Latest / Wellness, Actually with Emily Oster & Perry Wilson, MD / All About Midwives: What they do, and how they differ from OBs

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All About Midwives: What they do, and how they differ from OBs · Wellness, Actually with Emily Oster & Perry Wilson, MD

• 0:01
  Speaker 1: This is parent data. I'm Emily ostro. Midwives are having
• 0:09
  Speaker 1: a bit of a moment. Of course, that moment is
• 0:13
  Speaker 1: not at all new.
• 0:14
  Speaker 2: The midwife will turn it on and off for you.
• 0:16
  Speaker 2: But rule number one is you start to breathe the
• 0:19
  Speaker 2: gas before the contraction really gets its bruits on.
• 0:22
  Speaker 1: For a very very long time, hundreds, possibly thousands of years,
• 0:26
  Speaker 1: midwives or people who were effectively midwives were delivering all babies.
• 0:32
  Speaker 1: In my mind, they wear little white caps and ride
• 0:35
  Speaker 1: their bicycles to the hospital. But that is based entirely
• 0:38
  Speaker 1: on call the midwife.
• 0:41
  Speaker 3: You look worried. That's just my silent sympathetic class sweezie.
• 0:49
  Speaker 3: Can you raise your bottom.
• 0:51
  Speaker 2: As far as you can?
• 0:53
  Speaker 3: I think a boat unless it has an obstetrician on
• 0:56
  Speaker 3: hiptocks of no interest to me.
• 1:03
  Speaker 1: Even when doctor became a more formal job, births were
• 1:09
  Speaker 1: still nearly always attended by midwives at some point, though
• 1:14
  Speaker 1: especially in the US, that changed. By nineteen eighty, midwives
• 1:18
  Speaker 1: in the US attended only about one percent of births,
• 1:23
  Speaker 1: but swinging back the other direction in the past forty years,
• 1:27
  Speaker 1: that's changed a lot.
• 1:29
  Speaker 2: By twenty twenty.
• 1:30
  Speaker 1: One, about twelve percent of births in the US were
• 1:33
  Speaker 1: attended by midwives.
• 1:36
  Speaker 2: But this can still feel a bit mystifying.
• 1:39
  Speaker 1: I had a birth, my second child, with a midwife,
• 1:42
  Speaker 1: and people will sometimes ask, isn't that just for home
• 1:45
  Speaker 1: births in a tub? Isn't it just for people who
• 1:48
  Speaker 1: don't want epidurals? Isn't it only for people who care
• 1:52
  Speaker 1: about the flavor of the scented candle in the hospital
• 1:54
  Speaker 1: delivery room. The answer is no, no, no to all
• 2:00
  Speaker 1: those questions. Most midwives deliver in hospitals, and many people
• 2:06
  Speaker 1: who are attended by a midwife do have an epidural,
• 2:10
  Speaker 1: and it's not actually allowed to have candles in the hospital,
• 2:13
  Speaker 1: no matter who is attending your birth. With all of
• 2:17
  Speaker 1: these questions, I got curious about the data on midwiffery,
• 2:21
  Speaker 1: and so in parent Data I wrote a bit about
• 2:24
  Speaker 1: what we know about the labor support offered by midwives
• 2:27
  Speaker 1: and whether there are any benefits to having a midwife
• 2:31
  Speaker 1: rather than having a doctor.
• 2:33
  Speaker 2: And it turns out maybe there are. Actually The data suggests.
• 2:37
  Speaker 1: That spontaneous vaginal birth birth without a vacuum or forceps
• 2:42
  Speaker 1: increases in the care of a midwife, cesarean sections decrease,
• 2:45
  Speaker 1: and soda episiotomies.
• 2:49
  Speaker 2: When you look in the data, you can.
• 2:51
  Speaker 1: See these kind of results in black and white, but
• 2:55
  Speaker 1: you don't get a sense of why. So what is
• 2:59
  Speaker 1: it about the differences between midwives and doctors that drive
• 3:02
  Speaker 1: some of these results? How much is about the fact
• 3:05
  Speaker 1: that a midwife tends to be at the hospital during
• 3:08
  Speaker 1: delivery for a longer period of time.
• 3:11
  Speaker 2: How much is about.
• 3:12
  Speaker 1: The prenatal counseling and changes in how they approach to birth.
• 3:17
  Speaker 1: And so I wanted to bring on a guest who
• 3:19
  Speaker 1: could talk about some of these pieces of the data,
• 3:23
  Speaker 1: but also about the lived experience of what it is
• 3:26
  Speaker 1: to be a midwife and how that differs from what
• 3:28
  Speaker 1: happens with an obi. So my guest today and Ledbetter,
• 3:31
  Speaker 1: is a midwife, and she's put on her little white
• 3:34
  Speaker 1: hat and bicycled in to dive into all of this
• 3:37
  Speaker 1: and help us demystify the role of the midwife. We
• 3:40
  Speaker 1: talk about differences and similarities between midwives and obe's and
• 3:45
  Speaker 1: between midwives and dulas. We talk about epidurals, We talk
• 3:49
  Speaker 1: about the difference between healthcare in the US and elsewhere.
• 3:52
  Speaker 2: We talk about called midwife, and we take time.
• 3:56
  Speaker 1: To talk about the holistic process of birth and how
• 4:00
  Speaker 1: cool it is after the break. And led Better and
• 4:07
  Speaker 1: led Better, thank you so much for joining me.
• 4:10
  Speaker 3: Hi Emily, thanks for having me.
• 4:12
  Speaker 1: So I'd love to start by just having you tell
• 4:15
  Speaker 1: people who you are and what you do.
• 4:18
  Speaker 4: Sure, So, my name is and Ledbetter. I'm a certified
• 4:22
  Speaker 4: nurse midwife in Milwaukee, Wisconsin. I work at a federally
• 4:26
  Speaker 4: qualified healthcare center, which is a kind of clinic that's
• 4:29
  Speaker 4: designed to provide care to an underserved population.
• 4:33
  Speaker 3: So the majority of my patients are on Medicaid insurance.
• 4:37
  Speaker 4: And they tend to come from the Spanish speaking immigrant
• 4:41
  Speaker 4: community of Milwaukee.
• 4:43
  Speaker 1: So I love to talk a little bit about what
• 4:46
  Speaker 1: you do as a midwife and just almost to start
• 4:51
  Speaker 1: by level setting.
• 4:52
  Speaker 2: But what is a midwife.
• 4:54
  Speaker 1: And why is it different from an obstetrician? I think
• 4:57
  Speaker 1: many of us have most of our contexts come from
• 5:00
  Speaker 1: that television show called The Midwife. That's a great show Thereius,
• 5:05
  Speaker 1: you wear that type of uniform, if you ride a
• 5:07
  Speaker 1: bicycle anyway, say more, really seriously, it would be great
• 5:10
  Speaker 1: to just hear a little bit more about about midwiffery
• 5:13
  Speaker 1: in general from you.
• 5:14
  Speaker 4: Okay, sure, Yeah, So my job as a midwife is
• 5:19
  Speaker 4: split between two settings. One is the clinic. In the clinic,
• 5:24
  Speaker 4: I'm mostly doing prenatal care. I would say about eighty
• 5:26
  Speaker 4: percent of my patients are pregnant, but I'm also doing
• 5:29
  Speaker 4: some sort of basic gin care, pap smears, contraceptive care
• 5:33
  Speaker 4: procedures like implanons and explanons, and iud's that kind of thing.
