Learning to Trust Birth through Continuity of Care
Editor’s note: This article first appeared in Midwifery Today, Issue 125, Spring 2018.
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Continuity of care, with the same care provider, can dramatically improve a woman’s pregnancy and birth experience, her recovery, and her ability to successfully process her birth journey. Deep bonds of empathy, mutual respect, and emotional safety can develop between the birthing woman and her birth attendant. These qualities, though rarely measured, enable and empower a woman to delve into the depths of her strength, self-reliance, and independence. This care-giving-and-receiving relationship, founded on trust and honesty, is an ideal model. It is profoundly satisfying, as a care provider, to experience what it means to be “with woman.” When we emphasize the importance of being present with a client—connecting, listening, and relating—we promote quality relationships and focus on key concepts in the context of a positive birth experience.
A woman who views birth as an opportunity to process her past childbearing experiences, explore options, and get perspective on specific situations or challenges may find that her fears can be transformed into personal insights and self-acceptance. These births are some of my favorites and I’m pleased to share with you one woman’s transformational journey and how our relationship influenced this growth.
At 26 years old, Esty married a few years later than most women in her close-knit, Hasidic community in New York City. She was willing to wait it out until she found what she was looking for in a husband. She says with a smile, “I got exactly what I wanted when I married Itzik, even the blue eyes.” She preferred someone Hasidic, yet open-minded, and it took her a little longer to find her soulmate.
Esty’s mother paved the way for her by “marching to her own beat,” and let her free spirit and love of learning facilitate a more out-of-the-box method of schooling. Esty and her sisters enjoyed a multitude of enriching, hands-on experiences in museums and with cultural activities. Consequently, Esty is one of most highly educated of her family, having completed a BA in speech pathology.
Esty’s mother was motivated to use natural birthing techniques, took Lamaze classes, and refused epidural pain relief for all four of her births.
Being raised in a Hasidic community means that you are linked through a combination of family ties, tradition, and culture, where everyone is supported and accompanied through all the joyous events in life—engagements, weddings, births, and the coming of age of all the children in the community—as well as being loved and comforted through the pain and anguish of losing a loved one or battling an illness. The Hungarian Jewish community is an intricate web of grandmothers, mothers, and sisters, all intertwined in a complicated social network designed to help all who need it. “When everyone is there for you, and everyone knows what you’re dealing with, then everyone is bound to have an opinion about whatever it is. That can be hard sometimes, especially when you make an unpopular decision.”
Esty’s First Birth
Esty’s first baby was born about a year after her wedding. She spared no expense as she prepared for the experience. Even with classes, reading, and planning, she still felt terrified. All she craved from her community was a bit of reassurance about giving birth. She found none—one woman even made a reference to “the curse of Eve.” She still remembers the panic that became more pronounced as her time grew near.
Labor, which started a day before her due date, was long and intense, with baby stubbornly remaining posterior. Esty’s husband remained by her side and offered soothing comfort and massaging through that first long night. She had two long days of start-and-stop-labor, a sushi date with Itzik, overwhelming nausea, a two-hour car ride in traffic, while alternately clutching her doula and a birth ball—all punctuated by a random bank robbery in progress and a shoot-out in the alleyways of her neighborhood. She finally arrived at the hospital late afternoon and practically crawled inside, stopping every few minutes to hug the labor ball and crouch on the floor. Upon making it to the labor and delivery ward she was met by her doctor who confirmed that she was only 3 cm dilated. She refused admission and found a table in a hallway where she lay underneath to take a nap. Plying Esty with crackers for energy, her dedicated doula was apparently so well-equipped for a situation like this that she produced an enema kit from her bag and proceeded to administer it in the public bathroom of the hospital.
Within an hour, back pains were stronger than ever, which caused Esty to question whether she could handle it any longer. She was admitted after she was checked and found to be dilated to 6 cm. Labor progressed painfully and slowly while she was hooked to a monitor and bed-bound. By midnight, a rough check by the same doctor revealed that she was now open to 8 cm. Even today, she remembers his face as he insisted on giving Pitocin, an epidural, and breaking the bag of waters to “get things going.”
“When I refused all those treatment options, the doctor informed me he’d return in two hours to prepare me for a c-section.” Her husband, Itzik, remembers watching the doctor storm out in a rage—angry about his uncooperative patient—pull off his gloves, and shove them in the trash. Feeling scared, they began to pray even harder, pleading with God to be merciful.
