Your BIRTH Partners

History & Future of Collaborative Birth Care

December 21, 2020 Season 2 Episode 14
Your BIRTH Partners
History & Future of Collaborative Birth Care
Your BIRTH Partners
History & Future of Collaborative Birth Care
Dec 21, 2020 Season 2 Episode 14

In our last episode of season 2 we are joined by Dr Nathan Riley, MD of the Obgyno Wino Podcast to discuss collaborative birth care.
We discuss how medicine & obstetrics has historically excluded midwives and other community caregivers and the intentional harm that has caused, particularly in communities of color.  
We identify the challenges in changing the mindset about what responsibilities physicians have for birth, and the conversations that need to be happening between hospital-based birth professionals and their patients and the community at large.
We also explore some of the present-day barriers to collaborative care and our vision for working through them!

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Show Notes Transcript

In our last episode of season 2 we are joined by Dr Nathan Riley, MD of the Obgyno Wino Podcast to discuss collaborative birth care.
We discuss how medicine & obstetrics has historically excluded midwives and other community caregivers and the intentional harm that has caused, particularly in communities of color.  
We identify the challenges in changing the mindset about what responsibilities physicians have for birth, and the conversations that need to be happening between hospital-based birth professionals and their patients and the community at large.
We also explore some of the present-day barriers to collaborative care and our vision for working through them!

Support the show (

Maggie, RNC-OB  0:05  
Welcome to Your BIRTH Partners. I'm your host, Maggie Runyon, birth nurse, educator and advocate. And I invite you to join us as we break down barriers and cultivate community, discussing issues that impact pregnancy, birth and postpartum. We welcome you no matter what your background is, and are so excited to learn together. So today, we are discussing collaborative birth care. And we are joined by Dr. Nathan Riley, who is an OB GYN who's done a lot of work on community and growing birth advocacy in his role as an OB. And to gain some context around that, Nathan starts by sharing a lot about the history of medicine and how we kind of developed this supremacy and hierarchy within medicine where that causes a lot of challenges as then we work to truly be in collaborative care with all of our colleagues across the disciplines and all the different roles that we have as birth workers. So we'll share that and a lot of our vision for how we move past where we're at right now. So that we can truly have collaborative care that meets the needs of the individual birthing person in all of the married facets that that presents us. So I am really excited to welcome you all into this conversation. On to the show! 

All right. Well, Nathan, I am just delighted to have you on here to have a conversation about collaborative care, and where, where we've been how we got so far away from it, and kind of circle around with some of the ideas we have for hopefully getting back to that. So if you want to just introduce yourself to our audience and tell us all about you.

Nathan, MD  1:51  
Sure. Thanks for having me, Maggie. It's a pleasure. Really, it is like of all the opportunities to just talk about what you you know, everybody talks and talks and talks for for somebody to ask you to come on to their platform, and to say a couple kind words is really, truly a privilege. So thank you. So I'm Nathan. I'm an OB GYN, currently not practicing ob gyn, but I'm actually also a hospice and palliative care physician, which is very, very similar in its practice, believe it or not, and that's kind of one of the things that I'm always harping on people to understand is that the way that we care for people at end of life is very, very similar to how we care for them during the beginning of life, so to speak. So my practice is predominantly right now hospice, but one day in, you know, the 15-20 year span, I imagine opening up a birth center/hospice center, it's going to sit on the same property somewhere in the woods, with chickens and all of our own produce growing and, and water charging stations, and just this in this central area where families can commingle during these two amazing human experiences that we can, that we can share together. And so that's that's sort of who I am, I'm also working on a holistic gynecology practice to sort of, because I see that what I've been studying and sort of my approach is really helpful in that in that realm, and I haven't really been paying homage to that through my hospital based birth work, but now that I'm not doing hospital based birth work, and I'm eventually going to end up back in the community, or in the community to begin with, it's going to kind of just where I belong, whether that be that be home birth, birth center work, whatever, or just birth advocacy, which is what I've been doing for the past several months since we had our baby back in February. And, and that will be a combination of Eastern and Western philosophies to meet some of the needs of women's health that is not just very easily satisfied by a birth control pill or surgery, which is what most of us learn to do for virtually everything. And I don't know too many people who are super excited about either of those options every single time. But anyways, that's me.

Maggie, RNC-OB  4:03  
Right. Wow; that's awesome. I, I think I think that's great. So I you know, I came upon your podcast, I don't know, maybe last year at some point, and have listened to several of the episodes and one that really drew me into what you are, what you're about, and what you are focusing on was the episode that you did when you were preparing to leave hospital based birth practice. And I think part of what drew me to it is because birth care in the hospital is really hard. And it is hard on the people, the birthing people. It is hard on the people who are offering that care. And I just really resonated with a lot of the frustration that you expressed about kind of your journey through medicine through medical school into residency and then you know, practicing as a physician, and you know, as a nurse, like so many that is mirrored in our interactions that we have with those in our care when we're not able to, to, to do or be enough of what they need, because of the constraints of, you know, working within the hospital system. And so I really wanted to talk about collaborative care with you, because I think it's something that's like, has that feeling that it's kind of like a buzzword checklist like, of course, collaborative care, we're all collaborating. Yeah. But, as you said, when we were emailing back and forth about this topic, like, it's not enough to just say, right, we're all supposed to get along, everyone works a little harder. And we all just kind of make it work. Because there are several things that have been intentionally set up to make that very difficult, if not impossible, particularly when you're getting outside of the hospital realm and trying to work in between the community and the hospital, like you want to do in your kind of grander vision. So I wanted to kind of start in reverse with kind of the history of modern obstetrics, and where physicians have kind of positioned themselves. Within this, if you want to kind of give us a little bit of your understanding of that, and how we've kind of gotten to this place.

