Hands on, Hands off: Midwifing the Inner Life of Women
Editor’s note: This article first appeared in Midwifery Today, Issue 118, Summer 2016.
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“Do you have any other questions or comments?” I asked. Silje floated in her boat on the southern shore of Norway, and I paused in admiration from my cozy rural library in Missouri. I was a Skype midwife to this gorgeous woman with her rosy cheeks and new mother enthusiasm. Silje easily moved in and out of yoga poses while showing me her growing baby. Her Cocker Spaniel companion nestled in to watch us.
Then, I asked again. “Assuming all is well, what would your ideal birth look like?” She relaxed. Her head dropped back and her eyes closed and she started describing the scene.
“No, I don’t think so,” she beamed. Silje was now 33 weeks pregnant. We had met in Norway months prior when she discovered she was expecting her first baby.
“I have one,” I said. “What would your ideal birth look like? What would you be doing and who would be there and what would they be doing?”
At first she told me things that have to do with safety and I could hear the anxiousness in her voice. She began to describe medical back-up plans “in case the midwives say that transport is necessary.” I listened. Then, I asked again. “Assuming all is well, what would your ideal birth look like?”
She relaxed. Her head dropped back and her eyes closed and she started describing the scene. She was in the tub and her dog and her beloved were near. The midwives were not mentioned. She ultimately birthed in a strong yogic squat in her meditation room and her partner received the baby. They were happy and the new baby and dog were nestled in bed again, just as they were now only with the baby on the outside.
“Actually,” she continued, “I want my baby to be born into a community of strong women—women who know me and my community. The midwives are not my community. I have a friend who is calm and caring. I want my baby to be born into my community of strong women.” We talked some more about how to make that possible and what this powerful circle of women might be doing. Silje liked the idea that they would sing or chant to welcome her baby with first sounds from loving strong women voices.
Listening to a mother is the most important skill of midwifery. Asking her questions is the second most important. Third is making unrushed time together in nature with a bit of privacy so the important matters can be discussed. Everything matters to a pregnant woman—her health, her dreams, her fears, her stresses, her food, her relationships, her resources, her plans, her shelter, her sleep, her ideal birth, how her mother was born and how she was born. Too many things that matter to a mother have become rushed or eliminated in our modern health care system, including within midwifery education and practice. Everything that has become a diagnostic evaluator with a number that fits into a box has taken the place of what matters most to women who become mothers. These numbers, which create arbitrary barriers to basic human rights, now take up most of the time in the prenatal visit and in the labor and birth room.
Village midwives of antiquity knew the women they served by name and walked to the well with them. They knew what their mothers ate, where they slept and what kind of relationships they had with their own mothers, husbands, other children and with themselves. They knew of accidents, injuries, sicknesses and heartaches. They didn’t have to ask. They were a part of the life of the community they served.
We must visit the home and walk the block or land and sit at their table in order to know what kind of life a mother is living and what is possible for her to grow and care for herself and her baby. To help recreate a sense of belonging, I have been teaching the basics of the prenatal village in countries around the world. We can return birth to a woman’s local community through some simple steps. Women gathering together and sharing powerful birth stories, listening and talking to the baby, asking about a mother’s worries and fears as well as her ideals for her birth, walking in nature or howling at the moon and feasting together is something the village prenatal can do that a professional prenatal visit cannot do: return the power of birth to the people. The human spirit and the inner life of a woman thrive with rituals such as dancing, drumming, singing, storytelling, eating together, lighting candles, making prayers, sharing wisdom and creating a sense of deep and lasting belonging. Babies need to be born into the arms of their mothers, and mothers need the loving arms of a community to hold them in new motherhood. The village prenatal becomes the elephant circle, holding sacred space at birth; the stories become word medicine to give hope to a new generation of birthing mothers.
The more hands-on during the prenatal journey, the more hands-off is possible at birth. The countless visits and phone sessions necessary for a mother to build trust and ask sensitive questions and open her body and mind and feelings require conscious and consistent hands-on care. The power of instinctual birth and the irreplaceable moments of motherbaby attachment during the “golden hours” following birth require hands-off care. Successful breastfeeding, bonding and becoming a mother during the infamous 40 days of lying-in require hands-on care. Hands on. Hands off. Hands on. That is the key to supporting the inner life of women during childbirth.
