The Cara Muhlhahn Midwifery Blog

Cara's Blog

May 16 2008

Moving Forward

ON THE FUTURE OF THE PRACTICE

 

It seems that recently, homebirth midwives, or more importantly, the services we offer have come to the attention of the general public. Jennifer Bloch wrote Pushed Birth. There have been many articles written, notably in The Times (June 2006), featuring Joan Bryson CNM, and in Vogue magazine (November 2007), featuring the writer Daphne Beal, sharing her experience of birthing at home with myself (as her midwife) and Jenna Hutchens (as her doula) in attendance. Then came the movie, “The Business of Being Born” (by Ricki Lake and Abby Epstein) expounding on the care of midwives in many settings, with special emphasis on the experience of birthing at home. Up and coming is the movie “Orgasmic Birth” (although, please don’t everyone count on having one, while giving birth - I’ve only seen this happen twice in 26 years of experience. It’s fair and fun to hope, though, and definitely more possible at home, if at all).

Change is in the air. All of this exposure has encouraged women and families to rethink their childbearing options. Some organizations that bear responsibility for setting policy have gone on record as well. RCOG (Royal College of Ob-gyns) and RCM (Royal College of Midwives) in the U.K. have issued a joint statement encouraging homebirth and delineating steps to make manifest the option for all of their pregnant citizens by the year 2009. This was done partially in response to a study published in 2005 in the British Medical Journal reporting excellent outcomes of homebirths in North America (Canada and USA) conducted mostly by CPM’s (Certified Professional Midwives). ACOG’s (American College of Obstetricians and Gynecologists) response has been to reiterate their opposition to homebirth as a cause celebre while blaming increased cesarean rates in part on women being fat and/or “elderly” (35 and over). I don’t know what percentage of American Obstetricians share the viewpoint of their professional organization. I’m hoping that it is not high.

Currently, in New York City, there are about 7-10 private homebirth practices, most of them solo, most in Brooklyn, all of them run by midwives. In general, this format has been the preferred option for homebirth midwives. We can each accommodate somewhere between 5 and 10 moms-to-be a month depending on how hard we decide to work. That means that, at this point in time, 100 mom’s a month (not nearly enough), approximately, can give birth at home, in the New York city area with the experienced midwives on nyhomebirth.com. I would like to extend that option to more women from here on out.

For this purpose, my practice is currently undergoing an expansion/renovation, as you will. Currently, the basic structure is fashioned after the Dutch midwifery model of care. Midwives have remained the guardians of normal birth in the Netherlands, their system of care continuing to provide and guarantee safe and empowering birth until present day. In this system, midwives are the primary care givers for all pregnant women that begin their pregnancy with the assumption that the pregnancy will progress normally. If a mother already has certain medical conditions, such as hypertension, heart disease, or diabetes and becomes pregnant, her care will probably need to be managed by an obstetrician and/or perinatologist (maternal-fetal medicine specialist). Certain conditions and/or situations that could develop or become known during pregnancy will, as well, necessitate care, either exclusive or collaborative with an ob-gyn, such as pre-eclampsia, insulin dependent gestational diabetes mellitus, thyroid disease, certain inherited thrombophilias (Factor V Leiden), and/or malpresentation (baby in transverse, or breech presentation in labor). Until now, this is how I have conducted care. I use my clinical experience to screen for high risk conditions of pregnancy and refer appropriately, much as a GP does, to a specialist, as necessary. Of course this discussion refers only to the system of addressing and minimizing risk in pregnancy and birth. However, there is another, very important element of care that is rarely addressed or elaborated on for pregnant women choosing care.

The lucky moms to be who do choose midwives for care have the pleasure of discovering that our model of care emphasizes much more than the mechanical elements of growing and pushing out a baby. One of the important elements are, for example, placing an emphasis on power sharing in terms of decision making, a process we call giving genuine informed consent. In general, good informed consent consists of allotting enough time to explain and review honest risks and benefits of any and all procedures, while helping parents come to a decision about which genetic testing, for example to allow (i.e. sonograms, afp, nuchal translucency, amniocentesis), according to their own personal philosophical tenets. In general, we aim to serve as a guide and support through the psychological and physical transformation that begins the journey into and through motherhood/parenthood. We do this by understanding that this transformation occurs in a more empowering way when families have the time and space to have an experience that is not institutionally dictated, often by organizations that necessitate an adversarial agenda underwritten by defensive medicine. We agree, as well, to help create a humane support system for the mom that involves giving attention and reassurance, information, all with the idea of putting parents at ease as they try to navigate this demanding life change.