Nathan, MD  6:12  
Yeah, I think every great story in conversation starts with a really, really nice history lesson. And some context. So for anybody who's listening to this podcast, you were without a doubt, trained in a system that is patriarchal by nature. And I don't mean men are bad women are good, it's not what I'm talking about. What I mean is that there was a that there is a system of rules put into place as to how you, as the employed person, are supposed to execute your position, right? And you were, you've got a superior, who's organized by some other superior and ultimately goes to some other superior, etc, right? There's this hierarchy. And at the end of that hierarchy, are the people who are actually on the ground caring for one another.

And so if you grew up in this system, as a medical trainee or nurse trainee, midwife trainee, whatever, if you grew up in the system, you were told that you have a place, right, here's your spot, this is your domain, and don't dare encroach on somebody else's domain. Well, if we, if we were to use to look at that, through the end of life care proceedings, me as a physician, I don't have too much to offer. Right? If I just take my medical school knowledge, or my residency training, or whatever, I don't have too much to offer, apart from the symptom management, right? Like, let's give some medicine for this purpose. Right. And that's, that's what modern medicine is, or at least Western medicine is right? Let's find the problem. Let's meet this meet it with a solution. Well, the end of life, there's a lot of needs that are not met by medicine. In fact, most people, many people don't want medicine. So what is my role then? And and we we we approach birth, the way that we approach death, we approach birth with this idea that as long as you're a cognitively intact, upright walking, bipedal human, you probably can do all of that other stuff, that you went to medical school, and now that makes you special, you have this special superpower, that you can walk into a room and fix things. Well, you can't fix death. And you also can't guarantee a safe birth. Most births are safe, we can we can say that probably 999 out of 1000 are safe. But the majority of things that doctors are doing, are in order to eliminate the risk of that one in 1000. And that's okay, we as a culture, appreciate that. And we need doctors to do that. The problem is that what if a person has emotional trauma or they have some sort of sexual abuse in their in their past or they have some other social work need or spiritual concern, whether it's at the beginning or after you've lived this human experience? Who do we turn to? Well, just because you're an cognitively, unimpaired human, you don't have the training and the skillset to take care of the spiritual, emotional, psychological needs of a dying human, or a birthing human. And I, I challenge anybody to convince me that those two that these two events aren't the two most perfect but also most avoided events when we're sitting around Thanksgiving dinner or otherwise. So, and I am getting to the history lesson, but how we got here is we have physicians who walk around as if because they went to medical school, specifically a western US accredited medical school, they now have domain over all aspects of the human experience. They know it all because of course, they know what the normal stuff is. This is the fluffy stuff to you know, that we, we, you know, we can talk about in humanities and whatnot, but that's not the medicine you weren't "good enough" to do the medical thing and that's why I'm here. So thank god, I'm here. So we have this God complex, I don't mean that lightly, we really, we really are trained. And if you're a surgeon, you're trained that if you're not the best surgeon in the room, you better hand your scalpel to somebody. So I am not also giving this lesson so that ob gyn so bad about themselves, but if you're trained as a surgeon, and you're not the best one in the room to do that surgery, ethically, it's not, it's sort of imperative that you actually hand that scalpel to somebody else. So you're trained to think that you are infallible. And as a result of that infallibility, other people must be fallible. I described this sort of system in order to illustrate that what we're lacking right now within our modern medical system, and, to your point about collaborative care is that we have people within the system, who think that they're a sort of end all to every issue. But it gets worse than that, because even the people who, who trained in all this medical stuff, at some point, they decided I'm going to step away from the table. And I'm going to go and worry about the medical stuff, while some other business person steps in and actually says, Doctor, you are so important. We pay you a nice salary. It's not a great salary, but it's a really good salary. While we take care of the rest. And so now what you see there's a recent article, and I think it was JAMA, the article really looked at the expanding health care workforce, right. And the vast majority of our health care dollars now are not going to you and nurse me a doctor, the social worker, the chaplain, the people that are actually on the on the ground caring for people, it's actually going to hospital administrators and the business of providing medical care. And so what we're seeing between me, you know, talking down to you on labor and delivery, or speaking poorly about a doula that comes in, even though that doula knows this woman better than anybody, they may even be their sister, or their aunt or somebody else, like, this is like the old school way of caring for one another, and we're gonna dismiss it, that's actually horizontal violence, this is actually not about me versus you or versus anybody else. This is about me versus the system. And that's why I had to leave the hospital, because it didn't allow me to not only take care of you, the person who's administering drugs in the middle of the night, while I'm trying to get sleep, it didn't allow me to take care of my family or anybody else, either or myself. It really was just a matter of caring for things in order to check the boxes from the C suite that the C suite had passed down to us graciously, while they're walking away with millions of dollars per year in salaries and bonuses and all that other stuff. How did we get here, that's what you asked. It's important to illustrate where we got to before we can talk about how we got here. So, you know, for about four centuries, I think that the big issue that men have had with women, I mean, it goes way, way, way, way, way back, there were some ancient civilizations like ancient sumur, where women were actually worshipped for what they provided to the equation. But you fast forward, and we'll get to that a little bit, the woman, the goddess of the feminine, right, the church of the goddess, that was a thing, and that still should be a thing. But what happened probably in the 13th 14th century, up through the 17th 18th centuries, especially in Europe, and we had our own version of this in the United States, but the witch trials of Europe were a perfect, they were exemplary to what we're at what we're actually seeing nowadays, which is this kind of siloed set of skills that we expect people to have in the hospital. And what was happening then, is that we didn't have a professionalization yet of medicine, there wasn't a doctor walking around. But we had a church and state who felt very, very threatened by women who had skills to care for themselves in ways that God could not. So instead of God providing you healing through prayer, you now actually have herbs and you have tender human touch, and you have maybe some,

