Interview with a Midwife

A few months ago, a friend of mine, Sara Mackey Dunn, who is a mother of many, a mentor to a great many other moms in her area, a doula, breastfeeding advocate, and a student midwife, asked me if she could interview me as part of an assignment for her midwifery school. When I got done laughing and trying to deflate my big head, I finally sat down and answered her questions by Messenger one afternoon. I think we were both enjoying big cups of coffee from our separate locations that day; I’d have loved to sit down with her in person, but such is life in our busy modern world.

Anyway, in the course of writing replies to Sara’s interview questions, I realized I had a blog post almost ready-made. Figuring I might as well make the most possible use of what I wrote, I decided to slightly edit and re-organize the interview, and post it here. I hope you have fun reading it!

Why did you become a midwife? I think in hindsight there were probably many signs along the way steering me toward midwifery…reading my mother’s pregnancy books during her pregnancies with my younger sisters, watching my cat give birth when I was about 5, catching my first “baby”, a Siberian Husky pup, a year or two before I had kids. I hated my experience giving birth in the hospital even though I was with a nice group of CNMs, and I noticed that they all had their babies at *home*, and with my second, Bea, I decided to go that route. It was the research I did around that decision, and the experience of receiving care from a CPM and her advanced student, that really solidified the idea for me. That, and seeing my midwife sitting and sipping a big Frappuccino while Labored. I remember thinking I’d have rather been on her side of the table while my oldest two kids were little, I kind of shelved the midwifery idea, and was considering working some as a postpartum doula (which I did for a time), and was kind of dragged kicking and screaming into pursuing my birth doula certification by a friend who thought I ought to have it “just to fall back on.” I got much busier than I would have expected to do that and found I loved it, but I got frustrated and fed up seeing the negative experiences so many women were having (still have) birthing in the hospital with doctors, how disempowering that system and that environment often are, and got sick of watching what should have been a perfectly normal birth get sabotaged. I finally started really thinking about seriously pursuing midwifery training, and my first apprenticeship just about dropped into my lap (but it was *hard* work!!!). Things just went from there.

What is your philosophy of care? My philosophy of care, in a nutshell, is that I, as the midwife, am a consultant and a lifeguard. Most of the time, the lifeguard aspect of my job doesn’t come into play much. Most births are straightforward and don’t require intervention. Likewise, most of the pregnancies I see are normal, and not much needs to be done for the mother beyond answering her questions and keeping an eye on how she’s doing. The clinical components of care can be and most often are very minimal–blood pressure checks, fundal height measurement, listening to fetal heart tones at each visit, along with palpating carefully for a position, and addressing any of the mother’s concerns. I don’t automatically require any particular tests or procedures. I’m a big believer in informed consent, giving the mother accurate information about the pros and cons of various tests, options and alternatives, and letting her decide what is best for her and baby. I have only once or twice encountered a situation where I *really* needed to strongly insist on a test/procedure if I was going to continue to care for that client. Ordinarily, I make my recommendations and explain my reasoning, and let the client ultimately decide, and then she owns that decision, that responsibility, which is as it should be.

How would you describe your clients/practice? My practice is a very small solo practice. I do homebirth, and all in-home care. Both due to my family’s needs (and my desire to actually have a personal life!), and my strong belief in the importance of very personal, individualized care, I intentionally keep my practice very small. My average is about two clients per month, which in practice means I’ll have some months with only one or no births, others with two, or three if someone goes a bit late or early. It works out to 20 or so births a year. My client base right now is probably 2/3 or so made up of mothers of larger families, mostly homeschooling and mostly relatively conservative Christians. Nearly all my clients have chickens! A few only have a dog or cat. but that doesn’t necessarily risk them out of care.

Have you seen a change in how you practice or who your clients are since changing to a smaller practice? Since switching to a smaller, solo practice, I see some change in my clientele, yes. I have had lots of repeat clients (whom I first worked with as a student or in my former group practice) this year. Most pretty well match the description of my typical clients above; these are moms who really appreciate in-home care. It’s very important to them to have that closer, more intimate relationship with their midwife, and to not have to pack up multiple children and spend half the day going to and from their appointment away from home. Also, for some of these moms, it’s important that we share at least somewhat similar religious views/values, and that’s fine by me, too! The way I practice has changed considerably now that I’m in solo practice. Without any disrespect to my former partners or preceptors, I have found that I really enjoy being able to design my client care according to my own ideal of what homebirth midwifery should look like. It has been really interesting for me this last year of being a solo practitioner to explore what I believe about midwifery and birth, and how I can put that into practice in the ways I serve my clients. It is inherent in a group practice that sometimes everyone will have to compromise, and that’s usually fine, but it does feel different and freeing to be able to follow my own vision.

