Janet Schwab, CNM: Pioneering Midwifery, Empowering Women, and Revolutionizing Maternal Healthcare

Certified Nurse Midwife Janet Schwab shares her inspiring journey, sparked by the feminist movement and a pivotal Life magazine article, which led her into the empowering world of midwifery. We take a look back at the evolution of midwifery in the U.S. during the 1970s and 1980s, exploring the diverging paths of Certified Nurse Midwives and Certified Professional Midwives. Janet’s collaboration with Dorothea Lange to integrate midwives into hospital settings shines a light on the dedication to improving maternal healthcare for underserved women.

Our conversation underscores the evolution of midwifery from traditional roles to independent practices, marked by the creation of the Certified Midwife credential. Janet recounts shedding patriarchal norms in nursing to embrace a more autonomous midwifery role. Together, we discuss the challenges and milestones in gaining state recognition for this credential, emphasizing the importance of hospital training for enhancing safety. Through compelling narratives, we highlight the contrasting midwifery models in the UK and the US and the ongoing struggle for midwives to gain full autonomy and recognition.

We wrap up by focusing on empowering maternal healthcare providers and the families they serve, encouraging informed choices and uninterrupted care access. With insights into obstetric complications and the importance of personalized care, Janet’s expertise offers a glimpse into the complexities and triumphs of maternal health. Join us for an episode that informs and inspires confidence and strength in your maternal journey.

 
To learn more about Janet Schwab, CNM, and her work, visit https://www.besholembirth.com/ or contact her at BesholemBirth@gmail.com.


Music Credit
https://uppbeat.io/t/soundroll/kitchen-dance
https://uppbeat.io/t/tobias-voigt/hope-and-wonder
https://uppbeat.io/t/oliver-massa/brighter-days
https://Uppbeat @ you-and-me-abby-noise

Transcript

SPEAKER_03 0:00

Welcome

SPEAKER_00 0:17

to the Maternal Wealth Podcast, your space for all things maternal health, pregnancy, birth, and beyond. I am Stephanie Terrio, a labor and delivery nurse and a mother who to three beautiful boys. Each week, we dive into inspiring stories and expert insights to remind us of your power in giving birth and motherhood. We're here to explore the joys, the challenges, and the complexities of maternal health because every mother's journey is unique and every story deserves to be told. This podcast is for entertainment purposes only. It is not intended to replace professional medical advice, diagnosis, or treatment. Always consult with your healthcare provider for medical guidance tailored to your specific needs. Are you ready? Let's get into it. Good morning and welcome to the Maternal Wealth Podcast. Today is a special day. I have Janet Schwab with me. She is a CNM and we are excited to talk about midwifery services in the community. As a labor and delivery nurse, I have noticed many patients coming into the hospital requesting midwifery care, but they have hired an OBGYN or an MFM. a maternal fetal medicine doctor for their birth provider. Today, Janet and I will discuss what it means to be a midwife and learn more about midwifery care. Welcome, Janet. Hello, glad to be here. Great, I'm glad to have you here too. I would love for our listeners to learn more about yourself and what led you to become a midwife.

SPEAKER_01 2:21

Okay, well, I've been a nurse midwife since 1982, so 42 years now. And when I was a young woman in the 1970s, the second wave of feminism was in full force. And some of the things we thought about as young women were, how did we give birth? You know, how were women treated when they were giving birth? And then when I was in high school, I read an article in Life magazine that said, depicted the history of the frontier midwifery and nursing service in Hyden, Kentucky. And this practice was started in the 1930s by a woman named Mary Reckinridge, who was the daughter of a former governor of Kentucky. And she had been in England during World War I and had been introduced to midwives while she was there. And she thought, This would be a great thing to bring to Kentucky, to Appalachia, to the very poor women who don't have access to care. And she ended up doing that. She brought some British midwives to Appalachia in the 1930s, and they're still there today. It's now the frontier. I think they call themselves now Frontier Nursing University, where they educate nurse midwives and nurses. other types of women's health care nurse practitioners. But in their early days, they were midwives providing only home birth care because there was no hospital in the region. And they had to travel by horseback and muleback to get to the women they cared for because there weren't roads or electricity or running water. And that really appealed to me as a 15-year-old, even though I was growing up in New York City and probably never ridden a horse. But I thought, hey, that's what I'd like to do. And that's what started me on the journey. And then in my 20s, I had to think about what I wanted to do, because at that time, there were nurse midwives, but they mostly weren't practicing because they weren't able to. They were in a very few areas in the United States where they were fully practicing their profession. And then there was these People, these folks who were called lay midwives, who were mostly illegal, and they were really coming out of that whole women's movement and kind of the hippie era. Many of you may have heard of Ina May Gaskin. Well, that's the person who kind of ended up being the leader of that movement. And it was from that movement that they created their credential, the Certified Professional Midwife. And so the two professions, the CPM and the CNM, were... striving for more reach to American women in childbirth in the 70s in kind of parallel ways. The CPMs were in out-of-hospital birth, primarily home birth, and the CNMs were in hospital birth. Now, the CNMs were in inner-city hospitals, in rural areas where there were no physicians. CNMs were not welcome into hospitals. university settings and that kind of thing. If a midwife, a CNM, could get into a hospital, it was typically in some very underserved inner city area. CPMs were primarily caring for young, more or less privileged women who were thinking about their choices in childbirth and were saying, hey, you know, there is another way, and I've heard about these other kinds of midwives. So we practiced sort of in parallel. And in the 1980s, I was here in New York City. I was working for a woman named Dorothea Lange, who is deceased now, but she was a great leader in American midwifery. So she grew up in Japan in the 1930s. She has her own story, but ended up in the U.S. and ended up a nurse midwife. She was one of the first nurse midwives in an early program at, I believe it was Hopkins Hospital. And she came to New York and she ended up heading a federal program called Maternity Infant Care Family Planning Project, which was a way for the federal government to help provide care to poor women because Medicaid was not at that time paying for poor women's pregnancy and birth care. Or not necessarily. It was more limited than it is now. And so that was my first job. And I worked in public health departments where we held clinics where we saw women for prenatal care, postpartum care, and GYN care. And Dorothea wangled her way into hospitals. She would say to a hospital, for instance, in Williamsburg, Brooklyn, where that fed into the Brooklyn Hospital. Why don't you take one of our midwives one day a week so that she can deliver babies in your hospital? Just one day. And you'll pay a very small part of her salary and maternity infant care, family planning products will pay the rest. And so she did that. So she was the first to wedge midwives, nurse midwives into hospitals to actually deliver babies.

