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Lately, I've been asked a lot by prospective student midwives and classes of high school students to share about the hardest part of being a midwife.

I usually will laugh and say it's the lack of sleep that goes along with birth work. But honestly, I don't really mind missing sleep. In the moment, it can be hard to have been physically awake for more than 24 plus hours, but we make do.

I've been really pondering this question internally, though: What is the hardest part of being a midwife (for me)?

I've come to the conclusion that it is the never ending questioning that I do of myself, or my actions, of how things play out.

There are a handful of births that haunt me, that I constantly turn over and over in my head, thinking about them from different angles, wondering why things happened the way they did. This has got to be the hardest thing. I've attended a couple of births which I have thought about daily for what seems like months, and then the memory slowly fades from my daily thoughts, and then when a random occurrence brings up the memory, it feels as if a scab has been pulled from my skin and my emotions are raw all over again.

(I want to make it clear that these handful of births had good outcomes...healthy mother, healthy baby. Some were transports, some were homebirths.)

Being a midwife has taught me so many things that have nothing to do with birth or babies. It has been an amazing journey. I suspect that many midwives begin their journey with their ego leading the way. There are many other professions where this is probably the case, but in midwifery, I run across it often. I know that for me, personally, being involved in birth and midwifery has taught me (and I am still learning!) big huge lessons about the ego.

Where are the mothers?

I live in a city with a hospital that has roughly 3,500 births every year.

Their cesarean rate is very hard to find (as are most hospitals'), but based upon information from some of the doctors and nurses that work there, it is estimated to be around 50% (some say closer to 60%). The rate is, in part, this high because the hospital doesn't "allow" VBACs. So, the many first-time mothers whose labor inductions fail (induction rate is very high in my area) or whose labor is taking too long that end up having a cesarean...with future babies, they are told that they must have a repeat cesarean. I have met many mothers in my city that have had 4 and 5 cesareans. It is criminal.

There is a hospital about 20 minutes away that allows providers to attend VBAC, though not every provider does.

Where are the mothers? I am a little surprised to see how very, very few women seek out the services of a midwife for an out of hospital VBAC. I would expect there would be such a demand that we would be needing more and more midwives to accommodate the demand. But, there isn't.

Of course, not every mother will decide that an HBAC is the right choice for her. But, it makes me wonder...where are the mothers? Ar they signing up for repeat cesareans? Are their doctors telling them that, although their hospital doesn't 'allow' VBACs, even the National Institute of Health came to the conclusion that a VBAC is a perfectly safe option and that perhaps they should look into different birth options? I seriously doubt that.

There are approximately 50-60 homebirths each year in my county. It would make me so happy to see that number sky-rocket in the coming years.

Pet peeve

I need to clear something up.

I notice all of the time on message boards, news articles, or among conversations in person, that many people are under the assumption that DEM (direct entry midwife, a midwife who has not entered midwifery through a nursing degree first) and CPM (certified professional midwife, a term created by NARM) are synonymous. When asking about midwives or referring to midwives, it sounds like you now have two choices in the US: Certified Nurse-Midwife and Certified Professional Midwife. This is not true. CNM and CPM are not the only options, and DEM is not the same as CPM. (Though most CPMs are indeed DEMs, the reverse is not true).

All of these letters make things confusing.

A midwife can be a midwife without being a CPM. There are many, many fabulous and highly expereinced midwives in our country whose title is 'Midwife', not CPM or CNM or CM. And there are currently wonderful student midwives in this country who are apprenticing with a homebirth midwife who have no plans whatsoever to become certified. We need to stop expecting some certifying body to determine who is a midwife.

Please, please, please, people...stop referring to ALL non-CNM midwives as "CPMs". This is simply not true and it does a huge disservice to midwifery.

EC the second time around

The following is my own experience with EC. There are many great website explaining the why's and how's of EC, and I will include links to some at the end of my post. I am not attempting to teach people how to practice EC with this post, but I simply want to share my own experience with it here.

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With my first son, we practiced elimination communication (EC) from about 3 months old onwards. We used cloth diapers when we went out until about 7 months old, and from then on, we just took him potty wherever we were and stopped putting him in diapers. He was reliably dry (or would wake to potty) from about 7 months onwards, as well. We had carpeted floors at the time (for those wondering).

I wasn't sure how I was going to approach diapering with my second baby. I knew we'd use cloth diapers, and I knew I'd be taking him potty sometimes..I just wasn't sure how I'd manage doing EC full time this time around, since I not only had an another child to care for, but I knew I'd be taking my baby with me to births and appointments for a good part of his first year.

