Midwife delivery

[paeonia]

Hi Kris,

I was wondering if you have any children and were they delivered by a midwife? Monique is such a heroic spirit, in her efforts to make pregnancy, birth, and the early years of children's lives safer. In this country, the status of midwifery seems threatened again--in my town, the only ob/gyn practice that enables midwifes to deliver babies in the local hospital has just said it will no longer do so. (Having a midwife deliver my son, and having experienced the wonderful care and caring from the team of midwives during my pregnancy, I am a huge believer in this approach, by the way.) Any comments?

[ande]

That's a great question and rich topic for discussion. Kris: I know you have a lot to say on the subject. Have others out there had midwives at the births of their children? Are you considering it?

[KrisH]

Thanks for your comment!

Yes, I have two children, 12 and (yikes) almost 10. Both kids were born at home, with midwives. My first experience with birth was working with Monique, attending women in Mali. Thus midwife-attended, low-tech birth was what felt normal to me. When it came time for me to give birth here in the U.S., I knew I wanted to give birth at home, and with midwives, but I also was concerned about safety. I was in public health grad school at the time and researched safety and birth meticulously. Here's what I found: it's safer to give birth at home with midwives for women at low-risk for complications (i.e., no twins, no high blood pressure, etc.) than it is to give birth in a hospital. And here, in the states, we have the best of both worlds: great midwifery care, and back-up hospitals with physicians in case of emergency.

Why do you think your town is shutting down its midwifery practice? Midwives not only tend to be safer, but also lower cost.

Kris

[maur]

Hi. You asked about midwife-assisted births.
I delivered my daughter at home in the late 70s in northern Vermont, with 3 lay midwives and a friend who was in nursing school in attendance. Although difficult (calling it labor is such an understatement), there were only minor complications. At age 21 this became for me a pivotal entrance into my role as mother and woman, among a community of supportive women and incredible role models.

The concept of birthing as family-centered care had not yet been fully embraced in the 70s. At that time, it was not even guaranteed that the father would be allowed in the delivery room. Today, the family-centered approach to childbirth is de riguer in hospital care, and I might think about my options differently if it were today. Regardless, I would always choose to be under the care of a midwife. The relationship of a midwife to a laboring woman, and one who has seen you through the pregnancy process, is one of the richest experiences possible, and adds a level of safety because of the thread of continuity and mutual respect.

This personal background made my reading of Monique and the Mango Rains that much richer, and also more complex. I eschewed modern medicine in my own daughter's birth, which the women of Mali don't even have access to. I think of Monique as an angel, as I do the midwives who attended my beautiful and blessed daughter's birth. Thanks to every midwife out there.

[paeonia]

The big answer? health care in this country has big problems everywhere, the safest, simplest, even cheapest ways of doing things are not necessarily what prevail. In this instance, I think the practice probably doesn't want to pay any longer for the liability insurance, which has made many obstetricians give up delivering babies. And these things come in cycles. Maybe midwifery needs to be re-introduced to a new generation of women who are planning to have children. We former hippies are grappling now with menopause!
Let's hope your book revitalizes interest in an alternative to the doctor-centered approach. When I gave birth, the doctor assigned to me, whom I liked very much, popped his head in to say he was on the premises if needed, then left us to it. I felt totally covered, in terms of any unexpected complications arising, but none did. I even had my baby without any drugs for pain, although I had been prepared to ask for them if I felt I needed it.

[LSB]

Hi - I am an aspiring midwife currently completing my RN degree to become a Certified Nurse Midwife. I am greatly encouraged by all of your wonderful, positive birth experiences with midwives!

Yes, I would agree that the practise in question probably closed down due to the ever increasing liability insurance costs for Midwives, which from what I have read, have gone up 10-20% in the last few years alone, which doesnt seem to be reflecting popular opinion. I believe that midwifery is gaining popularity among women as a safe, better quality of care and more cost efficient alternative. Which leaves me to question, why the increase? Is it simply that insurance companies view this as another revenue stream or is it that there are actually more lawsuits being brought against midwives? Obviously, this is an important factor in determining the futre of midwifery in the US which is an insurance driven health care system.

I am American by birth but grew up in Vancouver, Canada where midwifery became legislated under the provincial health care system in 1997 meaning that the government pays for midwifery care. As a result, midwives in Vancouver are growing in numbers and cannot keep up with the demand! Hopefully, this trend will follow in the United States.

[KrisH]

Great birth stories, ladies!

The countries with the best birth outcomes all have midwives for pregnancy care and birth, with OBs as backup if needed. It's cheaper and healthier for mom and babe. A recent article stated that in the U.S., 8% of births are attended by midwives. And 27.6% of all births are by c-section! I'm sure malpractice insurance has lots to do with both.

Working with Monique, I experienced a different way of thinking about blame and fault and who takes the heat when things go wrong. In Mali, there is communal responsibility; here there is individual responsibility. In Mali, events can be "the will of God"; here, we try to find someone or some entity to sue. I think these cultural differences in who we believe is in control ultimately affect how we view birth.

Thoughts?

Kris

[SueB]

Kris - your last post was interesting - can you explain more about communal responsibility in Mali? Can you give an example of something going wrong where the community took it on?