you know, tinctures and things like that, which very, very quickly became witchcraft, you know, that magic. But what women were practicing during that time was not magic at all. And I do actually, I believe in magic. I think that there's a lot of important things that we can't actually observe through our randomized control trials. But that's a different conversation for different time. What women were practicing was the use of stuff that they knew worked based on what their mother told them what their grandmother told them what their great, great, great, great, great grandmother had told their progeny. And it was passed down in through empirical evidence, they knew that if you give this plant during this time of the cycle, that it decreases your fatigue, right? And, like what I'm talking about is, let's find some herbal remedy for heavy menstrual cycles. Right? And, and the woman takes that in they become more productive in whatever capacity they operate, you know, in their family or whatever. Right? But that is modern medicine, like they had pharmacopoeias that were practiced through what eventually became midwifery. But we're not even talking about midwives, we're talking about the, the sage, sort of respected woman in a small town or village who actually just had this knowledge, and maybe it was written down, maybe it wasn't, but they knew what to do. Well, if you can care for yourself, you don't need a state to tell you what to do. And you don't need to actually pay taxes, or pay into some sort of coffer, to get that care. And you certainly don't have to pay to the Catholic Church, or the Protestant church for that matter, in order to have the blessings of your pasture and God to get better from your maladies. So fast forward, you know, millions of women died in Europe, during these witch trials, right. Towards the end of that, they actually started to see the emergence. And it actually wasn't even towards the end of that actually, earlier than that, in the middle of the witch trials, the role of the physician actually became critical, because you actually will see there's a lot of texts this the Malleus maleficarum, I think is what it was called, it was like the Witch Hunters guide from the 13th century or something. It actually describes as well, how do you identify a witch? Well, a doctor will give you will give you no credence to that to that claim. And so once you have one person who's now claimed as a witch, you torture them, and you get them to accuse others. And now you have other women who, and so it's slowly you squash out this knowledge base. And I'm not going to go further into detail about this, because there's plenty of books out there to read about this. But you can imagine how then after the witch trials, they didn't eliminate all of those healers, like the healers that at that point, the women who were doing this, this great important work, they, they were really that the healers of the people, right. And that, that that kind of understanding, still kind of live, because poor or otherwise, what we would call an underclass or, or underserved people still had to go somewhere, right, and there was still that little bit there. So they didn't need to squash it out. They didn't need to hang every single person who possibly had that knowledge. But it's certainly allowed them to then further clarify, oh, the women who are attending births that was kind of like the little Bastion left of where women were, were so valued in this space, and that and that gave birth to gave birth to the modern midwifery movement, which is very, very, very, very old. 