SPEAKER_02 7:40

And

SPEAKER_01 7:41

then a funny thing happened. First of all, when we started taking care of these, by definition, very at-risk population of women, right? They were poor. They had all of the attendant issues that accompany poverty, nutrition, housing, safety. And their outcomes began to improve. And so what... researchers started taking note of was, hey, when you bring a midwife to a setting, there are fewer preterm births. There are fewer low birth weight babies. There are fewer deaths of mothers and babies, even in these high risk settings. And then another funny thing was happening. While we went into those hospitals, the inner city hospitals, in an era when it was normal where women would labor in one room, And then after she pushed and was close to delivery, she'd be pushed into the delivery room and then she'd transfer onto the delivery table. It was just basically an operating room table that did not necessarily have the ability to even raise up her head. So she'd be lying flat and then stirrups would be attached and she would be strapped down. initially with leather straps, and then later when they invented Velcro straps. And usually there wasn't anyone with her. She was on her own. And she'd be draped in sterile drapes, and she'd have her vulva, vagina, bathed with a scrub brush with betadine. And then the doctor would... inject her perineum with lidocaine, cut an episiotomy, and deliver her baby. And this, you have to remember, was right at the end of the knock-em-out, drag-em-out era, which was prior to this, women were given usually a combination of Demerol and scopolamine in labor. So they were sort of in and out of consciousness, kind of like with the drug Versed. And so when they were in the delivery room, they usually were delivered by forceps because they couldn't really participate in the final effort to deliver the baby. So that's why it was called the knock-em-out, drag-em-out era. And that was when I started in the early 80s. That was fading away. But, you know, women were strapped down on the delivery table and have these episiotomies, and then the baby would go immediately to the warmer. The cord would be clamped and cut. The baby would go right to the warmer. The mother would briefly see the baby, and then the baby would go to the nursery. And then the mother would go to the recovery room where she would often have an injection. I believe the drug was Delodimone to dry up her milk. Like we didn't ask, do you want a breastfeed? Who breastfed? The baby went to the nursery. Mom was in the postpartum recovery room. As midwives, we came in and said, hey, you know, this is really not the way it was meant to be.