Individualization of care is a foundational cornerstone of midwifery care. It takes a very engaged, vital and caring mind to assimilate the multifarious impressions and information provided by a pregnant, birthing or nursing mother. It is unique to every mother. It is distinct at every visit. The ever changing and increasing pieces of information take a thousand eyes and a vocational as opposed to a professional heart to assess and midwife. Attaining the vital signs is the easiest part.
Mastering the rudimentary and repetitive skills of taking blood pressure, pulse, weight, uterine height, fetal heart tones, blood and urine analysis and dating for comparison can be taught to the simplest of minds. In fact, machines now do most of this. Creating a “safe standard” for these vital signs, whether in pregnancy or labor, insures the continued use of simple minds. Reducing the dynamics of physiological birth to acceptable patterns and norms eliminates the need for critical thinking. Machines are actually better equipped to make such decisions with less error. As Michael Odent has warned, we are fast approaching the time when there will be little evidence to contradict the conclusion that most babies can be saved with scheduled cesareans at 39 weeks. Without the wisdom of what my Cherokee people and most native cultures call “unto the seventh generation,” short-sighted people with power will choose short-sighted solutions that affect the masses for a very, very long time.
I like to make frequent home visits, and I also like visits at my home where I can make a cup of tea and we can walk along the creek line and see how we both do in our different environments. If a mother has had several babies and is a busy Mennonite mother with summer gardens, we may go four or five weeks between visits, trusting one another. If the mother is expecting her first baby and has worries or feels poorly in body, mind or soul, we might visit every week. We always make a plan and agreements and if necessary, we talk between visits to adjust the plan. What good is a plan if it is not working? Prenatal care is the care a mother gives herself between visits with her midwife.
I have never used a Doppler. It may sound old-fashioned but I value hands-on skills. I have watched my colleagues lose their natural capacity both to hear baby heart sounds and placental sounds and amniotic fluid sounds as well as lose confidence in what they do hear. I love listening with fetoscopes and with Pinards and with my ear. I love teaching mothers and fathers and siblings how to listen and connect with their babies in this natural way. Listening tells a quality and distinction that a number acquired with a machine can never tell.
I watch for “nature deficit disorder” and “city dweller syndrome” in mothers who feel awkward in their bodies or shy to pee in front of others. I encourage mothers to walk in nature and float or soak in water and take time alone as well as time with like-minded souls.
I watch for “nature deficit disorder” and “city dweller syndrome” in mothers who feel awkward in their bodies or shy to pee in front of others. I encourage mothers to walk in nature and float or soak in water and take time alone as well as time with like-minded souls. One out of three women is an adult survivor of childhood incest or sexual abuse. Survivors carry the marks of their early wounds in their posture, dress, intimate relations and dreams. Midwives are meant to be gate keepers for healing. If harm was done going in, healing can often occur when baby comes out. Addressing the delicate issues of sensual and sexual assault to women’s bodies (which can be first experienced in childbirth even if they escaped abuse in childhood) is another reason we need unrushed and private time with women. I often wonder why we insist on putting things up and in during pregnancy and birth when we want things to come down and out. More money in health care is made off of women’s bodies than any other area of medicine. Most of that is acquired during the reproductive years. Hospital administrations know that to keep the doors open, the obstetric wards must be full.
Books have been written on the deviations in pregnancy and birth and the complications of both. It is sometimes valuable to know as much as we can about problems and what to do, especially in urgencies. But midwives were originally the experts in normal, not abnormal. Fear, pathology and managing birth has begun to rob a mother and a midwife of knowing normal and all its variations. Interestingly and maybe out of necessity, midwives are now more skilled and have gained more confidence in caring for vaginal births after a cesarean, which is not normal, than breech and twins, which are normal. Quite frankly, death is also a normal process as surely as birth and that, too, has become a forbidden area of knowledge, experience and acceptance in childbirth for midwives.
There is no greater gift to the soul life of a midwife than to have regular opportunity to observe birth without being in the role of a professional with all its responsibility. To observe the power and inevitable purpose and wonder of birth renews the steadfast fact and faith that birth works. Two brilliant quotes always settle my mind when worrisome yet concerned legislators or citizens question me during the trainings I offer in Basic Disaster Birth Support, EmerGently education or Physiological Resuscitation. One is by a brilliant colleague, Pat Edmonds, who says, “You don’t have to be in a birth room to be at a birth.” And, Dr. Gregory White, who, upon being asked how to get a baby out if, if, if… responded, “How do you keep them in?”