And so, you know, you now then are left with like, Oh, well, well, there's just a few people left doing this. And those few people are now living with this narrative that has been developed the mythology of like the dirty old housewife, right? Like, it's an old wives tale. This is all part of our history. And those women continued to do the, you know, perform the role of an of an obstetrician until men started feeling like well, maybe we could take over a part of this, there wasn't a lot to go around in the 17th 18th centuries, and into the 19th century. So you know, they developed mechanical ways of helping to deliver, quote, deliver babies, not birth babies, not to attend or catch babies the way we say now. But like, let's put two big salad prongs in and let's pull the baby out, you know, and if you only give license to certain men who actually were barbers, barber surgeons, they call them the the sort of license to use these things. Well, that actually eliminates most business for the midwives not that you needed those to do it. But you create the story that this is this is the right way to do it, right. And there's there's middle upper class men that are telling you this. So we're still dealing with classism and sexism now. But if you fast forward then to the sort of professionalization of medicine, it was systematic in the way that women were kicked out of the profession, it was made impossible, there was a whole there was a propaganda scheme. In order for white rich men, to be supported by other white rich men in order to professionalize the the sort of what we now considered standard operating, you know, procedure, where a birth is kind of now considered more of a surgical procedure than it is an actual natural, physiologic process. But the midwives could have told us that we push them out by creating a space for white male physicians to do this work. And there were a couple female physicians, and they actually probably were the dis most disliked by the feminist movements of the time, because they were saying, hey, hey, those lay midwives get them out of here. Like, like, Look at us. We're the ones in the white coats like, you know, and it's like one out of 100 are actually women. So what what did we do later? Well, and actually, I should mention the flexner report, there was this report that came out I think in the 1830s, something like that, where some big money like the Carnegie's and Rockefellers actually finance this stuff. Of every single medical training facility in the United States, and they kind of gave them a grade. And if you weren't in the in the good graces of the flexner report, you weren't going to get money in order to open up your hospitals and your facilities and your medical schools. And they found that, hey, if we have medical schools that allows us to take care of more people and open bigger hospitals to make more money, well, women weren't going to be a part of that, especially old wives. Right? Who, right, they had sort of characterized midwives as for hundreds of years now. So fast forward to now and we're left with a system in which predominantly white middle to upper classmen myself being one of them, I'm not gonna not gonna lie, I was a shoe-in in for medical school, you know, go through residency, you don't see many people of color, you don't see a lot of you do see a lot of women nowadays in medicine. But it took us a long time to get there. And the biggest concerns that I developed when I was in my residency training, which actually feed into why I left hospital based medicine were people, my colleagues saying things like, Well, did they go to medical school, you know, fill in the blank, the doula, the midwife, the labor and delivery nurse like you? "Well, I'm glad they have an opinion, did they go to medical school?!" Like that is actually not your original thought... What you are actually regurgitating is something that was passed down through 50 generations of sexism, classism, and the professionalization of a sect, a specific sect that sort of defined how we should be practicing, so to speak, the attendance of birth, and women's health issues.

It was one little sect one little idea as to how this can be done, and through money and power in classes. And we actually just wiped out all the competition. So by you saying, Oh, you didn't go to medical. So you're literally just regurgitating it's the most unclassed, the most an educated thing you could say. Because you don't even have any idea what the relationship is for this person that you're that you're demeaning in labor and delivery, when they're coming to you for help. You're demeaning them. And they've got a patient who needs your help, and they might know everything you need to know about them. But you walk in and you say, "well, glad you you took them for a home birth, like, well, that was really smart, huh." And then we go and publish things just to, you know, confirm our biases about where birth should take place, just because we're we've got this stronghold, and we're losing grasp of it. Now I say we because I still consider myself a part of the system, but we are losing that stronghold. And we are doing everything in our power to disparage the people that can actually do this, right. Mm hmm. And my greatest secret is I wish I had gone to midwifery school.

Maggie, RNC-OB  22:48  
Oh, yeah, there are so many layers to all of this. And I think we see, particularly in our country, obviously, the impact that all that had in crowding out the lay midwives, the, you know, the old grand midwives have, you know, particularly from the South, old Black women who had been birth keeping, right, for generations for everyone, including these little white babies, who all of a sudden, these white men decided they needed to protect with all costs, by putting all of this into this, you know, allopathic medicine system. You know, the, that reverberates so much today, in terms of the, you know, maternal mortality rates, that we have the infant mortality rates that, you know, impact Black and, you know, other individual color, so much higher, you know, three to four times more for, for people during birth, two to three times more for infants by their first year of life. And I think one of the things that is hard for people and like you said, and myself as a white woman who very much is, you know, part of this system, and does this work in hospitals, like it is hard for people to accept the intentionality that was behind this system, that this is not something that just happened and we're stuck with it. So I do appreciate the history lesson really spelling out kind of some of this, where we have come over centuries of work.

Nathan, MD  24:11  
Yeah, and one thing that that I forgot to mention that you brought in so beautifully is that the work of midwives of women attending women in birth, not only is it is it ancient, like we just described, I mean, this goes back as far as humans were attending other humans and caring for other humans. But in the professionalization of nursing, which you and I talked a little bit about, before we started recording, the professionalization of nursing took all of those middle, mostly, I mean, it was actually all three classes. And it was really a kind of spanned the classes. We created this role for women in medicine that allowed that allowed us to say, well, there's this place here, Isn't this great? And a lot of feminist leaders really supported that role. Like, hey, look, here's a place for us like we do have a really good thing to do well with as the white women went there and got out of birth work. Who was going to do that work, it was going to be a lot of indigenous and Black women and women who had still been doing this, but had sort of like flown under the radar, so to speak. I mean, I don't mean to make light of the role of that any Black woman or any of her ancestors has had in this country, it's been a tragedy. And I absolutely believe that. On the other hand, at this time, people didn't care what Black women were doing, because they weren't a threat to the the sort of patriarchal white, upper class system that was being professionalized right within medicine. So I'm glad you brought that up. Because it wasn't until later that those midwives also are being, you know, persecuted, and continue to be persecuted for doing this great work. And so, fortunately, I think you have colleagues, I have colleagues, there are people that are sort of rising from the ashes, so to speak, and bringing this work back. And so I guess that's what we're here to talk about. How can we get them? 