UNKNOWN 10:52

Music

SPEAKER_01 11:00

And we wanted to change things. And so I was in a hospital in Brooklyn where I said, you know, there's this new thing called birthing beds where women labor and give birth in the same bed and they can be sitting up and so on and so forth. Initially, they weren't interested. So I would bring women to the delivery room and saying, I don't want to put them on the delivery table. And they'd say, you have to put them on the delivery table. So I would put them on the delivery table, but I would have them lay on their side. I would help them have their baby sidelined, which was a British midwife technique. And of course, that was met with a lot of hostility because I was... doing something no one was familiar with. How could I be doing this? I even got called on the carpet by the assistant chair of the OB department because I wasn't cutting enough episiotomies because I was trying not to cut episiotomies. So we gradually changed the culture of hospital birth with mostly poor inner city women, right? I said, I'm not giving women an enema when they come in and they're admitted to the labor and delivery area. They don't need an enema. I can remember telling a resident, you know, she's still going to be able to give birth even though she hasn't had an enema. They were very skeptical about that. I said, I'm not shaving women anymore. Women didn't wax in those days. And when they came to be admitted to labor and delivery, their perineums were shaved. Their vulvas were shaved in preparation for birth. I said, I'm not going to do that. It's not necessary. So what funny thing happened, at least in the New York area, I'm sure around the country, but suddenly white middle class women from the suburbs with commercial insurance started coming to these inner city hospitals because they wanted what we had to offer. And with that, my answering machine exploded because headhunters would be calling, because all of these suburban OB practices were trying to recruit a midwife so they could compete, right? Because this is the United States and it's all about competition. And even though they had segregated us in the world of poor women, so they thought they had carefully sealed us away from their source of income, right? Those women were voting with their checkbooks and saying, hey, we don't want what you have to offer. We're going somewhere else. And I did eventually get recruited to a suburban hospital. I was their first midwife in Westchester. What got me to go was I said, well, I'll only come if you'll let me rewrite the entire policy manual for labor and delivery so I can provide midwifery care. You can keep doing what you're doing, but I'll do midwifery. And they agreed. This was the mid-90s, so I rewrote the policy manual. I took away continuous electronic fetal monitoring, allowing them to eat and drink and labor, allowing them to have their children present if they had other children, you know, a whole slew of things. And it wasn't just myself. Midwives from my generation nursed midwives in the hospital. That's what we did. And so now in hospitals, you know, birthing rooms and so on and so forth, that's where all that originated. And I do remember into the late 90s when I started to see that they adopted a lot of this kind of way of providing care, at least in terms of the cosmetics. And now we were seeing women obstetricians because when I was a young nurse, there was still a quota on how many women a medical school would accept, right? So... Of course, there were lawsuits around that kind of thing, and quotas were dropped, and then we started to see more women entering medicine. And of course, they gravitated to obstetrics because that was for the care of women. But I noticed, at least in the early generation of obstetricians, that they were philosophically provided care very similarly to their male antecedents, which is understandable. I mean, they, you know... they were being acculturated in that same way. And they came to it as very young women. And there wasn't yet the internet and so on and so forth that might help them to start changing their thinking about how do we deliver care to women. I will say that has gotten better to this day, but I think still obstetricians, the vast majority, whether they're men or women, are still very steeped in what their background is, which is medicine and for obstetricians, surgery. In any event, so at the same time, here I am in New York and we recognize that there was a problem. You know, nurse midwives, first of all, especially from my era, when I became a midwife, I had to shed my nursing acculturation. That is, I'm a nurse. I take the doctor's orders. The doctor is in charge. I am not. And of course, it's not just you know, the definition of those roles was also the era that I became a young woman. And that era is much more patriarchal then. So older nurses would tell me how when a doctor came in the room, they had to get up and give the doctor their chair. So it had gotten better than that, but it still was pretty patriarchal. So when I became a midwife and I had to kind of unlearn that and say, no, actually, I am in charge of the situation. They are not. In any event, we said in New York, you know what? We recognize you don't have to be a nurse to be a midwife. And we recognize that the lay midwives who are now calling themselves, they created the title CPM, and they gradually were trying to establish standards for education, to establish schools, because their primary way of becoming a midwife was through apprenticeships. at that time. And we said, you know, this is a problem. We didn't couch it in these terms because this is a very, it's more of a present day kind of way of thinking. But what I would call it is internalized oppression. So, you know, in the early days of midwifery in the US in the early 20th century, it was medicine that directed how we were created, how the profession was established, the road it took. So initially, they had wanted to suppress midwifery altogether so that we wouldn't compete with them. Then they said, you know, we don't want to really care for poor women. And this was before the era of residents who would use poor women as learning material. They said, so let's turn public health nurses into midwives. And then they'll always have to take our orders. And most importantly, they won't bill. They won't compete with us. But nurse midwives... started to change their thinking because it was a different era. And we're saying, wait a minute, we can be independent. We should be independent. And at the same time, we had the CPM, the Certified Professional Midwife, who were saying, yeah, I am independent. This is a woman-based model, women teaching women, and we're experts at physiological birth, and we're experts at hospital birth, and we're the true bearers of tradition of midwifery as it should be.

