Midwives & OBs: How Collaboration Can Make Birth Better 

Introduction and Welcome

Britta: Hello folks, and welcome to Transformed by Birth, a podcast about the rite of passage of pregnancy, birth and new parenthood. I'm your host, Britta Bushnell, author, mythologist, childbirth educator and all around deep diver with a side of goofball. I'm so glad you're here.

Today's episode is all about thinking outside the false dichotomy box of either/or - home or hospital, doctor or midwife. So grab your tea, or take us for a long walk as we dive into collaborative care in birth. Before we begin, we start the way we always do by lighting a candle. If you want to join me, please do or just take a breath as I light mine. Today's candle is in honor of collaboration.

The Reality of Current Birth Care Options

One of the most important decisions expectant parents face is who will provide their care. The spectrum of possible possibilities can be vast, from high risk specialists to unattended, free birth. But for many families, that spectrum isn't much of a choice at all. Instead, it's entirely dictated by insurance coverage, economic privilege or what's geographically available. And when choice is possible, it usually means a trade off. Opting for one type of care means opting out of another.

But here's what's fascinating. Studies consistently show that integrated continuous care between obstetricians and midwives leads to the best outcomes for both parents and babies, and those same studies also reveal that this kind of collaborative care is both extremely rare and difficult to achieve in our current healthcare system. So I guess you could say that my guests today are kind of a unicorn. And who doesn't love a good unicorn story.

Meet the Guests

Dr. Bente Kaiser is a board certified OB-GYN, with all the impressive education on her CV that you would expect, and then some. Sarah Howard is a licensed midwife and International Board Certified Lactation Consultant with a previous career in nonprofit and healthcare advocacy. In 2022 together, Bente and Sarah co-founded Moxie Birth, the only freestanding Birth Center in Los Angeles that was created and operated by a midwife and obstetrician.

On a personal note, I am so grateful to be in local community with these two stellar professionals, and I'm thrilled to be able to share them with you all today. Welcome Bente and Sarah. I'm so glad you're here.

Sarah: Thank you for having us.

Bente: So good.

The Typical OB-Midwife Relationship

Britta: So I want to talk about collaborative care and this unicorn that the two of you have co-created. But before we head there, I'm wondering if you could speak a little bit about what the more typical relationship is between OBs and midwives. You've each worked in the medical system for years prior to teaming up. What's happening there, like, when it's not this unicorn, what's going on? Talk about that. Sarah, you want to take that one?

Sarah: Sure. Yeah, thanks for having us. Britta, we're so excited to be here.

I think there's a range of things that's happening between obstetricians and midwives across the United States, and we're pretty much talking about the US here. I'd say at best, it's a hierarchical relationship in which obstetricians supervise midwives, typically in large systems. If a town or a city is lucky, you could access midwives in a system that are supervised by doctors, which means that it's a very top-down relationship.

I'd say, more typically, across the US, there's very limited access to midwives. So midwives are not in every town and city, unfortunately, juxtaposed to other countries, where midwives are virtually everywhere.

And I'd say the worst of it, of this relationship, is full of animosity, mistrust and competition, in a sense. Particularly when you're talking about midwives who are working outside of the hospital providing home birth or birth in freestanding birth centers, it's very challenging to find relationships with obstetricians that are collegial and respectful.

The Problem with Transfers and Communication

And we need that, because midwives are experts in normal. So when things are normal, it's very, very safe, and it's well documented that it's safe for people to birth outside the hospital. But there are times when things become less normal, they become higher risk, and then we want really good relationships to be able to go into the hospital. And unfortunately, because of this sort of animosity between midwives and doctors, we often see gaps in access to those transfer situations or communication breakdowns once transfers happen, and overall feeling that doctors don't trust midwives and midwives don't trust doctors.

Yeah, and that can end up leading to care that is not good for the birthing families.

Absolutely, it has a huge impact on not only experience for the clients, but certainly for safety. And as you said, because we have all this research about the benefits of the collaboration, it's just really unfortunate because it doesn't need to be that way, and that's what we're excited to talk about, is another way.

Bente's Journey from Hospital to Birth Center

Britta: Yeah, well, and that's what I'm excited to talk about as well. Bente, what's your take on having been an obstetrician in a hospital? Like, how did you end up being like, "Hey, maybe I want to do birth outside of a hospital." Because that seems so different than what Sarah was just talking about of that more hierarchical... I mean, is what you're doing now - I'm asking three questions at once, but is what you're doing different than that? Talk to me about that and how that came to be.

Bente: Usually, when I talk about how it happened, I always reach back to 20 plus years ago, when I was in residency, when basically when your doctor brain is being molded into what later might be a little bit how you're thinking about things. And my residency was a little bit unique. It was a small, high risk, high volume, community based hospital that happened to have a very thriving midwifery service. And we collaborated, and so that's how I was raised, if you want, as a doctor.

I didn't know at the time that that was unique. So I just took it for granted, and I really enjoyed that collaboration, and I became friends with lots of the midwives, and saw how we could do things differently. We even had water birth in my residency and all these things.