Maggie, RNC-OB  25:58  
Yeah, exactly. So I mean, I think this, there is, is really complicated history that makes it like we had said, This is way more than just, let's we'll get along. It's not like a moment for everyone to just somehow put aside their differences and come together, which is a lot of what we hear spoken about. So especially, you know, if you're the people who are in power, it's easy to say, "Oh, well, sure. I mean, just pull up a chair at the table, I guess. And let's do this." While having there be absolutely no path for anyone to to do that. And so one of the things that, you know, I, I feel like I have had an issue. And so most of my work has been in hospitals, but I've also been involved in, you know, the home birth community. And one of the things that I think just really reverberates when we talk about like collaborative care is the idea that every community birth worker, I know from midwives, doulas, childbirth educators, anyone who's involved in you know, kind of body work and takes care of pregnant and you know, birthing people, they all have referral lists out the wazoo. They have so many colleagues who they know to refer to, if someone comes to them and has something that's going on, it's outside of their expertise, their profession, what they can take care of, they are so quick to say like, Oh, hey, I know so and so who does this? Oh, they're, you know, what, they're really great at this, I think they'd be really good fit for you. They have all of this ability, including, obviously, reflections of the hospital birth, they're available from, you know, birth facilities to, you know, physicians and midwives, and you know, all of that they have all these resources, and they're really well versed in all that is kind of available as options for people who are coming into their care. And then the other hand, the vast majority of hospitals, and physicians I talked to do not have such lists there may be going to have like, Oh, sure. I mean, there's like the childbirth education at the hospital. Yeah, you could go to them. And that's fine. And that's good. And I've worked in hospital childbirth ed, that there's nothing wrong with that. But you know, they'll have these couple of like, kind of rote things like, Oh, yeah, that you could do that. Or like, oh, but how many of them have a list of doulas, you know, that they're going to refer patients to or even to let them know, like, Oh, hey, you feel like you would really benefit from maybe acupuncture? Chiropractor anything's like, it's just that is so rare to see kind of that return. And they certainly even if they have a name, they're not gonna be able to tell you anything about the person just like, oh, I've heard this is a person in our community live look kind of locally. And so I feel like that piece of it like when we are trying to change, birth care, and I say this as someone who I, my goal is to change birth care from the inside out from being in there and doing it is like, how do we do that? When the people who care the most about kind of effecting change in the system continue to be excluded and pushed to the outside? 

Nathan, MD  28:34  
I think for and I didn't have an answer to this until just now. So bear with me...

Maggie, RNC-OB  28:40  
It's the perfect timing for it. 

Nathan, MD  28:41  
Right, just just in time. So what one really important thought that I have now is that if you look at the so the way of the birth plan, right, the birth planning thing, I had an attending in residency who used to say, you know, "when people show up to get on their airplane, they don't hand the pilot a flight plan, like who's to say they have any sort of right to give us a plan as to how their birth is going to go." And like, there's so much wrong with that. But the biggest part of that is that you don't even understand what the point of creating a birth plan is. They're not; it's not a dictation. It's a conversation that you weren't willing to have. And so now here they are. They're bringing it to you in narrative form in nine pages, and you're making fun of them for it. I mean, that's, that's Unfortunately, the experience I've had with a lot of docs. Absolutely. It's not a surprise. So back, like back to our history lesson. Women were using empirical evidence as wise. I don't want to say wise elder women, they weren't even necessarily elder women were being women. And they were young and they were beautiful. And they were still doing this great work. Like they weren't in a little old lady in some hut, like this was an incredibly important role. And they were passing this information down because nobody else was Doing it, nobody thought that it was useful to care for one another. And that's an inherently feminine quality, which is why women are so important. We'll get back to that. But the reason that men feel so threatened is that like women actually, were doing things that worked. Hmm. They were demonstrating like, oh, if I give you you know, it wasn't eye of the newt, but like, let's say it was eye of the newt, like eye of the newt totally takes away your diabetes like, well, that's way better than injecting myself with insulin. Right. You know, the herb logy, like all of the all of the things that we now kind of laugh at, right? Like, how about like, the role of compassionate touch for people like there's ways to touch people that make them feel better? Well, just because we don't have some Harvard study that says that it doesn't make it invalid. But at the time, the men didn't have any evidence that they had something that worked better. But there was not even a medical sciences like that this thing that dates way back, but there wasn't really a practice of medicine. We were still in like humor theory, around the witch trials. So intemperance, right, which was a Galen, one of one of Galen's concepts. And not to say that there's anything wrong with that either, like that was pretty darn, like pretty, pretty special and pretty useful. But it wasn't to replace the empirical evidence in empirical really means, like, I have done this 1000 times, and I've seen it works 900 times. That's pretty good odds, you know, and so, so. So in order to change the system, from within, I'm a little bit discouraged by the ability to change it within. Because it's not just, it's not possible to demonstrate how it can be done well, within the thing where it's not being done well. So what I mean by that is, if we had more physicians and nurses and women who are going to the birth center, or homebirth route, and more entities that were willing to, to acknowledge that there's good work being done here. Like in other words, if we had a giant Instagram account that could show just how freaking great birth can be. And we have a lot of them. I don't mean, to say that. But if we had like, sort of like this centralized notion, right, like, like if we as a culture could, it could understand just how important this event is, and how beautifully it's being done, attended mostly by women.

