Editor’s note: This article first appeared in Midwifery Today, Issue 87, Autumn 2008.
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The happy little secret is that there are doctors throughout the world who either are already practicing in ways congruent with the midwifery model or are eager to learn how. I’m not wringing my hands over how few and far between they are, but rather exalting in the fact that some exist and that they are listening to what the midwifery world can teach them. Their presence doesn’t eclipse what midwives contribute, but enhances the birthing world by giving even more birthing women the opportunity to encounter a professional who will attend them with respect and patience. Besides, who among us couldn’t benefit from consultation with or backup from a supportive doctor?

I’ve had a long succession of Good Guys in my professional life. The first was obstetrician Sam Apachai in central Illinois (circa 1980) whom I interviewed when I moved to the US from Holland. After hearing about my homebirth he requested that I attend births with him to teach him about vertical birthing.

“Can you show me what a squatting birth is like? Have you ever used warm compresses on a woman’s perineum? Have you read that they are birthing babies in water in Russia?”

His parting gift to me was a copy of Williams Obstetrics 16th edition—the one with the index listing “chauvinism, male, copious amounts, 1–1102.”

With my family’s relocation to Mexico in 1990 I connected with an obstetrician who was responsible for the obstetrics program at the University of Guadalajara. Among other topics, I was invited to teach his  fourth-year students why valsalva breathing (sustained pushing with closed glottis) was detrimental to mother and baby and to demonstrate (graphically) that second stage is a three-phased physiological event instead. The interns at this teaching hospital were taught that episiotomy was never “routine” and was best avoided. During this three-year exchange, the lessons weren’t just theoretical. I attended births three days a week in the teaching hospital and worked alongside dozens of residents and interns whose “midwifery classes” were given in vivo by a teacher with a funky Spanish accent! One of those residents went on to request my presence for his wife’s homebirth and then to attend homebirths himself.
Yes, Jan, each one teaches one!

At an international childbirth conference in the mid ’90s I met another obstetrician, Tonatiuh Nuñez, who stood up before hundreds of attendees and in an anguished voice asked, “Why aren’t we taught any of this in medical school?”

After the rabble of voices had quieted, I approached him and said, “I know a great teacher!” It turned out that he too was responsible for training new doctors and was happy to invite me to speak to them. He arranged for me to attend births with him in one of the behemoth national hospitals, Instituto Mexicano de Seguro Social (IMSS). During that period I had the opportunity to catch a birth at the side of this 20+ year veteran obstetrician and to “remind” him that a baby being born to her mother who is in a hands and knees position is not a posterior positioned baby! (Yes, obvious to us, I know.)

He was convinced that gentle birth techniques would maximize the health of mother and baby and went about comparing fifty births we attended in which the midwifery model prevailed as much as it could within a government institution (which means no fathers were in attendance). His data demonstrated that infections were diminished, mother satisfaction was increased and Apgars of the babies were superior when mothers could choose their birth position, had a caring woman to accompany them and avoided routine interventions such as IV, episiotomy and manual removal of the placenta. The other revolutionary practices offered at these births were no separation of mother and baby in the first hour and immediate breastfeeding.

His evidence was shared at hospital-wide conferences and, though it wasn’t heeded, he did join with Plenitud to attend birth center and homebirths as a back-up physician.

My 13-year collaboration with Guadalajaran obstetrician/midwife José Luis Grefnes has already been described (Midwifery Today, Issues 65, 75 and 76) but even those articles haven’t described his attending midwifery conferences or sitting at the feet of a traditional rural Mexican midwife taking notes, his impossibly long days and office cancellations while labor sitting with his gordas or his gradual attendance at breech births (both at hospital and home). He’s our pioneer in Mexico!

When José Luis and I presented at Barbara Harper’s Gentle Birth Congress in Portland in the fall of 2007, we met Drs. Alfredo Lomeli (pediatrician) and Humberto Lelevier (obstetrician) of Culiacán, Mexico. These two reminded me of walking sponges, eagerly absorbing ideas during the formal presentations, in the exhibit hall and during breaks. At meal times, they appeared more interested in talking and listening about birth than they were with eating. Sounds familiar, doesn’t it? In February they called and invited me to fly to their city and share more of the techniques/philosophy of what they like to call “gentle birth,” although the buzz words in Spanish now are parto humanizado or humanized birth.

There I discovered that these guys weren’t sponges but rather batteries—of the rechargeable sort! For three days we talked about birth for 18 hours a day. They patiently listened as I critiqued their birth videos and showed them a few of ours from Plenitud. We watched my midwifery teachers from Amsterdam catching babies (at home) in videos that were more than 20 years old. We practiced the Kama Sutra of possible birthing positions, talked about the exquisite needs and vulnerability of the birthing woman, visited the hospitals where they are pioneering waterbirths as well as immediate and uninterrupted motherbaby contact, and made a private tour of the amazing breastfeeding conference and meeting center that was about to be inaugurated.

When I showed them my copy of Midwifery Today, Issue 54 “Waterbirth” and Ancheta and Simkin’s The Labor Progress Book, Humberto immediately scooped them up and requested to borrow them. As I was surprised that he was able to avail himself of my English language materials, he acknowledged taking private language classes to better understand the evidence of resources like the Cochrane database. Doctor and midwife truly can speak the same language!