• 5:42
  Speaker 4: In the hospital, it's a different approach, but basically we
• 5:47
  Speaker 4: are when I'm on call, it's a twelve hour shift,
• 5:50
  Speaker 4: and I am, you know, providing care during birth to
• 5:53
  Speaker 4: anyone who comes in. I'm attending that labor and that birth.
• 5:57
  Speaker 4: I do postpartum rounds, ob triage my practice.
• 6:03
  Speaker 3: We even do circumcisions.
• 6:05
  Speaker 1: So in terms of what what you do in let's
• 6:08
  Speaker 1: talk about the birth part specifically, how is what you
• 6:12
  Speaker 1: do different from what an OBI would do if if
• 6:15
  Speaker 1: it is.
• 6:16
  Speaker 4: Yeah, well that's a that's a hard question because I
• 6:20
  Speaker 4: don't want to stereotype.
• 6:21
  Speaker 3: You know, I think there's a lot of overlap. I
• 6:23
  Speaker 3: will say that, you know, as midwives were really trained
• 6:27
  Speaker 3: to appreciate the physiological aspects of labor, So you know,
• 6:32
  Speaker 3: I think that on average, right, you're going to see
• 6:34
  Speaker 3: midwives doing more things like different positions for labor and birth.
• 6:40
  Speaker 3: Midwives are big supporters of you know, hydrotherapy and alternative
• 6:44
  Speaker 3: pain control methods during birth. I would say fewer of
• 6:48
  Speaker 3: our patients choose to get an epidural. We're big supporters
• 6:52
  Speaker 3: of vaginal birth after cesarean in general. Over over the years,
• 6:57
  Speaker 3: I think that midwives have really been pushing the envelope
• 6:59
  Speaker 3: and how hospital birth about, like what options are given
• 7:03
  Speaker 3: to women, Like I think about you know, a coworker
• 7:06
  Speaker 3: of mine who about like twenty years ago spearheaded this
• 7:09
  Speaker 3: effort to change the unit policy so that all babies
• 7:14
  Speaker 3: were sort of handed directly to their moms after birth
• 7:17
  Speaker 3: rather than being separated. So like skin to skin and
• 7:20
  Speaker 3: delayed cord clamping are really common in midw free care,
• 7:24
  Speaker 3: and I think now they're even becoming more common in
• 7:27
  Speaker 3: centric care because in part because midwives have really like
• 7:31
  Speaker 3: pushed for policies like that.
• 7:33
  Speaker 1: Yeah, you guys were out ahead on both of those things,
• 7:35
  Speaker 1: which have quite good evidence behind them. So I want
• 7:40
  Speaker 1: to talk about who, from an individual standpoint, how people
• 7:45
  Speaker 1: would think about choosing a midwife versus an obstetrician for
• 7:51
  Speaker 1: their individual birth, because this is a question that comes
• 7:55
  Speaker 1: up from many people. You have to choose a provider.
• 7:57
  Speaker 1: These are different kinds of providers. Sense is that for
• 8:00
  Speaker 1: a lot of people, their perception is a midwife is
• 8:05
  Speaker 1: appropriate if I want to have a baby at home,
• 8:09
  Speaker 1: or if I'm committed to no pain medication. I let's
• 8:15
  Speaker 1: just start with the question of are those stereotypes accurate?
• 8:19
  Speaker 4: Well, I do feel that people who want to have
• 8:24
  Speaker 4: an unmedicated birth are really great candidates for midwif free care,
• 8:28
  Speaker 4: and I think they're likely to get the support that
• 8:30
  Speaker 4: they want during their birth. But I do not think
• 8:33
  Speaker 4: they're the only candidates for MIDWI free care. And I
• 8:36
  Speaker 4: mean personally, you know, I work with a patient population
• 8:40
  Speaker 4: that really isn't like seeking midwif free care per se,
• 8:44
  Speaker 4: but they do great with us. Like I think most
• 8:47
  Speaker 4: of my patients come to my clinic because it's, you know,
• 8:50
  Speaker 4: a bilingual clinic that accepts Medicaid insurance, not because they're
• 8:53
  Speaker 4: seeking some certain kind of birth experience. But you know,
• 8:59
  Speaker 4: because mostly receiving care from midwives, they do have lower
• 9:04
  Speaker 4: epidural rates. I think that there's a whole lot of
• 9:09
  Speaker 4: women who probably fall into this category of somewhere in
• 9:12
  Speaker 4: between someone who wants a lot of medical medical intervention
• 9:16
  Speaker 4: and someone who wants none, and so you know, I
• 9:19
  Speaker 4: think midwives were really great providers for those people as well.
• 9:23
  Speaker 1: One of the things we talk a lot of people
• 9:24
  Speaker 1: talk about is the idea of midwives as appropriate for
• 9:27
  Speaker 1: low risk births.
• 9:29
  Speaker 2: What does that mean? Is that true?
• 9:31
  Speaker 3: Yeah?
• 9:31
  Speaker 4: Good question, Good question, because I mean I really don't
• 9:36
  Speaker 4: love the sort of high risk low risk ditotomy because
• 9:38
  Speaker 4: in my experience, so few women fit neatly into one
• 9:42
  Speaker 4: or the other. I mean, there's probably like a small
• 9:45
  Speaker 4: percentage of women that just have zero risk factors whatsoever,
• 9:48
  Speaker 4: they're very low risk. And then there's women who are
• 9:50
  Speaker 4: obviously very high risk. But I would say most people
• 9:53
  Speaker 4: fall into like what I would call a medium risk category.
• 9:56
  Speaker 4: And you know, I take care of a lot.
• 9:58
  Speaker 3: Of those patients.
• 10:00
  Speaker 4: Like, for example, as a midwife, right, I take care
• 10:04
  Speaker 4: of women of all different body sizes, all different ages.
• 10:07
  Speaker 4: You know, I've had patients as young as thirteen and
• 10:10
  Speaker 4: as old as forty seven. I take care of patients
• 10:14
  Speaker 4: who have risk factors like you know, complications in a
• 10:17
  Speaker 4: prior pregnancy. You know, people who have had a preterm birth, preclamsia,
• 10:23
  Speaker 4: who had a c section for their last birth. That's
• 10:25
  Speaker 4: a really common patient for me to care for. And
• 10:29
  Speaker 4: then there's some people with you know, risk factors that
• 10:32
  Speaker 4: develop during pregnancy where I have I can take care
• 10:35
  Speaker 4: of them as long as I have access to a
• 10:38
  Speaker 4: collaborating physician, So that would be things like gestational diabetes,
• 10:43
  Speaker 4: especially if it's still diet controlled.
• 10:45
  Speaker 3: I do take care of those moms.
• 10:47
  Speaker 4: I've taken care of moms who have substance use disorder
• 10:51
  Speaker 4: and are on suboxone because they're addicted to opiates. I've
• 10:55
  Speaker 4: taken care of moms that you know, had mental health
• 11:00
  Speaker 4: health disorders and just really needed a lot of extra
• 11:03
  Speaker 4: TLC for that reason. So again I think, you know,
• 11:07
  Speaker 4: midwives were great care providers for people that need a
• 11:10
  Speaker 4: little extra time and TLC to like process a challenging
• 11:16
  Speaker 4: birth that they had last time, or to deal with
• 11:18
  Speaker 4: you know, stressers they're experiencing during pregnancy. You know, as midwives,
• 11:22
  Speaker 4: we really it's like a big focus of ours to
• 11:26
  Speaker 4: care for the individual as a whole. And so, you know,
• 11:29
  Speaker 4: we tend to spend a lot of time with people
• 11:31
  Speaker 4: both during prenatal care and birth.