So, my second boy was born. Within the first few days, I started putting him on his potty for bowel movements. It seemed to help him calm down and he was less gassy. (I recall this as well from my first son.) He was still almost always in a diaper, usually a prefold held on with a snappy. I didn't put covers on his diapers when we were home, because I wanted to know right away when his diaper was wet, so I could promptly change it. I would also always talk to him about his pee "Oh, did you just pee? OK, I'll get you a clean diaper. You can pee in the potty, too. That might be nicer for you."

My second son sitting on his potty, 5 months old.

When he was with my during prenatal appointments or births, I always had a diaper and cover on him (or an all-in-one diaper), and wasn't able to pay much attention to his pottying. I'd just try to check frequently to see if he'd peed yet (maybe every 30-60 minutes when he was awake) and then change his diaper. Yes, I went through MANY diapers this way. But, I think it was key in helping him to not get used to the feeling of ignoring that function of his body or the feeling of a wet diaper.

When we were home, I began to let him be diaper free more and more. I found that we 'caught' more pees this way, and it felt like much less work to wipe up a 'missed' pee than to put his diaper on, take it off to offer the potty then put it back on. I also noticed that when he was diaper free, he seemed to empty his bladder more fully. When he would pee in his diaper, it was as if he'd pee a little, then 10 minutes later a little more, etc. When we took him potty and he peed, he wouldn't need to pee again for maybe 30 minutes. The interval between pees has increased as he has grown. (For example, he is now 17 months, and sometimes goes 3-4 hours without needing to pee).

He was in diapers MUCH more than his older brother was during his first year, partly because he was with me at work and partly because I don't feel like I was able to pick up on his cues as well as I could with my older son. In fact, I'd even say that I feel like he wasn't doing any cues for a long while. I mostly relied upon my own intuition that he needed to pee.

In the car, he was in diapers, and around 12 months old or so, I started just setting a diaper in his carseat and then setting him in his car seat. That way, it was there in case he peed, but it wasn't attached to him. If we drover more than 30 minutes or so, he'd usually end up peeing. We also had these nifty waterproof pads in his seat that I really like. In the last month or so, I've stopped putting a diaper in his seat, as he is so reliably dry now. My normal routine when we are driving somewhere is to take him potty just before putting him in his seat, and he usually pees. Then I pull his pants up and sit him in his seat with no diaper.

In the baby carrier, I place him with just pants, not diaper. When he was younger, I would sometimes place a folded prefold between he and I when he was in the carrier, just in case. However, he normally lets me know he has to pee by sort of squeezing his legs when he is in the carrier.

For bowel movements, he has much more reliably let me know since the beginning. The sign that he gives me now is so hard to explain. I can actually even hear it in his step if he is running to me from another room to tell me he has to poop. It is so interesting to see how I have learned that cue so well.

At night, we have been sleeping with him diaper free since about 4 months old. It was just easier to keep his diaper off and take him potty than changing his diaper. I keep a little potty (or two) by the bed on the floor, and have gotten to know his nighttime elimination habits. He normally won't pee until he has nursed when he wakes in the middle of the night. When he starts to sort of move around and not able to focus on nursing anymore, I know he needs to pee. When he empties his bladder in his potty, I know he won't need to pee for a few more hours, so we sleep deeply in peace. And, now that he is 17 months, he usually only needs to pee once in the night (even though he wakes to nurse 2-5 times during the night), and occasionally, he won't pee at all and will hold it all night. We he wakes in the morning or from naps, the first thing we do is take him pee. He will then pee almost all of the time. I do keep a large over sized waterproof pad that I made underneath the sheet in out part of bed, just to help protect the bed. I also have 2 smaller waterproof pads that I place a prefold on top of and then lay that underneath him. When he was younger, I would regularly miss pees every few nights, and this was a nice and easy way to keep the bed clean. Now it rarely gets used. Nighttimes are actually pretty easy. This is no doubt due to the fact that babies don't pee when sleeping deeply. They will always rouse to pee (though it may seem that they are sleeping...they are likely just in a light sleep cycle). They also tend to produce less urine at night, thanks to the antidiruetic hormone.

The aspect that I love about EC so much is the simplicity. It feels so normal and seamless to me. There is no 'potty training' time, it just sort of morphs into a baby/toddler who knows what their body is doing. I don't think it is the "best" way to approach diapering and pottying, but it is certainly a real option and one that some people will really come to enjoy. However, I do acknowledge that the vast majority of people in our culture do not want to fuss with taking their baby potty.