[KrisH]

Hi Sue,

Communal responsibility happens for a number of reasons in Mali. There are so many layers to it.

People must depend on one another to survive in an small, agricultural communities. The bonds of extended family, village, and ethnic group are key to survival. Thus, authority, responsibility and accountability lies more on a group level than an individual one. Example: when my crop of millet fails, I depend on getting some more seeds from my neighbor, whose house I helped build last year after the flood, whose mother delivered my sister's baby, etc. Interdependency is the key to living.

People in Mali are heavily dependent on their environment and on the rains (i.e., on things out of their control), therefore responsibility lies with something greater, something unpredictable. When things go wrong, like a season with little rain, no one person is to blame, it's too big to lay in someone's human lap. Don't we say, here in the states, that people find God when they're going through hard times?

When someone's child died of malnutrition in Mali (which far, far too many did in my village), many people viewed it as that child's time to go. No one blamed the mother for not giving enough fluids, or blamed the father for not bringing home enough meat, or blamed the family for somehow not noticing in time. The community gave the child's its blessing upon arrival, God took the child, and the community gave its blessings as they laid the child to rest.

Here in the States, we're the ultimate individualists. We believe that each person pulls herself up by her bootstraps, whether it's true or not. We believe that each person is responsible for her own successes, and for her failures. We want heroes and villains. Failure is hard b/c we take it personally. If we lose a child here in the states (god forbid, and I hate to even write it), the blame and shame (as opposed to the previous example in Mali) is immense. And watch out b/c someone is going to be sued - the doctor. the hospital. the driver of the other car. the babysitter. Some parents will never get over it b/c they cannot stop thinking that they should have been able to prevent it. I can totally understand this thinking.

For another example of communal responsibility, the task of repairing the birthing house in my village was a communal one. Not that of a business that repaired birthing houses, not that of the families who were most likely to use it. It was a village task and it was shared among all families. As you know if you've read the book, the organization of the labor was not always easy. But my point is that the idea of private property and therefore private responsibility was not prevalent. This can be beautiful - a gift to one person in Mali is a gift to that person's family. Everything is shared. As they say, "a gift to one is a gift to all."

Kris

[ghikes]

Kris - I am interested in your comments about who is or is not responsible for bad outcomes. I compare all health care in Mali (and developing countries in general) to that in the US - ie that here we expect that anytime we have a health problem, our doctor or practitioner should fix it - and if they can't we blame - We feel that our doctor, our government, our insurance co - is responsible for keeping us healthy for a long life! Even when the problem is our own lifestyle!! Whereas in Mali, cancer is automatic death sentence, and as you say when someone dies it is God's will --
Illness (inc mental illness) has a different meaning there -- Gayle

[KrisH]

Hi Gayle,

I, too, compare most healthcare in the world to healthcare here in the U.S. b/c our system is the one I know best. I'm not sure about the views and treatment of mental illness in Mali. Sometimes people viewed it as a sign of a curse and would try and take action to rid the afflicted person of said malevolent wish. At least on the village level, the acceptance of people with mental illness seemed pretty high, but treatment was non-existent.

Here in the states, we tend to blame a person for her mental illness (a sign of weakness) and not for physical illness.

Kris

[hollyrcpm]

Hi - I'm Holly, I'm an LDEM (licensed direct-entry midwife) doing homebirths in Utah. I also just returned from two months in Africa, where I have totally fallen in love with the people. In fact, I have been to Africa 4 times in the last 14 months. I am absolutely DELIGHTED with this book. I ordered it from Africa and devoured it almost the second I got home - great job, Kris.

I wanted to comment on the community responsibility - it exists in other countries as well. An on-line midwife friend of mine from the Netherlands has taught me that there is no such thing as malpractice insurance there. They assume that sometimes things happen over which they have no control and they ALSO assume that everyone makes mistakes sometimes. (A dirty little secret we practioners are generally loathe to admit - we are not perfect!) The country will help care for children who are "damaged" during the childbirth process. Reviews happen and if there is an on-going pattern of problems, then action will be taken against the practitioner, but it is a much kinder, much gentler environment than in the US. Oh, and the vast majority of births are done by midwives there, with something like 1/3 being homebirths. Their infant mortality rate is significantly better than ours . . .

And Kris, I'm blogging about your great book over on the Africa adoption blog on adoption.com.

Holly

[ande]

It's so great that you are enthusiastically spreading the word about MONIQUE's message of hope. And you might let that person in the Netherlands know that the Dutch translation of MONIQUE is coming out soon (Kris, do you know the exact timing of that?).
Are there other widwives, doulas and health professionals out there who are or can see using MONIQUE as an educational tool?

[KrisH]

Hi Holly,

Thanks for blogging about the book, and for talking about how midwifery is practiced in other places. We in the U.S. could certainly benefit from the balanced approach to birth practiced in the Netherlands. From a practitioner's standpoint - what do you think can be done to move our country in the direction of better birth outcomes and increased midwifery care? Does it have to start with education? With the insurance industry? With medical school training? Where to begin? I'm asking because these are the questions that I think about all the time.

Kris

[KrisH]

Ande - to answer your question about the Dutch translation of Monique (called "Monique en de Mangoregens: Het Leven Van Een Vroedvrouw In Mali", don't you love the sound of that) - it came out last month, April.