SPEAKER_02 18:32

And

SPEAKER_01 18:33

the nurse midwife was saying, no, we're the ones who have, you know, bachelor's degrees and master's degrees. And we're the ones who have all the expertise in seeing abnormal things and being able to recognize when there's a problem and respond to it appropriately. So really what it was, was this dichotomy that had occurred and it was what medicine had caused to happen. And so we said, We want to change this. We want to make a new credential, an American credential called the Certified Midwife. And we did. We had a fight tooth and nail, but we did it. And at the same time, we said, and you know what? We need our own board. We don't want to be regulated by nursing, the Board of Nursing. Because all 50 states recognized nurse midwives and all 50 states had a board of nursing or in Utah, a board of nurse midwifery that regulated midwives. We said, no, we need our own board. We're midwives. We may have been nurses once, but we're not functioning as nurses anymore. We want to be regulated by our own profession. So we created a board of midwifery in the United States and we created the certified midwife credential. And we hoped that eventually the certified midwife credential would be recognized in all 50 states and that with that, the CPM and the CNM would simply disappear as archaic. And we would say, no, the CM is the truly independent American midwife, university educated. And it wouldn't mean that if you were a nurse, you couldn't become a CM. Of course you could. You could be a doctor and become a CM, or you could be an art historian and become a CM. But if you were an art historian, you had to go back and complete the sciences, right? And then once you completed the sciences, along with your bachelor's in art history, then you could apply to graduate school to become a certified midwife. And gradually, the CM is spreading throughout the United States. In the last year or two, Virginia recognized it. Colorado, where I practiced for many years and where they told me, the midwives of CNM said, not going to happen here. No way, Jose. July 1, they recognized it. And that's a whole other story. But it's gradually spreading. And when a state recognizes the CM, it means that the CM can practice everywhere. with the same rights and responsibility as the CNN. They can prescribe, they can practice in hospitals, et cetera, et cetera. And the CM, we hope, then, would bring the two philosophies together of the CPM and the CNN, bring their strengths together so that it's truly an American midwifery credential. And I still have hope it will continue to spread and continue to grow. I became a midwife because of the era I grew up in. For my personal reasons, when I read that article in Life magazine, it all came together. And I've devoted my life to midwifery, and I've practiced midwifery. in the inner city, hospitals, in suburban hospitals. In rural America, I've practiced in freestanding birth centers and I've practiced in the home. I will say, yes, as a nurse midwife coming from the hospital, there were things I needed to learn once I left the hospital about providing care outside the hospital. But I will also say that my education and my experience in the hospital made me a much safer provider outside the hospital. And you know, when I first became a nurse midwife, when I pursued that, I had to make the choice. Did I want to be a lay midwife? Because I wanted to provide home birth care right from the beginning, like those midwives in Kentucky on horseback and all. But I thought, Well, if I provide home birth care and I'm a lady midwife, I felt very strongly I have the lives of this mother and baby in my hands. And I want to be the best prepared that I can be so that I can protect their lives. So I became a nurse midwife. And I have to say, when I was a nurse... and I was strapping women down to the delivery table, I would think, how is this helping me be a midwife? I don't believe in this. This is wrong. But when I was in the home, and now I am in the home, I've encountered some of the biggest complications of my career in the home, which if I didn't have the background I have that came from my education and then my experience in the hospital setting, These women might have died. The babies might have died. But it was my strong background that keeps mothers and babies and kept them safe at home. And so I actually argue that out-of-hospital birth providers need to be more experienced. If you're going to come out of school and say, okay, I'm done. I'm a midwife now. I want to do home birth. You should be working with an experienced person because you're not really ready. And here's the final thing. I think that in the US, women say, I'm a home birth midwife. I'm a hospital midwife. I'm a birth center midwife. And this is kind of unique to the United States. And it goes back to this whole internalized oppression. Because midwives provide care where women need them, anywhere that they need them. And in countries with socialized medicine, you can't do that. You can't say, I don't do hospital birth. I don't do home birth. They say, no, if you want to be paid by the government, you can't say no. Now, I'm not suggesting that would ever happen here or even that it should. But I will say that that's, to me, the real definition of a midwife, that you could walk into a hospital and care for somebody. You could go into the home and be equally as accomplished and care for them at home or in a freestanding birth center. And That's true midwifery. Until midwives can do that on a large scale, I don't think you're going to see a whole lot of change in how maternity care is delivered overall in the United States. And I would also say that there have been many, many, many government studies and so on over the years that have repeatedly said we need to increase the number of midwives practicing in the United States to improve maternal child outcome. It's been shown so many times. It's so redundant. And yet, when you read it out in the news about mothers dying and so on and so forth, they say, oh, well, we need more obstetricians. No, we don't. We need more midwives. You know, it's not saying that midwives don't need obstetricians. Of course we do. But obstetricians need midwives because we're the ones that know how to provide care to women that promotes normal outcomes. The physician is needed when there's a medical problem that they are needed to address. And North Central Bronx Hospital years ago had a model like that. They had all midwives. And the midwives took care of everybody. They had a consultant obstetrician. So it was an inner city practice, high volume. The midwives took care of everyone coming in. And if there was a patient with a medical problem, they consulted with the doctor. And on occasion, they transferred the care to the doctor. And it wasn't a resident, right? It wasn't a doctor in training. It was a board certified obstetrician. And they had wonderful outcomes. And that was the hospital where Westchester women, women with good commercial insurance, started going to, this inner city, grubby inner city hospital, because that's the care they wanted. So I think that if the myth of this idea that it's a doctor, that