Her strong refusal to cooperate with all the interventions led the nurses to approach her after the birth, commenting on how much they all secretly admired her strength and determination. “We couldn’t believe how strong you were. We couldn’t believe how you stuck up for yourself. So many women come in here with a birth plan and the moment the pain hits, they toss the birth plan in the trash.”
The nurse on shift that morning took charge and said, “I’m going to help you; don’t worry!” This former Indian midwife got her out of bed and helped with all sorts of positions and exercises to correct the malpresentation and aid baby’s descent. Not only did the midwife not wake the doctor after two hours, but she did everything in her power to help Esty’s labor progress. This woman’s compassion is in Esty’s memory forever.
Almost immediately, she felt a huge movement and the contractions shifted from agonizing to very intense, but the back pain was suddenly gone! She was told to blow through the pushes as the doctor came in and placed her on her back. After she adamantly refused the episiotomy he told her she needed, her son came flying out with only a few more pushes around 7 am.
Esty remembers the moment of disillusionment in her doctor more than the pain. She had placed so much faith in him, she realized—in his power over her birth experience. “It was so hard when I saw that my doctor really wasn’t my advocate. Instead, he was an angry man who made me feel pressured and out of control. I had set my hopes on him and he let me down. I really had to work to let those feelings go.”
“I was so glad my husband encouraged me to hire such a wonderful, dedicated doula. Without her, I feel certain I would not have had a vaginal birth. I was so tired at that point, I hardly remember the first hours after birth,” she recounted. “I remember trying to nurse and how hard it was to recover from such a long and painful labor.”
Though she feels that first birth was traumatic, it was also the perfect starting point for four profoundly transformational birth experiences.
First Birth in Israel
“I hadn’t been living in Israel long when I began the third trimester of my second pregnancy.”
She remembers calling me and explaining that she was looking for a doula for her first birth in Israel. She was already close to her due date, but we squeezed in a couple of meetings. At our first meeting, she went into detail about her first birth experience and how challenging it had been. We enjoyed a good rapport and I could feel she trusted me. She was reassured to know that I was also a midwife. She knew that I had a friendly and amicable rapport with many of the hospital staff and, if need be, I could examine her if she wanted help deciding when to leave her house.
“I was so, so afraid to have that next baby!” Esty vividly recalls. “I just felt terrified inside! Even though I was reassured by having had a ‘natural birth’ the first time, I was very scared of the pain. I spent a lot of energy worrying about negative outcomes.” She remembers how she became more nervous as the due date came and then passed.
A week after her due date, Esty’s deepest fears were triggered when she heard about a woman who had lost her baby in labor. She brought it up at our visit: “You didn’t explain my fears away and tell me everything was going to be fine, and I really appreciated that. Instead, you validated my experience. You told me that, ‘Yes, these things did happen, and they can happen to anyone, even though it’s rare.’ You reminded me that ‘it’s our job to do the best we can do to prepare, to take care of ourselves, and to get good care for the pregnancy and birth. We prepare, and then we let go in the faith, trust, and surrender that the process is not in our hands.’ That really calmed me down. Still, I think it was the trauma of that first birth and all my fear that led me to carry so long.”
Three weeks after her due date, she called to let me know things were starting and, soon after, her husband phoned to ask me to come. The moment I walked into their small two-bedroom apartment and saw her on all fours on the bed and listened through one contraction, I knew we had to go. A quick vaginal exam confirmed that she was complete. Her relief and joy, combined with utter disbelief, joined my tension as I drove to the hospital with a woman who was pushing her baby out in the back seat. Twelve minutes after walking through the door of the hospital, she easily birthed a lovely baby girl.
Esty’s Third Birth
The benefits of continuity of care can be found in the dynamics of the doula-client alliance. Most doulas give one-on-one care, thus building a solid relationship. Trust and good communication germinate in this fertile soil as a close relationship flourishes.
Esty called me much earlier in her third pregnancy than she had previously. We now shared a history and a lovely and comfortable connection, so she looked forward to the prenatal care meetings and came regularly throughout the pregnancy. Then her familiar birth fears began to emerge due to a lot of stress in her life.
