activated. I want all of my health care providers paid better and become an advocate. There's a lot of room for that and if that's not your thing, then just search really hard for Midwives who believe that the system is, is going to and should work for both them and the people in their care.

Speaker 1: 1:09:16

Yeah, how wonderful would it be if every hospital that delivered high-risk had a low risk birth center attached, so that we weren't understaffed and overpopulated with patients that probably would qualify for a lower level of care.

Speaker 3: 1:09:30

That's the data I actually reduce.

Speaker 2: 1:09:32

Yeah, yeah, it would hugely reduce the quote-unquote burden of People who don't need hospital care. It is it's like going to the emergency department for an earache and there's a lot of reasons socio-economic reasons that people do that. But that's not appropriate use of the emergency department resources. And also, I think you know it's an interesting thing that happens in labor and delivery, because labor and delivery is a combination of med-surge and surgical and pack you and Emergency department. It's all the things in one unit for a very specific set of experiences, whereas in the emergency department they're not.

Speaker 2: 1:10:09

Like clearly no one should drive because another motor vehicle accident has just arrived today, right, they're not. Like that's what you get for crossing the street, you moron, right, like you're living your life, your life thing, and Things go sideways. And it doesn't mean you planned poorly, maybe you did, maybe you didn't look both ways before you crossed, but Probably you were doing all of the things that that are appropriate. And then Nature does things and it's an interesting conundrum in labor and delivery world at large that's for some reason there's this perspective that like if you weren't here for this event, that was your first mistake, whereas the worldview of everybody outside the hospital is the first intervention is leaving your home. If you can make the birth center environment more like your home, with all the things that Jody Lynn was talking about, that's an improvement, huge improvement. You still are the boss of your space, but when you walk through the doors of the hospital you're not, even though you should be. But that's also not like how on earth with the hospital I don't even know, I don't know what the lawyers and all the like there's just different liability. There's a lot of different stuff going on.

Speaker 2: 1:11:24

But in and out of hospital, like all of the providers also much like in the hospital have very clear roles, and so you have no midwife wants to be at a birth all by their lonesome. That's not ideal, because you have two patients, right, and so you need at least two people besides the doula, which is amazing, but not a healthcare provider, right. So you want that person there because that's wonderful and very helpful, especially when they're well trained and like, wow, that great team player. And then baby comes out. You've got someone assigned to baby, someone assigned to parent.

Speaker 2: 1:11:58

It's a truth of postpartum that frequently, if the baby needs help, something happened in labor that the mom probably is also going to need help now. The parent is also probably going to need help now. Like, maybe it's a really fast birth. Well, they're more likely to bleed and the baby's more likely to have trouble breathing. Okay, you need more than one person for those two people and, like Jody Lynn said, we just rarely is it an emergency and when it is, you train and you train, and you train, and you've trained for it and you do all the things you can do while you're waiting for EMS to arrive, and then you keep doing all the things that you need to do in that fast approach to get to a place where they can expedite delivery or whatever needs to happen.

Speaker 1: 1:12:42

So my question then would be it sounds like it's going to be hard if people are listening all over the country decide if they, in their state, would be A qualified, b safe to have either a home birth or a birthing center birth. So what can somebody do to kind of investigate the laws and the practice guidelines and make decisions? That would be?

Speaker 2: 1:13:08

safe for them. I mean the first thing if you don't want a home birth, you want a birth center birth, it needs to be an accredited birth center. So that's all right, I can't think of any other. A, a, b, c, you can find a birth center. You can learn about what happens at birth centers. You can learn about what's going on in your state with birth centers. What do you think, jody?

Speaker 3: 1:13:33

What I would really do is just this is where all the gold is, and when you're pregnant for the first time, you don't know this, but there are robust, amazing parenting groups online and usually like your Facebook, and the problem is they always have like kitschy names, so if you're just looking for them, they're hard to find. Our best one is called the South Seattle Stroller Brigade. It's one of the most supportive, amazing environments. As a new parent or a young parent or parent of any age frankly, of any age children to receive, like what's going on in the neighborhood, I would, first and foremost, just go to a midwife, look up a home birth midwife or birth center midwife and go in and ask is this legal in my state? Do you have access to the medications that I might need if something goes wrong? And hear from them and ask from them where to look, because you can look at your state rules and laws. If you look up any state in the Department of Health, you can look up Muslim Adwifery licensed in the state of. There's a big list of which states are licensed that are kept up to date on the North American Registry of Midwives, which is NARM, and they keep a current list of the states, but it doesn't really matter.