That, in some ways, is drawing now women out of the hospitals, and when I have colleagues who say, hey, like, Can you believe people will have homebirths, and I'm like, I kind of want to have home births. And you know, and, like, I love the idea of having home births. Like I think it's a really beautiful way for us to in fact, when my wife and I had our baby, and about 10 months ago, when I checked her here at the home, because of because of course I checked her when people are like you did that like "Yeah, because like she's my wife, and we're intimately connected." I checked her she was nine centimeters. So had we waited any longer, I would have just been having a baby right there in the bedroom, which wouldn't have necessarily been bad because we went to the hospital and had a completely unintended unassisted birth really. So and the reason I say all this is that what we're what we've what we're demonstrating for people is that, hey, this is not an unsafe option. And yes, bad things happen. But bad things also happened in the hospital, whether they want you to believe it or not. So here in the homebirth setting, not only are things going well, and it's drawing women away from the hospital, and getting them to question like, this hospital based birthing thing is not doesn't sound great anymore. Like maybe I should explore some of these other ideas, home birth, even free birth for women who have actually had for many women who have actually just had a bad experience. Like this actually is way better. You know, and for many women who haven't had that experience as well, I don't want to say people only do free birth because they've had a traumatizing experience in the hospital. But the vast majority of people are thinking about that only because they're cultural sort of tendencies to believe that being in a hospital as a safe place is going to care for me inside and now. It's starting to change. And that's why the hospital systems like let's do everything we can to really disparage this practice, like, yes, there are some bad things that happen. But there's a lot worse things that happen from my experience in the hospital, where women are having vaginal exams without people introducing themselves first. I mean, that in and of itself is a harmful practice. It's not it's not just like, not ideal. It's suboptimal, like this is a traumatizing, dehumanizing thing that we're doing two women every four hours based on some arbitrary clock somewhere. And I know you know what I'm talking about, because I was chastised by my nursing staff when I was in residency and they were like, do we really have to check her in I'm like, "the attending's mad at me like, what do you want me to do?" I still have nurses I wish I could, like have coffee with them and be like, "I am so happy that you pushed back." Because otherwise we're not teaching people that you don't need to go by the standard labor curves. There's there's one ways of doing this. So this is a long answer to your question. But what we're doing now what we're, I say we because I'm a huge advocate for this. What we're demonstrating as a birthing community is that there's better that there are other ways to do this. And in many circumstances, that's better. So that's a serious threat to the hospital system, which is why there's a lot of disparagement. That's why there's a lot of reinforcement of what we've been doing in the hospital. Because if we admit that we aren't doing it well, then what are we like, the second best? Or what are we I mean, like, this is a natural human thing. This isn't just a medical thing. This is how people get you to go to their place to have their car fixed, you know, right. They want to be the best. They're number one, the number one Nissan sales, and they're in the region.

Maggie, RNC-OB  35:44  
Right, right. Yeah, I mean and we've talked about that, too, like often in birth communities, especially when we're talking about changing birth care, it can come across it, you know, that we're anti-ob-gyn, that physicians are just the worst around. And obviously, my belief is not that at all, I believe that physicians learn a very particular skill set in their training, which is very valuable. And at times what is needed most in a situation. However, it is obviously not what is needed, right, every single time, just like my skill set, as a nurse is not what is needed in every birth at every moment. I mean, that's just because that is because we are all human. At the same time, you know, it's not the job of a doula to feel like they're supposed to somehow cover for everyone's singular needs during, you know, their birthing, it is no one's responsibility, it shouldn't be any one person's responsibility to provide all of the care and all of the different realms from, you know, the physical, to the spiritual, to the emotional, that someone has during a completely primal experience, like birth. And you know, to your point is the same thing, when we talk about the end of life as well, like, we put way too much pressure on ourselves, to be the all for that. And so, you know, I say that, because I think when we do this, it's for many of us who have worked in the hospital system, who have spent a lot of time and money learning to be a medical profession and take care of people during birth. And who did that, obviously, with the best of intense, it can be really hard to swallow the fact that we're not doing the job, or the best job of doing this. And, and I say that not because, you know, this is not it's not to meet people feel guilty, or just beat yourself up about it. Because like I said, I still am a nurse in the hospital. And I am constantly learning from speaking to people from you know, from reading books and articles and working, you know, with other birth workers, about the ways I can improve my practice, the ways I can do less harm and be more supportive. And, you know, all of us are looking to do that, I think there is so much about the way that we have set up the hierarchy in birth care, where we have positioned physicians right at the top at the pinnacle, that then it puts all of the pressures ultimately on them. And I have been a part of care that has not been ideal, and I have been told, nope, you did everything as a nurse, but the doctor did not. And that doesn't sit well, because I do think we are a team and we were all working with the same information and trying to do you know, the best thing. And so I do feel like that pressure that gets put then on physicians, it is a lot to carry. And I really do feel like that is where true collaborative care would come in. So if instead physicians were able to just be in charge of the part of the care that they have trained to care for. Yeah. And we actually had, like consistent networks of care that involve people who specialized in, in the mental health piece of it in, you know, in doulas who are there for that emotional connection that people need during an experience like this 100%. Right. You know, if we have people who are actually doing that, and doing that, well, that that would take away some of some of the pressure and some of the antagonism that goes both ways to know it, because it and I, because of that, because