She looked forward to our prenatal visits because they were the only time she set aside to bond with this new pregnancy. Delighted in “all things birth,” she talked about her fast previous birth and shared how just talking about her birth experiences helped her tremendously, keeping her fears in check even as her thoughts tried to convince her that her good luck might run out with a third baby.
Esty thought it would be so nice to have her mother there to care for her two younger kids and take care of her after the birth; she arrived shortly before the due date. Together, they came for a prenatal visit around her 41st week. Baby was in a good position and her cervix was soft and beginning to dilate, but Esty was stressed and insisted that I strip her membranes because she wanted the baby to be born before her mother left in a week. She phoned a week later sounding increasingly anxious.
She shared concerns about leaving the kids with her mom for the birth and her general fears and tension prior to labor. “Remember how I burst into your office? I was so irritated and stressed in general and I remember feeling so uncomfortable having my mother staying with me.”
She insisted that she had to have the baby before her mother left. I reminded her that it doesn’t make a difference how dilated you are or what position the baby is in; if you are uncomfortable with something, your discomfort often doesn’t allow the labor to happen.
Later that day, as her mother pulled away in a taxi, Esty reached up to wave goodbye and at that exact moment was overcome by a powerful contraction. It was so all-consuming that she couldn’t even wave. When it passed she rushed back to the apartment to call me. I came over and we went to the hospital. The labor was hard and Esty had to wait for a pesky cervical lip to resolve, but she managed to push out a vigorous son—all before her mother arrived at the airport. Between laughter and tears, she phoned her mother, who was still in the taxi, to surprise her with the good news.
It was beneficial for both of us to reflect on Esty’s birth during our postpartum discussions. Being a smart, emotionally intelligent woman, Esty was eventually able to accept the way her mother’s departure had allowed her to relax and give birth. “It was because you knew me so well by then [that] you saw something in me that I didn’t even know was there. I couldn’t believe how you picked up on something so deep. It was just so wonderful to speak about it and process it together,” she recalls, “I cherish those meetings with you sitting on my bed, helping me nurse, laughing at the hilarity and irony of God’s way of teaching us life lessons through birth.”
I love how continuity of care allows for creating that type of “space” for women.
Esty’s Fourth Birth
Esty runs a very successful in-home day care for Yiddish-speaking children. Her groups always seem so relaxed and happy when I come to visit her. We had become friends by this time. She called early in the pregnancy to tell me the good news. She was so happy to be pregnant and this time I was providing her with complete midwifery prenatal care.
Her previous three deliveries had changed her perspective. She no longer dreaded birth or wanted to “get it over,” but was genuinely looking forward to it. She had been an active participant in the previous labor and found the close caregiving relationship very empowering. “You taught me by giving me the tools to really do it on my own. You didn’t ‘tell’ me how to let my body do the work. You taught me by example and demonstrated the right attitude and approach to this concept of ‘letting go and letting God.’”
We spoke about homebirth a couple times, but she didn’t feel that it was the right choice for her. Her pregnancies are straightforward, and she is very conscientious about her nutrition. As the birth got nearer, we spoke every day or two. I have always found that keeping in close contact during the last weeks is important.
The day of the birth arrived and she phoned to let me know things were starting to pick up. I advised her not to wait too long. She was in such a good emotional place and I could tell that her birthing energy was really flowing. She proclaimed how delighted she was. The babysitter arrived, and Esty came over to get checked. When she arrived, she had the widest smile I’d ever seen her wear. The baby sounded amazing and she was already a good 5 cm, with contractions intensifying. Each time she would contract, she would giggle. Her joy was contagious.
Esty and Itzik hardly ever went out by themselves. She was so happy to have a babysitter watching their children, even if it was only because she was giving birth. She was determined not to miss an opportunity to spend some time together and asked me if they had time to go out for ice cream. Off they went for a walk and 15 minutes later she called me from the ice cream shop, this time laughing very hard while she told me the contractions were picking up. Ten minutes later she burst in my door with a mostly uneaten cone in hand, shoving it at me as she ran to the toilet. When she emerged, she was glowing. With each strengthening contraction something came over her and by now she was howling with laughter, each wave coming stronger and lasting longer than the last.
I drove them to the hospital and Esty opted to walk up four flights of stairs to the labor and delivery ward. Each time we reached a new floor, a contraction would hit—she was laughing hysterically, attracting stares and a lot of general attention. I remarked to one concerned group, “What, you’ve never seen a woman giving birth joyfully before?”