• 11:34
  Speaker 1: Can we talk about that time because one of the
• 11:38
  Speaker 1: biggest complaints might be a little strong, but concerns that
• 11:43
  Speaker 1: women expressed to me about their prenatal care and birth
• 11:46
  Speaker 1: experience is a lack of time. You know, I was
• 11:48
  Speaker 1: in the doctor's off I didn't get a chance to
• 11:50
  Speaker 1: ask my questions. I forgot something, you know, the appointment
• 11:54
  Speaker 1: was very short. This comes up all the time, and
• 11:57
  Speaker 1: you talk now, and we've talked. You and I have
• 11:59
  Speaker 1: talked in the asked about the the value of time
• 12:03
  Speaker 1: and the fact that that in midwif frey care there
• 12:05
  Speaker 1: is more of that time.
• 12:08
  Speaker 4: Yeah, for sure, I think you know, it probably varies,
• 12:11
  Speaker 4: you know, again based on physicians, and I don't want
• 12:14
  Speaker 4: to stereotype or say that everyone practices a certain way,
• 12:18
  Speaker 4: but I do know from talking to obstetrician colleagues that
• 12:23
  Speaker 4: they're often seeing just you know, many patients in a day,
• 12:27
  Speaker 4: let's say, like twenty five to thirty five. In contrast,
• 12:31
  Speaker 4: you know, the midwives that I've talked to and myself,
• 12:33
  Speaker 4: you know, it's more common for us to see maybe
• 12:35
  Speaker 4: between fifteen and twenty patients a day, so there's just
• 12:38
  Speaker 4: more time. I also think, you know, midwives tend to
• 12:42
  Speaker 4: spend more time with patients in labor. I can't speak
• 12:45
  Speaker 4: for every midwife, but myself and the midwives in my practice.
• 12:50
  Speaker 4: We're in hospital for call, which means that we have
• 12:55
  Speaker 4: time to sit with people in labor. I think that,
• 12:58
  Speaker 4: you know, it's really important to me to be with
• 13:00
  Speaker 4: anybody who is sort of laboring without an epidural, and
• 13:04
  Speaker 4: then when someone's pushing, I am with them for the
• 13:07
  Speaker 4: entire time, like whether it's thirty minutes or four hours,
• 13:10
  Speaker 4: I usually am not leaving the room for that pushing phase.
• 13:14
  Speaker 4: And that's a difference that I hear a lot of
• 13:17
  Speaker 4: women talk about, you know, and I know this as
• 13:20
  Speaker 4: well from being a labor.
• 13:21
  Speaker 3: And delivery nurse.
• 13:22
  Speaker 4: You know, the idea was to call in the doctor
• 13:25
  Speaker 4: at the last minute to catch the baby, so that
• 13:29
  Speaker 4: you know, you weren't kind of wasting their time.
• 13:34
  Speaker 1: Why is it useful to have can you It's it's
• 13:38
  Speaker 1: such an ambiguous question. Because we're gonna I think we
• 13:41
  Speaker 1: can talk a little bit about the data, and we
• 13:42
  Speaker 1: can talk about the data on birth DODCRAM. You've talked
• 13:44
  Speaker 1: about the data on epidurals, and I think this is
• 13:46
  Speaker 1: a place where the share of people who are having epidurals,
• 13:50
  Speaker 1: even if you're pulling in a population who is not
• 13:54
  Speaker 1: particularly coming and intending not to have an epidurol, you
• 13:57
  Speaker 1: are going to have a lower epidol rate with midwifery
• 14:00
  Speaker 1: than obstetrics. I think that shows up in the data.
• 14:03
  Speaker 1: But do you have a sense of why, Like, what
• 14:07
  Speaker 1: are you doing?
• 14:10
  Speaker 3: Oh, that's such a good question.
• 14:12
  Speaker 4: I mean, I'm just gonna say it, like labor support
• 14:16
  Speaker 4: is key, Like birth is really freaking painful, and if
• 14:20
  Speaker 4: you don't have supportive people in that room helping you
• 14:22
  Speaker 4: through it, it's nearly impossible. I would say, you know,
• 14:29
  Speaker 4: I'm not I'm not against epidurls. I think they can
• 14:31
  Speaker 4: be a really useful intervention. I even have times that
• 14:34
  Speaker 4: I recommend them to people, you know, people who've been
• 14:36
  Speaker 4: in labor for days, people who are just at their
• 14:39
  Speaker 4: wits end. I don't think it's a bad choice. I
• 14:42
  Speaker 4: think there are very good reasons to get an epidol sometimes.
• 14:45
  Speaker 4: But I also think that you know, women are just
• 14:48
  Speaker 4: inherently capable of childbirth, and for women that don't want
• 14:53
  Speaker 4: an epidurl, and there are really good reasons to not
• 14:55
  Speaker 4: want an epidol, you know, it's my job to support them.
• 14:59
  Speaker 4: And I think what unfortunately happens a lot in hospital
• 15:02
  Speaker 4: birth is Number one. The staff are just not used
• 15:05
  Speaker 4: to accompanying women who are giving birth without an epidurl,
• 15:09
  Speaker 4: so they're not very skilled in helping them through that.
• 15:13
  Speaker 4: And like number two, it's like, to be honest, it's
• 15:18
  Speaker 4: a lot easier for the staff if a woman just
• 15:21
  Speaker 4: gets an epidural because then she's sort of laying in bed, comfortable,
• 15:25
  Speaker 4: not needing as much hands on care. So, I mean,
• 15:29
  Speaker 4: I just kind of feel that if someone's in labor
• 15:33
  Speaker 4: without an epidural, like her way of coping is her
• 15:36
  Speaker 4: way of coping. Like, I don't care if she screams,
• 15:38
  Speaker 4: if she cries, if she drops the string of f bombs, like,
• 15:40
  Speaker 4: I'm okay with that. I just kind of view it
• 15:43
  Speaker 4: as my job to help her get through that really
• 15:45
  Speaker 4: difficult moment. And I do see a lot of value
• 15:49
  Speaker 4: in getting through labor without an epidural. It tends to
• 15:53
  Speaker 4: make the labor shorter. You know, you avoid certain risks
• 15:57
  Speaker 4: like epidural headaches because they can puncture the Super Bowl's
• 16:00
  Speaker 4: final column and have fluid leak out. Anyway, There's just
• 16:04
  Speaker 4: there's reasons that epidurals also have some risks you know,
• 16:07
  Speaker 4: there's also the bill for the epiderral. You know, some
• 16:10
  Speaker 4: people have deductibles and you're gonna get, you know, a
• 16:13
  Speaker 4: couple thousand dollars bill that maybe you could have avoided
• 16:16
  Speaker 4: if you could avoid the epidurl, which I'm hoping isn't
• 16:18
  Speaker 4: the reason people make that decision, but in American healthcare,
• 16:21
  Speaker 4: it is possible.
• 16:22
  Speaker 2: Unfortunately, it is, it is possible.
• 16:25
  Speaker 1: We talked recently and I had I had sent you
• 16:28
  Speaker 1: something I wrote in which I used. It was about midwives,
• 16:32
  Speaker 1: and I use the phrase delivered. The midway can deliver
• 16:34
  Speaker 1: your babies. I'm like, and you wrote back and you said,
• 16:36
  Speaker 1: you know this, well, here's here are some comments on
• 16:38
  Speaker 1: this piece. And one thing is I you know, we
• 16:39
  Speaker 1: don't say delivered. We say attending birth. The midwife attends
• 16:44
  Speaker 1: the birth. And I thought that was such an interesting
• 16:48
  Speaker 1: linguistic turn and and like but but underlying such a
• 16:55
  Speaker 1: different attitude to like, what is your job?