While I would have loved to stay longer I had prior travel commitments and had to return to Guadalajara. Before leaving, however, I mentioned that my friend and Plenitud colleague, Marilu Navarro, might be interested in continuing the course of study and that I would talk to her upon my return. As expected, Marilu was up for the challenge!

Four days later the Good Guy docs called her at dawn and asked if she would fly to Culiacán that same morning and accompany them at a birth. While I had the advantage of having met Lelevier and Lomeli prior to my visit, Marilu was taking off for the unknown based only on my assurances. Off she went, though, and after attending a hospital waterbirth with them, she came back equally enthusiastic about their commitment to birthing families.

Two days after Marilu’s return, Humberto was on the phone with me at 6 am requesting a return visit on the next flight out. His doula, certified childbirth educator Silvia Lomeli, now nine months pregnant, needed a respite during a long and somewhat unproductive labor that he felt could benefit from some midwifery “tricks of the trade.” After using warm water therapy, Bach flowers, the rebozo and traditional Mexican midwife Angelina Martinez’ “pull the leg” technique (useful for liberating asynclitic babies), a robust little boy made his way into the world that night, inches above the floor as his mother “hung” from her mother and partner’s arms in a deep squat.

I only discovered afterwards that it was the first time that Humberto had actually caught a baby with the mother in this position. Pediatrician Lomeli, as ever the most ardent breastfeeding supporter, finished snapping photos before gently drying the baby and helping the new mother lie down so baby could be placed on her chest and begin his crawl to her breasts. Both docs were so excited about the lovely birth that they decided our time at 4 am was better spent reviewing the birth and the contents of my birth bag than sleeping!

The next day dawned with a phone call from Silvia (who is also Alfredo’s oldest daughter) to say that she was bleeding. It was one of those moments in which we were grateful for the easy access to ultrasound technology, so we could assure Silvia and her husband Antonio that their baby was fine and the source of the bleeding wasn’t the placenta. It was also an opportunity for the gentle birth teacher to show them all how dim lights, massage, visualization, hushed voices and that old favorite “tincture of time and patience” could contribute to a relaxed and oxytocin/endorphin-conducive setting even when a planned homebirth requires temporary transport to the hospital. After returning home, Silvia and I spent a low key day in the company of her other two children. Antonio returned to his nearby work and the doctors gave her the privacy and space she desired.

With her best girlfriend enroute from La Paz in Baja California and 7 pm evening mass approaching, Silvia called Antonio and made plans to attend. An enjoyable girls’ dinner ensued with Silvia, her friend Karina (who had a VBAC with Humberto and is the first La Leche League leader in her city) and Silvia’s daughter, Pia. Throughout it all Silvia was rhythmically contracting. By 9:30 pm we had Antonio at home and were working on tub preparations. Somewhere after 11 pm the doctors arrived and by 11:45 am the first home waterbirth had occurred in the city of Culiacán!

Silvia had spontaneously chosen a hands and knees position, which she maintained when she moved to the inflatable birth tub. Once again I had the pleasure of orienting a veteran obstetrician who was receiving the baby of a mother whose birthing position made baby’s position appear to be “posterior,” when in fact he was perfectly anterior. Doctors can benefit from having a doula guide just as the mother can, although by 5 am when the doctors were still discussing the birth, this doula was not giving very coherent feedback anymore.

The exchange between the Good Guys continued in April when Humberto and Lomeli were my guests in Guadalajara for the weekend. This time I was the curious student. A baby born early on Friday had shown no interest in latching on that evening or during my Saturday morning visit. Lomeli left his dinner hosts waiting for more than an hour while he accompanied me to the birth center to assist the motherbaby dyad. Then, during the course of our dinner, the new father called to report that the baby was nursing! Removing mom and baby’s clothes and giving the baby the opportunity to make his way to the breast on his own worked, as did the pediatrician’s hands-on instructions on how to offer slight compression of the breast and to form a sandwich of the breast tissue. Of course, so had the attitude of our Plenitud pediatrican who didn’t recommend any supplementation during this period of the baby’s learning stage.

At breakfast the next day with José Luis and childbirth educators Marilu Navarro, Adriana Peregrina and Ceci Briseño, the subject of conversation was, once again, birth. Talking about how to make a cesarean birth gentler, I wound up lying on the floor at the restaurant so they could demonstrate a creative and safe way to make room for baby to be passed directly from the incision to mom. They’ve come up with a way to optimize the opportunity for the baby to spend the time in surgery lying skin to skin along the long axis of the mother’s body rather than horizontally from breast to breast (which is how we’ve always positioned the baby). Lomeli’s belief is that this position (longwise) enhances the baby’s opportunity to “crawl” towards mom’s breast, which is a better start for breastfeeding. (I’m leaving the homework of describing this technique in detail for a future Midwifery Today article to Humberto and Lomeli.)

During our “restaurant class,” without too many props on hand, we used the table’s placemat as the surgical curtain and my purse as the baby!

This fluid rapport between Good Guy caregivers and a childbirth educator/doula continues although we have returned to e-mail communication rather than face-to-face encounters. Our next time together will be in the company of hundreds of midwives when we all attend the international midwifery and humanized birth conference sponsored by MANA and Luna Maya in Chiapas, Mexico in June. (www.lunamaya.org)

With this article I hope to herald a roll call of many professionals who, though trained within the traditional, insensitive and often non evidence-based paradigm, have found their way toward the midwifery model of care.