The midwives made comments about the “laughing gas” I had given her on the way. Nope, this was a certified-organic laugh attack.
We were fortunate to be given the natural birth room and an amazing midwife. We only had to watch her laughing and, of course, we began to laugh. In between contractions Esty would remark that it was her most painful labor yet, then another round of hilarity would ensue. By now everyone was laughing. I’m not making an understatement when I say how profound it was to witness the way her body had “decided” to use this method of pain relief.
An hour or so later, Esty made her way to the bathroom. The midwife and I crouched down at her feet. Sitting on the toilet, she used her fingers to explore inside herself and her eyes widened as she felt the head. Then she explained that she felt something else between her pubic bone and the head, something squishy. The notorious cervical lip (which seems to happen again and again to the same woman) was on the scene. She asked us, should I push it up? We both looked at each other and replied enthusiastically, “Sure!” In no time at all he was out—a yummy baby boy, born “en caul”—inside an unbroken amniotic sac.
We had a good time processing this birth together. It was so lovely and empowering for her. I loved witnessing her falling in love with normal, physiologic birth. She was comfortable with her body in a way she’d never been, and it was okay to feel her feelings and allow what was happening to just happen, free from any judgments or criticism. We spent hours talking about all she’d learned through this birth experience. She remembers how moved she was at the first touch of her baby’s head, “I cried tears of joy when I felt him. I realized it’s not about the pain, it’s about the baby!”
Esty Gives Birth at Home
Esty’s most recent birth, our fourth together and her fifth, was in many ways the highlight of our time together (so far). She was in touch with me early in her pregnancy as she wanted regular prenatal care. We decided to do the visits at her home, because her daycare had grown to 15 toddlers, making it difficult for her to leave. She also confided in me that, after searching her heart, she and her husband really wanted to have this baby at home.
“Originally,” she explained, “I knew if I chose homebirth and anything were to go wrong I’d never forgive myself. Then, after more consideration, I realized that even after doing everything in our power, we aren’t the ones who decide the outcome. Why am I choosing homebirth? I came to see it as the way to have the best birth experience possible.”
Birth supplies were gathered and it seemed like everything was in order. At 39 weeks I came by to visit her and as soon as I put my hands on her belly I could feel that the baby was breech. To correct the baby’s position, we worked with a rebozo. Additionally, we used Naolí Vinaver’s breech-turning regimen (crawling, slant board, and knee-chest), as well as seeking care from an acupuncturist for moxibustion. We could see how hard the baby was trying to turn, but he remained breech.
We discussed her fears and delved into what might be going on for her. She told me about two women she knew who had lost their babies in recent months. She said it really affected and triggered her and that she’d internalized the pain. Now she was finally ready to address and deal with these feelings.
During a visit around 40 weeks I started to massage the baby. He was responsive under my hands, so I checked his heart tones and felt confident to massage him a bit more. I slipped my hand under his little feet, which were on her lower right side, and started to jiggle them. He responded by bouncing and kicking. I tucked his head and he flipped right over. Esty got up, walked, and squatted and I stayed and listened for a while. Mom and I were relieved and I believe the baby was, too. His mother had needed time to process some emotions and fears and, now that she had, it was time.
One evening a week later I came by and she said she thought something was happening, but she was going to go to sleep. At one o’clock the next morning, she called to say things were starting but she still wanted to try and sleep. I’m not one to argue about sleep, so naturally I lay back down too. Exactly one hour later, Itzik called to let me know Esty was definitely in labor and she was sitting on the toilet. Pushing!
All I know is that one moment I was in bed answering my phone and the next moment I was in my car, closing the 10-minute distance between us. I never hung up the phone, keeping the line open for communicating. I gently coached her to move off the toilet and get to somewhere soft. I was instructing Itzik about how to help his wife and how to help receive the baby. He never sounded nervous or panicked, just totally focused and present. I had to urge him to describe what was happening, so I could guide them, although her sounds told me pretty much what was happening. About three minutes before I arrived, the baby came. He was crying and his mother was laughing and as soon as she could catch her breath she said, “I’m so glad I did this by myself. I feel so strong, so powerful! I’m so glad you weren’t here! This was my best birth ever!”