• 16:58
  Speaker 3: Yeah, yeah, that's a really good point.
• 17:01
  Speaker 4: I you know, I think I'm not gonna say I
• 17:03
  Speaker 4: never accidentally slip up and use the word delivered. But
• 17:07
  Speaker 4: you know, as midwives, we really do prefer to say
• 17:09
  Speaker 4: attended birth.
• 17:10
  Speaker 3: In fact, I submitted.
• 17:11
  Speaker 4: An article to a journal and they responded it was
• 17:14
  Speaker 4: a Midwiffree journal, and they were like, go back, and
• 17:16
  Speaker 4: every time you said delivery, change it to birth. So
• 17:20
  Speaker 4: it's not just me. I mean it is parlance right
• 17:23
  Speaker 4: in midwif Free speak that we don't like to use
• 17:25
  Speaker 4: the word delivered because I think it gives a little
• 17:27
  Speaker 4: too much credit to the provider and not enough to
• 17:30
  Speaker 4: the mom. Because you know, this baby's here, because this
• 17:34
  Speaker 4: mom did a ton of work, right, like just staying
• 17:36
  Speaker 4: a baby, pushing on a baby.
• 17:38
  Speaker 3: It's no joke.
• 17:38
  Speaker 4: And so for me to just show up at the
• 17:40
  Speaker 4: last minute and say I deliver it to you your baby.
• 17:44
  Speaker 2: It's Amazon.
• 17:45
  Speaker 1: It's like Amazon, you know, it's like same day, right.
• 17:50
  Speaker 3: Yeah.
• 17:50
  Speaker 4: I just feel like it kind of devalues everything she did,
• 17:53
  Speaker 4: which is most of the work. Like I think of
• 17:57
  Speaker 4: myself sometimes like almost like the cox of a boat,
• 18:00
  Speaker 4: you know, like as a midwife.
• 18:02
  Speaker 3: Like I'm not the one rowing the boat. I can't
• 18:04
  Speaker 3: make the boat go.
• 18:05
  Speaker 4: Faster, but I do have like a pretty clear view
• 18:09
  Speaker 4: of the finish line and a pretty good view of
• 18:11
  Speaker 4: the conditions. You know, I can tell if the waves
• 18:13
  Speaker 4: are getting choppy. So I think it's like it's definitely teamwork.
• 18:17
  Speaker 4: I'm not going to say that I don't have an
• 18:19
  Speaker 4: important role, but I would not give myself the credit
• 18:23
  Speaker 4: by saying, like, oh, I delivered this baby. That's why
• 18:25
  Speaker 4: you'll hear a lot of midwives like we'll talk colloquially,
• 18:30
  Speaker 4: kind of like I caught babies, Like how many babies
• 18:32
  Speaker 4: did you catch this weekend?
• 18:33
  Speaker 3: That's kind of how we talk to each other.
• 18:35
  Speaker 4: Yeah, when you're speaking about it officially, we'd like to
• 18:38
  Speaker 4: say I attended a berth, not I delivered a baby.
• 18:43
  Speaker 1: Okay, So I want to talk about data because there
• 18:49
  Speaker 1: is some data on the impact of midwif free care
• 18:54
  Speaker 1: on birth outcomes, and I think you and I differ
• 18:59
  Speaker 1: a little bit and how in what kinds of data
• 19:02
  Speaker 1: we would want to rely on there, And so I
• 19:05
  Speaker 1: want to set the stage a little bit and then
• 19:06
  Speaker 1: we can, like, then we can sort of talk about
• 19:08
  Speaker 1: where we where we agree, and where we disagree.
• 19:12
  Speaker 2: So sure, one thing one.
• 19:14
  Speaker 1: Might imagine doing is comparing women who have midwife to
• 19:18
  Speaker 1: women who have an obstetrician. And that, like, as a
• 19:22
  Speaker 1: general approach, if you don't do any other adjustments, doesn't
• 19:26
  Speaker 1: really work because the kind of women who are selecting
• 19:29
  Speaker 1: into MIDWIF free care are.
• 19:31
  Speaker 2: Going to be different on average.
• 19:33
  Speaker 1: True, there is then a version of studies like that
• 19:36
  Speaker 1: that tries to hold more things constant across women, so
• 19:40
  Speaker 1: it tries to compare more comparable women with different.
• 19:42
  Speaker 2: Kinds of care.
• 19:44
  Speaker 1: And then there are randomized trials in which people are
• 19:46
  Speaker 1: randomized into MIDWA free care not And I am always
• 19:50
  Speaker 1: going to be of the I am generally of the position,
• 19:53
  Speaker 1: let's say always maybe a little stronger, I'm generally of
• 19:55
  Speaker 1: the position that I want to rely on the randomized trials.
• 19:59
  Speaker 1: When you look at the randomize trials, there definitely are
• 20:01
  Speaker 1: some benefits to MIDWIF free care.
• 20:06
  Speaker 2: They are real, but in.
• 20:08
  Speaker 1: Magnitude relatively small, So something like a reduction in cesarean
• 20:12
  Speaker 1: section but like one or two percent, you know, an
• 20:15
  Speaker 1: increase in the chance of a spontaneous vaginal birth, so
• 20:19
  Speaker 1: vaginal birth without four steps or epidural but maybe a
• 20:21
  Speaker 1: five percent increase.
• 20:22
  Speaker 2: So real numbers.
• 20:24
  Speaker 1: And certainly there's nothing that would suggest that MIDWIF free
• 20:27
  Speaker 1: care was less good. But if you asked, you know,
• 20:30
  Speaker 1: is this a little bit better?
• 20:32
  Speaker 2: A lot better?
• 20:33
  Speaker 1: The numbers are relatively are relatively small, and I think
• 20:39
  Speaker 1: you're well, I don't want to put words in your mouth,
• 20:42
  Speaker 1: but I think that you're more optimistic about some of
• 20:46
  Speaker 1: the positive impacts based on some of the non randomized data.
• 20:50
  Speaker 2: So I'd love to just dig into that a little bit.
• 20:53
  Speaker 1: And tell have you tell me how you read how
• 20:55
  Speaker 1: you read the evidence on these outcomes.
• 20:58
  Speaker 3: Yeah, I mean, I'm not a to like the idea
• 21:01
  Speaker 3: of an RCT.
• 21:02
  Speaker 4: In fact, I think it's kind of crazy that that's
• 21:04
  Speaker 4: not been done in the United States. Like, I mean,
• 21:06
  Speaker 4: that would be a fascinating result to see, you know,
• 21:08
  Speaker 4: in the US. You know, when if we randomize women
• 21:11
  Speaker 4: to either op centric or midw free care, like what
• 21:13
  Speaker 4: kind of outcomes are we going to get? But I
• 21:15
  Speaker 4: really wouldn't hang my hat on that result because I
• 21:17
  Speaker 4: think people just behave differently when they're being watched and
• 21:22
  Speaker 4: like in an RCT.
• 21:23
  Speaker 1: Yeah, tell me more about what you mean by that.
• 21:26
  Speaker 4: Well, I mean it's like, you know, supposing we have
• 21:29
  Speaker 4: this hypothetical RCT where people are either being cared for
• 21:34
  Speaker 4: by obsentricians or midwives, Like those care providers are both
• 21:37
  Speaker 4: going to be working really hard. I mean, they know
• 21:39
  Speaker 4: they're competing, They're going to be trying to get the
• 21:41
  Speaker 4: best outcomes possible, and I think that both groups will
• 21:44
  Speaker 4: probably have really good outcomes and in the end there
• 21:46
  Speaker 4: may not be a very big difference.