Despite the age of information, mothers tell me they prefer to read birth stories. I teach them how to disengage well-meaning family and friends from telling them birth horror stories. As mothers, we must learn how to protect our womb baby with positive thoughts and feelings. Worry won’t help and it is so harmful to worry a mother. She already knows she is a mystery with many possibilities. Building her confidence in her own instincts is her wisest path both for birth and a lifetime of motherhood. It is the wisest path for a midwife as well.
I have watched mothers with no training other than their instincts crawl into a dark corner to get privacy, hike a leg to realign an asynclitic baby, flip or jump up to dislodge a stuck baby, roll to reposition a posterior baby, throw back their head and open their mouth when their baby is coming to prevent pushing too hard or fast, pull out their own placentas when they are tired of it hanging around, chew on cords (which prevents excessive blood loss), resuscitate their own babies and suckle other children to bring in their milk.
Many factors shape maternal-infant health and nothing matters more than nutrition. Nutrition is anything we metabolize, not just the food we eat. We metabolize thought, feeling, environmental toxins, fear and joy. That is why everything matters to a pregnant mother, including the things she thinks about. I serve women who are carnivores, herbivores, vegans, have special dietary needs and those with few resources. We can follow the USDA, WHO or Brewer food guides for teaching a mother how to grow a healthy baby, but her budget, cravings, traditions, beliefs, terrain and genetics will influence her choices far more than something she learns with her head. The first winter I was working with my local Mennonite community, I learned a little something new regarding how folks who live close to the earth think about food. Mary was pale and weak with her seventh child. I was encouraging and recommending more rest, help from other family members and eating more high-protein, high-calorie food more frequently, emphasizing fresh leafy greens. The husband stood up, peered out the window at the several feet of snow that had recently fallen and said, “Well now, green food wouldn’t be growing here about this time.” We learned to grow sprouts in their windowsill.
I talk about eating like the deer and how to nibble all day long, just a little bit, until the body finds its balance. We talk about what grows locally and naturally and how to build balance of calorie input with calorie output. We drink to thirst and salt to taste. There is no formula that will work for all women. It is critical to know the life of the mother. Does she sit at a desk or garden in the sun? Is it her first baby or her sixth? Is she happy or sad? Does she have a budget for supplements or does every penny go to providing shelter? Is she urban or rural, highland or lowland, tropical or Icelandic, native or ethnically displaced? The humble villagers in Mexico eat beans, nopal cactus, avocados and mango and grow healthy babies for pennies. Sometimes the poor are richer than the rich. When I travel the world and hear that a certain area has mothers who are undernourished with rising rates of prematurity, I look around to see if there are any wild mammals. If there are mammals growing healthy offspring, we can too. We are animals and we sometimes forget how to use our instincts.
After some trust is built and agreements are made by being unrushed together, assessing the well-being of a mother and baby becomes a fun and meaningful journey together. Hands-on assessments for initial and ongoing well-being I use include:
- General vitality, cheerfulness
- Freedom of movement, gait, pelvis
- Shape and color and whites of eyes
- Tone and texture of skin
- Markings on skin
- Ease of breath: sitting, walking, stairs, bending forward
- Ease in swallowing
- Color of tongue and markings
- Ease of hearing
- Clarity of voice
- Eye contact
- Strength in arms and legs
- Flexibility of joints in fingers and hands and ankles and feet
- Symmetry going into and out of a squat
- Spinal symmetry and flexibility on all fours
- Heart and lung sounds
- Pulses in wrist, groin and feet
- Nail beds in hands and feet, capillary refill
- Reflexes in elbows, knees, ankles
- Abdominal tone/comfort
- Breast shape or surgeries or implants
- Color and smell of urine
- Frequency and consistency of stools
- Appetite—diet review, cravings, aversions
- Sleep and nap patterns
- Discharges: quality, quantity and odor from nipples or yoni
- Reproductive narrative—history of moon flow, sexual life, previous pregnancies
- Dating for estimated due date based on menstrual history, accounting for parity, length of cycles, previous births, breastfeeding and maternal lineage
- Relationships—mother, grandmother, partner, children, siblings, friends, co-workers
- Baby—growth, position, heart rhythms, response to speaking other languages
- Placenta—sounds, position
- Dreams—sleep side and wake side
- Resources—financial, emotional, spiritual, internal and external
- Hardest thing they have experienced and how they dealt with it
- Fears, desires, concerns, ideals
- Ideal birth
- I also take notice if we can laugh and cry together.