absolutely people out in the community have been maligned again for much longer, everyone's just pushing back against them. People don't want to let them have space, in hospital birth, they don't want to acknowledge that as a legitimate and safe choice. You know, people have wanted to make it seem as if having a home birth is because you're concerned with the optics, you know, because you just want the candles and like you really love your bedspread. No, like it is because that is where you feel you will receive the safest care on all of the different levels that are available to that, you know, I think people we have again, we've been trained and it is it was intentional and very effective that you know, the hospital that is for safety, and that's where you're gonna get this great care. And that is deeply, deeply embedded in people. And so it is hard to push through that and see a different option and recognize that safety right can be achieved in other places. And that is one thing that I've heard, I believe it was like Cristen Pascucci with Birth Monopoly. I think she had recently had a post talking about that idea. Do that like, right, we need to really push that piece of the safety component, a birth outsideof hospital that it's not being done just for like the fuzzy feelings and the fuzzy feelings matter, so that is the reason you're doing it, that's also valid, because it's your choice as an autonomous person. One of the concerns, I guess, that I have is that as we keep going, and we have these, you know, the, the birth care system in the hospital that is desperately clinging to what it has by continuing to publish, essentially the same article over and over again, looking at data and trying to pretend that it's all either. Exactly, you know, you know, and then we have people and I think the pandemic is certainly amplified this, you know, we have had a surge, obviously, an out of hospital birth, as people have recognized it, like, oh, shoot, maybe the hospital really isn't the safest place to have a baby right now.

Nathan, MD  40:48  
And more limited prenatal care. And yes, we are not having worse outcomes. Sorry, I probably took that that probably stole your thunder, sorry.

Maggie, RNC-OB  40:54  
no, that's good, [laughter] thunder to be shared. But like the as we are having these two things, kind of these competing pieces of it, you know, my goal. And again, I say this, as someone who's like, I've worked in hospitals and home, I had a hospital birth, that was beautiful. I've had a home birth, that was beautiful.

Nathan, MD  41:10  
That's such a cool, experienced you you bring such great personal experience to this conversation.

Maggie, RNC-OB  41:15  
Yeah. And I think it's, and it's important to me, because I don't find that they are mutually exclusive, like, and if I was to have another baby, I might choose to have another home birth, I might choose to have another hospital birth, I wouldn't know because I wouldn't know all the circumstances of that birth. And all the things that would go into it at that time in my life, physically, mentally, every other way. And so I feel like sometimes there's this idea that people feel like they have to like, you have to dig your heels in, right on one side of something, instead of just really trying to focus in on that the individual piece and the ways that we can work together so that we actually have our, our individual skill set. And again, the reason that you spent time and money, a lot of money training to do a job. And that's whether you train you know, as in the medical profession or outside of work, like you've spent a lot of time and energy learning to do this well, right. So often, we don't have the opportunity to actually do that.

Nathan, MD  42:12  
I think that was so beautifully put, you really it really was I don't really have much to add to that I I do want to draw in some other ideas that. So first of all, in my sort of monologue about home birth, I'm also not saying that home birth is the only way to have a baby and I want to I like want to make that crystal clear. What I'm in support of is a person's right to choose what they feel best about. And for some reason, in the medical system, we preach that, but we don't actually walk that walk. And what's important for you, Maggie, is that when you get to the point where if you have another baby, and you're there, wondering what would be best, it would be great if you had a provider who would say "Wow, well, what do you think is best? Where do you feel most comfortable? What was your previous birth? Like? Tell me about your experience? What are some of your fears, what brings you joy, what's important to you?" And that's what we do in an end of life care. And I think that, I think that when we start to do that, we actually start to have a conversation, which is called birth planning, by the way, everybody.  We have a conversation about who is this person, I am not just a technician here, going through the motions of putting on this Darth Vader look, and putting a thing under your butt when you're when you're on the labor and delivery bed. Like that's not your only job, it doesn't have to be your only job. And yes is to harken back to a little bit of what I said about this sort of role that we play as physicians, you have an extremely important skill set for modern humanity. And I want to I like will say that, again, you are extremely important to the system. But you're not the only person that a birthing woman needs in order to feel safe and to feel heard. If you can expand your vocabulary, you might be a little bit more of what you are. But the good news is you don't have to be every other person. You don't have to be a nutritionist, or an exercise expert. You don't have to be a diabetes educator, you don't have to be a doula or a person who has sat with a person who's been in labor for 34 hours, you don't have to be that person. You also don't have to rush out of your house to go to somebody else's house, like midwives do. In order to comfort the partner, while you're also comforting the birthing woman. You don't have to do those things. There are other people out there that can do that for the people that that that feel like that's the right thing for them. I've been harping on this at talks I've been doing I just gave a talk at the University of Louisville Grand Rounds kind of thing. And the whole the whole point of my talk was You don't have to be everything like why aren't we right off the bat identifying that we have the skill set and when we've done our job, why can't we feel comfortable bringing in other people to help us? That should be a sense of relief? Yes, sure. Be because you can't do everything as a nurse, I can't do everything as a doctor. But if you need me to do surgery right now, I can get a baby out in 30 seconds and that baby and that mom are probably going to be okay. If, if everything from the time when I decided to do that until the time the baby comes out, there's a good chance that we're going to have a good outcome. But beyond that, if I'm not, if I don't have the skills, why can't I feel comfortable, and that's, I guess, the heart of what needs to change. And so by demonstrating in a home birth or birth center community, here's how things could be done. The reason I brought that whole monologue in is because we can demonstrate that it can be done differently. And it's going to be a multidisciplinary approach or transdisciplinary approach where I have a little skills in your area, but you need a little skills in my area. But like, Hey, we're we're going to work as a fluid, we're going to be an amoeba here, and we're going to do whatever it needs to happen to keep people feeling. Okay, we can't guarantee a good outcome, but we can at least make this experience suck less. In the event that there is a bad outcome, then if there's a good outcome, then man, we've hit every piece because we've got all the important people there to make sure you feel safe and cared for by your community by your people. 

