Midwifery and personal freedom
Midwifery is about personal freedom. "I define myself as a mother and choose to give birth squatting in a dark closet". "I know the evidence on vitamin K and I choose that my baby does not receive that shot". " I understand the public health benefits of the pertussis vaccine but I choose to decline it". This is democracy, personal freedom, midwifery. Mostly, a midwife's job is to move out of the way. I want to understand a woman's choices in order to be sure that these are her free choices and in order to help her clarify her needs and wishes. A mother chooses to have her abusive husband or her controlling mother by her side; her choice, her freedom. What is the midwife's role in this freewheeling world of maternal autonomy? The midwife must be free in order for her clients to be free. Of this I am convinced. The midwife cannot feel the power of a paternalistic institution or a meddling physician restricting her ability to be present for an autonomous mother. But reality can rub our midwifery noses into limits nevertheless.
Years ago I supported Jane and David through their first pregnancy. Jane had "sensory issues". She could not lie on my exam table fully dressed with her body on the clean cloth cover and her head on the clean pillow case. She needed paper covers. Touch was difficult. Trust was difficult. She trusted David and , over time, she trusted me. Jane planned a home birth. The intense intimacy of the process could barely be imagined for her. It had to happen in a corner of her bedroom. I came to her house at 36 weeks to discuss her plans for the birth. Both her condition and her wishes pushed against my limits. Her blood pressure was rising. Her plan for the birth was that I would stay in the other room as she pushed her baby out and her partner would call me in after it had happened to check them out. It made me squirm. We talked.... civilly. I described how quiet and in the corner I could be, hopefully an imperceptible presence, (but a presence nevertheless). I also talked about watching her blood pressure closely. We talked and then I left.
A few days later at the birth center, her blood pressure rising, Jane explained that if I had to be in the room in order to provide care, they would have to have an unassisted birth. Who would watch her blood pressure and possible preeclampsia symptoms? Would she be willing to go to the hospital if it worsened? What if she had a preeclamptic seizure alone with her husband at home? David was uncomfortable with Jane's plan to just go it alone. But he knew her best. He was loyal. They would leave my care.
I made sure that they knew that I was happy to provide care that I could feel was safe midwifery care. I gave them their record. I drew up a document describing the responsibilities that they were taking on and what could occur. They signed it. I sadly said "Goodbye and good luck". My fear for them remained but my fear that I was being forced into irresponsible midwifery was relieved. Freedoms can conflict.
They let me know that the birth had gone well, unassisted. No blood pressures were recorded and mother and baby were fine.
Recently Cindi pushed my freedom buttons again. One of the main causes of medical intervention is induction obsession and the overblown paranoia of babies dying if mothers go much past their due dates. I am proud to ignore both the 40 week mark and the 41 week mark. I will not be pushed into postdates pressure and I work hard with the women I see to encourage patience and confidence that pregnancies do not last forever! So when Cindi past 40 weeks we barely noticed. When she past 41 weeks, I encouraged patience and made sure that we had set her due date appropriately (we had). A few days later a sonogram confirmed that the baby was doing well with a fully functional placenta and plenty of fluid. At 42 weeks we were still confident. Babies just come out. "If you get this far, all your body needs is a little nudge and you're on your way" I said. By a nudge, I meant membrane stripping and if absolutely necessaary ...... castor oil...nasty stuff but it sure makes recalcitrant babies past 42 weeks come out. The physician I called to get his input and OK for the plan of care (a necessary limit on my freedom), was OK and said "If it doesn't work, send her over". Having been there before I was confident Cindi would not show up at his door. Unfortunately, less than a centimeter dilated, it was not possible to strip her membranes. Oh well, the baby was in a good position, a little castor oil will do it. But it didn't. Nothing but diarrhea and a sore bottom.
Then Cindi and her husband Paul, began to assert their personal freedom. They went in to see the doctor and told him they were not ready to be induced. "OK, you are free to choose. I can't force you", he said. She was now getting close to 43 weeks with the weekend looming. I was up against the limits of my professional freedom, my license, my ability to serve the majority of women in my care. I do not believe that Cindi was really in a truly risky position. Risk is relative. Her baby was active. There was plenty of fluid. Cindi was healthy. But I couldn't continue care. I couldn't put my midwifery colleague, who was on call that weekend, in danger of defending her license. I din't want to abandon Cindi and Paul. I discussed her wishes with the doctor with whom she had declined an induction. He was willing to attend her birth if she called in labor as he had already seen her. I don't know if she did that or even if she is still pregnant four days later. Her freedom is intact. So is mine.
The day after Martin Luther King day, I am reminded that the path to freedom can be tortuous but it is worth fighting for.