Speaker 3: 1:14:43

In some ways you could be legal, but it's not accepted in your community. And so there you might find midwives who are practicing legally but who are a little bit underground still Not because they're doing something wrong, just because there's no support from the system for what they're doing, but there are parents who are using midwives. There have been since the beginning of time and that has never ended, even though it has ebbed and flowed in different countries and different ways all over the world. In every country all over the world, there have always been midwives. There have always been somebody who's with people while they are birthing. But now we have this other thing of yeah, we could do it legally and we can do it with everything we need and all the resources we want and as part of a larger system.

Speaker 1: 1:15:25

I feel like I would be more comfortable with a home birth or a birthing center birth, knowing all these things Maybe not where I'm at, but if I were to go deliver in Washington state, that sounds like a great place to do it.

Speaker 2: 1:15:38

No place to have a baby. The other thing I think is keep in mind that if you're having a community birth which is any birth outside the hospital, right, so you're having a community birth with a midwife Already your entire course of prenatal care is going to be longer, with more frequent visits. Longer, as in each visit is longer and we have more frequent visits. So we're not just taking the obstetric model and taking it out of the hospital with candles and incense and right. We are actually providing a very different approach to care, besides just being relationship based, but also we are working toward this common goal in a collaborative way with this family, and that takes time, but during that time you also get that much more time to see with your eyes and your clinical mind is this still meeting criteria of safe for out of hospital birth, appropriate for midwifery care?

Speaker 2: 1:16:46

It's the multiple, multiple, multiple touch points quality touch points that help us determine. Besides, just, oh well, clearly you have a chronic condition that would be better cared for in a hospital setting. There's all these little threads sometimes that you have to kind of pull and be like is that a thing? And we have the time to be able to do that and develop the trust ideally with our clients that they trust us. To let the thread get pulled a little bit Sounds incredible.

Speaker 2: 1:17:19

And they trust that we have common goals, but ultimately, their best care in mind and will make recommendations based on that it's not just picking it up and removing it from the hospital and plunking it down in someone's home. It's a completely different experience from the beginning.

Speaker 3: 1:17:37

Yeah, I'll say also that when I first started in this work, the people that would come through the door had some exposure already in their life. Their mom gave birth to some midwife or their sister. They kind of knew about it because there was no internet at that old, but the internet was not functioning the way it does now, so there wasn't like YouTube videos and TikToks and all of this kind of thing where you get this mass exposure to this idea. Frankly, 99% of the people who call because they want a water birth they saw a water birth on TikTok but they don't know anything else about midwifery or anything about you know where's the epidural and where, like if they don't know anything, which is fine, you don't have to know anything. You can come in having seen something about a water birth and we can help you figure out. Is this the right space for me?

Speaker 3: 1:18:26

Everybody wants to keep somebody out of the hospital when being in the hospital a much better fit for them. But now what we're seeing is that there's so much in the air about the health and safety of midwifery care, the questions that people have around am I safe in the hospital emotionally or physically and it's driving people away from the hospital in a way that I find very concerning, and if we know that only a small percentage of the population is really qualified for home birth, but a large percentage of the population is suddenly moved by what they're hearing and their stories of midwifery care, the way that the births look so gentle and they are so gentle compared to what happens in a hospital. We are so respectful of new babies. You would not recognize how we treat a new baby in the first moments after birth compared to a hospital. You wouldn't even know where you are, having not seen it before.

Speaker 3: 1:19:29

We're so respectful of this little, brand new human and what that journey must be like for them, and of the grand importance of the parent whose birth, waking up to their baby in their own way, in their own time, an undisturbed birth, looks very different than it does in the hospital. When we are gently supporting people and we bring the baby to the parent, or the parent brings the baby and we support them to bring the baby up, all parents are still looking up at the sky, and that is where Sarah Buckley said we go out to the stars to meet our babies and you have to give space and respect for the place that parents are when they first birth. They're not here. They're just not here and you can see it. And if you don't disturb them, if you wait about 10 to 15 seconds, all of a sudden their eyes open up and they look down and they smell their babies. That's the first thing they do. And if that space is left undisturbed, we are creating something in this little, tiny space which I guess you can't see me on the podcast, but I'm holding my arm like a cradle and I'm pointing to this little, tiny space which is less than a foot round. In this space is the foundation for the mental health for the future of humanity.

Speaker 3: 1:20:45

This is where babies develop their mental health, right in this tiny little space, by being held by the person who is the best expert and knows exquisitely how to hold that baby in a way that nobody else does, and they wake up to each other over the first few moments of life. The baby wakes up and smells. They use their smell, they start massaging the breast and leaving a trail of amniotic fluid that they will later use to follow. Like a little bird, they peck down the chest and they will self-attach. You can look at lots of videos online of self-attachment and you will see that they have left a trail. They massage, inevitably they massage the skin and inevitably massage the nipple and then they slowly peck over and a person who's holding their brand new baby allows that process to happen, because there's no choice. They're ultimately aware of what this baby's wants are their unique wants and their unique needs are and they follow that baby's process through. And if the providers, if we can keep our hands off and not rough that baby up and let that baby transition into life, and we listen, we listen with the stethoscope and we listen to them transition and I have listened to hundreds and hundreds of lungs of brand new babies and what physiologically happens when they transition to life is a very different than when we are rattling a healthy newborn around and vigorously stimulating them. There's no need. Their parent stimulates them for themselves.