Maggie, RNC-OB  46:16  
Right. Yeah. And I feel like on that note, I feel like it would be like remiss to have this whole conversation, and not talk about having more cultural congruence, in care. And in the paths that we have towards people getting into any of the medicine, midwifery, nursing, doulas all of it right, that we have more people from all of the different communities, but especially from those that are typically been really underrepresented, and intentionally excluded from this has not been random. So we do we need more, you know, we need more Black midwives, we need more birth keepers for all for all of it, any of our Black and Indigenous and all other communities of color, we need more people who already have establishing these relationships within their community to be the ones that are then there, right, offering care. And I think it's very easy. And again, like it's, again, very much taught to us in a lot our medical and nursing kind of that whole savior piece. And it's really the white savior ism that comes into it, that you know that you're gonna write in your white horse and fix it with your magical nifty, you know, medical knowledge. And so I do just think I also, I want to be very clear that like collaborative care, absolutely has to be between, you know, all of these different people who have intentionally studied, but it also very much about that relationship with the person who's who is in care, and the other people who support them in their community. And it's not about coming in and like having a care management piece of it, that is a really important piece. But it is no more important than actually having the person who's making care, picking out who they want to support them. And having that be respected.

Nathan, MD  47:55  
That's right, by everyone. That second part, it's extremely important to. So it's not just about giving choices, it's not a sushi menu. Yes, it's about providing the information that's required to make an informed decision while providing the room for the refusal of treatment, if it's against cultural values, or your personal experience or values, or you just don't feel right about how it was presented. And then we support you and your decision. I mean, that's, that's the collaborative care model. That's like, I've got your back. You got me if you need me. That's what we all need to be doing. Not just the doctors, but everybody needs to be doing that. Like this is not your, you can't control this. You can't. But the medical system loves to protocolized things and give us checkboxes and yes, lists are important for doing major surgery. Lists aren't as important if we're attending to a person who's going through one of the most scary but also exciting and joyous opportunities of their life. Mm hmm.

Maggie, RNC-OB  48:57  
No, and I feel like we often to big size at the end of these conversations, because there is just a lot there. There's a lot and obviously, I mean, I, we could unpack this for several more hours as we keep kind of diving into all these different, you know, pieces we've seen. But, you know, as we're coming to kind of coming to a close, I just want to say to our audience, like I am so grateful for everyone who tunes in and who listens and takes part of these conversations and who you know that comments on social media and gets in touch with us to talk about how this is impacting your practice and your community as you're kind of reaching out because I really do believe that that it is possible for us to change this. This was very intentionally made to be this way. And we can very intentionally undo all that and create something that actually serves everyone who is involved in birth. Obviously, most importantly, people we're caring for but all of us who provide care as well. And so I really appreciate everyone kind of listening and taking this to heart and then hopefully taking this into your spaces and getting back in touch to us to see like what is happening in your community. How are you going to make a difference in creating some inroads, and getting rid of some of this toxic crap that is stopping us from actually making change? So, thank you so much for joining us for this conversation. Is there anything else you want to share with us, send out to the room?

Nathan, MD  50:21  
No, it's again, it's just such a privilege. If you know you've created something really great in your podcast and in your in your network, and it's it's truly an honor, that somebody would value my input enough to say, hey, come and chat for 45 minutes. That's pretty rad. So I, it's my privilege.

Maggie, RNC-OB  50:42  
Thank you so much, Nathan.

Nathan, MD  50:43  
Thank you for doing the work.

Maggie, RNC-OB  50:44  
Absolutely. Well, we'll keep doing this work together. 

Thanks for tuning in. We love to talk birth, and we'd love to talk about it with you. Please join the conversation by finding us on Facebook, Instagram, or Twitter, where your birth partners across social media. And in particular, we invite you to join our Facebook group, which is Your BIRTH Partners Community. There, we have a chance to really dig into the topics from each week's podcast as we talk about the challenges that we face changing our birth care practices. And we're also excited to share a new resource with you all this week. So we've developed a little form for you to get a sense of who are the birth partners in your community, who you might benefit from developing relationships with both personally as you know, a professional, and who are the people who those in your care, anyone who's out there getting ready to give birth, who are some of the birth workers out there who might have talents and skills and expertise that could help you as you are on this journey through pregnancy and into early parenthood. So we will be sharing that form that resource with you in our show notes and you'll also be able to find it on a regular website. You can also check out our show notes for more information about Nathan, and we look forward to hearing from you all about how you are making collaborative birth care a reality in your community.

Unknown Speaker  52:06  
Thanks for being here. Till next time.