In Search of a Midwife

I am 37 years old. I am an American certified nurse midwife. I am living in Ghana. I have lived in Africa for the past 8 years. I am married to an African. I am teaching nursing and midwifery. I am pregnant with my second child. I am looking for a midwife.

This summer I managed to squeeze a few video clips of beautiful home births into my class of high risk labor and birth. Even though my students had all been practicing midwives for 3 to 6 years, based on my experience in the labor ward, I doubted whether they really “knew” normal birth. When the video started, featuring a half naked laboring woman swaying and moaning in her husband’s arms, the drowsy eyes opened wide, slumped postures became erect, and lots of excited whispering filled the room. There were smiles and cheers when the baby delivered, and laughter and sighs when the new father held his daughter skin to skin against his bare chest. When the video finished, I asked the class, “So what did you think?” There was some quiet giggling and more whispering and then my best student in the front row said enthusiastically, “That was the most romantic birth ever!” The entire class erupted in joyful laughter. When I asked whether they would like to deliver like that there were only nods and smiles.

I know many midwives in the West who encourage women to birth like indigenous women everywhere – meaning fearlessly, trustingly, in response to the needs of their bodies. These midwives are trying to tell their clients that birth has been happening since the beginning of time. Birth happens every day, every minute all over the world, and no matter how removed your daily life and mind are from the natural world, your body has its own wisdom. They are saying, “I am here to support you but your body knows what to do. Listen and let go.” Many women respond to this and feel reassured. It is always good to know that you are not alone that many others have gone before you. But, the irony is that even indigenous women are forgetting how to birth like indigenous women.

Another day in my class when discussing why women labor in their villages far from the hospital, far from emergency care, I asked my 45 students, most of whom were mothers, how many of them felt they were well cared for during their birth experience. One student in the front row raised her hand and said, “But of course we were, we are midwives and have more control over our birth experiences.” She hadn’t looked around to see that her hand was one of two hands raised in the entire classroom before she spoke. When I drew her attention to that fact, she was surprised. I was also surprised. If midwives, delivered by their co-workers – people they are with every day, working, and laughing – still report that they were not well cared for during labor and birth, what about women who are uneducated? What about women who have no advocates in the labor ward? What about women who are just impoverished pregnant women in need of a place to deliver safely?

In the US labor rooms recently immigrated Latina and African women are typically quiet and stoic. They don’t scream or struggle against the process; they submit. Clinical staff often make comments about these women being “strong” and “easy to care for,” “they are not ‘spoiled’ like middle class American women.” The times when I asked these women about their birth experiences in their native countries, I heard stories about nurses and doctors who yell at them and who occasionally hit them. They almost always told me that they were warned by female relatives to be silent, obey, and endure. From their stories I realized that these women are not responding and listening to their bodies, they are rather responding to fear. Even though the behavior may be similar, there is a significant difference between being well-prepared and open to the process, and being more fearful of your care-givers than the pain.

I have seen many of these births in Latin America and Africa. In these environments the midwife seems to prioritize order – all women quietly lying on their sides laboring in one room – over all else. There is a formula for birth. Averting danger and chaos means close adherence to this formula and any deviation causes the volume of voices to rise and rebukes to shower on the head of the offending woman. Some parts of this formula are indeed important but the problem is that it is a formula and is applied indiscriminately; there is no room for variations of normal. The objective is a live baby and live mama (period). All women should labor on their sides quietly, then all women should move to the delivery bed when they are completely dilated, then all women should hold their knees and push. Episiotomies will be given for first time moms, for any delay, and to prevent tears. Vaginas are well sutured and manual evacuation of the uterus is done for just about any bleeding after the placenta. I have never met a midwife who was an unkind person, who could not speak passionately about the suffering of women. Most midwives I know are mothers. At the same time, I know only a few midwives in these settings who respond to the suffering of an individual woman with true compassion; who are truly able to see the woman and respond to her in her unique situation. Labor wards in the US have many of their own problems and although staff do not yell at patients, quiet women who lie on their sides and deliver on their backs are generally preferred.

It is now my turn to find a midwife again. I am seven months pregnant with my second child. My son who is now 2 was born at home in Ghana. Two dear friends traveled all the way from the US to be with us during the labor and delivery. Apart from early childhood, I cannot think of a time when I felt more supported and surrounded by love. My husband, my two midwife friends, and two additional dear friends were present. Each time I reached out my hand, it met another strong hand to hold. When I was thirsty, water was brought to my lips. When I was fearful, soft firm reassurance was offered. My son came quickly and smoothly. During the labor I walked around, I got in the shower, I lay on my side, and finally I delivered him on my knees with my arms around my husband’s neck. It was an amazing experience; an incredible blessing. It is also a lot to expect someone to come halfway around the world to catch your baby. This time I thought I would try to find a Ghanaian midwife to be with me during the labor and birth.