In this country, strangely enough, it has actually become necessary to re-frame this natural physiological and psychological process as normal and natural, in the majority of cases, as the medical establishment has insisted on defining pregnancy and birth as potentially extremely risky in the majority of cases… If we can’t as professionals and parents reverse this thinking, we are unfortunately endorsing and reinforcing a system of fear that inherently places doctors in the position of rescuing women from pain, and danger and being the ultimate purveyors of safety. If a woman experiences childbirth in this format, she will never get the full power she deserves, and as a result, may be left with a feeling that something is missing and that everything good that happened to her is because of someone else (usually the doctor). This trade off does have subtle residual effects on the way we as women engage in our lives and feel about our lives that are very hard to measure. I know and experience this reality by way of the VBAC (vaginal birth after Cesarean), moms that come to me wishing desperately to give birth naturally this time in order to reclaim an experience they feel they missed. Part of the reason that I have decided to expand sizeably is because I now (probably since the C/S rate is approaching 40%) have many VBAC moms requesting homebirths against the advice of medical professionals. It complicates their search for a natural vaginal birth. A better solution to solving the VBAC at home request would be to make inroads into preventing them in the first place. I have 12 years of statistics that prove a 4.5% Cesarean section rate and feel that it is essential to support and empower women in their ability to give birth vaginally and in this way prevent what all birth professionals know as a less risky form of delivery: vaginal birth, mother nature’s plan.

The small structural changes I have put into place are the following: In general, pregnancy care involves approximately 10 prenatal visits, a few more if the pregnancy exceeds 40 weeks and a few less if you go early or start care late. These visits occur in the home and have always been exclusively attended by me. Now, however, in answer to a need for community support that has both been proven to improve pregnancy outcomes (centeringpregnancy.org) and my own observations about women’s desire for support, I am incorporating some group prenatal visits at my office to enhance community. Usually these visits are attended by a speaker that is of interest to the group. So far Angelica Fox, CSW, a proponent of hypnobirthing, Amy Biasucci, a homebirth mom with a degree in wildlife sustainability who owns an online store ACORN and spoke to us about green pregnancy and motherhood have attended. Our meeting on May 14th, 2008 brought in Pat Cassidy, a long time proponent of the use of acupuncture in pregnancy and labor. She is currently working miracles at Lutheran hospital, aiming to reduce typical interventions such as forceps, vacuum and Cesarean section in the hospital setting. This format will continue into the future and pregnant moms in my practice will have the option of attending as many or as few of these visits as they wish during their pregnancy.

I have also begun incorporating midwife assistants into the practice. In addition to being available to the pregnant women in my practice as a doula-at-a-discount ($1000/birth), each of them has another degree, i.e. RN (Kate) or CNM (Emory) or Midwife in Peru (Tania). This way they can truly be an assistant to me if necessary, while at the same time learning the fundamentals of clinical management at home. There are very few settings where a nurse or nurse-midwife can learn these teachings from someone with experience. The midwife assistants schedule is as follows. They are present at the group prenatal visits so that women get a chance to get to know them. When chosen by a family to be their doula, they will do a prenatal and postpartum visit as well as attend the birth. Eventually, when these wonderful women, complete their further studies in midwifery, they will have the necessary experience to either start their own practices or expand ours. In the near future, then, I plan on hiring new midwives, one at a time. Each will take a caseload of however many patients a month they are comfortable with. Keeping the system of one on one care is important to me and to the women I serve. So, as my practice expands to allow more women the experience of homebirth with greatly trained midwives, we vow to never create a post industrial revolution of midwives on shift work. We are dedicated to spending the necessary time and energy to ensure safe and satisfying passage through this important life transition. And we plan on having fun.

- Cara

1 Comment

  • By Amanda Winrow, October 20, 2009 @ 2:31 pm

    Cara,
    I just finished watching the MSNBC newsfeed on the birth you attended after reading a blog from a concerned family member on homebirths. I must say that I am happy to see you are expanding and not allowing the media to dictate what a normal birth is. I am curious, however, to know if you have a policy on NRP for your employees? Thank you for your time and consideration.
    Respectfully,
    Amanda Winrow, NM

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