And that is unique. That is so different, especially because it was in the South Bronx. You wouldn't expect it there. And yet it was there because, I think because the director of residency had been trained in Scotland, the UK, so I think you had already kind of an underlying knowledge of how that could look.

The Evidence Paradox

What I don't understand is kind of like the opposite question - when we know that the evidence is saying that it's good for mothers and babies, it's cheaper, it is in every aspect better to have a collaborative care model. Why are hospitals, insurances, you name it, why are they actually moving more and more away from that, rather than towards it? That's what I don't understand.

Breaking Free from Hospital Limitations

And then your third question, how it came about for me to do out of hospital birth - that was not the point. I didn't ever want to do out of hospital birth, per se. That was not really my goal. My goal was to do birth where people had options, and I found myself always very limited in the hospital. I was kind of - I call it jail - like I broke it a little bit out of this labor room where you have to be in the bed to give birth, and it's like revolutionary if you do it on hands and knees or maybe in a side lie. It's hard, and also, there's so few options of movement and pain coping rather than pain control that you end up a lot of times with an epidural because there isn't really anything else offered, because that's just how it is. And when you have an epidural, movement is even less likely. And so there is that kind of domino effect of what you end up doing is the same kind of thing over and over again. And it can be different.

And so I was actually trying to get that into the hospital, but that was met with such enormous resistance. Like you would think people always easily say evidence-based, and mouth that kind of like as an empty bullet point, but they're really not. And so I had a real issue with that, and I couldn't bring evidence in, like there was resistance against the actual evidence.

The Birth of Moxie Birth

And with that experience, then it came about that we could have this space where we're at at Moxie Birth. So it was more like an opportunity that rolled down when I just hit another red tape moment in the hospital, and then I said, "Well, if we can do it in the hospital, maybe we can do it out of hospital." And so it wasn't really the goal to do it out of hospital. It was just having the opportunity to labor and deliver in water, moving around, going at your own pace, not having a million interventions, not us telling the person that's in labor how to labor and what to do next, but kind of following along with that process.

Britta: So centering the parent, the laboring person, in the ability to have choice that you weren't seeing that in the hospital.

Bente: Yeah, we don't see that in a hospital. We still don't see that in a hospital. And you wanted to really give options. I mean, after 20 years of doing it one way, but knowing it could have been done differently, I really felt that I was just getting older and older, and I was going to eventually retire not having really done it the way I wanted. It was a weird moment.

The Magic of First Births at the Center

Britta: Powerful. And so then this space became available, and what happened next? Sarah?

Sarah: Well, I mean, after so much banging heads against the wall trying to get this model into the hospital, it was just such a beautiful relief. I mean, I think our first birth at the birth center doing it - Bente and I did all of the births for the first year, just her and I and watching Bente receive her first baby in a birth tub was so magical, because her mind was blown. It's just as easy as I thought it was, and I've been saying all this time, and it is so quiet in the birth center. It's so intimate. It's so animal. Even when it's not actually, volume wise quiet, but it's like, it's just us. There's a relationship. So it was really beautiful to open that space and to just feel the relief of like, "Okay, we're gonna have to do this a different way. There's not a way forward inside the system right now, frankly, not in Los Angeles. And so we're gonna have to model what we believe is possible, and that's going to be the way forward."

And it, as practitioners, I would say it was incredible relief. And then also it's a behemoth of something to try to do, to model a new way, because it's in some ways, and I'll say in some ways, it's not new. It's really something that's being done in so many other places.

Looking for Models Worldwide

Britta: Yeah, can you talk about that a little bit? Were there models for you?

Bente: I mean, to be quite honest, even in places like the UK, Australia, New Zealand, Europe, other places in Europe, the model is moving away from the collaborative care. And so we always refer to the UK or Scandinavia as the ideal places to birth, because there is collaborative care. There was, at least there was a tradition of there being a collaborative care model there. But that's also going away just FYI. And I don't know why that is. I talk a lot, of course, to my friends over there, and I don't quite see it as we maybe romanticize it to be over there. So I think you really have to build your own microcosm, because there isn't a lot of examples that I can just name.

There are a few. There are a few collaborative care centers where I feel that it really works well. There's one in India, for example, Sanctum Birth Center that's run by an OB-GYN, together with midwives. And there is a hospital in Madrid that has an OB-GYN that works with a group of midwives. They all have the opportunity to do it in the hospital. They have water birth, and they have also the opportunity to do a C-section there. So that's kind of the ideal setting for me.

The Community Hospital Model

So I think we have a setting that is comparable with a community hospital way, way far out in the boonies, where we don't have an anesthesiologist, we have to go to hospital which is seven minutes away, or five minutes depending. And we don't have a NICU, we don't have an OR, we don't have a blood bank. So those are the things that small hospitals in the middle of nowhere in America also don't have.

But we do offer normal labor, and we offer the opportunity to have a normal, unintervened labor, and then when we do need more, we have to change location, like in a community based hospital setting.

Britta: Yeah, I hadn't thought about it like that, but that registers, and you're also kind of fortunate that you're not in a community based situation where the distance to that other kind of care is really long, you're really close.