Do you discuss nutrition with your clients? If so, what are your general 1. I *do* discuss nutrition with clients. A lot. At every visit. I am fortunate right now to have mostly pretty nutrition-conscious families in care, many who garden and farm, and make every effort to just eat clean, real, whole foods as much as possible. In general, I push for lots of high-quality protein and tons of greens, and I like to see people avoid sugar and refined carbs. Within those guidelines, I really think there is a very wide variety of acceptable, healthful ways to eat. I’m not sold on the safety of the ketogenic diet for pregnancy, and I think there are a few other ones that need more investigation or modification. A good friend of mine who is a nutrition counselor once commented to me that any diet that has a book to go with it is a fad and probably unhealthy. I think there are some of those that get pretty extreme in some way and are unhealthy or unsafe, but in general, there’s also a lot of room for variations as long as a mom is getting enough really nutritious calories in general. It’s also important to approach dietary suggestions without pressure or judgment because it’s amazing how many women already have body shame and guilt issues around eating (looking at diet choices in terms of “being good” if she’s eating healthfully, or “being bad” if she has fast food or an indulgent dessert). I try hard to avoid triggering any of that and just try to address food choices in terms of nourishing herself and the baby well. It doesn’t need to be perfect.

Do you have any automatic red flags when it comes to nutrition? Nutrition and red flags. Yep. I have risked someone out of care once or twice because all they ate was junk, like McDonald’s every day and no vegetables, and refused to drink sufficient fluids, and just were not gaining enough weight to have a healthy pregnancy. I don’t worry about moms who eat a little too much (what does that even mean??) if their diet is basically nutritious. What is a flag for me is if a mom is trying to restrict her weight gain in some way, or just eats nothing but processed and fast food. If that’s her starting point, she has to be willing to make big changes quickly and steadily. Also, I consider having had a gastric bypass surgery a likely reason for risking a mom out of care, because (based on an experience a few years ago) I think it’s exceptionally hard to eat sufficiently to grow a healthy placenta, normal cord, and well-nourished baby after that surgery.

About how long are your prenatal appointments and what routine assessments do you do? My prenatal visits last about an hour so that I can pet the dog, discuss the well-being of the chickens, and see the older siblings’ Lego projects and artwork. Also, a certain amount of time is usually spent hunting for tape measures and pens and chasing ferrets out of my bag (true story). We catch up on life stuff and gossip, and then I spend about ten minutes on actual clinical stuff, normally palpating the mother’s belly to feel baby’s position, measuring fundal height, listening to fetal heart tones with fetoscope unless the family prefers the Doppler. I take mom’s blood pressure, and if she is keeping track of her weight, I’ll record that. We do actually talk about how her pregnancy is going, and I’ll answer any questions she might have. If she’s at a point in pregnancy where a certain test or procedure is routine in the medical model, we discuss that and she decides what she does or doesn’t want to do. We might need to discuss financial matters, or whether she’s got all her supplies ready, etc. And then we schedule her next visit, and that’s it.

What topics do you make sure to always address with your clients at the beginning of care? At the beginning of care, if the client is new to homebirth, I like to make sure they have an understanding of what to expect from midwifery care and homebirth. We go over financial matters (meaning my fees and fee schedule, and insurance billing as applicable). We talk about what my responsibilities as midwife entail, and what her responsibilities as a client are, since that power dynamic between midwife and client is one of the equals, as opposed to the typical OB care model. I like to get a good feel for the mom’s whole family situation and support network, her past experiences with pregnancy, birth, breastfeeding, and her expectations, hopes, and fears.

What is the emphasis of care for each trimester? In the first trimester, I might not even be seeing a mom yet, since we can’t usually hear baby’s heartbeat with a Doppler until after 12 weeks. We might very well be in touch some if she has questions or concerns before then, particularly for a repeat client. Often, clients come into care just after 12 weeks, so in most cases, if I’ve done anything before then, it was probably a consult, or maybe sending her for an early ultrasound if she wanted one. The second trimester is where nutrition gets to be a bigger deal, and where we probably just focus on healthy diet, exercise, emotional health, maybe addressing any bigger concerns that might take a while to work out, so that hopefully by the time she reaches the end of the pregnancy, all that stuff is straightened out, if need be. The third trimester tends to be all about preparing her environment, her mind, body and spirit for birth. This is also the trimester of aches and pains and weird bodily issues. I tend to get more calls and texts with random interesting questions and sometimes pictures at this stage! I do pay some attention to fetal positioning if it seems warranted, but not every mom needs to do special exercises, etc. It’s all so individual that it’s hard to say if there’s really a particular main focus, but I do think the third trimester really forces most women to fully come into their bodies, and to (hopefully) tie up loose ends in their life enough so they can feel reasonably ready to have a baby.

That is where we left our interview and is probably plenty for one post.