What about muscle knowledge? We learn the ways of our people and how to adapt to our environment during the womb and pre-verbal period. What we learn in those early stages of development is called muscle knowledge. We don’t know when or how we know something. We think everyone does or should. Once, in the 1990s, I was walking on a village path in Mexico alongside a mother who carried her baby in a rebozo, held her toddler by the hand and walked beside her 8-year-old daughter. I asked, “How do you learn to carry your baby in cloth with confidence? Can you teach me so I can teach my mothers back in the US?” She looked puzzled, swung the rebozo off her back into the air, baby inside and swung it back into place tying it across her chest all in one fluid motion. “¡No se caye!” she exclaimed. “She won’t fall!” She handed the rebozo and baby to the 8-year-old who promptly did the same, saying, “¡No se caye!” The mother affirmed as they walked away from me, “All women know how to carry their babies.” It was that simple.
Whether it is muscle knowledge or raw instinct, pregnant mothers are the most intelligent and instinctual creatures alive on the planet. Their senses are more acute. The superiority and the complexity of their biological functions, especially during labor and the moment of birth, are so rapid-fire precise that to interrupt them, distract them, scare them or undermine them, even to help them, is to submit them to danger—sometimes grave danger. Interrupting the flow of the old brain at a time when millions of years of biology are working to preserve lives, both the mother’s and the child’s, is more than rude. It is dangerous. It is becoming defined by the human rights courts as “obstetric violence” in defense of human rights in childbirth.
If we go into labor with a healthy mother and baby, we will generally come out of it with a healthy mother and baby. Walking with women to the well was the way of midwifery of old. Modern midwives must find an equally engaging way to increase the hands-on time during the prenatal period so that when it comes time for birth, we can be more hands-off. We can aid the intelligence of biology and provide the critical needs of privacy, warmth and calm companionship. Unrushed and uninterrupted at birth, a mother and baby will become locked in the infamous “newborn gaze.” Skin to skin, they will bond for life. The imprint and blueprint for lifelong health and happiness are laid in those irreplaceable first moments and hours. Offering calm companionship, helping clean up, providing food, sharing her triumph, organizing others, listening to her story and needs and promising to come back are the hands-on actions that allow us to be hands-off when “doing something” causes more harm than good.
It is 2016 and there is so much wrong with the way the needs of out-of-hospital birthing mothers and midwives are met by the medical establishment that I don’t know where to start. If we can create a medical response structure in our society for automobile and air travel catastrophes and if we can help save lives of crash victims with compassion and immediate care, then we can receive a mother in need and use that same medical expertise to respond to emergencies in childbirth without scrutinizing, shaming or threatening her. If she isn’t walking in the door and doesn’t have an emergency, we can learn to respect her human rights, autonomy and privacy and leave her alone.
As we move closer to human cloning and carbon-based robots and test tube babies grown with altered genetic structures, who gets to decide who has human rights and who is human? Even gender tolerance is a necessary skill of the modern midwife who may have sentient beings under her care who self-identify from hundreds of gender identities. This is the new world of hormone, bio-chemistry, physiologic and anatomic specialization where what was once mysterious, hidden, unseen and misunderstood is revealed. May the human spirit, so capable of compassion as well as cruelty, mature along with a maturing techno world that has infiltrated the womb as surely as it now resides in our minds and homes.
It is tragic when legitimizing something as common as women helping women reduces the number of midwives available to mothers. State after state and country after country we are told that regulation and licensure creates more birth options for mothers. In fact, it reduces their options. I have watched experienced skilled midwives stop attending breech, twins, grand multiparas, early babies, late babies and more. The loss to mothers and midwives is great, but the greater tragedy is the loss of valuable skills and knowledge that once were naturally preserved and passed down via birth. It is possible that the desire for public health is innocent but it is equally possible that power, money and the control of women’s bodies is at the root of making a few legal and most outlaws. No wonder underground midwives and mothers groan when they hear of another “legal” state or country and dive further underground.
Today I sit in the home of Bailey, daughter of Cheryl, whose story is preserved in The Power of Women. Bailey is expecting her first child. She lies down on the plush multi-colored rug and excitedly we begin to listen for the tiny sounds of a tiny heart and working placenta with my fetoscope. Darin, her husband, sits nearby, crouching like a happy tiger. Their two miniature dachshunds, Carla and Liz, nestle in with one lying on Bailey’s legs and the other at her head. The cat prowls in wider circles. It is a family affair.
I have become like Doña Cuca, who answered me decades ago when asked the question, “Doña Cuca, how many babies have you midwifed?”
“Lord knows!” she exclaimed. “One grows up and along comes another.”