Perceived Safety vs. Real Safety

Bente: Very short distance. Should that need to happen. And even still, there's often a lot of indicators earlier on that a movement of location might be the best thing to do next. Typically, yes, not always, of course. There are surprises and when you have a surprise in the hospital, I usually talk about perceived safety. I mean, there's example, my prime example of hemorrhage, that I can bring up later. But perceived safety is the idea that you're always safe in the hospital, which is also not true. And you can have surprises in a hospital, that no matter how many people are in that room or how high tech your situation is, you can't really save the day. And there is, there has to be certain humility, knowing that you cannot save everything in everyone. Yet it's perfectly safe for a normal birth to happen outside of the hospital. And, I mean, I can't prove this yet, because we don't have enough births for that, but that the outcomes are very comparable to in hospital outcomes, if not better, and we know that our C-section rate sure as hell is a lot better. So there's that.

Safety and Community

Sarah: One more thing, which is that we live in the United States. We live in a world where going in the hospital is not safe for a lot of people. I mean, the vast majority of our country now is people of color, and it is not safe for them in there. So I think that for some of us, the hospital feels safe. It feels like a place where we associate safety, but for a lot of folks, it doesn't, it feels like a really scary place, and there's good reasons for that.

And so I also think that remembering that when you bring birth back to the community, you're really empowering those folks to grow their own midwives and have a community based system that's really going to support those families and is going to be safe for them and congruent care with folks who live where they live, look like them, have their identities deeply understood in their blood.

So I think we don't all look at the hospital as safe. Some folks are really desperately seeking outside of hospital options because that place feels unsafe to begin with. And then there's other of us who are like we were raised to think that was the safest place to be. And so it seems crazy to birth outside of the hospital, in which case I often think about the airplane car analogy. When you get in an airplane, it feels really crazy, and like, "Oh, how is this possibly okay? And am I really safe?" But honestly, being in your car every day is much more dangerous, statistically. So there is a little bit of something to think about there with the hospital and being in your own community outside of the hospital if you're really healthy and low risk, because, frankly, we are all animals, and if you look around at all the other large mammals, where are they birthing? Nobody's taking them to the vet after they've had their puppies or had their foal.

Breaking Down Hierarchies and Titles

Britta: I love it, and your analogy about the airplane and car is such an on point, because as someone with flying anxiety, and yet I feel like a badass driver, and I know that the truth is not that. And I also really appreciate, Sarah that you brought up the idea of safety as a concept, that safety, it sounds like it's a universal, and it isn't. It's a perception, and something that is felt and how one develops the sense or the perception of their own sense of safety, has so many different factors involved in it, and that's an important thing to be thinking about in regard to this whole conversation.

Which also brings me to thinking about the perceived sense of safety or expertise in regard to an obstetrician, an OB-GYN or a midwife, and that for many people, they think of the specialist in obstetrics being an OB-GYN, a doctor. So you mentioned Sarah, when you were speaking, that in some of these relationships between midwives and OBs, there's a hierarchical relationship. Now, you two are doing something a little different. What's going on here? I mean, here I am. I'm talking to quote, unquote, Dr. Kaiser, and I'm referring to her as Bente, her first name. So there's so much to unpack here around even those perceived ideas of expert or specialist. What is your take on this, and how is it different, and why? You want to take that one, Bente?

Bente: I mean, I think that saying Dr. Kaiser doesn't make me any more of an expert than calling me Bente. I'm the same person. I don't really feel that I need to assert my expertise by having my credentials named every time you call me. I really don't feel that that's necessary.

I come from a place where physicians are often called by their first name. When I visit my friends back in Belgium or in Holland, they go by, they're often department chairs by now, or whatever. And it's like Saskia. You hear the nurses calling down the hallway. It's completely normal. There's, it's kind of like a different place to be. My brain is still kind of a little bit there, and I find it much more comfortable there than in a place where we have to talk to each other differently depending on the credentials we've achieved.

The Cycle of Mistrust

I have called - I've heard colleagues say, "Oh, we have studied so much longer. Who are these midwives think they are? Doing this at home and then bringing these patients to me? I have to fix it." That's that negative, that extreme negative relationship, where there is this balance back and forth that makes it worse.

On both sides, there is this dichotomy where the midwives, the out of hospital midwives perceive the hostility in the hospital as difficult to transfer to, and so that makes the transfer threshold really high. And so then you're going to either go to a hospital that's farther away, that you think is more friendly, or you're going to wait to the last minute where I really don't have a choice, because you just keep hoping it's going to turn around, it's going to turn around, but you really kind of deep down, know you have to transfer this patient to the hospital.

And so by the time you actually arrive, that patient should have maybe been transferred sooner, but really, if you look historically, the transfer didn't happen sooner, because there was not a friendly reception. But now it's late, so now that reception is extra hostile, and so that really reinforces the bad relationship on the other end. So there is that relationship, and you have to completely break it down before you can rebuild. So we have to, in my opinion, be kind of eye to eye as humans if we're going to do something that is this high risk, basically, and can go lots of different ways, where maybe my extra knowledge needs to come in, or maybe also not, where I can totally step back and not need to be involved at all.