• 21:48
  Speaker 3: But I think, like, how do we translate those results
• 21:52
  Speaker 3: to the real world then, because I mean, just because
• 21:55
  Speaker 3: the circumstances are this way during an RCT, that doesn't
• 21:58
  Speaker 3: mean that's how they are in the real world.
• 22:01
  Speaker 4: Like in the real world, the pressures on obstetricians and
• 22:04
  Speaker 4: midwives are just different, and so you know, I think
• 22:07
  Speaker 4: we can expect something different from our RCT than what
• 22:10
  Speaker 4: happens in the real world, which is why I kind
• 22:13
  Speaker 4: of think the retrospective data is really valuable to us,
• 22:17
  Speaker 4: because that's showing us what actually happens in the real world.
• 22:21
  Speaker 1: In a sense, I think what you're arguing for, maybe
• 22:23
  Speaker 1: we could both agree, is that we need better kind
• 22:26
  Speaker 1: of almost natural experiments, Right, so cases in which people
• 22:31
  Speaker 1: show up at your clinic and you know, they sort
• 22:34
  Speaker 1: of show up not because they're seeking out a particular
• 22:36
  Speaker 1: kind of care, but because like that's what's available and
• 22:39
  Speaker 1: what Medicaid will will pay for. Because like that kind
• 22:42
  Speaker 1: of data is almost more what you want than either
• 22:47
  Speaker 1: a very controlled RCT or a retrospective study in which
• 22:52
  Speaker 1: you're comparing people who are selecting one thing to another,
• 22:56
  Speaker 1: which is potentially quite biased.
• 23:00
  Speaker 3: Yeah, I would tell that's the experiment.
• 23:02
  Speaker 4: I would love to see, you know, the study, because
• 23:06
  Speaker 4: I think that's more common than people even realize. I think,
• 23:09
  Speaker 4: you know, midwives, how this reputation is sort of caring
• 23:13
  Speaker 4: for the most let's just say easy patients.
• 23:16
  Speaker 3: Like all your patients are all.
• 23:18
  Speaker 4: You know, well educated, they're mostly not women of color.
• 23:22
  Speaker 3: But that's not my population.
• 23:23
  Speaker 4: I mean I see patients who, you know, really span
• 23:28
  Speaker 4: the gamut of different life experiences, and I wouldn't say
• 23:33
  Speaker 4: at all that my patients are quote unquote low risk.
• 23:36
  Speaker 4: I mean, being at a federally qualified healthcare center, we're
• 23:40
  Speaker 4: seeing the patients with kind of the most difficult socioeconomic circumstances.
• 23:45
  Speaker 4: And yet, like my practice, I don't want to brag,
• 23:48
  Speaker 4: but we get MIDW free outcomes, you know, the same
• 23:50
  Speaker 4: outcomes that you're seeing with people who are choosing MIDW
• 23:53
  Speaker 4: free care for other reasons. So I just, yeah, I
• 23:56
  Speaker 4: think there's plenty of opportunity for a natural experiment.
• 23:59
  Speaker 3: There are also some healthcare systems that are.
• 24:02
  Speaker 4: Starting to you know, just send lowerrist patients to midwif
• 24:07
  Speaker 4: free care, and you know, this is how it's done
• 24:10
  Speaker 4: in many parts of.
• 24:10
  Speaker 2: Them every place exactly.
• 24:12
  Speaker 1: I mean, it's it's an interesting case in which you know,
• 24:14
  Speaker 1: in the US, the share of births it's with windwives
• 24:17
  Speaker 1: has grown over it's about twelve percent now and most
• 24:20
  Speaker 1: of those are in hospitals. But in most of Europe
• 24:25
  Speaker 1: it's like enormously large share. That's the default, as opposed
• 24:29
  Speaker 1: to it being a kind of weird, weird choice, right.
• 24:34
  Speaker 3: Yeah, which is another thing.
• 24:35
  Speaker 4: You know, I think some of those are cets that
• 24:38
  Speaker 4: you were looking at Emily. You know, they're from countries
• 24:41
  Speaker 4: where a midwiffree is more normative. So I wouldn't expect
• 24:45
  Speaker 4: there to be a huge difference in the Netherlands between
• 24:48
  Speaker 4: you know, obkre and midw free care, because I think
• 24:51
  Speaker 4: that midwif free care is just kind of the norm there,
• 24:53
  Speaker 4: and even like a Dutch obstetrician is probably like intervening
• 24:57
  Speaker 4: less than you know, an American midwe because we're just
• 25:01
  Speaker 4: we're all attending bursts in certain cultures and I think,
• 25:05
  Speaker 4: you know, the culture of a labor and delivery unit
• 25:07
  Speaker 4: is this factor that we're not really able to parse out.
• 25:11
  Speaker 3: But I think it makes a huge difference in birth outcomes.
• 25:15
  Speaker 1: I just this morning, I was reading an email from
• 25:18
  Speaker 1: one of the people who works on it on a
• 25:20
  Speaker 1: different podcast that I work on, who had just had
• 25:21
  Speaker 1: her baby in the Netherlands, and she had a baby
• 25:25
  Speaker 1: at home with a midwife, even though she was two
• 25:26
  Speaker 1: weeks overdue. Yeah, they just, you know, they just she
• 25:31
  Speaker 1: said it was great, very fast, the third baby.
• 25:33
  Speaker 2: So it's just yeah, popped right out.
• 25:36
  Speaker 3: Oh that's cool.
• 25:37
  Speaker 2: Yeah, she was.
• 25:38
  Speaker 1: She was writing to tell me how great postpartum support
• 25:41
  Speaker 1: is in the Netherlands, which I.
• 25:43
  Speaker 2: Thought was you know, she was it was a little trolley.
• 25:46
  Speaker 1: But you know, that's for perhaps a different a different podcast,
• 25:58
  Speaker 1: More parent Data, including a conversation about home births and interventions,
• 26:03
  Speaker 1: the economics at Midwiffery, and and led Beetter's favorite part
• 26:06
  Speaker 1: of the birth experience after the break. You know, in
• 26:33
  Speaker 1: the case if we sort of think of of kind
• 26:35
  Speaker 1: of a view that we should have more more Midwiffrey care.
• 26:39
  Speaker 1: I think one thing people worry about is, you know,
• 26:43
  Speaker 1: what if I find myself needing something else. You know,
• 26:47
  Speaker 1: what if in the middle of birth I do need
• 26:51
  Speaker 1: an emergency section. You know, how am I then going
• 26:55
  Speaker 1: to find just some random doctor in the hospital is
• 26:58
  Speaker 1: going to do this? You know that I think that
• 27:00
  Speaker 1: fear is there, so curious just how that works.
• 27:04
  Speaker 3: Well, hopefully not. Hopefully it's not just a chaotic scene.
• 27:08
  Speaker 4: You know, as a midwife attending hospital births and caring
• 27:13
  Speaker 4: for patient population that can be fairly higher risk. I
• 27:18
  Speaker 4: find that I'm consulting in ob and maybe half of
• 27:21
  Speaker 4: the cases and when there's time, which hopefully is most
• 27:27
  Speaker 4: of the time, the obstetrician will come in the room
• 27:29
  Speaker 4: and meet the patient and say, hey, I'm here just
• 27:31
  Speaker 4: in case there are any complications. If things are kind
• 27:36
  Speaker 4: of going south, then I call them in and we
• 27:40
  Speaker 4: kind of work through the situation together. And you know,
• 27:44
  Speaker 4: I always feel like, as a midwife, like my job
• 27:47
  Speaker 4: is to make a patient feel comfortable. So you know,
• 27:50
  Speaker 4: I trust my attending obstetricians, so that's what I tell them.