Speaker 3: 1:22:18

The baby, when they're held, normally starts stomping on the uterus. Well, what do we do? We stomp on the uterus to stop bleeding. We do it with our hands. The baby does it. If you don't disturb them, you watch what that system does. That doesn't mean that we don't ever have to do fundamental massage. We do, but the baby does it and for the vast majority of people, that process works without my hands in the middle of it.

Speaker 3: 1:22:41

There's something so profound about respecting those two human beings. What is autonomy? Autonomy is the space to experience this process in the way that you need to experience it and the way your baby needs for you to experience it and for you to come to each other and wake up to each other and start your whole long life together, which, as midwives or doctors, we are not a part of that. We interfere tremendously in the first five minutes in something that needs to be perfect to carry those two people through what we know will be an exhausting first two weeks and a wakeful next 18, 20, 40 years. So we had to remember who we are in that world. We're there for a moment with our skills and our abilities and our time and our minds and all of that. But this is a lifetime that these two people have together and we have to remember how truly sacred that is and how much they deserve to know each other without our face, in the middle of it.

Speaker 1: 1:23:44

So what you're saying is when the baby's born, you don't slap the baby on the mom's chest and then throw a bulb syringe at whoever is drawing the baby off.

Speaker 2: 1:23:52

And make that stressed out face of like is it breathing? Is it breathing? Is it breathing Because it's still attached to the placenta.

Speaker 3: 1:23:58

Yeah, yeah, no, you can actually listen with this methoscope. It's amazing what the human lungs, the lungs, are incredible. I love the heart, I love the lungs. But newborn lungs are incredible because they are not supposed to have air in them. Until they're supposed to have air in them, right that whole gestational period, there's no air in them. Well, to me, I think that the reason some babies cry and not all of our babies cry some babies are born so gently that they're like I like it here, and they're just awake and they're looking around and they're breathing and they're doing what they're doing. But some babies, I think, when they cry it's because of the pain of opening your lungs for the first time. I think it must hurt. It's like getting the wind knocked out of you is how I envision it.

Speaker 3: 1:24:40

Yeah, they pull in that air and then they cry, and that crumming helps expel some of the fluid and push it through the lungs like it's supposed to, through the little, through the little abby olai. So that process, though I think, is a little bit painful for babies, but them doing it by themselves and I mean that's my parenting philosophy too of like all the way through. You know, it's time to use the potty training. No, you're gonna wanna do it by yourself. Humans are born wanting to do things by ourselves. We all know that, three-year-old by myself, I do it by myself. Well, they start out like that and we're designed to do those things and we're not designed for all of these interventions that other people shoving and breathing for us when we're not. We're doing it, we're getting there, we're almost there, and when they're clearing all of those fluids, their lungs open up faster and better than when we do it for them. Unless we need to and we do we don't sit around and watch a baby who's struggling ever, never, never, never. But most of the time they do it by themselves and it's just so gentle and so quiet. The first voice is the parent's voice. The first touch should be the parent's touch whenever possible. That's how we do it and we have caught.

Speaker 3: 1:25:56

I've had six-year-olds catch their siblings. I've had lots of partners. I've had grandmothers. I've had everybody else other than my hands welcoming that baby. I've had the person who's birthing just reach down and get your baby. Okay, you can reach down and catch your own baby. What a precious thing. This is your baby, this is your family's baby. Welcome your baby. Welcome baby, and be welcomed by the people who will love you forever. That's my real.

Speaker 1: 1:26:25

Yeah, I think it's really funny. Just the juxtaposition of the hospital birth when the dad's like, what happens if you're not in here and the baby's born, don't let it roll off the bed? Call me, I don't know, let me know that'd be amazing.

Speaker 2: 1:26:37

I had some interesting experiences as a student midwife in the hospital, because now I got to be the one being like I've got this you guys, I do know how to do this I finally just get to again but the nurses? It was in a hospital where I hadn't been a nurse and so they didn't know that I wasn't a noob, right.