Different Perspectives, Different Expertise

And for the patients too, in my other practice that I had where we all delivered at the hospital, a lot of people would come and say, "Oh, I want to come to you at the birth center." And I was like, "You're not coming to me at the birth center. If you're coming to the birth center, you're coming there because you want an out of hospital experience. And the less you see of me, the better, because most of those can be done by the midwives and will be done by the midwives." And so that kind of like, I saw that as an eye opening moment for a lot of my clients from then that they were like, "Oh, okay, that's a whole different concept." And some would take to it and be very positive, and some were like, "Okay, but that's scary to me," and that's totally understandable too. That's too new. That's too different. I haven't seen that model anywhere before.

And, I mean, that's kind of the hard part about what we're doing is there isn't all that much examples around us, so we have to constantly really feel comfortable in what we're doing. And then back to that human connection, I need to really trust everybody on my team. I need to have a relationship with everybody on my team. You can never actually cut a corner, like ever as far as going all the way with a human relationship when you're doing what we're doing, I feel.

Dismantling the Medical Marketing Machine

Sarah: I also think we have to remember that there's a really long history here, a strategic institutionalized history of bias. So basically, when I say peanut butter, you think jelly, and it's because it's been over and over and over. They've been associated and the trust in doctors has been taught. It has been marketed. It has been - it is the best branding campaign in the history of the United States, when doctors came along and said, "It's safer to do this with doctors" and took this from midwives. Let's not forget that midwives were the provider for all birthing people for the vast majority of time and in every community and in every country.

Over time, there's been this institutionalized, structured association between safety and doctor, the white coat, the marketing, all of it. And I think that when we go back to why do we call her Bente, is because we have to start taking away, stripping away all of that marketing and branding about what is safe and who you should go to and how you're going to be, what's fancy, what's best, and really look at ourselves as we're all experts. The parent is an expert in their own body. I am an expert. I've watched hundreds and hundreds of people from the beginning of their labor to the very end of their six weeks postpartum. That's not something Bente got to do in the same way, this intimate continuation of care with the same person over and over and over again, but I have never done a cesarean section. I am not going to scrub in on an OR and go do that, but Bente is, that's her expertise.

The Architect and Engineer Analogy

So I think of this other analogy with this around looking at a room from the perspective of an artist or an engineer. We need both to build the house. Without the architect or the artist or without the engineer, you really, literally need them both.

And for us, in a lot of ways, and I know there's a lot of folks out there who think, "Actually, I don't need either. When it comes to birth, I'm just going to birth at home by myself." And that's also a choice you can make, absolutely. But I think for us, when we think about the systems of birth in the United States, we want to see a place where we've got the engineers and the artists, and I don't know who's who, I'm not trying to say the midwives are the artists. But we need that to build these beautiful houses, and so we don't want to be reinforcing these hierarchies and these marketed - the doctor is the safe one, and so even just calling her Dr. Kaiser, it just reinforces this paradigm. So it's really important and we correct people. Because some people feel really weird about it. They're like, "I call her Dr. Kaiser." And we're like, "No, no, she's a first name. Like the rest of us, it's all good. She doesn't really want to be called Dr. Kaiser." It's weird.

Different Skills, Same Mission

Bente: I mean, it's honestly crazy that it has to be such a big deal. And then it would be easier if my name was Anna or Jane, where they're like, "Am I saying it right?" But we can learn we can. It's not a big deal if you even said it wrong. But it's really awkward sometimes that you can't just be Bente in a space where you just do what you do, but it means something to us or to me, it really means something about what we're trying to do. Because I feel that way in my relationship with Bente, I have never, ever felt like Bente was like, "I'll tell you how to do this now." That is not how we roll, and it's really because we just have different skills, we have different perspectives, not only just as human beings, but because of our training, it's just very different to train as a midwife than to train as a doctor.

And folks don't necessarily always know that difference, or they wonder about midwives and doulas, like, "What's the big difference?" And that stuff is really, we could get into that if you like, but doctors and midwives are both medical providers. We're there to safeguard the physical and emotional, psychological, all of it, safety of the person birthing and the baby coming, and that's our job. I'm licensed by the medical board. So is Bente and doulas are there, as physiological and psychological and emotional support people. They are not medical providers, but even when you look at the medical providers of doctors and midwives, it's just such a different skill set.

Bente is a surgeon. If we have a really complicated laceration at a birth, I want to call her because she's an amazing surgeon, and she's going to repair that beautifully. And we all learn from her, and she teaches us classes. And those are different skills that we didn't learn in midwifery school. But a lot of times in the arc of a normal birth, we'll know before Bente, when we need to go to the hospital. Bente will be like, "Oh no, it's probably fine, this is okay." We're like, "It's just crossed the line. This is the difference between working hard and suffering or this is gonna need. We can sort of see down the road," and it's just because we've watched hundreds and hundreds of them outside the hospital. So it's not that we know better. It's just we know different. And working together, that's such a beautiful thing, because if we have doctors and midwives who are working together. Then when you need to change location, or you need to change, you can slide in and out of needing these different things without being traumatized, because so much of what is happening in the US and birth is traumatic. People not being seen, not being heard, not feeling like decisions are being made about and for them.

