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The Gray, Grey Messenger: Trust

I knew I wasn’t ready to be a midwife yet. Instead, I worked for CNMs in birth centers, continued attending births in hospitals and learning all I could about birth. I then went back to where I’d studied for over a year, practicing as a primary midwife and I knew I was ready to take the spiritual, physical and emotional responsibility of two spirits in my hands. I acknowledged that I cannot save everyone, but I can do a phenomenal job helping women to have a far safer birth than if they chose not to have anyone present at all.
I’ve listened to the pain of women who’ve experienced birth trauma and birthrape. I know that some women have no trust of anyone but themselves when it comes to their follow-up births. I listen to the women who comment in my Myth of the Vertex post who speak of betrayal in midwives they once trusted.

But, I ask (as I have before)… how can a midwife succeed (in retaining trust) if she has to say something the mother doesn’t want to hear?

Cappuccinosmom says:

“But I do have one issue--I *thought* I could trust my midwives. But because they were working with backup doctors and a hospital that were not trustworthy, and had to protect their liability and that of the backups, I ended up feeling betrayed. They were very, very sweet, and gentle about it, but I felt the pressure nonetheless. They were correct in predictions about a large baby, but I felt very betrayed that they let the consulting doctor threaten me and tell me that if I didn't induce early or schedule a section, there was a high probability of my baby dying and me being severely injured."

“It was very frustrating to me to be told through my whole pregnancy ‘You're fine, we believe in you, you can birth a big baby!’ but the minute I crossed a certain liability point (not sure what it was-could have been several factors) to feel like I either had to fight for a natural birth on my own or go under the knife. That is why I arrived at the hospital pushing. On purpose.”

(end quote)

This isn’t a direct response to this poster, but it is a great springboard for discussing the crux of the issue:


Her story isn’t unusual, but she wrote so eloquently, I want to use her words as my “But…” and speak to her – and the others – about experiences like this.

Midwives who have back-up are in a precarious place. If the law requires the back-up and they will lose their licenses if they don’t have the blessing of the doctor, it is really hard to counter what the OB says when he makes the final call. Midwives with a good relationship are able to verbalize their thoughts about the situation, but if a midwife happens to be on-call with someone who doesn’t like midwives or who has power issues, then she is trumped.

Midwives who lose their privileges no longer are able to help the multitudes of women they could have helped.

Weighing the risk of being dismissed/fired/alienated versus one woman’s needs in labor can be a painful position to be in.

She can pray that the woman picks up where she left off, but all too often, women in labor just aren’t in that position. Doulas can’t help when there are extreme power/medical issues at hand. Doulas, too, have to stand by, helpless, watching the woman’s birth plan go down the tubes.

Even midwives without OB back-up have pressures upon their decision-making process; even those that swear they don’t. Some situations just bring the thoughts of lawsuit, malpractice, court appearances, finger-wagging lawyers and Medical Boards bubbling up in the gut.

When I became a midwife, I said I would never allow the Medical Board to influence a decision of mine with a woman, only my experience level. That was until scary situations arose and I saw the risks of giving women free reign to do anything in labor, with me as their midwife, just wasn’t going to cut it. It wasn’t long before I figured out I had the skills I have for a reason and I was being invited to births for a reason – and I was doing a disservice to women if I didn’t use my skills – of judgment, especially.

I know the arguments about allowing the Medical Board/lawyers in the birth room, but might there not be some place for guidance about situations that go far outside the realm of norm? Should midwives (or women!) be permitted to do anything they want, all in the name of autonomy? Is there no room for parameters? Anywhere? Ever?

(Depending on your beliefs,) We have chosen to live in this place where rules guide much of what we do in order to keep chaos from reigning. We all have to control our anger because if we lashed out as our anger led us to do sometimes, we would hurt people. Our culture fosters civility, not violence (although, it’s sometimes hard to tell by looking at the media!). We obey (most of) the rules of the road even when we are in a major hurry. We are punished when caught when we don’t. And we pay the fines because we know that’s what we’re supposed to do. We incarcerate criminals. We reward good students. We have hierarchy in most of our businesses, schools, groups and organizations.

The dichotomy, of course, is “It’s my body; it’s my choice.” Many of us work towards a more matriarchal community than a patriarchal one. Consensus sneaks into places where democracy would be expected. Many (if not most) of us reading this regularly buck many systems by homebirthing, homeschooling/unschooling, extended breastfeeding, co-sleeping, non-vaxing, baby-wearing and not circumcising our sons. We question authority (to quote the popular bumper sticker), we vote for the most just candidate, we support social equality, we march against causes, we take pride in being the black sheep of our family/friends/community (but, also find comfort in joining the other black sheep at the health food store).

Stretching the point, wouldn’t most of us do something if we knew someone was going to get hurt? The thought of a baby suffering certainly makes most/all of us ache to our core.

Doctors and nurses share that same inner turmoil we all do when thinking about a baby about to be hurt or damaged. They just look at things from a different vantage point.