I asked the obstetrician who was “on call” for me last time and has agreed to be on call again this time about a midwife. My question brought a quizzical expression to his face. Even though he supports home birth of low risk women he said he didn’t know any midwife who was comfortable with out of hospital births unless he himself was also present. He was kind. I’m sure he immediately noted my surprised expression and said he knew that was not what I wanted. He promised to ask around.

I called one of my students. She was excited to see my big belly and promised to get me a very good midwife. She immediately suggested someone who had recently retired, “a very good midwife” she said again, meaning experienced and kind. When I met this midwife I explained that I was looking for a midwife who would be comfortable delivering me at home in the presence of my husband and friends, that I would like to walk around and probably would not deliver on my back. The light in her eyes dimmed. She said in her 30+ years as a midwife she had never seen a birth except in the lithotomy position. I asked about traditional birth attendants, she said even they deliver women in the lithotomy position. She said she would be willing to learn if I could teach her but then she also started mentioning other obligations and saying things like, “God willing, I will be free.” I knew she was uncomfortable.

A few days later my husband Clement, who was at that time doing his obstetrics and gynecology rotation, shared a taxi with a senior midwife from the hospital. They began talking and he explained that I was looking for a midwife to deliver me at home. He told me later that he had hoped she would spontaneously mention someone or make a suggestion. Instead he was met with silence.

I asked a friend who heads the family practice residency program if she had any ideas, knowing she had plenty of contacts. Her suggestion was for me to deliver at a private clinic and “explain my wishes.” I would not want a midwife in my home wearing a nervous expression trying, however gently, to get me to lie down or turn on my back. I know labor is difficult and I know I can have a good delivery; I just need someone who will monitor me and my baby and support us through the process. I do not need someone trying to control the process (as long as it is normal). From my search I have realized how rare it is to find someone like this. In my home I could ask my husband to intervene if the midwife became too much of a distraction or domineering force. Or, I could move to another room, but no matter what I explain in the private clinic ahead of time, once I enter the door as a laboring woman I abdicate all my power. I am not ready to do this.

I wrestled with myself for a while. Am I the spoiled American demanding too much when other women are just fine with less? If so many other women submit to the process and just get on with it, why can’t I do the same? Then I realized that other women are not fine with less. Many women do not have a choice and many choose to take on the risk rather than submit. No matter how frequently they attend antenatal clinics and how much we strive to "put the fear of God" in them, almost half still choose to birth at home without a skilled attendant. I understand them. I am educated. I teach midwives. I have witnessed horrible births. I have seen women die from complications of labor and deliver. I know the risks. I would rather deliver completely unattended in my home than go to the hospital.

What happened to knowledge from witnessing and supporting natural birth? In our effort to eliminate risk have we also eliminated the wisdom guarded by midwives for generations, throwing the proverbial baby out with the bathwater? Have we forced the keepers of this knowledge so deep underground that few women now benefit from it? I am not a big woman, many people call me small, but my son was 4200gm (9lbs 2oz) and he came out in three pushes with only a superficial tear. I want to be clear, I am in no way arguing that all babies can be born vaginally or that all women can have easy births. There is ABSOLUTELY a place for emergency obstetric care and it should be readily available to ALL laboring women. I am personally very grateful to the obstetrician who will be on call for my home birth. Ensuring that all women have access to emergency obstetric care is a worthy goal that we should pursue until we achieve it, but in the process we should not eliminate the place for normal birth. After my son was born I was repeatedly told by physicians that they would never have allowed me to labor, that they would have sectioned me based on the estimated fetal weight. All I could think was, “Why?” And, “Thank God I’m a midwife who would never agree to that.”

My labor never deviated from normal. My son never experienced a moment of distress. I knew the midwives were monitoring us well so I never worried, I was confident that they would act if necessary. Why tell women you can’t do it or limit their attempt to do it by forcing them into a certain position? I feel confident and strong about birth in general but when I imagine myself without my husband, lying on my back, I feel fearful and unsure. I am not sure that I could deliver vaginally. Why do we as midwives, nurses, and doctors fear women who move, who are vocal, who deviate from the formula? I believe it is because we are quickly forgetting how to respond to them. We are forgetting how to support them. We must re-establish the space for normal birth. We must relearn normal labor and birth. If our international intentions to improve maternal and child health are genuine, our efforts must not stop at reducing mortality, we must also improve care. And by this I mean “care” in its full sense, not only access to emergency medications, and procedures, but the compassionate individualized responsive treatment of women and children.

I put out another plea to my midwife friends back home. One of the friends who came for my son’s birth will come again to meet my daughter.