Learning to See Physiologic Birth

Bente: I think a huge lack of our training as OB-GYN in the United States and also elsewhere, is the lack of seeing physiologic births. And I told Sarah that too, the first time we had a couple of births at the birth center, after a while, I was like, "I have never actually seen physiologic births before this."

And that sounds really crazy, but I would say 99.9% of OB-gyns have not seen physiologic birth. They have seen unintervened births. They have seen unmedicated birth in the hospital, but they haven't really seen physiologic birth, and I think...

Unintervened vs. Physiologic Birth

Britta: Unpack those for us so folks who are listening can understand what you're saying about the difference between an unintervened birth and a physiologic birth. Can you? What did you see that was so different?

Bente: Well, physiologic is when you just let it unfold without doing anything. And everything you're doing counts, and I think that at the hospital we cherry pick. It doesn't count to us that that person had to walk all the way from the ER to labor and delivery because it was past 10pm or that you had to stand at the front desk and give her ID and tell them what her driver's license number was while she was breathing through her contractions, and even unintentional things like the smell of the hospital, the brightness of the hospital, you're still walking through this long, strange corridor, hallway where you haven't been before, and then you end up in a room and you're basically being told a couple things. You're being told to put on a gown. You're not being asked if you want to, or if you brought something, or if you're okay with this, or if it's a good time. You're basically being told you're going to change into this gown. You're giving me some urine in this cup, and I'm going to take your vital signs, and then I'm going to start an IV, and it's all without any kind of interaction with the person in labor. It's just like we are doing this because you're here now. So those are all interventions already, because a lot of people consider a pelvic exam an intervention, or Pitocin, augmentation an intervention, or an epidural intervention breaking the water. Those are more aggressive interventions, more invasive, but it's already an intervention to drive to the birth center, so there's that too. So I think true physiologic birth probably is what happens at home, and I haven't been there. I haven't done a home birth or attended a home birth in my life, but as close to that is when you come to the birth center and it's dark and you just labor on. And we do also do your vital signs, but we do it when you're ready. We listen to the baby, but we don't have you on your back for that necessarily. We don't tether you to anything. We do it with a Doppler. And those are, again, there are interventions, but they're a bit softer. They're a little bit less invasive, of the sort, and that allows that physiologic process to continue uninterruptedly. Because, I mean, it's not for nothing that a lot of people go to hospital with roaring contractions and then get there and stall out. Because the smells, the light, the disruption, the talking to this person in their bubble kind of makes that oxytocin flow really halt, and you get more into fight and flight. And so you're not going to continue that physiologic process, because now you're being asked to get into bed. Basically, you're not being asked to get into bed. You're being told to get into bed. You're given very few other options, even if they were to say, "Oh, but we allow you to walk around." It's not like they encourage you to walk around. They don't encourage you to do what you want. They encourage you to do what they want because that is part convenience, and it's part also because there is continuous understaffing at every hospital. You don't have one nurse for one patient. That is utopia, that's unheard of, that doesn't happen. So you have one nurse for maybe two or three laboring patients, unless they're pushing, then they get to give up their other patients, which means the other nurses have more patients. And so then it's much more convenient, if you can tether all the babies to the monitors and then see them all at one monitor at the front desk, where you don't have to be in the room all the time.

Reflecting on Hospital Interventions

Britta: Boy, that really lands as I think about my experience as someone attending births in a doula role. I was just rethinking some of the - and I'm going to put it kind of in air quotes - the least interventionist births that I've attended in a hospital setting. One of them involved me sitting in the waiting room for 30 minutes while the couple was in triage, and that was a form of intervention. It was a fantastic birth. When we think about the birth, and how they felt about the birth and so many different things, it would go in the category of a quote, unquote, natural birth in a hospital. And got so much of what they wanted, but they also got separated from me. They had this 30 minutes where they were poked and prodded and engaged with and stripped of clothing and put in a, in closed by curtain, little partitioned area in a room with a lot of other people prior to going into their room where then magic was able to happen. But all of those things that happened prior to them going in there really was shifting so much of what was occurring already.

The Magnanimous Hospital

Bente: I'm not dismissing hospital birth either. It's not like that at all, but it's just I like people to have the options and to unfold, but you also asked, what is the physiologic birth process, and what are we interrupting here? Of course, it can still happen. I've done it many times too, and I've been in that same position as a birthing person myself, but it still could have been maybe different if I'm having that, there's a spectrum here of what it is that we're talking about, and it's often spoken about in a more binary way.