I think about my dogs that bark at anyone that comes near the house. It drives me crazy when they both get to yapping, but I also know they are trying to protect me from danger. That there isn’t any danger doesn’t faze them because all they know is, “Someone’s coming close that doesn’t belong here. DANGER!” and they bark. I would never consider teaching/punishing/training them to not bark because the one in a million times they do bark, it will be to warn me of someone who doesn’t belong here.

Doctors, too, are barking dogs, warning, warning and warning of dangers. Most of the time, they are heralding nothing but potential dangers, especially if nothing changes to shift the concerns. But, because of their instinct/experience/training, they do recognize and are ready to defend the baby and mother against severe trouble and turmoil.

Do we really want doctors to stop barking altogether? (I try and keep my dogs from barking inside, instead sending them outside to bark.) Perhaps we can encourage them to use their indoor voices when the mom/energy needs to change positions instead of screeching so loudly we cover our ears.

And then, the question becomes: Who is the translator? Who really knows if there is danger or not? I know many believe a mom will intuit something amiss, but I have been around enough births where the woman was the least aware of what was going on. Do we take a vote from everyone present? Do we ask for a second or third opinion? (I am reminded of people with severe illnesses who traverse from doctor to doctor, looking for the response they desire, it not mattering that they really are sick; they just want to hear that they aren’t.) Do we ask for more time? Who is holding the hourglass? (The baby?)

How can anyone say to a woman who’s worked for nine (or many more!) months to create the birth of her dreams that she’s out of time and her dream is morphing into a nightmare… how can that messenger not be attacked/hated/resented by her? Are there words care providers don’t know about that would help them/us to impart shitty news without having flailing arms swinging at our heads (and hearts)?

In the example above, I just don’t know how the midwives could have done anything different, nor do I think they could have done anything to remain in the good graces of the laboring/birthing mom. She speaks of their kindness, yet they are still demonized because they had to turn her out-of-the-range-of-not-even-normal birth over to an OB who made a decision someone had to make. By her own admission, the baby was big! Yet, that doesn’t remove even a droplet from the mist of guilt surrounding the entire lot of ‘em.

Sometimes, we (providers) have to tell women bad news. Altering news. News that changes the course of the whole birth experience.

I think, “If most providers didn’t howl at the moon, maybe it would be more palatable to hear that not-so-sweet stuff from us.”

So, how does one earn trust?

You know the annoying saying that doctors only see birth as normal in retrospect? Is that how a provider is judged to be trustworthy? Only in retrospect? The same saw says, “Midwives see things as normal until proven otherwise.” How come we don’t get trust that easily? (I know the answer; it was rhetorical.)

When birth is something the woman didn't expect, she's often left to pick up the pieces by herself, which is, I believe, what Cappuccinosmom seems to have been left with. What do women do with it all?

Reader Comments (7)

Without knowing the particulars of this situation, all stories like this share what seems like a communication problem. The mother took her midwives' supportive and positive attitude to mean that the midwives do not consider macrosomia a risk factor. Wishful thinking perhaps, or maybe something the midwives themselves inadvertently led her to believe while discussing big babies -- we'll never know. I've had two home births with two different midwives, and I had no precise knowledge of when either of them risk out. First time, I let the midwife make all the calls, second time I was too apprehensive to ask. I thought I had covered the basics, including what if baby's breech... we sort of laughed it off like we could pretend it's a surprise, and call 911 when the presenting part comes through. Fast forward to 38 weeks: baby flipped to breech, which was when I found out that the "surprise" breech birth idea was apparently only a joke. It didn't seem at all funny then. I had actually spent the entire pregnancy with a midwife I *imagined* was open to attending a breech at home. How did I feel? Betrayed, disappointed, desperate, and DUH! stupid all at once.

February 11, 2008 | Unregistered CommenterJudit

Well, I guess the question is, who is responsible for the life of mother and baby? Midwife/Dr. or mom? (This is assuming mom is aware enough to make decisions.)

Midwives take two souls into their hands...*but so do the mothers*. That is the fearful truth that makes allowing drs or midwives all the power so seductive. It is the reality of parenting itself, in which there is no one to save your baby from you. You are responsible for yourself and them, and that is a burden no one really understands till they feel it.

The mom who showed up pushing decided she was responsible, and acted on it. Her actions can have a good or bad result, but ultimately I think they do have to remain her choice. In the legal climate we currently have, this reality isn't recognized, and midwives do have to deal with that, and they do have the right to disengage and save themselves. But they don't have the right to pre-empt the choices made, only to advise. Otherwise, women will be forced into c/sections and other procedures by judges' orders. Just as in abortion, we have to trust women to administer the power they have been burdened with.

February 11, 2008 | Unregistered Commenteremjaybee

I think humility might be the key. Things change in every pregnancy, but instead of stringing a woman along with false hopes, a midwife should have the courage to come forward and say, "I'm sorry. I was wrong. This isn't going to work out the way we planned. We're going to have to do X. I wish we didn't have to, but we do."