• 27:54
  Speaker 4: I'm like, this person is here to help us, like
• 27:56
  Speaker 4: they're recommending this.
• 27:58
  Speaker 3: I think that's a good idea. I don't find myself.
• 28:02
  Speaker 4: Very frequently in conflict with the OBI doctors that I
• 28:05
  Speaker 4: work with. I think that we have similar goals and
• 28:09
  Speaker 4: you know, mostly that's to make sure that we give
• 28:11
  Speaker 4: the patient the best outcome possible.
• 28:14
  Speaker 2: Yeah healthy Mom'm healthy baby.
• 28:16
  Speaker 3: Yeah yeah.
• 28:17
  Speaker 2: Can I ask why you got into this?
• 28:20
  Speaker 3: Oh good question.
• 28:21
  Speaker 4: So, Okay, I grew up in rural Iowa, so I
• 28:24
  Speaker 4: don't even think I knew what a midwife was growing up.
• 28:27
  Speaker 4: I just kind of went to college and I was
• 28:30
  Speaker 4: kind of following a pre med track, but I happened
• 28:33
  Speaker 4: to get in like an anthropology one on one class
• 28:36
  Speaker 4: where I kind of learned about midwif free for the
• 28:38
  Speaker 4: first time, and I learned that like, not only is
• 28:42
  Speaker 4: it a thing, it's something that's very common in other
• 28:44
  Speaker 4: parts of the world.
• 28:45
  Speaker 3: And then I.
• 28:46
  Speaker 4: Ended up majoring anthropology and I took a lot of
• 28:49
  Speaker 4: classes in reproductive anthropology, and I read a really good
• 28:54
  Speaker 4: book called Birth and Four Cultures, where I guess that
• 28:57
  Speaker 4: was kind of what tipped me off to the fact
• 28:58
  Speaker 4: that no, a lot of birth is just it's tradition.
• 29:02
  Speaker 4: It's it's not like we like to think, oh, well,
• 29:05
  Speaker 4: everything's evidence based and you know, medical science.
• 29:08
  Speaker 3: But I mean it's not really.
• 29:09
  Speaker 4: So, I mean there's plenty of things that we just
• 29:12
  Speaker 4: don't have like great evidence on you know, what's the
• 29:14
  Speaker 4: best position to give birth in or Yeah, I can't
• 29:17
  Speaker 4: really think of any of their examples right now, but
• 29:19
  Speaker 4: it just made me realize what a strong factor culture
• 29:24
  Speaker 4: has on birth. The way people give birth in different
• 29:27
  Speaker 4: cultures can be like vastly different, and so I kind
• 29:31
  Speaker 4: of it made me kind of question the sort of
• 29:33
  Speaker 4: medical model of childbirth.
• 29:35
  Speaker 3: And I was like, you know, I kind of feel like.
• 29:37
  Speaker 4: I fit best with this midwiffery model, Like it kind
• 29:40
  Speaker 4: of afforded me the option to spend a lot of
• 29:43
  Speaker 4: time with patients in a way that I didn't see
• 29:45
  Speaker 4: happening as much if I'd followed the more medical route.
• 29:48
  Speaker 1: So you're trained as a nurse, you're certified nurse midwife, right, Yeah.
• 29:53
  Speaker 1: Can you say a little bit about what that involves
• 29:55
  Speaker 1: and why that's different?
• 29:57
  Speaker 3: Yeah, So, I mean.
• 29:57
  Speaker 4: In the US, the most common trac to become a
• 30:01
  Speaker 4: midwife is the CNM route. So, you know, I was
• 30:04
  Speaker 4: not a nursing undergraduate major, so I had to do
• 30:06
  Speaker 4: a program that kind of caught me up on the
• 30:09
  Speaker 4: sort of BSN portion. So I had a slightly longer
• 30:12
  Speaker 4: master's degree program where I first became like a BSN
• 30:16
  Speaker 4: and then became an MSN, which masters of science and nursing.
• 30:20
  Speaker 4: It's sort of the same degree that like a nurse
• 30:22
  Speaker 4: practitioner would have.
• 30:23
  Speaker 2: And then you trained as a midwife.
• 30:26
  Speaker 4: Yeah, so I mean the master's program I did, I
• 30:31
  Speaker 4: became a nurse, and then I did the.
• 30:33
  Speaker 3: Midwiffery portion, which was two years.
• 30:35
  Speaker 4: So during that time I actually also worked as a
• 30:38
  Speaker 4: labor and delivery nurse.
• 30:40
  Speaker 3: And you know, that was.
• 30:43
  Speaker 4: A really interesting, you know, comparison and experience for me
• 30:46
  Speaker 4: between just kind of getting to see what birth was
• 30:50
  Speaker 4: like on both sides, you know, the obstetric side, and
• 30:52
  Speaker 4: then also learning about midwiffrey and also attending burse with
• 30:57
  Speaker 4: midwife preceptors and just kind of comparing the differences.
• 31:01
  Speaker 2: What is the most significant difference.
• 31:04
  Speaker 4: Oh gosh, Well, I don't know. I think I think that,
• 31:10
  Speaker 4: you know, as midwives, like I, we just have this
• 31:14
  Speaker 4: really strong belief that the female body is capable of
• 31:18
  Speaker 4: vagual birth. And I mean, I think that applies to
• 31:20
  Speaker 4: people of all different races and ages and body sizes,
• 31:25
  Speaker 4: and so I feel like as midwives we just come
• 31:28
  Speaker 4: at it with like a respect for birth.
• 31:30
  Speaker 3: And you know, I think I would use the term
• 31:33
  Speaker 3: physiologic birth.
• 31:34
  Speaker 4: You know, I think we have a strong bias towards
• 31:37
  Speaker 4: allowing labor to come on its own and progress. Normally,
• 31:42
  Speaker 4: we don't tend to intervene unless we think there's something wrong,
• 31:48
  Speaker 4: and at times spent with patients. It's definitely a difference,
• 31:52
  Speaker 4: you know. I think, like I'm a midwife, I'm not
• 31:55
  Speaker 4: a doula, and I think, you know, it's really important
• 31:57
  Speaker 4: that people understand the difference between midwife wives who are
• 32:00
  Speaker 4: healthcare providers and dulas who are not. But I do
• 32:03
  Speaker 4: think that a big part of my job is just
• 32:05
  Speaker 4: being a doula, you know, supporting people in labor. I
• 32:10
  Speaker 4: think midwives are just kind of trained we to observe labors.
• 32:15
  Speaker 4: Like I remember as a mid of free student, my
• 32:18
  Speaker 4: preceptors would assign me to labor sit, which was you know,
• 32:22
  Speaker 4: they really thought it was important that we spend a
• 32:24
  Speaker 4: lot of time watching people in labor. And I do
• 32:27
  Speaker 4: feel that that experience, like, because I've observed so many labors,
• 32:31
  Speaker 4: it gives me a lot of insight into how to
• 32:34
  Speaker 4: best support the mom and affect a normal birth.
• 32:39
  Speaker 3: And I mean I.