There is also this idea in obstetrics that we - I mean, there's not even the idea. It is just more like a habit where we take things away, and then we give it a name and offer it back like we're the grandiose people that are able to give you these things. For example, I'm going to delay your cord clamping. But instead of asking, what is the evidence for cord clamping in the first place? Am I allowed to clamp your cord? No, I'm gonna allow you to have a minute before I clamp your cord, because that is the optimal cord clamping time, according to some studies. Some other studies say five minutes. Some say two minutes. There is zero consensus, to be honest. And why are we clamping the cord at all? Do we really have to clamp the cord? What is the evidence for that? Another intervention that we're doing that we're magnanimously now giving you some time before we're doing it. The same thing is with the golden hour. We made that hour to give to you, whereas it's your baby. Can I take it away. Am I allowed to take it away? Because I would like to weigh, measure and do whatever with this baby. Are you ready for me to do that? Instead we give you magnanimously the golden hour, and "Oh my gosh, aren't we so great for doing that?" And so I have some issues with that kind of stance, and I see it more and more because I'm seeing it from the other side, like, why are we doing these things?

Britta: I love this. I love that you're shining a light on this, Bente, about the sort of repackaging, in this magnanimous way, of something that should be questioned from the get go, and just for folks who are listening, who may not know what the golden hour is, it's kind of that place, of that time after immediately after birth, where often in a hospital setting or in different settings, it's like, we'll leave you for this hour to bond with your baby and as if it's something that isn't just a part of what can be true, it's now being thought of as "Here you go."

Returning to Our Animal Nature

Sarah: And I'm so always so excited when I hear other practitioners that are flipping this script. I saw there's a great Dr. James McKenna, who does a lot of safe sleep research, and I saw him speak, and he said, "You know, mothers always ask me, 'Is it safe for me to sleep with my baby?' And he says, 'I always say, is it safe that we stopped sleeping with them?'" That we, that's really the question like that. You know, we kind of have to take a lot of this back and and unpack how it was, how it was marketed to us, like how we are animals. We really, we really just are, like, we are more in birth to like a horse or a cow, then you want to believe or a monkey.

And when I think about that hospital scenario that Bente was just describing, I think about how we really take comfort in relationship as human beings. That's a, and we're not unique in that other mammals do that too, but in that scenario of going into the hospital and sort of having all of the things about the hospital impact your nervous system, I think about what would that look how could that look different in the system of the United States, if we really integrated midwives into that system, and there are places in the country where we have that happening, especially on the coasts, we have more enlarged metropolitan areas, we have more midwifery groups in hospitals, and people get to build relationships with those midwives in their prenatal care, and then when they get into that room, even if they had to go through the 30 minutes in triage and somebody's asking them their pre-pregnancy weight while they're mid contraction or the what was your first day of your last period? Was this an abortion? Or was this a miscarriage? Like it makes a difference. But if you can get through that and you can get into the room. And then someone walked in who you had built a relationship with that and you and you trusted them, and they knew what physiologic birth look like, and they were an expert in that care. Your nervous system could relax, you could come back down from flight or fight, fight or flight, and come back into your body and feel supported, and have a medicated or an unmedicated birth with a low risk provider in that system. And then if you had a really great collaborating physician, if things become higher risk, that person can come in and and you can work together. And that doesn't mean then the midwife's out and has to leave. It just can mean like, "Okay, now we're going to look at this issue together, and we're going to tackle this together," and that's kind of the world we want to see, like we know that we can our model is hard to scale, where we have a free standing birth center with midwives and obstetricians working together five minutes from a hospital with admitting privileges like this is, this is a little bit of a unicorn.

Growing Demand for Change

But what we what we know is possible, is to build on the model that is popping up. There is so much interest in this. I mean, I was in midwifery school. I think when the business of being born came out, that documentary that really helped the pendulum start to swing about it for in the United States, folks started being like, "Oh, wait, yeah, I have options." Like, "I this is a business. Let me look at this differently, and let me think about what's safest and best for me."

We're seeing a lot more demand for from people who are pregnant that they want different things, like they want more intimate relationships with their providers. They want some of these basic, basic things, like dimmer lighting or not being put in stirrups when they push their baby, or not wearing a hospital gown, just simple, simple, like cheap humanizing things. These are not things that make it less safe. These are things that just make you feel like an actual person who's bringing their baby into the world. You're not going in there to get a colonoscopy. You're going in there to bring your baby into the world. And the reverence for that is another thing that I think midwives are taught. It isn't, frankly, beat out of us the way it is out of doctors.

The Dehumanization of Medical Training

And I think we should take a minute just to say that, like that is a thing, that the training of doctors in the United States is also inhumane. And then we expect these people who've gone through essentially like a military style training and have been totally dehumanized themselves and torn up. We expect them to come out and be compassionate, thoughtful providers. It's also absolutely problematic. So we really need and some of some of you know, we see there being more limits on their hours and things put in. But like as humans, we just like tear each other apart in all these in all these systems. And with birth like it's so detrimental to the people who are having their babies for them to be in systems like that that are full of traumatized people.

And so that is to say, I think we have to start with our training programs. We have to start with looking at like, how we can humanize everybody and honor everybody more. And it's, it's a huge undertaking, for sure, but it is so possible to make really big impacts on clients and people pretty with pretty small changes. I mean, if you look into midwifery groups, like in your own home area, in hospital settings, like a lot of times, some of those changes are starting. They're happening.