I hope from this post you gleamed a small insight into what it is like to EC. It might sound like a lot of work, and indeed, there have been times where I feel crazy for doing this, and I wish I could just stick a diaper on my baby and not think about it for a few hours. But, those feelings of exasperation are short-lived, and I truly love the connection that EC'ing has given me with my babies as they have grown.

I always tell people that I don't view EC as easier or harder than traditional diapering potty training. I figure that it may really be about the same amount of work overall, but simply expended in a different manner.

I could talk and write so much about EC. However, I already feel like this post is a bit scattered, so I will stop here. Maybe I will write more another day.

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Here are some links if you would like to learn more about EC:

Diaper Free Baby groups

The EC Store

What is EC?

What is EC? (a different article)

Diaper Free! The Gentle Wisdom of Natural Hygiene

Born Potty Trained

Visions of Breastfeeding

I wrote this post back in August during World Breastfeeding Week and am finally getting a chance to post it.



Some reminders to the pediatricians, perinatologists, and other care providers who may have forgotten (or never learned otherwise):

• Breastmilk DOES have everything all of the vitamins and nutrients that babies need. Really, they don't need vitamin drops made by a huge artificial baby milk company given to them daily. (Since Vitamin D is the 'hot button' on this topic, read this page if you want more info.)
  
• The amount that you express, by hand or with a pump, is NOT reflective of how much your baby gets when nursing, nor of your milk supply as a whole.
• Babies don't know how to read a clock. Please follow babies' signs and signals for as to when and how often to breastfeed. (Imagine someone telling you that you may not eat as it hasn't been X number of hours yet, even though your body is telling you that you are hungry.)
• Co-sleeping is SAFE and one of the best ways to promote breastfeeding in the early weeks. Please don't tell parents to simply not co-sleep, telling them they will kill their baby. Instead, please teach parents how to co-sleep safely. Sleeping snuggled in bed with baby happily nursing at the breast is far safer than an exhausted mother sitting in her arm chair nursing her baby, trying desperately to not drift off to sleep.)
• Nipple shields can be a useful tool when used judiciously. They are not a band-aid fix for sore nipples, baby not latching or not latching well, or every breastfeeding mother. Yes, nipple shields can save the breastfeeding relationship, but 99% of the times when I encounter them, they were unnecessary and cause problems.
  
• Babies do not all gain at the same rate. Read this, please! An excerpt:
  

  Many rules about weight gain are taken from observations of growth of formula feeding babies. They do not necessarily apply to breastfeeding babies. A slow start may be compensated for later by fixing the breastfeeding. Growth charts are guidelines only.

• Six months of age isn't a magic number. Babies don't suddenly begin needing solids at six months old. Many babies aren't interested in solids until they are 8-9 months old, and sometimes not until they are 12 months old. That is ok. Breastmilk is enough to meet the nutritional needs of a healthy baby for the first 12 months (and sometimes beyond).
• Rice cereal is not necessary. In fact, 'baby food' (the sort you buy in cans) is not necessary. Please, tell parents to skip the processed food (mainly, boxed rice cereal) and offer their baby real food when they are ready for solids. Fruit, vegetables, beans, meat, whole grains. The sort of iron that is in frortified baby cereals is nasty junk, nothing near as effective or good for your baby as the iron that is in breastmilk.
  
• Please visit Dr. Jack Newman's site. He is an amazing resource, and you can even email him directly with clinical questions.
  

I leave you with a quote from Dr. Grantly Dick-Read

A newborn baby has only three demands. They are warmth in the arms of its mother, food from her breasts, and security in the knowledge of her presence. Breastfeeding satisfies all three.

Reversal of position!

It seems the AAP has heard the public outcries to their revision of policy in regards to infant female genital mutilation. It has reversed this policy back to the original one of nonsupport.

To quote Dr. Judith S. Palfrey, president of the academy:

“We’re saying don’t do it. Do everything that you can to support that family in this tough time, but don’t be pulled into the procedure.”

Dare we hope that they will continue to NOT endorse male genital mutilation?

Our boys deserve to be protected just as much as our girls.

Let's just stop cutting our babies

I recall talking once with an Intact America rep at a midwifery conference and he was very happy to hear that I was interested in getting some literature to hand out to my clients. He told me that many of the midwives he had talked to at the conference said that, while they supported his orgainzation's aim, they didn't feel it was their place to bring up the topic of circumcistion with their pregnant clients; that is wasn't their place to discuss it.