• 32:39
  Speaker 4: Think in contrast, like, of course it varies widely, but
• 32:43
  Speaker 4: you know, the obstetrician residents that I see you know,
• 32:47
  Speaker 4: their education is focused on pathology, right They're trying to
• 32:51
  Speaker 4: like identify and treat medical conditions. So from their point
• 32:55
  Speaker 4: of view, like spending you know, eight hours in a
• 32:58
  Speaker 4: room with a mom is laboring is not. That's not
• 33:00
  Speaker 4: useful way to spend their time. Whereas for me that
• 33:03
  Speaker 4: was like specifically my assignment.
• 33:05
  Speaker 1: It's interesting, do you do homebirths? I do not know
• 33:11
  Speaker 1: what do you think about? It's okay, you can ask
• 33:15
  Speaker 1: what is your what is your orientation towards home birth?
• 33:20
  Speaker 2: Let me ask it in that right.
• 33:21
  Speaker 4: Wing Yeah, I would say another feature of midw free
• 33:25
  Speaker 4: care is that we do believe that homebirth is a
• 33:27
  Speaker 4: good option for some people.
• 33:29
  Speaker 3: And I I'm very supportive.
• 33:31
  Speaker 4: You know, I've had friends and neighbors who chose homebirth
• 33:34
  Speaker 4: and I thought that was a great decision for them.
• 33:37
  Speaker 4: That being said, I just don't feel that homebirth can
• 33:41
  Speaker 4: ever take the place of hospital birth, Like we really
• 33:44
  Speaker 4: need to offer women options in the hospital as well.
• 33:48
  Speaker 4: I think that, you know, homeworth can never take the
• 33:51
  Speaker 4: place of hospital birth on a large scale because there's
• 33:55
  Speaker 4: just too many people that either you know, want an epidural.
• 33:59
  Speaker 4: You know, That's like we talked about a very reasonable choice,
• 34:01
  Speaker 4: and I would say at least fifty percent of moms
• 34:04
  Speaker 4: want that or will want that while they're in labor,
• 34:07
  Speaker 4: So that's obviously an option that's only available in the hospital.
• 34:11
  Speaker 4: And then, unfortunately, what has developed in our country is
• 34:16
  Speaker 4: this sort of ditotomy between the sort of low risk,
• 34:20
  Speaker 4: low intervention home birth and the like highly medicalized, very
• 34:24
  Speaker 4: highly interventive hospital birth, and it feels like in many
• 34:30
  Speaker 4: places in our country there's really no in between, and like,
• 34:34
  Speaker 4: I personally feel really frustrated on behalf of American women
• 34:38
  Speaker 4: who have that experience where they don't really get a choice.
• 34:41
  Speaker 3: They kind of are only allowed to.
• 34:44
  Speaker 4: Have this hospital birth where they're you know, have continuous
• 34:48
  Speaker 4: fetal monitoring, they're attached to maybe it's even internal monitoring.
• 34:54
  Speaker 3: They can have the you.
• 34:55
  Speaker 4: Know, epidural catheter, which means they have a catheter in
• 34:57
  Speaker 4: their bladder, they have ivy flu, it's running and it.
• 35:01
  Speaker 4: I mean, I think that those interventions can all be
• 35:03
  Speaker 4: really important and useful, but I think they're also overused
• 35:07
  Speaker 4: in hospital birth, and a lot of women aren't really
• 35:10
  Speaker 4: getting the choice for things like you know, birth without
• 35:13
  Speaker 4: an epidural intermittent ouscultation. Instead of continuous feedal monitoring, the
• 35:19
  Speaker 4: option to give birth in different positions instead of just
• 35:24
  Speaker 4: lying on your back with your feet up in stirrups.
• 35:27
  Speaker 3: You know.
• 35:27
  Speaker 4: Unfortunately, women aren't often given these options. And I think
• 35:31
  Speaker 4: this is where midwives can really make a big difference,
• 35:34
  Speaker 4: because we are attending hospital births and offering more and
• 35:37
  Speaker 4: more options.
• 35:39
  Speaker 1: I really share this frustration because I think so much
• 35:42
  Speaker 1: of the pull almost of a home birth is just
• 35:47
  Speaker 1: I don't want to be pushed into the following, you know,
• 35:52
  Speaker 1: interventions that I might you know, when I have my
• 35:55
  Speaker 1: first kid in the hospital with it. I had both
• 35:58
  Speaker 1: my kids in the hospital. They're pretty different experience is.
• 36:00
  Speaker 1: But with the first one, we I said, you know,
• 36:03
  Speaker 1: I don't want an epidural. I'm not gonna and and
• 36:05
  Speaker 1: they were like, okay, we're gonna as soon as you
• 36:07
  Speaker 1: get in, we'll hook you up to an IVY. And
• 36:08
  Speaker 1: I was like, well why, Like for like, I have
• 36:11
  Speaker 1: no risk factors, like there's no reason to do this.
• 36:14
  Speaker 1: They're just like, well, that's the policy. And it was like,
• 36:16
  Speaker 1: but what, like then I will not be able to
• 36:18
  Speaker 1: move around, I'm not gonna be able to share. Like
• 36:20
  Speaker 1: all of these things meant basically we end up being like,
• 36:23
  Speaker 1: let's wait as long as possible to get to the
• 36:25
  Speaker 1: hospital because you're gonna make me do all this stuff
• 36:28
  Speaker 1: and you know, when I show up, I'm gonna have
• 36:30
  Speaker 1: to wait in triage for you know, an hour. Well,
• 36:33
  Speaker 1: they it just it felt like this is not a
• 36:37
  Speaker 1: good use of their time, a good use of my time.
• 36:40
  Speaker 2: And when I had my second kid, it happened.
• 36:41
  Speaker 1: That there was a birthing center, like inside there was
• 36:44
  Speaker 1: like a birthing center room inside the hospital and then
• 36:48
  Speaker 1: you didn't have to do any of that stuff. And
• 36:50
  Speaker 1: I had a midwife, so it was a much different
• 36:52
  Speaker 1: It was a much different experience. But it made me
• 36:53
  Speaker 1: realize like that intermediate experience would pull in a reasonable
• 36:59
  Speaker 1: number of women, And it is also what every other country,
• 37:05
  Speaker 1: like every European country is offering that as the default, right, Like,
• 37:11
  Speaker 1: I mean, that's this is a very we find ourselves in.
• 37:14
  Speaker 2: I think it's always quite an odd structure.
• 37:17
  Speaker 4: Yeah, yeah, I think it's it's unfortunate.
• 37:20
  Speaker 3: And you know, depending on where you live, you might
• 37:22
  Speaker 3: have more options.
• 37:24
  Speaker 4: Yeah, Like I was the support person for my sister
• 37:29
  Speaker 4: when she had a water birth at a hospital in
• 37:30
  Speaker 4: New Jersey and that was a really awesome experience, and
• 37:34
  Speaker 4: that's you know, I think again midwives are really pushing
• 37:37
  Speaker 4: the envelope and what's possible in hospital birth. And even
• 37:41
  Speaker 4: in Milwaukee, like a hospital recently opened to water birth suite,
• 37:44
  Speaker 4: and you know, it's attracting a lot of attention because
• 37:48
  Speaker 4: some women really want that experience, and you know, the
• 37:51
  Speaker 4: room is beautiful and it, you know, will be a
• 37:53
  Speaker 4: great place to have a low intervention birth.
• 37:56
  Speaker 3: Which is what a lot of women are seeking.