I mentioned my PPH in a note on your latest entry, and I don't mean to keep harping on about that, but it ties in with this entry too. When a doctor I'd never seen before came to me, held my hand, and gently told me that they might have to remove my uterus, I felt no anger towards him. (I didn't even know until I was out of surgery whether it had actually been done or not.) He used compassion and empathy to break the news to me, instead of announcing it like it was a total on a cash register, and for that I had an immediate deep respect for him.

If my midwife had done the same, perhaps said, "I'm so sorry, Jill, but it looks like this baby isn't coming out, and we're going to have to do a C-section," instead of coldly demanding that I push when she ordered me to and then flatly stating, "We're going to do a C-section" when nothing happened, I might not have held (and still hold, I admit) ill will against her.

I'm a big believer in the power of words and how they are used. Bad things happen, and it's how our care providers deal with those things that can make or break our trust in them, in my opinion. I am willing to be more forgiving if the messenger acts like they deserve it (even if it's not their fault).

February 11, 2008 | Unregistered CommenterJill

Here are few thoughts on this;

If you go get your teeth cleaned, and the dental hygienist viciously attacks your teeth and gums and is unresponsive to your objections, you are probably going to wince and tense up every subsequent time that your teeth are cleaned until they are cleaned often enough by nice and compassionate hygienists that you begin to trust that not all dental hygienists will hurt you. Unfortunately, women don't often have this opportunity with birth, because we just don't have that many babies anymore :-)

If every woman had the opportunity to process her birth with her care provider, no matter what type of birth it was, then perhaps she could understand what and why things happened, and why her care providers acted the way they did, and did the things they did. The system is set up so that communication is avoided and discouraged. Most women only have this opportunity at their six week check-ups, but the atmosphere is not usually very conducive to it, as we are usually lying on a table naked with our feet in stirrups. With midwives, this type of processing can sometimes happen, but I've read many stories of not so good births where the midwives basically abandon their clients or preemptively blame them if they didn't have the perfect birth.

And finally, how can we trust what anybody has to say about birth when so much of the information is so conflicting? It depends on what book you read, what website you visit, what movie you watch, which doula you talk to, or which care provider you ask, as to what answer you get about any given thing that has to do with birth. I can ask a doctor when I should cut the cord, or I can ask a midwife, or I can ask my online buddies and I'll get three different answers. Which do I believe, which do I choose as the "correct" answer? Who is correct, and who is wrong? How do I know? Now, if I expect one thing to happen during birth, and my care provider does another, I'm not really going to have complete trust that this was the right thing to do. I may go back to my books/websites/etc. to see if you really did do the "correct" thing or not, and I'll get all kinds of different answers, and I wont know what to believe. And because there is no unity in the birth world between doctors and midwives and nurses and doulas and everyone else, then none of you can really be trusted. We don't know who to trust, and just when we think we do, they go and do something we didn't expect, and we are left feeling betrayed. It isn't a personal thing against the provider, it is just that it often seems that there is no right or wrong answers, there are just a lot of them in the mix and we have to try to navigate this very uncertain world and hope that we choose the people to attend us who mostly agree with our own personal philosophy. If we are met with a clashing of our philosophy, like the mentioned midwives who suddenly changed their tune when a macrosomia risk factor was introduced, or when a baby turned breech, then we suddenly feel betrayed by our care provider.

February 11, 2008 | Unregistered CommenterJennifer

Trust actually goes both ways, and the supporter also needs to know that when she sees something going awry that the mother will trust her sincerity and well wishes upon both souls.

This post also reminds me that there is a point at which the doula/ midwife has to let go and work with the mother's request *for* intervention.

That can feel like a breech of trust to the birth supporter; when a woman seemed to have an idea of birthing from within but gets scared of it all, and wants to be 'saved' iyswim.

I hope that makes some kind of sense. There has to a be a free flowing mutual trust that whatever choice and observation is made from either side will be respected, honoured and upheld. That it will be a positive story, whatever the outcome.

February 16, 2008 | Unregistered Commentershukr

Do you mean the midwife/doula/provider removing their ego from the situation and not taking it personally if the mom chooses a different route other than the one planned for? An epidural? Hospital?

If that is what you are saying... ABSOLUTELY!

While a midwife/doula walk *beside* the laboring woman in a few circumstances, it is ONLY the woman's walk - no one else's during that time in labor.

Midwife/Doula are servants who either toss rose petals before the woman's traversing feet or walk behind her, in her wake, sometimes picking up the psychic poop and using it for fertilizer (changing the energy from negative to positive).

(Sometimes the metaphors just flow out of me; I don't know where they come from. It probably annoys a few people reading me. Sorry! They help me, though.)

Is that what you were saying?

February 16, 2008 | Unregistered CommenterNavelgazing Midwife

Yes, but you say it so much more beautifully .)

February 17, 2008 | Unregistered Commentershukr

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