Speaker 2: 1:26:55

And I remember one of my last touches this baby was like you know, the ones that are like all parachuted and like triple around the neck, Like I had to untangle the child was tangled. I have, you could feel it like velociraptors. The nurses were all like give us the baby. And I was like I will not give you this baby, partly because I cannot and also because I don't need to, because they were like do we need to do NRP? They were just all like you know, we haven't heard anything. We haven't heard anything. I was like of course not, it's still attached and I'm gently unwinding it, like I can't even pass it to the parent yet because I have to untangle it from itself and that's not always a straightforward process. And they were like the anxiety level coming from these people behind me and I just had to like throw up a shield of like the baby gets a minute and, frankly, like that timer can't even start yet because we have to like unwrap the baby and also it's still getting blood and therefore oxygen. Like settle down, just settle down, because then the parents are looking past me, to these eyes behind me going you know, with a mask on Right, so they're like, like, manage your eyeballs please

Speaker 2: 1:28:09

because you're freaking people out and this is all under control. I think also Jodi Lynn, the guy everything you say is so beautiful, but I come back frequently in working in women's health with this idea of empowerment. There are a lot of people who like to say they empower people and my position is that you don't empower people. You remind them of their own intrinsic power. They empower themselves and you can support that process. But to say you empower someone is to maintain that power dynamic of you having the power to empower them, which is bullshit. I am not in the business of empowering. I do love reminding people of their power, and this kind of pregnancy, birth and postpartum care does that in a way that I have goosebumps, just thinking about my own experience as a consumer of midwifery care and the home birth that I had just amazing.

Speaker 1: 1:29:12

Well, ladies, this has been very inspiring and educational, and I hope that this can start to open up more conversations about bridging the gap between midwifery and low risk birthing experiences and how we can work together with the hospitals that provide medium to high risk birth experiences and maybe take the load off of some of those centers so that we can all have a healthier experience.

Speaker 2: 1:29:41

Yeah, really everyone, right? Not just the birthing people, but the people caring for them as well. Oh, absolutely, we would love for the people who are medium to high risk to go be in the place where the care is attenuated to them, so that we really can focus on the lower risk population for whom this scope is appropriate.

Speaker 1: 1:30:03

Yeah, and also merge the midwifery model with the higher risk population. Like they need more and a lot of one to one.

Speaker 3: 1:30:11

Yeah, they benefit very much and we need each other, like the OBs and the nurse midwives in the hospital. They need us and we need them. And sometimes, when we have two really robust relationships with different hospital systems and clinics, where we have a bi-directional relationship, where they call us when they need something and we call them when we need something, and when I'll say that to other OBs who have an experience and I'll say, or nurse midwives in the hospital, hey, call me if you ever need anything. These are the kinds of things I can do that you can't do. For example, my liability follows me. So if there's somebody who needs something in their new shelter or in a transitional home or they need a home visit and there's something going on, a barrier to accessing care, we can help bridge some of that for the system. Midwives can do that. And then we have this great relationship where we can take care of people who are moderately low risk but for some reason need to have their baby in the hospital or want to have their baby in the hospital. We can give them this great experience of prenatal care and they can go in birth with those other practices. So I think for and that works really, really well and it's a win, win, win, it's a win for me, it's a win for the client, it's a win for the OB or the CNM in the hospital. It's just a beautiful system. So I think for people who are listening, if you're a parent and you're thinking about I want to know more, if you're a provider and you want to know more, how can we do more work together?

Speaker 3: 1:31:32

I would say I don't have the most open schedule, but I do spend, and even this weekend I spent two hours on the phone with somebody who was just she wanted to learn and she wasn't getting answers from her OB, she was not safe or out of hospital care. We just hung out on the phone and talked for two hours. That's something I feel like I can really contribute to people when you just don't know. I am so happy to have those conversations and to help you think about what kind of questions should I be asking next time I go in and where should I be seeking this care and what if this or what if that?

Speaker 3: 1:32:06

That's the kind of thing I love to think through with people who are pregnant and I love to think through systems solutions with people who are in the middle of the system but want to start to make a change? How do we connect with each other, how do we turn towards each other and create a relationship between each other so that people who are walking around and doing this miraculous thing of growing a human, that amazing superpower, that they're, better cared for, and all of that just? I very, very much welcome being reached out to, and I think the easiest way to do that is on LinkedIn, but otherwise Google, whatever. I'm very happy to connect with other people who are thinking about these ideas and learning, and I love learning.

Speaker 1: 1:32:51

So yeah, and we'll put that information in the show notes I was just gonna say.

Speaker 2: 1:32:55

the midwives I've known in the hospital also are passionate about the midwifery model of care and many times they provide it in the hospital on purpose, by choice in the hospital, because they know that's where most people have their babies and they want more people to have access to this model of care to the extent they're able to provide it in that environment. And so there's. There are many pathways to experience midwifery, but as our topic was specifically for the first day.

Speaker 1: 1:33:25

We can do another topic in another day if you'd like. Yeah, I know Well, ladies, thank you so much. This has been very educational, very inspirational, and I hope that it can be one of the first steps towards just making it better for everybody.