In my experience, education is of the utmost importance on this topic. I have seen countless families who originally planned, without question, to circumcise their baby boy, but then once they learned more and because informed, they instead kept their boy intact. Indeed, more and more families in the United States are keeping their boys intact. In my region of the country, around 70% of baby boys are now left intact. Even still, 30% of boys being cut is too high.

I bring up the topic prenatally with my clients, if they know they are having a boy and if they don't know the sex of their baby. It is sometimes an anxiety-filled conversation, but its an important one. I myself am the mother of 2 intact boys and married to an intact man (as are the majority of men in South America, where my husband was born).

Quoted directly from the National Organization of Circumcision Information Resource Center website, here are the basics on male circumcision:

No national or international medical association recommends routine circumcision.

Only the USA circumcises the majority of newborn boys without medical or religious reason.

Medicalized circumcision began during the 1800s to prevent masturbation, which was believed to cause disease.

Today's parents are learning that the foreskin is a normal, protective, functioning organ.

Today's parents realize circumcision harms and has unnecessary risks.

Circumcision denies a male's right to genital integrity and choice for his own body.

This brings me to the recent news that the American Academy of Pediatrics revised their policy on female genital mutilation (now called 'cutting'). I believe that this move is likely related to the fact that they (along with the CDC) are currently reviewing their policy on infant male genital mutilation (aka circumcision), exploring whether or not they are going to continue to NOT endorse circumcision. If I am correct in my connecting the two, I am fully expecting the policy of infant male genital mutilation to be reversed. (I hope I am wrong.)

When I originally heard the news of the AAP and CDC reconsidering recommending circumcision and now backtracking on their original opposition to all female mutilation, I felt such shock and disgust. How about we just stop cutting our babies? No, really! Sharp objects belong nowhere near genitals of babies and children, in my opinion.

Marilyn Milos, director of NOCIRC, recently sent the AAP this letter in reply to their policy revision on female genital mutilation, which ElementalMom so wisely blogged about.

CNN recently published a good article on the topic of female genital mutilation. A Somali film director and activist, Soraya Mire, counsels genital mutilation survivors and families who want to have their daughters cut:

She sleeps with her cell phone tucked under her pillow, so she can answer at all hours.

"You don't have a right to do this to your children," Mire tells the immigrant community. "You are continuing the abuse."

Fatima Mohamed, a Somali immigrant and activist, was herself cut and says of her own daughter:

Her 11-year-old daughter is too young to comprehend genital cutting, Mohamed says. Instead, they discuss her daughter's dreams to become a pediatrician. Perhaps in a few years, Mohamed will tell her the truth.

"I would never do it to my daughter," she said. "I don't want it. This has nothing to do with religion or culture. I believe nobody should control my child."

Really, this applies to both sexes.

On the topic of Jewish male circumcision, have you seen the documentary CUT? It's worth a watch!


This is something that affects all of us. Our babies are born perfect, whether they have labia and a clitoris, or a penis and scrotum between their legs. How about we just don't cut our babies?

Clarification

Because I think there may be some confusion from my last blog entry, I wanted to clarify something.

The rule changes that are being proposed will not make breech, twins, VBACs and postdates 'illegal' or absolute risk factors for licensed midwives. They will still be 'allowed' to attend them out of hospital.

But, they are creating stringent criteria in each of those categories, proposing to dictate under what terms a VBAC, breech, twin, postdate birth would be considered safe enough to stay home (with a licensed midwife).

For example, if the baby is breech, is must be frank breech with an estimated fetal weight less than __gms. Or....once you hit 41 weeks, you must have a weekly biophysical profile and get a score of __ or better to continue with a homebirth. (AGAIN, THIS IS JUST AN EXAMPLE OF SOME OF WHAT I HAVE HEARD BEING PROPOSED. ITS STILL ALL IN PROCESS).

Oregon's current rules dictating what is an absolute risk factor for out of hospital birth with a licensed midwife are very BROAD with lots of grey area. They were originally written this way on purpose.

It should be up to each mother and each midwife individually to decide if they are comfortable proceeding with an out of hospital birth, not up to the licensing board. I think that the informed choice process is critical in this issue.

So, when writing those letters, please remember they are not (at this point) discussing making VBACs, twins, breeches, and postdates illegal...but are trying to put restrictions and set in stone guidelines around them. (Not good for birthing women!)

Come to the meetings if you can!!!