WEBVTT 1 00:00:01.040 --> 00:00:08.920 This is parent data. I'm Emily ostro. Midwives are having 2 00:00:09.360 --> 00:00:13.039 a bit of a moment. Of course, that moment is 3 00:00:13.080 --> 00:00:14.160 not at all new. 4 00:00:14.520 --> 00:00:16.319 The midwife will turn it on and off for you. 5 00:00:16.760 --> 00:00:19.000 But rule number one is you start to breathe the 6 00:00:19.040 --> 00:00:21.759 gas before the contraction really gets its bruits on. 7 00:00:22.400 --> 00:00:26.360 For a very very long time, hundreds, possibly thousands of years, 8 00:00:26.760 --> 00:00:32.120 midwives or people who were effectively midwives were delivering all babies. 9 00:00:32.720 --> 00:00:35.440 In my mind, they wear little white caps and ride 10 00:00:35.479 --> 00:00:38.879 their bicycles to the hospital. But that is based entirely 11 00:00:38.920 --> 00:00:40.080 on call the midwife. 12 00:00:41.280 --> 00:00:49.040 You look worried. That's just my silent sympathetic class sweezie. 13 00:00:49.080 --> 00:00:52.919 Can you raise your bottom. 14 00:00:51.600 --> 00:00:52.520 As far as you can? 15 00:00:53.240 --> 00:00:56.200 I think a boat unless it has an obstetrician on 16 00:00:56.240 --> 00:00:57.480 hiptocks of no interest to me. 17 00:01:03.840 --> 00:01:09.400 Even when doctor became a more formal job, births were 18 00:01:09.520 --> 00:01:14.640 still nearly always attended by midwives at some point, though 19 00:01:14.760 --> 00:01:18.920 especially in the US, that changed. By nineteen eighty, midwives 20 00:01:18.959 --> 00:01:22.880 in the US attended only about one percent of births, 21 00:01:23.880 --> 00:01:27.559 but swinging back the other direction in the past forty years, 22 00:01:27.880 --> 00:01:29.240 that's changed a lot. 23 00:01:29.560 --> 00:01:30.760 By twenty twenty. 24 00:01:30.480 --> 00:01:33.440 One, about twelve percent of births in the US were 25 00:01:33.480 --> 00:01:35.039 attended by midwives. 26 00:01:36.040 --> 00:01:38.679 But this can still feel a bit mystifying. 27 00:01:39.959 --> 00:01:42.720 I had a birth, my second child, with a midwife, 28 00:01:42.720 --> 00:01:45.559 and people will sometimes ask, isn't that just for home 29 00:01:45.600 --> 00:01:48.120 births in a tub? Isn't it just for people who 30 00:01:48.120 --> 00:01:52.440 don't want epidurals? Isn't it only for people who care 31 00:01:52.480 --> 00:01:54.800 about the flavor of the scented candle in the hospital 32 00:01:54.880 --> 00:02:00.000 delivery room. The answer is no, no, no to all 33 00:02:00.160 --> 00:02:06.360 those questions. Most midwives deliver in hospitals, and many people 34 00:02:06.520 --> 00:02:09.160 who are attended by a midwife do have an epidural, 35 00:02:10.040 --> 00:02:13.600 and it's not actually allowed to have candles in the hospital, 36 00:02:13.720 --> 00:02:17.480 no matter who is attending your birth. With all of 37 00:02:17.480 --> 00:02:21.320 these questions, I got curious about the data on midwiffery, 38 00:02:21.680 --> 00:02:24.560 and so in parent Data I wrote a bit about 39 00:02:24.600 --> 00:02:27.480 what we know about the labor support offered by midwives 40 00:02:27.560 --> 00:02:30.880 and whether there are any benefits to having a midwife 41 00:02:31.080 --> 00:02:32.240 rather than having a doctor. 42 00:02:33.040 --> 00:02:38.400 And it turns out maybe there are. Actually The data suggests. 43 00:02:37.800 --> 00:02:42.000 That spontaneous vaginal birth birth without a vacuum or forceps 44 00:02:42.040 --> 00:02:45.520 increases in the care of a midwife, cesarean sections decrease, 45 00:02:45.680 --> 00:02:47.360 and soda episiotomies. 46 00:02:49.440 --> 00:02:51.680 When you look in the data, you can. 47 00:02:51.600 --> 00:02:55.520 See these kind of results in black and white, but 48 00:02:55.639 --> 00:02:59.480 you don't get a sense of why. So what is 49 00:02:59.520 --> 00:03:02.720 it about the differences between midwives and doctors that drive 50 00:03:02.800 --> 00:03:05.560 some of these results? How much is about the fact 51 00:03:05.639 --> 00:03:08.720 that a midwife tends to be at the hospital during 52 00:03:08.800 --> 00:03:11.239 delivery for a longer period of time. 53 00:03:11.720 --> 00:03:12.959 How much is about. 54 00:03:12.680 --> 00:03:16.480 The prenatal counseling and changes in how they approach to birth. 55 00:03:17.560 --> 00:03:19.480 And so I wanted to bring on a guest who 56 00:03:19.560 --> 00:03:23.040 could talk about some of these pieces of the data, 57 00:03:23.160 --> 00:03:26.000 but also about the lived experience of what it is 58 00:03:26.160 --> 00:03:28.000 to be a midwife and how that differs from what 59 00:03:28.040 --> 00:03:31.480 happens with an obi. So my guest today and Ledbetter, 60 00:03:31.720 --> 00:03:34.080 is a midwife, and she's put on her little white 61 00:03:34.080 --> 00:03:36.800 hat and bicycled in to dive into all of this 62 00:03:37.040 --> 00:03:40.400 and help us demystify the role of the midwife. We 63 00:03:40.480 --> 00:03:45.040 talk about differences and similarities between midwives and obe's and 64 00:03:45.120 --> 00:03:49.080 between midwives and dulas. We talk about epidurals, We talk 65 00:03:49.080 --> 00:03:51.840 about the difference between healthcare in the US and elsewhere. 