I let myself in the front door and found Esty and Itzik beaming with joy in their bedroom. Soon her placenta came out, with absolutely no bleeding. I was delighted for them. I spent the whole morning there, checked baby, and ate the delicious meal that Itzik prepared for us while we all processed together and reveled in the birth story. He was very happy to have had such a special, unconventional experience catching his own baby. It was not something he had ever seen himself doing but was so glad it had happened that way. Incidentally, my phone has an app for recording phone calls so I managed to preserve the audio recording of the birth. I was slightly surprised and definitely pleased when he asked me to e-mail the birth recording to his family, so they could hear. I’m sure this gave them a lot of naches, which is Yiddish for a mixture of pride and pleasure that a parent receives from their children and grandchildren.
Esty Reflects on Giving Birth by Herself
“Initially, I didn’t wake up my husband; I didn’t feel like I needed anyone. I would wake up with a contraction, then go back to sleep. I felt so in touch with everything. I felt so empowered. I didn’t need a doctor, didn’t need an ambulance, didn’t need a midwife, a doula, and it wasn’t until the end that I felt the need to wake up Itzik. I was just enjoying being with myself and knowing that God was going to deliver this baby and just letting it happen. I felt total acceptance of all the outcomes. Ultimately God is in charge.”
“Near the end, I sat down on the toilet and suddenly remembered the previous birth and thought to check myself. I felt the head! It was only excitement—I had no panic, no fear; I knew that all I had to do was let it come, let God be in control; nothing made a difference. It was an amazing feeling!”
Esty’s Practical Advice for Doulas
As is our doula/client “tradition,” we have logged many hours discussing this birth. When we spoke about the care she received, she easily broke it down into four attributes. She is adamant: “These are the things that you did for me that helped me tune into my inner power, have faith, and let go.”
- You educated, explained, and empowered me to make my own choices and own my own experience.
- You validated my fears, hopes, and experience in general.
- We processed, discussed, and reviewed the birth in a thoughtful, honest way during the postpartum period.
- You acknowledged (through deeds, attitude, and personal lifestyle) that we can do our best to prepare and plan and, in the end, we must let go and allow God to guide the outcome.
“I wish all doulas could give their clients the confidence to deal with whatever happens.” She shared, “In Judaism we have a concept of hishtadlus, or personal effort, which we must do to the best of our ability. Because we can’t prepare for every eventuality in life, we need to learn the right balance of when to try and when to let go. I realized with my first that I was overcompensating for my fear of birth by trying and planning and preparing too much. With this last birth, it was the opposite. I learned that when I put in the appropriate amount of personal effort, I can release that which I cannot control and allow God to guide the process. Your continuous, consistent support helped strengthen my emunah, or faith. Our trusting relationship created real emotional safety for me, which helped me see each birth as another, deeper lesson in letting go.”
We Never Stop Learning
I never want to “miss” a client’s birth. Even though most midwives do miss some births in their careers, I can admit I experienced a bit of regret for the few times a woman has given birth before I could reach her. While I would have loved to have been right there by her side as Esty pushed out her son, it wasn’t meant to be. I try to see meaning in all things and particularly in the birth journeys I’m invited to attend. Through my reflections on this experience, I’ve learned a valuable lesson about what it means to support a birthing woman. I now believe that when Esty declared how delighted she was that I wasn’t there, it was the biggest compliment I have ever received as a guardian of normal, physiologic birth.
So many clients tell me, “I’m so glad you were there; I couldn’t have done it without you!” Of course, I love hearing that I did a good job serving them and my reply is usually something along the lines of, “Yes, you could have! But I’m glad you didn’t have to.” As nice as that is to hear, I wasn’t expecting to feel such joy and satisfaction at her declaration. It was so gratifying to know that she got the birth she wanted, even if she didn’t admit it to herself until after the birth.
Now, more than ever, I feel that through excellent education, patient, loving support, and continuity of care, a woman can achieve an entirely new depth of strength and self-love. I love this work, and I love the women I serve. I sincerely hope that all women who desire it can experience such a rewarding relationship with their doula or midwife and that the care provider herself can feel the fulfillment in a job well done—even if that means missing the birth.
For Esty, her journey was one of positive transformation and growth. The continuity of care that she received not just in one single pregnancy but, throughout her whole childbearing career thus far, is profoundly and beautifully reflected in her positive self-perception and love of bringing life into this world.