The Ripple Effect of Midwifery Care

Britta: I mean, some of the the most rich, meaningful, tender birth experiences I've I've witnessed in a hospital setting have been in under the care of collaborative team, and really amazing, because I'm also noticing that in a hospital setting, sometimes when there are midwives there, they also impact how the nursing staff operates. And one of the things that is kind of not expected by a lot of people who are going into their first birth in particular, is how much the care they're getting in the hospital is not from their primary care provider or their their OB or their midwife, but is actually the nursing staff. And when there is a midwifery team as part of the staff in the hospital, there is a way that that can influence how the the nursing staff operates as well.

Changing Entrenched Practices

Bente: 100% because if you've done something for 20 years and you've only watched that done a certain way, you're not even going to know that there is another way to do it, necessarily. So if you have been an L and D nurse for 20 years, but you haven't seen physiologic birth, I've had nurses that tell me "I don't believe in that. I don't believe that exists," belief like a fantasy. Well, because, "that doesn't really happen. If I let it be, it wouldn't really happen the way you say," because they have never seen that, and I don't really, I really don't blame them. I mean, that's a very honest stance to take. Quite honestly, you've done it for 20 years, so you think there's nothing you haven't seen. But it's also tragic. It also hurts when you say that, like, I understand it, and it sucks my heart, which gives me this intense desire for them to come and see it at the birth center. Come see what we do. But I mean already changing things, like not taking the baby out of the room when I'm doing a C-section is apparently, like, rebellious. Like, why are we doing that? But if you do certain things always, and every doctor is like, "Yeah, this is how I want it. Take that baby out of my room when I'm doing a C-section, when, when the baby's out, I don't need that baby in here anymore," because if it's a family that's just had a baby, but that is kind of, that is what's happening all the time, everywhere. And the nurses about the stirrups, I have to just go there, because I find stirrups. They're great practical things to hold your legs when you have a heavy epidural and you need a repair. But if you're birthing a baby, even if you have an epidural, you can still usually move a little bit, and that can be quite helpful. When you're pushing, we can then turn side to side, or you can get your legs or, I mean, whatever it is we're doing, we can do something rather than you just have your legs hanging in those stirrups, which is so standard as sometimes when I come late to a birth for whatever reason, because it went fast, the stirrups already out, the legs are already in stirrups. And I'm like, "we are. We're doing this really..."

That is, that's how it's been seen and taught and modeled, though, year after year after year of their working experience, I'm not blaming the nurses. That's what they see all the time, which, again, brings me to like training, and especially for residents, residences around LA. I mean, my biggest wish is that some OB-GYN residents would come and do a rotation at the birth center and see something different. Because if you can plant the seed of someone, if they can see that it is possible, then they can believe, and then they might aspire to do something like that in the future.

Transformation and Rites of Passage

Britta: Oh, yeah, absolutely love, love that dream. And I'm I'm thinking, a lot of you know that a lot of my work is about rites of passage and the transformative aspect of going from individual to parent, going through the journey of birth, and this, when you're speaking about this different kind of way of of holding birth and and supporting birth, What difference do you think that makes on the transformation for the individual, like, Sarah, you sort of started to kind of speak to that a little bit in talking about ways that it's it's happening and the individual, the even the the transformation For the doctor going through medical school has a kind of dehumanizing transformation, and now, when we're talking about a different kind of care, let's refocus on the the individual giving birth, what's, what's, How's it different for them in a collaborative Care Model? Sarah, you want to start on that one?

Sarah: Sure. Yeah. I mean, we talk a lot about, like, or I do about becoming a parent, especially that first time as like a massive puberty. Before puberty, you saw the world one way. After you go through puberty, you see the world totally differently. And you're like, "Oh, there was this whole other thing happening out here, and I didn't even know." And having a child is sort of like that. And I think unfortunately, people end up doing that. They're very alone in that process in our culture. So maybe they have their families and whatnot, but there, there aren't care providers who are really connecting with them about that. So I think that's the biggest difference in in midwifery care, but also in collaborative care. Having relationship, building like that's what humanizes everything. Is relationship. It's how Bente and I got here was our relationship that we made. It's how we break down some of these barriers in systems, is by building relationships with each other, building trust. Just seeing where we are now from, since we opened the birth center with the trust with the nurses at the hospital that we go to, versus where we began, when we first opened. Trust is everything. And so I think for for people who are walking through such a vulnerable time, having providers who they really deeply trust and who are going to see them all the way through is everything. I mean, it is, it is the really, truly, for me, the difference between having something be hard and having something be traumatic. Because we can't predict where anybody's baby's going to come out of their body. I mean, frankly, I can't look at you and tell you, "Yes, you're going to birth at the birth center, or you'll be able to stay home and birth, or you'll be, you'll end up in the operating room with a cesarean." There is no way for us to know that, like, if we could have that crystal ball, that'd be so cool. But in some ways, it's really, really part of the magic that we don't exactly...

Britta: I was going to say, maybe if we had the percent. I don't want to know we could know, because the whole thing is the journey.