we need a doctor to ensure safe outcome, and the midwife is kind of like, Oh, it's like we're a boutique thing, like on the side. Oh, that's nice. You know, a midwife, sure, whatever. And I have to say, all through the years when people would ask me, are you a midwife? I'd say, yes, I'm a midwife. And they'd say, well, who's your doctor? Like somehow I wasn't safe or complete without a doctor. And of course, I found that incredibly insulting, but I understood that it reflected our culture of birth. right? Because docs sold themselves saying, you won't die. Your baby won't die if you use us. Even though you might have a birth experience that you find very traumatizing, it's worth it, isn't it? You're alive. Your baby's alive. I think very peculiar to the American birth experience. Because when you go back and look at the history of medicine in the early 20th century, before there was a specialty of obstetrics, right? And they had something called the Great Midwifery Debate. They were trying to clean up their act, medically speaking, because you could become a doctor in many ways, like they were the CPMs of the medical world, where you could just get a mail order degree to become a doctor. And then there were on the other end of the spectrum, men who were going to Johns Hopkins to become a doctor. And they said, we have to eliminate these substandard physicians. We have to standardize our education, standardize our licensure. Oh, and what are we going to do about midwives? Because we don't really want to attend births. It's boring. You know, it's a natural process. We're not really interested. It ties us up for hours. We could be in our office doing things we're more interested in and making more money. But we're concerned because we know that women are the ones in the family who choose where to bring the family for health care. And we know if they deliver their baby and they're happy with that, then they'll bring the family for everything else. They were very much trying to raise their social status. They had very low social status. They weren't trusted. That's where that expression, an apple a day keeps the doctor away, comes from. There was a progressive health movement in the late 19th century where people were promoting exercise and healthy food so you wouldn't have to see a doctor, who were still doing things like bleeding people and giving them calomel, which was mercury, because, again, they weren't necessarily educated. And even though the germ theory had come along, not all of them were educated and knew about those kinds of things. So they were harming people. So they said, well, let's turn public health nurses into midwives because we don't want to take care of the poor. We want to raise our status. We want to take care of the well-off. We want to hobnob with them. We want to make money. And we don't want to care for the poor immigrants. We'll let public health nurses become midwives, then if they're nurses, they'll always have to take our orders and they'll never bill. That's how, as I said earlier, the nurse midwife came about. Later in the 30s, the specialty of the obstetrician emerged. And everyone should be aware, all medical specialties are labeled one thing or another, like internal medicine is a medical specialty. Obstetrics is a surgical specialty. So obstetricians view themselves as surgeons first. Normal physiology, labor, and birth isn't that interesting to them as surgeons. And now we have 33% or more or less of births occurring in the U.S. occur by C-section. And the C-section is the most performed surgery in the United States. Well, that makes complete sense because you have a surgeon taking care of women undergoing a normal physiological process. Not only is their care does not promote normal birth, during labor and birth, but think about it even prior to that, during pregnancy. If you ask women, they say, no one ever talked to me about eating. What should I eat or not eat? Or weight gain. I mean, I have a client right now who just said that to me. She had a C-section at her first birth. And I've been talking to her a lot about nutrition because she eats more or less the standard American diet with a lot of processed foods and so on. doesn't get a lot of exercise. And so I've been talking to her about how these things are important to promote health throughout pregnancy and also help her to give birth normally. And that's a midwifery mindset where we want to speak to women, we want to counsel them, we want to help them stay healthy and help them come to labor and birth more ready both physically and psychologically to give birth normally. In our true tradition, we stay with women throughout labor. I know that's unfortunately not true in a lot of settings in American hospitals. I always tried to do that even when I was employed in a hospital setting, to just be there, just be present in the room, because it makes a big difference. That whole mindset, that whole way of delivering care is absent in labor. medical care in labor and birth. And, you know, I always tell women when they're going to have a hospital birth with a doc, I say, you know, the important thing when you're in labor is the nurse who's taking care of you. Because the nurse is the one of how she thinks and feels about what's going on with your particular labor and birth that's going to really drive your outcome. If you're in labor and you're feeling like the nurse isn't someone who's jiving with your mindset, you don't feel comfortable, you don't feel supported, you should ask to speak to the nurse in charge and ask to have a different nurse. And I think nursing, as I remember it as a nurse many years ago, we tried to do that. I mean, we're like, oh, this patient wants X, Y, and Z. And So the nurse who was more into, say, natural labor would be like, I'll take her, you know, because they're the ones that are on board with that. Because women, of course, when they're pregnant, want to bond with the person who is taking care of them. And they want to be taken care of by preferably only one person. But if they can't have that, they'd like it to be maybe two or three so they can kind of get to know everybody so that they can feel very safe, like they are connected and safe so that when they're in labor, they can feel that way. But in our system now, even in the bad old days, there used to be private practices where two or three obstetricians were in practice together. So you kind of could get to know your doctor. Now, private practice is virtually gone. And physicians like everybody else are employed by a corporate employer. And they're huge practices. And so you probably don't know the doctor who's taking care of you when they actually are in the room. So the shift changes and another doctor comes and another nurse comes. Those are precisely the things that are not going to help you give birth normally because our neocortexes want that sense of safety. to be able to go where we need to go to labor and give birth. Hence the importance of a doula, because at least that's somebody that you've made a relationship with and can provide you with that support and caring through your labor and try to help you get the kind of birth that you were hoping to have.

