Caring for Women Who Do Not Seek Out Midwifery Care

“But….when’s the doctor coming?” An exasperated first-time mom howled at me as I rushed into the room, introduced myself as the midwife on call today, saw the baby’s head beginning to crown and hastily threw on a gown and gloves.

We had just changed over shifts, and, evidently, the physician that I took over for did not mention that a midwife would be taking over her care. I sighed. I usually like to have this conversation a little earlier than say, well, when there’s literally a baby’s head emerging.

I quickly explain that as a midwife, I take care of healthy, low-risk women with normal pregnancies and births, so the fact that I was there meant things were just fine. (Note to self: midwifery humor is usually lost on women pushing a baby out their vaginas.)

“….but….when are you going to cut me?” She was in a break between pushing, and had some more questions.

I rarely cut episiotomies, the cutting of the perineum to allow a baby’s head to emerge faster. I have cut exactly two in my life, both when extremely worried about the baby’s well-being. Up until recently, episiotomies were routine practice, and many of my patients expect to have one cut, or have had them cut in previous deliveries (with or without their consent or knowledge).

“Oh, honey, this baby is doing just great, we don’t have to do that, he’ll come when he’s good and ready. All this skin and muscle stretches to let babies through.” A look of relief passes over her face but quickly returns to a grimace that starts in her brow and I can sense her beginning to gather her strength to push again. A few big pushes later, we have a squealing, pink, and gooey infant directly on her skin.

I work in an environment where very few women seek out midwives for their care. The midwifery program at my hospital is just over a year old, and the word that there are midwives at our hospital is still making its way through the community. This is far different from the image that many people have of midwifery. We have to be honest, midwifery has a class problem and sure enough, midwifery also has a race problem.

I have many friends that work in the large metropolitan city that I live in, which has been increasingly gentrified. Poverty has been suburbanized in my area, and most of the poorest people have been pushed to suburbs south of the city. All of the midwives in her practice are white. Nearly 100% of her clients are white and have very good private insurance. All of them have sought out midwives, desire unmedicated childbirth, and most have not heard of the concept of food deserts.

The community I, and many other midwives work in looks very different. 80% of our patients are on state-sponsored insurance or medicaid.  I am surprised when I don’t need to explain to a new patient what midwives are and what makes us different than physicians. There are multifaceted reasons for this,  mostly having to do with the fact that many midwifery practices don’t function out of major hospitals that accept medicaid, or at least they didn’t until recently. The practice I trained with did not accept medicaid, and was in the same city that I am currently working in and our populations are extremely different even though the clinics are just miles apart.

Working with women who are facing pregnancy and childbearing while also facing poverty, low-wage labor, and many other struggles that the working class deals with is an honor, and listed below are some things that I have learned to help me be the best midwife I can be for low-income women and women who have not gone looking for midwives, but have ended up in my office because we are the only office that takes their insurance:

  1. Don’t be offended if you explain who you are and what you do and your patients still want to see a physician. Like with birth, if women aren’t comfortable in a certain environment, they just won’t labor well there. Don’t take it personally.
  2. Be versatile. Women need their midwife to be many things for them, sometimes you will need to know the local doulas and natural childbirth education classes and have good recommendations and then in the next visit need to be able to clearly explain labor law and what types of accommodations women’s employers are obliged to give them.
  3. Get to know your local WIC office, eligibility criteria, and familiarize yourself with the paperwork so that you don’t make the process any more difficult.
  4. Discuss food security with every patient at their new OB visit. Oftentimes this gets me quizzical looks, but for the patient that is experiencing food insecurity and is ashamed or scared to discuss it with you it will mean the world
  5. Be gentle in discussing breastfeeding. By this point we all know that breast is best. But when a women tells you they can’t do it because the idea of bringing a breast pump to work, asking for the breaks, and having somewhere to store the milk is too overwhelming (even though she is legally allowed all these things), believe her. Gently encourage her, but never shame or tell her “Don’t worry, you can do it!” and brush off her concerns. Have you ever tried to take a hospital-grade breast pump and all your milk home with you on a crowded bus?
  6. Know your labor law. Know your labor law. Repeat: know your labor law. Many pregnant women need some form of accommodation during their pregnancies and the way in which you phrase your notes and the specifics you write on FMLA paperwork can mean the difference between a women receiving the accommodations she needs and not. If you have a question, contact your local Labor and Industries office and encourage your patients to contact them as well.
  7. Advocate for in-person interpreters instead of the phones and for double the time in visits. Using interpretation services well means that it takes time. Women who don’t speak English as their first language often have significant barriers to good health care, don’t let short appointment times or low-quality interpreter services add to that stress. I know this is easier said than done, as the clinic I used to work for never had in-person interpretation because it is exceptionally expensive. I feel incredibly lucky to have in-person interpretation where I’m at now, it makes a huge difference in the visit.
  8. Finally, don’t assume who needs what services. I take it to the lowest common denominator for everyone and then work upwards. I ask everyone if they need referrals to get on WIC, need a prescription for a breast pump, or need a prescription for prenatal vitamins. If they don’t need it, fantastic, but I consider myself having failed if someone ever needs to sheepishly ask me for these services.

Midwifery care looks different in every practice. In mine, it tends to look more like talking about food and housing security than about prenatal yoga. All women deserve midwives, but each midwife needs to be able to give the kind of care her patients need and be familiar enough with her local resources to provide what we all strive for in midwifery: the true care of the whole person.

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1 Response to Caring for Women Who Do Not Seek Out Midwifery Care

  1. Teresa says:

    Great post, so much useful info. Thanks Michelle!

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