• 37:59
  Speaker 4: But I think even beyond what you're talking about with
• 38:01
  Speaker 4: your experience, Emily, is there's a group of women who,
• 38:04
  Speaker 4: like I think, are being almost forced to have pretty
• 38:08
  Speaker 4: dangerous out of hospital births. So I think about people
• 38:12
  Speaker 4: who want to v back. You know, many places in
• 38:14
  Speaker 4: our country you don't have access to a hospital that
• 38:17
  Speaker 4: is willing to attend a v back. They pretty much
• 38:20
  Speaker 4: force you into a repeat C section. There's also people
• 38:23
  Speaker 4: who want, you know, vaginal breach birth, which is it's
• 38:27
  Speaker 4: a risky birth, but you know, their C section also
• 38:31
  Speaker 4: has risks. So I think unfortunately in the US, probably
• 38:36
  Speaker 4: the people most well trained at breach birth are some
• 38:40
  Speaker 4: home birth midwives who do it frequently, whereas in the
• 38:43
  Speaker 4: obstetric field. Many obstetricians have sort of lost the skill
• 38:48
  Speaker 4: to attend breach birth. So I mean, I'm not in
• 38:51
  Speaker 4: any way advocating for out of hospital v back or
• 38:54
  Speaker 4: breach birth, but I just think, you know, too many
• 38:57
  Speaker 4: women are kind of put in this position where they
• 39:00
  Speaker 4: have to decide between you know, a very medicalized birth
• 39:04
  Speaker 4: that they don't want in the hospital or this very
• 39:07
  Speaker 4: risky out of hospital birth where you know, they can
• 39:11
  Speaker 4: have a really bad outcome and that could have been
• 39:14
  Speaker 4: avoided in the hospital.
• 39:15
  Speaker 1: Yeah, it just seems like with many things, just something
• 39:18
  Speaker 1: in the in the middle would be right, some kind
• 39:21
  Speaker 1: of middle middle ground would be uh, would be helpful.
• 39:25
  Speaker 2: And it's hard.
• 39:25
  Speaker 1: I mean it's I'm an economist, so I'm always looking
• 39:28
  Speaker 1: for what's the what's the economics, uh, and what is.
• 39:33
  Speaker 2: The reason for this?
• 39:34
  Speaker 1: But this is actually a bit of a confusing one
• 39:37
  Speaker 1: because your midwif free care tends to be less expensive
• 39:40
  Speaker 1: than EBS ceterac care for a bunch of different, you know,
• 39:44
  Speaker 1: reimbursary reasons. It's part of why medicated I think sometimes
• 39:47
  Speaker 1: started to to kind of have this be a good
• 39:49
  Speaker 1: option because there are many reasons why it costs less,
• 39:52
  Speaker 1: So you know, the economic incentives are a bit more
• 39:56
  Speaker 1: complicated than just well, of course we don't have this
• 39:59
  Speaker 1: because it's expensive.
• 40:00
  Speaker 2: It's actually not necessarily more expensive, right.
• 40:03
  Speaker 3: Yeah, I mean it is.
• 40:04
  Speaker 4: It's a little complicated because it's also true that in
• 40:07
  Speaker 4: certain states midwiffree care is reimbursed at a lower rate.
• 40:12
  Speaker 3: So you know, when that's the case, of course, it
• 40:15
  Speaker 3: doesn't make any sense for healthcare companies to invest in
• 40:19
  Speaker 3: midwives because they can only bill you know, a certain
• 40:23
  Speaker 3: percentage less than if they had an obstetrician deliver the
• 40:26
  Speaker 3: same baby. So, I mean, I think there's various ways
• 40:29
  Speaker 3: we could like incentivize midwiffrey. But unfortunately, like our country, like.
• 40:34
  Speaker 4: Our healthcare system, as I'm sure you know, Emily is
• 40:37
  Speaker 4: just it's really not a consumer driven healthcare system. I mean,
• 40:41
  Speaker 4: I think if it were, we'd see midwiffrey really take off,
• 40:44
  Speaker 4: because women's interest in midwiffrey has really spiked over the
• 40:47
  Speaker 4: last decade. And yet you know, there are hospitals who
• 40:50
  Speaker 4: won't give midwives admitting privileges. You know, midwives often aren't
• 40:56
  Speaker 4: included on hospital staffs, like and they don't have voting
• 40:59
  Speaker 4: right about decisions. And then there's the Medicaid reimbursement problem.
• 41:05
  Speaker 4: There's a lot of unfavorable laws that make midw free
• 41:09
  Speaker 4: difficult to practice in many states and including my own.
• 41:13
  Speaker 4: So yeah, it's gonna be a long road. But I'm
• 41:17
  Speaker 4: hopeful too.
• 41:18
  Speaker 2: We could all be hopefully.
• 41:19
  Speaker 1: And it is true that the trends we can end
• 41:21
  Speaker 1: it look a hopeful note, which is that the trends
• 41:23
  Speaker 1: have moved very much in this direction. You know, in
• 41:25
  Speaker 1: the past maybe you know, ten or fifteen years. Actually
• 41:29
  Speaker 1: the share of births attended by midwivet has gone up
• 41:31
  Speaker 1: quite a lot in the US.
• 41:33
  Speaker 3: Yeah, they see.
• 41:34
  Speaker 2: It's like a positive note.
• 41:37
  Speaker 1: Yeah, so before you go, let me ask you. You know,
• 41:41
  Speaker 1: you attend a lot of births. What is your favorite
• 41:45
  Speaker 1: moment in a birth?
• 41:47
  Speaker 3: Oh?
• 41:47
  Speaker 4: I love this question. Oh I love this question. So,
• 41:51
  Speaker 4: I mean, nothing compares to passing the baby to the
• 41:55
  Speaker 4: mom for the first time. There's usually just so much
• 41:59
  Speaker 4: relief in that moment. I also think, like, one really
• 42:04
  Speaker 4: beautiful thing I get to witness all the time is
• 42:06
  Speaker 4: like I don't know what I call it, the like
• 42:09
  Speaker 4: postpartum kiss. Like usually like if a partner's been with
• 42:12
  Speaker 4: his partner for this labor and he's seen this really
• 42:14
  Speaker 4: hard thing take place. I think that often his respect
• 42:18
  Speaker 4: for his partner has gone up a ton. And usually
• 42:22
  Speaker 4: there's this like moment where they just kiss, Like I
• 42:26
  Speaker 4: would say it's like two minutes after the birth, Like
• 42:28
  Speaker 4: when once we're like totally sure that everything is fine,
• 42:31
  Speaker 4: and you the babies, you know, breathing and crying and
• 42:34
  Speaker 4: on the mom's chest. That's a really beautiful moment for me,
• 42:37
  Speaker 4: and I feel really, you know, blessed that I get
• 42:40
  Speaker 4: to witness that all the time.
• 42:42
  Speaker 2: That is amazing.
• 42:43
  Speaker 1: Tomorrow, and thank you so much for being here. This
• 42:49
  Speaker 1: was really a treat.
• 42:51
  Speaker 3: Yeah, thanks for having me. I appreciate it.
• 43:09
  Speaker 1: Parent Data is produced by Tamar Avishai with support from
• 43:12
  Speaker 1: the parent Data.
• 43:13
  Speaker 2: Team and pix.
• 43:14
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• 43:17
  Speaker 1: conversation on my Instagram at prof Emily Oster, and if
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• 43:30
  Speaker 1: data to help you make better, more informed parenting decisions.
• 43:34
  Speaker 1: For example, the article that I referenced earlier with Anne
• 43:37
  Speaker 1: that I wrote about midwives with her help is called
• 43:40
  Speaker 1: How Midwives May Improve Birth Outcomes. It includes not just data,
• 43:45
  Speaker 1: but charts and graphs to parse through the weeds of
• 43:47
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