SPEAKER_00 36:34

As a labor and delivery nurse, I was really taken by the information that you were saying, that you learned skills in the hospital that transcended into your care at home. There is this general consensus that home birth is dangerous. I would love to hear the skills that you talk about that you learned in the hospital and how, in the event of an emergency... You use those skills, keep moms and babies safe and alive at home.

SPEAKER_01 37:05

Well, this idea that home birth is unsafe, I think, derives from the fact that most home birth in the U.S. is attended by the certified professional midwife. And despite their title, in my view, not professionals. They're not well-educated. They learn by mostly apprenticeship skills. And they don't get, first of all, the didactic foundation to understand even, I mean, and I have long experience interacting with CPM, so I'm not, this is not just my biased opinion. I mean, this is based on experience. Even things like the difference between a virus and bacteria. And in addition, so they don't have the didactics, when they have problems, at home, they don't necessarily recognize them because they don't have the didactics and they don't have the experience, and they have an underlying mindset that birth is natural, so therefore you shouldn't intervene. So when there is a problem, they don't recognize it, or they recognize it too late, and then you have a bad outcome. So how is it? Yeah. So when I am at home, I had the worst hemorrhage of my career, postpartum hemorrhage of my career at home. And if not for my long experience, she would have died. But, you know, I recognized there was a problem because she started to have bleeding. Once the baby was born, we're in the third stage. I assessed that the placenta was still Not separated. And I thought, I'm having some partial separation here. Why is that? I mean, I hadn't done anything like pull on the cord or massaged her fundus. This was happening spontaneously. I immediately gave her an injection of Pitocin IM. I immediately started an IV and put Pitocin in that. And then her placenta deliberated. She was hemorrhaging. And we got it under control. She'd lost probably a liter of blood, and I had the IV going, and I'd given her many meds at that point. And then all of a sudden, she started bleeding again. And in the end, I got it under control. Her uterus was very atonic, without tone. And I was very perplexed, but I got it under control. I said to her, you know, I think we need to go to the hospital. You need to get blood. And of course, she was an RN. Of course. You know, health care providers, that's a risk factor. I don't list that in the list of risk factors, but definitely it's a risk factor. And she was a NICU nurse, note to boot. So I said, you know, I think you should go to the hospital. We need to get you some blood. And she's like, no, no, I don't want to go. I don't want to go. And at that point, I had a Foley catheter. in her to keep her bladder empty. I had IV going. I had oxygen on her. I said, we've got an ICU going in here. So I spent like 12 hours with her. And when I was convinced she was stable, I left. Both the grandmothers were there, so they were taking care of the other two kids. I came back the next morning and I pulled out her Foley and She was able to barely walk. And I finally convinced her a day or two later to go into the hospital and get blood. And then weeks later, she started having some bleeding again. And I sent her for an ultrasound. I thought, oh, maybe it's sub-involution, you know, after everything she went through. Well, it turned out that she had an accessory lobe to that placenta that was a procreta. And that's why we had that hemorrhage. And so I thought, wow. She was closer to death than I thought. Now, if I had not immediately given her that pit, started that IV, given her all those meds, yeah, she would have bled out. So how did I know to do that? Right? Just from a little bit, not much, just a little bit of this odd bleeding. Well, that was years and years of experience combined with having seen many postpartum hemorrhages. And I'm like, This is something's up here. I don't know what it is, but this isn't normal. And it's interesting to me because a lot of my interactions with CPMs and abnormal outcomes has been around the third stage, management of the third stage. Or I'm listening to a baby. right, with my Doppler with intermittent auscultation, which is recognized as totally appropriate to do even in the hospital. And some hospitals do offer it, whether they're midwives, where you listen to the baby with a Doppler every half hour during and after a contraction because they're a low risk. They're not on Pitocin, anything like that. They're just laboring. They don't need that continuous electronic fetal monitoring. And I've picked up late decelerations. Now, how did I do that? Well, Years of watching late decelerations on fetal monitors. I'm like, oh, that's a late. We're not staying here anymore. We're going to the hospital. Someone pushing, a molten pushing and having minimal descent, very slow descent. And I'm like, yeah, we're heading towards a shoulder dystocia here. We're going to the hospital where we have a shoulder dystocia and a hemorrhage. Yes, so over and over and over again, that was from, how did I know that? Well, I'm very experienced, and I've seen that. I think I brought three women in my career, my home birth career, to the hospital, not in labor, saying, this woman has help syndrome, which for your audience, that's like a very severe form of preeclampsia, but it's even more dangerous because they can rupture their liver. And three times I've been told, no, she doesn't. And I'm like, yeah, she does. And I've been proven right every time. One time I remember the doctor was totally mocking my client and saying, now, why do you think you have health syndrome? Like she was insane. You know, like she had von Munchenhauer syndrome or whatever. You know, why do you think that? And so finally, I was trying to send her home. And it was in a small city, Colorado Springs. And I thought, well, I can bring her to Denver Health, but it's over an hour drive. I don't think she's stable enough to do that. So I called the University of Colorado and woke up the doctor and said, this is what's going on here. What do you think? And she's like, oh, you're right. She needs to be admitted and started on med. And going back and saying to this doctor, well, I just called Dr. Such and Such, and this is what she had to say. And that mother got admitted. And I have to say, in labor, she had an epidural placed because she was not in pain from labor. She was in pain from her liver. Her liver pain, referred liver pain to her mid-back was so bad that she was just out of her mind. So they started an epidural for that. It was her third or fourth baby. Once they broke her water, she was 37 weeks. She was laboring. And of course, they were pouring IV fluid into her, which is something I object to even in healthy women. But here she was, you know, with help, which they're still denying she has. I point out to the doctor and nurse, I say, look at her Foley, her catheter. She had no urine, like a little bit of, you know, a few cc's of brown urine in the tubing. That was it. I said, all this IV fluid, no urine. And they went, oops. And all of a sudden, they turned down the IV and put her on a pump because, yeah, she was sick. And then what happened? Oh, her liver enzymes exploded and blah, blah, blah. And I recognized it. Why did I recognize it? And she was only one of three women. I would feel like Oliver Twist. Please, please, doctor, can we have, can we admit this patient? She's sick. And they're like, no, she's not. She needs to just go home. You know, there's nothing wrong with her because I'm picking up. Look, her bone now is pushing out immature platelets because her platelet count is falling. Oh no, this isn't health syndrome. It's like it has to hit them over the head with a sledgehammer. And why is that? Because they're not very good at what they do and they haven't seen very much health syndrome because you don't see very much health syndrome in your career. But I had because I'm so old. So I'm like, no, this is help. And they're like, no, it's not. So I've had that happen three times where I literally saved a woman's life because she was so sick. And, of course, you know with help, one minute they're like, is she sick? And the next minute you're like, oh, my God, she's really sick. It's so fast. Three times. Now, if I had been a CPM, I would not have recognized it, obviously, because even the doctors weren't recognizing it. Yes, education and experience matters. And, you know, I have a very dear friend who's a CPM and she's an excellent CPM. And the reason is she recognizes, wait, there's something going on here that I don't know enough about. And she consults. with somebody else who knows more, and hopefully that person recognizes the problem and says, yeah, you're right. You were right to ask me about this. This is a problem. We all do. You know, when I was a midwife