Work Like A Midwife / Care Like A Woman
I’m driving to a restaurant by myself. I’m wearing makeup and my hair is washed, blow dried and brushed. I’m meeting with someone for an interview, so in some ways, this could be considered a work outing. But, as a new mother to an eight-month-old little boy, really, it’s just what the doctor ordered. Or, should I say, what the midwife ordered?
This treat is made possible by none other than my own midwife, who I’m featuring this week for Like A Woman Series’ second issue: Work Like A Woman. Months ago, I approached her about this interview. She accepted, and expressed a preference for an in-person interview, a welcome surprise. Spending time on a laptop typing out answers was not her style, as one might expect of a woman whose profession is literally hands on, and necessitates honest, face-to-face communication.
Our interview creates an easy excuse for two busy women to come together. Over shared tapas at the bar top of a quiet restaurant, our conversation bounces back and forth from questions about her role as a midwife and the politics of midwifery, to catching up like old friends, laughing, sharing, and trailing off topic (at one point I learn that her daughter is a food blogger and at another time, we stop talking altogether to admire a pair of Westies trotting through the restaurant).
In so many ways, this experience mirrors the differences between medical care and midwifery care. In both, you get the basics. You get the standard of care that is required by medical and licensing boards. Tests are run and vitals taken, and typical bedside manner may be offered in both. From there, the paths diverge.
It is these differences that we keep coming back to in our luncheon, my two-hour respite, and where I discover so much more about Paula Tipton-Healy, a woman I’d already felt so close to in our short time together. That level of intimacy between midwife and patient is not unusual in her practice. In fact, it’s what has kept Paula delivering babies for over forty years and even interrupted one attempted retirement.
Meet Paula, a Midwife from North County San Diego, California.
“As a midwife you are really loved, and a lot of times adored by your clientele. As much as my clients adore me, I adore them. I missed the intimacy you have,” Paula says of her decision to return to delivering babies after a temporary retirement. “There’s no other profession that I know of where you have that [intimacy]. You give birth and we helped you with your baby, and we have an instant connection. I know you. I know you really well, not just as your midwife, and I feel like you know me not just as a professional but as a person. That fast-track to intimacy, I don’t know what other profession where you get that.”
“I still get emails and Facebook things and telephone calls,” Paula adds. “I had lunch out on the deck with a client whose son I delivered almost 21 years ago. You don’t forget those people, and you sit down and you haven’t seen them for years and years and years, and they’re like a close friend. I don’t think OB-GYNs have that. They do 30 births a month. In my practice, I do six.”
“I believe that midwives have a combined role as an educator, a counselor, a support person, a medical person, a spiritual guidance if you will, nutritionist and so on. All of those roles come together with our care. That’s what I believe a woman needs when she is pregnant.”
Those unfamiliar with the practice of midwifery care may be skeptical of the standard of care midwives can provide compared to the medical practitioners we are accustomed to treating women and delivering babies here in the U.S. Being close with your doctor may not be necessary for some women. It may even make them uncomfortable. This, however, is something that midwives not only account for, but the very art of midwifery is to provide care for the individual woman. Midwifery, Paula explains, is unique to traditional medical care in that it is tailored to meet each woman’s individual needs, a more holistic and personal approach. What works for one woman isn't necessarily going to work for another. This kind of woman-centered approach might be an appealing option those who want to be an active participant in the care they and their child receive.
“Women have different needs, and I really feel that hopefully the wise thing for a midwife is to be able to understand what it is the woman needs and provide that for her. That can be all kinds of different things.”
Midwifery care is not a new concept, even in our country’s young history. Midwives attended nearly all births in the American colonies, passing along their training from Britain to new midwives as they settled into their life in the colonies. Midwifery also had its place in the South since West African midwives, brought to America as slaves, attended the births of both black and white women in the South. Even after the emancipation of slaves, African-American midwives continued to care for black and poor white women in the rural South. American Indian tribes had birth traditions that incorporated care similar to the practices of midwives. All this is to say that our history is rooted in the role of the midwife, and our country’s foundation in childbirth started with the midwife. By the beginning of the 20th century, with the professionalization of medicine in the U.S., midwives only attended about half of all births in the U.S. From there obstetricians took over.