Sarah: Yeah, the entire whole thing is the process. And so in our model, people never transfer out. They never have to leave their team - their team goes along with them the whole way. So whether or not they birth in the birthing center or we end up in the operating room, they still have the people that they built the relationship with. And that's to me, that's everything, because a lot of times the folks who do end up with a C-section in our care are some of the ones who rave the most about what they experienced, because we just need to be honored and heard and respected and treated like human beings with the ability to make decisions even when we're working hard or going through something challenging, and really just in our system, people aren't treated that way.

The Magic Comes from Within

Bente: I also want to add to that, because you're asking, what is the diff like? What is what makes that? How does that make that transformation from from birthing person to parent. Ultimately, that person brings the magic. It's not us that's bringing the magic and doing it so special, and now you have the special birth. It's really whether you have your baby in stirrups with the hospitalists. Don't call it's fine. You're badass, and it's it's the magic that you're bringing to that moment. It's just so much harder for you to do it that way. And we are trying to offer more pathways, and more little ways to do it, not that one way that you have to fit into this one way that's all but ultimately, it's them that are bringing everything to the table. We just try to honor it as much as possible and remove some of the barriers, because there's not many barriers. There's so many barriers to being right Access Your Magic like your magic is going to be popping at home, maybe in early labor, because you've done all this prep, and you've done all this stuff, and you're on the phone with your doula, if you're lucky, and you're like, if you do is coming over, and now you're making a plan to come in, and then you're going to just hit all these opportunities, unfortunately, for the magic to, like, fizzle, because your adrenaline pumps up and your cortisol pumps up. And you're, it's all it our system is really challenging to navigate.

Sarah: And like I am a, I was a home birth midwife before I became a birth center midwife, and I you were talking to somebody who had two surgical births. Surgical birth can be really traumatic, and it can also be really magical. Like there is no one way to do this. It's really about the process and that, that for me is everything.

Team Growth and Expansion

Britta: Yeah, and and I agree, I concur, as in the work that I've done and the the folks that I've supported and worked with the there's so much power in in the individual and their journey through it. And I love how both of you and your team, because now you've expanded. I mean, you started off, it was the two of you, but now you have more midwives. I mean, I know you've got the remarkable Jessica Diggs. Do you have more than than Jessica now?

Sarah: Thank you, yeah. Underwood, oh yes, okay. We have an awesome student, Anae Sanabria, who just finished midwifery school. So we have another student coming on.

Britta: Yeah, you're you're deepening and expanding. That's amazing. It's amazing.

How to Connect with Moxie Birth

Well, so how do folks learn more or connect with your work if they're not local, or if they are local, like, what are the best places to learn more about you both.

Sarah: Yeah, you can follow us on Instagram at Moxie Birth. We're at Moxie Birth. I'm Los Angeles midwife. On Instagram, that's a good way just to see what we're up to and follow along. And a lot of times, folks will send us messages saying, like, "Do you know anyone in North Carolina," and we, we know a lot of people, so we're always happy to try to connect folks to...

Britta: Okay, and your your birth center, Moxie Birth is tell us just a little bit about where that is. And you know, if, if local folks to the LA area are interested in that, how do they find out more about that?

Bente: Moxie Birth is in South Pasadena. It's about five minutes away from Huntington Hospital, and they can find they can either email info@moxiebirth.com or they can go to moxiecare.com and look at the website, or they can just give us a call.

Final Question: Wisdom for New Parents

Britta: Love that. So as we begin to close our conversation, I like to end with the same question every time. So are you ready for our final question?

Sarah: Okay.

Britta: What's one thing you feel passionately about that you want new or expectant parents to see, hear, feel or know during this profound period of their lives, what do you want to highlight for them?

Sarah: You know, after serving so many families and walking alongside them, I am more convinced than ever that people know what's right for themselves and for their own bodies and families. On a deep level, you do know what's best for you. And yes, there are experts out there and there are people, but everybody's gonna give you an opinion and ultimately, like, from choosing your care provider to choosing diapers or choosing whatever like you you know what's best for you and your family. And I, I'm a firm believer in that, and hope to empower people to find what is their own path.

Britta: I love that. Sarah, thank you. Bente. What about for you?

Bente: I think that I would like for people to know that there's not just one way to do something, that there is a million ways, and that your particular birth hasn't happened yet, and that not, there's no two different births, two same births, and so how you want to do that birth? You're going to figure it out. You're going to do the right thing. Like Sarah said, You're the expert in your own body. But it hasn't happened yet, so you don't there's no precedent for what is the best and what's presented as evidence today may not be the evidence we're looking at tomorrow. So what they're telling you and are adamant about just take it with a grain of salt and look what else is out there.

Closing

Britta: I love that. Thank you to both of you. Sarah, Bente, I'm so grateful to have this time with you and thank you listeners for sharing this time with us. If something today that was shared impacted supported or moved you, please share this episode with a friend. I produce this podcast myself, and your support makes it possible to show a little love for the podcast and these conversations. Please follow rate and review. If you'd like to continue the conversation, please join us on Instagram at transformed by birth. I look forward to being with you again on the next episode of transformed by birth. Now, let's take a moment and gather what you want to take away from this conversation with an inhale, and as we exhale, I'll blow out our candle, until next time bye, friends.