in the mid-90s at a fancy private practice, it was the one where I rewrote the policy manual, and I was in the operating room with a client of mine who needed a C-section, and the surgeon said, was continually reminding us that he was Princeton educated, did his residency at Mount Sinai, very prestigious OB residency. He nicked her bladder while doing the C-section, which was a primate. And this is, you know, a possible risk of cesarean birth. And he turned to the circulating nurse and said, well, who's the urologist on call today? And I went, what? What about vicarious liability? Now, do you have a written practice agreement with that urologist that he agrees to respond to your call if your patient needs urology care because you screwed up in the OR? I'm thinking all this. Because that's what we had in New York at the time. At the time, the law said we had to have a written practice agreement with an obstetrician saying, yep, if you need help in your midwifery practice, I'll be your savior. I'll be your daddy. I'm your daddy. And I went, oh, the light bulb goes on. And then another time, the same practice, they had a patient they did a C-section on and she got a post-op infection. But it was so bad, they couldn't cure her. So they had to consult with an infectious disease physician. And I'm like, wow, what about vicarious liability? Like, what if she has, you know, permanent whatever, disability or, you know, she's going to sue that doctor. Because of course, everybody gets sued, right? When there's a lawsuit, you all get sued. I mean, my joke used to be in the ghetto when I'd be asked to take on some patient that the doctor had been royally messing up. I'd be like, You're not even going to find my fingerprints on that chart, because then we had paper charts. Because I'm like, no, I'm not getting involved in this lawsuit that's about to happen. You've so messed up here. So wait, we all in the healthcare universe need each other. We all have our contribution. And the doctor is not the captain of the ship. Doctor is not God. Doctor does what the doctor does. And we do what we do, whether it's a nurse or a midwife or what have you. We all contribute to the care of the patient. And so when we come into the hospital, we're independent. And you just butt out until we ask for help. Just like the urologist doesn't check in when you're going into the OR and say, hey, you know, I know this is her third section, so be careful. There's going to be a lot of adhesions in there. Don't nick her bladder. Or the infectious disease doctor doesn't say, hey, she's got chorionitis and she's GBS positive. Listen, are you giving her the right antibiotics right now? You know, I don't want to have to be called in later. No. They're like, I'm here if you need me. Give me a call. Same thing with the midwife. And by the way, in the UK, nurses don't practice where the midwives practice. The midwives do all the care. The care that here would be considered nursing care, like running the pit, giving the antibiotic. No, the midwives do it all. And I find that interesting. As I told you when we spoke earlier, I don't think I could do that. I'd have to be brought up to enough on those skills. But they are keeping the medical model out of birth, including nurses, because nurses take care of sick people. Why would they be with normal women in labor? So they're not. I think the British midwives really got to lose that blue and white pinstripe uniform. But otherwise, I think that's a pretty good deal. And of course, they do everything. They go to the home, right? Now, the NHS, National Health Service, is supposed to provide home birth care. But because they don't have enough midwives and they find it difficult to offer it, because the midwives from the hospital go to the home. Oh, so they're on the floor. Yeah. They cover all areas. And let's say you're an independent midwife because there are independent midwives in Great Britain and you're an independent midwife. And normally you deliver babies, I don't know, in a certain part of London, but then it turns out you're going to do a home birth in another area that you don't normally go to. You can just go to that local hospital and go, hey, I'm going to be in this area for a home birth and I need temporary admitting privileges in case I have to come here. And they go, okay, fine. You got them. Can you imagine? No, I can't imagine that. So in the United States, hospitals are governed by CMS, the Center for Medicare and Medicaid Services. They write all these rules. So if hospitals want to get money from the federal government, either for Medicare, Medicaid, or if they have residency programs, right? Like all those obstetrical residents, right? Their salaries come from federal funds, come from the CMS. So if they want to get that money, they have to follow their rules. They have a lot of rules to make standards about delivering patient care. And they have a rule about admitting privileges and they address Midwives, and they have said for years in their rules, you know, as long as there's nothing in your state law that doesn't allow a midwife to be independent, meaning a certified nurse midwife or a certified midwife, if there's nothing in their state law that says, you know, they're not independent, and there are still some states that have that clause slowly being diminished. But like, for instance, in New York, we don't have that. then the hospital can choose to say, oh, then the midwife can just show up like a doctor and say, here's my license, here's evidence that I have medical malpractice insurance, don't have any felonies, et cetera, et cetera. I'm proving that I'm not a risk in any way. Give me admitting privileges. And they're like, okay, fine, you can have them. And not only that, but you're an active member of medical staff. Very few hospitals choose to do that, even when they could. What they do is they say, no, we want to have allied health or other terms they use for that, meaning the midwife is part of allied health, like a PA is. PAs, their licenses are tied directly to a physician license. They were created that way so they could never be independent and bill independently. That's a whole other story. But in any event, So they say, no, midwife, you have to show up and have a signed agreement with an obstetrician, not just any doctor, an obstetrician, not a family practice doctor who does birth, not even a family practice doctor who's credentialed to do C-section, because we're not going to let them do a C-section because then they'll compete with us, be an obstetrician who says, yep, I'm going to be the daddy for this midwife. What does that do? Well, that makes it very difficult for midwives who are not employed by a doctor or not employed by a facility, right, or a corporate entity, get their own independent admitting privileges. So what does that do? It prevents them from billing, prevents them from competing. So let's just say that Two or three midwives came to a hospital and said, hey, we want independent midwifery privileges. We're doing home birth. We're doing hospital birth. Oh, and we're going to even build this freestanding birth center. And we're going to really do this woman-centered care, et cetera, et cetera, et cetera. What would that do? Well, that would start to take patients away from either doctors and private practice, if there are any of those left, or the corporate model, where These are our 15 doctors and our 12 midwives, you know, and try to get to know one at each visit. Women will be like, oh, you know what? I have my checkbook here. Nobody has a checkbook anymore. I have my debit card, my credit card, whatever, my HSA card. I'm going to that other practice down the block because I like that model better. So, of course, they're not going to let that happen. Of course not. And they always couch it in safety. Oh, you know, you don't want to go, they're not safe. You know, their babies, they die. Even though we know, the data says, anywhere a midwife practices, outcomes improve. Even if she's employed. Even if she has to put up with a bunch of bozo doctors who are, I mean, I remember when I practiced in Brooklyn, I mean, All the doctors were supposedly attendings, right, that were employed. This was a relatively new model. This was the 80s. And they were so bad that actually the chair of the department met with the midwives privately and asked us to supervise his doctors and to call them when they were screwing up, which we were already doing. So they were so bad. But we went into facilities like that and we improved safety of the mothers. But Obstetrics as a whole has always driven this home since their inception. We are your protector. If you want to be safe, use us. Use a doctor, use a hospital and put up with everything because after all, right? You want to be alive. You want your baby to be alive. But the problem is that their outcomes stats are not that great and they're getting worse. There's a bit of a conundrum there. Like, well, time in the background. What everyone knows, anyone who's ever looked into it, is that midwives improve outcome.