While 98.5% of births occur in hospitals today (2015), the role of the midwife has never been obsolete. Nurse-midwives have proved influential working alongside obstetricians in hospitals for decades. They introduced and encouraged the concept of family-centered maternity care, to include the idea of having fathers in the delivery room. They played a large role in providing childbirth education to expectant parents, introduced the idea of mother-baby rooming in hospitals versus having them in a separate nursery, and encouraged a return to breastfeeding at a time when hospitals were promoting formula and sterilized bottles.
If the responsibility of attending births at homes and in birth centers wasn’t enough, Paula also has been a mentor to student midwives for nearly her whole career. If you are using a midwife in the general San Diego County region, there’s a pretty good chance that she was trained by Paula. Her role as a mentor is one that she is very proud of, and it is clear that each student has taught her a lot about establishing an positive, open, and effective mentor/mentee relationship.
“I’ve always said, if I’m trying to teach something to a student and they’re not getting it, then I have to find a different way to teach it. It’s not really the student, it’s me.”
This philosophy about teaching is not purely for the benefit of her students. In Paula’s work environment, ensuring that her students understand what to do is critical; having a student who hesitates can be life threatening.
“One comment I get from the midwives I’ve mentored is that they felt like I respected them as professionals from the minute they came in. And I benefit from that too. It’s not all altruism. From the moment they start with me, I don’t see them as a student, but as a midwife. So, they learn to step up and be the midwife because they are treated that way. I really want to do that because, even if they don’t have all the training at that point, I can see that is who they are going to be.”
The reason it has been Paula's customary practice to always work with a student midwife is quite simple and beautiful at the same time: “When you’re in a birth, or even a prenatal, you’re not taking care of one person, you’re taking care of two, all the time," Paula shares. "And I’ve always said that, you need two people to take care of two people, whether the baby is inside or out."
Our healthcare system is coming around to the benefits of midwifery care, especially given the cost savings and positive outcomes of such care. In 2013, the rate of Cesarean sections in hospitals in the U.S. was 32.7%, double the rate that the World Health Organizations recommended. The early 2000s saw a 41% increase in the number of home births performed in the United States. As a result, a study conducted from 2004 to 2010 to determine the safety of planned home births out of concern for the sudden rise in this alternative method. Of the 16,924 planned home births followed during this time period, 93.6% had normal physiological birth, and only 5% were Cesarean sections. Hospitals are waking up to these figures and looking for ways to integrate midwifery practice into their delivery rooms and support the care of midwives for women’s health. Gentle Cesarean sections, an increase in nurse-midwives, and birth centers connected to hospitals are growing in popularity and need.
Still, the idea of giving birth at home is extremely uncommon and met with fear from the general public. What is the first question that comes to your mind when you think about having a home birth? If it has something to do with safety, you aren’t alone.
What if there’s an emergency? is a common question Paula has to field when meeting with potential clients, and a question those who choose to have home births have to answer often. This is the result of a public perception that hospital births are safe, while home births carry an increased risk. A misconception that can be frustrating and downright insulting for someone with Paula’s qualified training and experience.
“In the old days, they [the public] thought we were hippies. People thought we just burned incense if something went wrong or something,” Paula says.
“When people find out that we are equipped like a labor and delivery room, that we have the same certification as the ALS team that comes in if you have a baby with complications, they are surprised. But, we’re able to treat those things. We have the meds, we have the equipment. The only difference is that we’re bringing all that stuff with us. Most of the time, we end up just packing it all back up afterwards. But when you need it, it’s there.”
“I had a birth a few years ago," Paula shares. "A woman hemorrhaged, and I called 911 right away, but by the time the paramedics walked in the door, I had done a manual removal of the placenta, I had my hand up in her uterus doing compressions, I had meds on board and they walked in. I told them everything I had done, and asked them to just stand right there, ‘If I need you, I’ll put my hand back in and we’ll go in the ambulance, but if I pull out and she’s not bleeding, I called you for nothing and I’m really sorry.’ And they were just standing there like, ‘Okay. Sounds good.’ I took my hand out and she was fine. In those situations, that’s how it usually goes. When I explain that to people they understand and feel better.”
“This concern is not true elsewhere. I have a friend who was in Denmark and she told someone she had her baby in a hospital with a doctor and the person went ‘Oh what happened? What was wrong?’ This is because 70% of births are done with midwives and often at home there, and unless you’re a diabetic or have heart disease or other risk factors, you have your baby at home with a midwife."
