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Tuesday, August 23, 2011

Illegal Midwives?

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

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

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

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

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

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

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

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

The doula is the interface between the birthing community and the medical establishment. This puts us in a difficult position. I have spoken to  women who thought that I would leave them to give birth alone if they decided to take an epidural (this is beyond cruel). I have been yelled at by a physician who thought I had removed an intravenous drip (the nurse hadn’t had time to put it in). I have been looked upon as a knight in shining armor (I don’t even like horseback riding) by women who had not yet understood that the birth work is done by the birthing woman.
I have also been thanked and cherished by hundreds of women who have been happy to have me by their side as they go through the experience of giving birth. My task, our task as doulas, and in a bigger sense, our task as human beings in the 21st century, is to “humanize” birth. To me, that means affirming that all of us are different, and that we all have needs, desires, and histories, that cannot and should not be judged. 

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

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




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