SPEAKER_00 57:50

Well, Janet, we're reaching our time. This has been a great conversation. I think about the earlier part where you said when you were a new nurse, a new midwife, and you're going into the hospital and you're telling these doctors, This is wrong. We're going to change it. We're going to do it this way. And how strong you had to be to be able to speak up and use your voice. And I think that's amazing that you did that for those women.

SPEAKER_01 58:18

Yeah. Well, I wasn't alone. My whole generation did it. Why things at least are somewhat better. Yeah. They ultimately will only truly improve until there are more midwives and there won't be more midwives. unless there's a concerted effort to make the CM legal in all 50 states and grow the midwifery profession. Because there's a sea of women out there who would like to be midwives who don't want to go to nursing school. And many of them already have bachelor's degrees.

SPEAKER_00 58:56

Well, thank you again for joining me.

SPEAKER_01 58:58

Thank you.

SPEAKER_00 59:10

I want to remind our listeners that maternal wealth is a safe space for all maternal health providers. I truly believe there is a need for everyone involved in this field. Each woman, mother, and family has specific needs and unique desires for their individual care. Here at Maternal Wealth, we respect and honor the diversity found in maternal health, and maternal wellbeing. I believe that all women deserve to be fully informed about their options and have uninterrupted access to care. Please follow us on our social media platforms at maternal underscore wealth on Instagram and and maternal wealth on Facebook, visit our website at www.maternalwealth.com to sign up as a maternal wealth provider or search for maternal wealth providers near you. Lastly, check out our birth course where I discuss how hospital staffing, policies, and access to medication can affect your birth experience and outcome. Stay strong, stay empowered, and remember you got this.