"Here though, we don’t have a real education in normal birth and normal pregnancy. Our education," Paula adds, "comes from Friends with Phoebe running out the door after her water breaks. There’s no normal understanding of birth.”
While the misconceptions regarding midwifery and births outside the hospital are plenty, there is one that is especially frustrating for Paula, “What really bothers me is If you chose to have a hospital birth in this country and it goes sideways, and you lose the baby or something like that, no one will say anything to you. If the same thing happens at home or a birth center, then it’s all about your choice to be there and it’s too bad. That’s why I feel like with women, this is one of the areas we need to empower women. That chatter out there is not true and it should not alter your decision.”
“Look at the infant mortality rate in our world,” Paula begins. "At the very best, the US is number 65, and that fluctuates some, but generally speaking, that’s where we hang out in infant mortality rate. That means that 64 more countries per capita save more babies than we do. That is unbelievable. The average American has no idea about that figure.”
It is in this discussion, the staggering rankings for infant and maternal mortality in our country, that I hear the impassioned Paula come through. Seated next to me is a woman who is not just delivering babies for the intimacy or the joy of childbirth. She is driven by a charge to right a wrong she sees exist around her.
Paula has touched on a fact that I too am familiar with. I share with Paula that recently NPR has been reporting on this epidemic in our country. In the series called Lost Mothers, its investigation focuses not only on maternal and infant mortality, but also the rise in complications in hospital deliveries and the postpartum period, as well as the disparities among white women and black women with regard to maternity care. For those of us in California, local newspapers are also reporting on these findings, which mirror the national trends.
In May 2017, NPR reported that the U.S. has the worst rate of maternal deaths in the developed world. The public is slowly starting to get wind of this and the outcry will hopefully lead to normalizing the other options for women when it comes to prenatal care and birth. Whether or not you are sold on the idea of home birth, these findings should make one fact clear: the status quo in our country is no longer working, maybe it never did. It is broken and must be fixed. Until then, we are failing our women.
Our conversation shifts to the trends Paula has observed over her decades in this practice. "In the late 70’s and early 80’s, as you may imagine, home births were all 'hippies' – people into natural everything, growing their own food, making their own tofu, growing kefir. It was all those people, and certain religious groups. That was it.”
After that, the demographics were more widespread for a bit. From there, the early 2000s, there was a surge in interest from the highly educated, more affluent communities. “All of a sudden, I’m doing births in Rancho Santa Fe and Fairbanks Ranch, you know, in mansions.” Paula points out that in that past, when she did births in this area, it was for migrant workers who lived on these properties, taking care of the horse stables.
Paula has noticed a change in the people who are coming to her in search of a midwife today. One stark difference between her patients then and now has to do less with their demographics, and more to do with their main concerns.
“Back when I started, it didn’t matter to them if insurance covered or not. They would pay out of pocket because they wanted it. The main deciding factor now, the first question out of people’s mouth, is if we take insurance.”
The answer, fortunately for those looking for midwifery care, is often yes.
“Tricare now pays, so all of a sudden, we have a lot more military families, and now we can take Medi-Cal. PPO insurance pays. I would say about 80% of our clients’ insurance pays at least some of the costs. If I’m in network, 80 to 100% is paid for.”
Paula makes a point to add that her practice doesn't turn people away for monetary reasons, and she chooses to work with her patients so they can have the birth experience they want versus the experience they can afford, something she’s been doing since the beginning. “When I first started doing births, I’ll never forget, I did births for a number of blocks of tofu. That’s what they paid me to deliver their baby. I have done births for homemade yogurt and chicken eggs, and painting my house, fixing my car.”
It may sounds outrageous to an outsider to consider that an acceptable form of payment for the services of a midwife. To Paula, she simply understands her clientele's motivations. “These people were going to do it anyways. A lot of them were going to birth at home whether I was there or not, and I thought, pay me what you can and I will be there.”
With all her heart, passion, and life seemingly dedicated to the care of women and babies, its hard to imagine this wasn’t something Paula knew she was going to do from the get go. Instead, she fell into the world of homebirth and midwifery care in a roundabout way.
Here’s how she tells it:
“I have a client right now and she was born at home, and so was her brother. She’s pregnant and for her it’s a natural choice, not me. This is how it happened, and it’s a weird story. I was really young, 18 or 19 years old. I was studying a lot on my own and going to junior college to become a registered dietician. I had just started this course and one of the things we were supposed to do was a little project where we take diet intake and analysis on one group of people. We were allowed to pick any group that we wanted. Some did the geriatric community, some did children ages 1 to 5. You know, any group that you could put the data together and get an idea of what they ate.”
“I really wanted to do pregnant women [for my assignment]. It just made sense to me. I was a kid but I thought if you could change the nutrition of a woman while she is pregnant, maybe it will help with the baby. I had no reason to believe this; it was just my thought pattern. I didn’t know anyone with babies, by the way, so I was trying to find a bunch of pregnant women. I didn’t know any pregnant women; I wasn’t pregnant.”
“Back then, there were no OB-GYNs, at least, I didn’t know of any or see any. So, I started calling around doctors and nobody would talk to me, they wouldn’t give me the time of day for anything. The secretaries didn’t have time, and I rarely got to even talk to the doctors. Some would say, nutrition doesn’t have anything to do with pregnancy, or they just didn’t have the time.”
“Then, a lady at church told me about a doctor in Point Loma and said you should call him. I called his office and the secretary said, ‘I’ll give him the message,’ and I thought, ‘Okay here we go again,’ and that was it. About two days later, he called me back. He was just so nice on the phone. He listened to me about my assignment, and I waited for him to say ‘I don’t have the time,’ but then he said, ‘Well, I do prenatals on these days and I have an extra little room where I do my stuff’ and he said, ‘If you wanna come in on one of those days, you can sit in that room and I’ll ask each of my clients after they are done if they would like to talk to this woman about their diet.’ And I said, ‘Great.’ So I went in and that’s what happened. And a lot of the women did.”
“I’m meeting these people and [one day] I met this woman and instantly fell in love with her. She was smart, and beautiful and funny and she was having her third baby. She had two little boys and I did the diet intake and all that kind of stuff. We were talking, and she said, ‘Can I ask you a question? Why’d you pick Dr. Repaire’ and I said, ‘Nobody else would talk to me.’ And she goes, ‘Did it have anything to do with him doing home births?’ And I said, ‘Doing what?’” This woman went on to explain to Paula, that, in addition to attending births in hospitals and ABC centers [Alternative Birthing Centers], he also delivered babies at homes."
“Right then, my head was spinning because I had never heard of anything like that, I had no idea. But you know, I’m a child of the 70’s, I’m a hippy, and I just thought, that made so much sense, and sounded super cool.”
“Anyway, she invited me to her birth. About two weeks later, she’s sitting on this side of the wall on the side of her room, I’m on the other side. Her husband is behind her holding her, squatting on the edge of a sofa. Dr. Repaire, he weighed like 300 lbs., he was on a stool in front of her catching her baby. And, I’m on the other sofa, facing them with each of her two little boys, who are just quietly watching the birth.”
“When her third son was born, it rocked my world. I was like, ‘Are you kidding me? This is amazing.’ I was so amazed and Dr. Repaire let me help afterwards, just clean up. It really rocked my world. The next week, I asked Dr. Repaire if I could have five minutes at the end of the day to talk. I told him, ‘That birth was incredible, I am still high a week later.’ I said, ‘I have to do this. This is what I have to do for my life. What do I have to do, go to medical school?’ And he said, ‘Why don’t you come to births with me?’ And I said ‘Okay!’ and I did. That was my first exposure to birth.”
There is a quote that I return to often when I am thinking about birth. It is a nice summation of my learning about the birth, primarily home birth, for the first time as a young adult. It describes the feeling of empowerment that washed over me after making the informed decision to take the unconventional path myself. It is a quote that comes to me when I reminisce about my own pregnancy and the beauty in the messiness of birth. It is a quote about the woman that comes out on the other side, the woman who should be celebrated.
"There is a secret in our culture and it is not that birth is painful but that women are strong." - Laura Stavoe
For Paula and other midwives, this was never a secret.
This is clear to me in our meeting, and in all our prior interactions. It is clear in the stories I hear Paula tell, and the stories others tell about her. Paula and her fellow midwives are working hard to make this fact known, working hard to make sure women believe this about themselves, and working hard to educate the others, so that one day there is a new normal about birth, and it involves a midwife.