66 00:03:52.400 --> 00:03:56.720 We talk about called midwife, and we take time. 67 00:03:56.520 --> 00:04:00.440 To talk about the holistic process of birth and how 68 00:04:00.480 --> 00:04:07.560 cool it is after the break. And led Better and 69 00:04:07.680 --> 00:04:09.480 led Better, thank you so much for joining me. 70 00:04:10.080 --> 00:04:11.760 Hi Emily, thanks for having me. 71 00:04:12.480 --> 00:04:15.040 So I'd love to start by just having you tell 72 00:04:15.080 --> 00:04:17.360 people who you are and what you do. 73 00:04:18.320 --> 00:04:22.160 Sure, So, my name is and Ledbetter. I'm a certified 74 00:04:22.200 --> 00:04:26.400 nurse midwife in Milwaukee, Wisconsin. I work at a federally 75 00:04:26.480 --> 00:04:29.599 qualified healthcare center, which is a kind of clinic that's 76 00:04:29.680 --> 00:04:32.240 designed to provide care to an underserved population. 77 00:04:33.480 --> 00:04:37.440 So the majority of my patients are on Medicaid insurance. 78 00:04:37.200 --> 00:04:41.279 And they tend to come from the Spanish speaking immigrant 79 00:04:41.279 --> 00:04:42.479 community of Milwaukee. 80 00:04:43.920 --> 00:04:46.680 So I love to talk a little bit about what 81 00:04:46.760 --> 00:04:51.080 you do as a midwife and just almost to start 82 00:04:51.120 --> 00:04:52.239 by level setting. 83 00:04:52.680 --> 00:04:54.760 But what is a midwife. 84 00:04:54.240 --> 00:04:57.880 And why is it different from an obstetrician? I think 85 00:04:57.920 --> 00:05:00.400 many of us have most of our contexts come from 86 00:05:00.440 --> 00:05:04.960 that television show called The Midwife. That's a great show Thereius, 87 00:05:05.120 --> 00:05:06.960 you wear that type of uniform, if you ride a 88 00:05:07.000 --> 00:05:10.640 bicycle anyway, say more, really seriously, it would be great 89 00:05:10.680 --> 00:05:13.160 to just hear a little bit more about about midwiffery 90 00:05:13.400 --> 00:05:14.159 in general from you. 91 00:05:14.920 --> 00:05:19.560 Okay, sure, Yeah, So my job as a midwife is 92 00:05:19.600 --> 00:05:24.200 split between two settings. One is the clinic. In the clinic, 93 00:05:24.279 --> 00:05:26.599 I'm mostly doing prenatal care. I would say about eighty 94 00:05:26.640 --> 00:05:28.960 percent of my patients are pregnant, but I'm also doing 95 00:05:29.000 --> 00:05:33.680 some sort of basic gin care, pap smears, contraceptive care 96 00:05:33.960 --> 00:05:40.039 procedures like implanons and explanons, and iud's that kind of thing. 97 00:05:42.000 --> 00:05:47.000 In the hospital, it's a different approach, but basically we 98 00:05:47.200 --> 00:05:50.040 are when I'm on call, it's a twelve hour shift, 99 00:05:50.120 --> 00:05:53.880 and I am, you know, providing care during birth to 100 00:05:53.920 --> 00:05:56.840 anyone who comes in. I'm attending that labor and that birth. 101 00:05:57.480 --> 00:06:03.440 I do postpartum rounds, ob triage my practice. 102 00:06:03.440 --> 00:06:04.719 We even do circumcisions. 103 00:06:05.520 --> 00:06:08.840 So in terms of what what you do in let's 104 00:06:08.839 --> 00:06:12.640 talk about the birth part specifically, how is what you 105 00:06:12.720 --> 00:06:15.600 do different from what an OBI would do if if 106 00:06:15.600 --> 00:06:16.120 it is. 107 00:06:16.520 --> 00:06:20.039 Yeah, well that's a that's a hard question because I 108 00:06:20.040 --> 00:06:21.200 don't want to stereotype. 109 00:06:21.200 --> 00:06:23.880 You know, I think there's a lot of overlap. I 110 00:06:23.920 --> 00:06:27.400 will say that, you know, as midwives were really trained 111 00:06:27.440 --> 00:06:32.320 to appreciate the physiological aspects of labor, So you know, 112 00:06:32.400 --> 00:06:34.760 I think that on average, right, you're going to see 113 00:06:34.760 --> 00:06:40.160 midwives doing more things like different positions for labor and birth. 114 00:06:40.680 --> 00:06:44.640 Midwives are big supporters of you know, hydrotherapy and alternative 115 00:06:44.920 --> 00:06:48.880 pain control methods during birth. I would say fewer of 116 00:06:48.920 --> 00:06:52.120 our patients choose to get an epidural. We're big supporters 117 00:06:52.160 --> 00:06:56.919 of vaginal birth after cesarean in general. Over over the years, 118 00:06:57.000 --> 00:06:59.839 I think that midwives have really been pushing the envelope 119 00:06:59.839 --> 00:07:02.919 and how hospital birth about, like what options are given 120 00:07:03.000 --> 00:07:06.159 to women, Like I think about you know, a coworker 121 00:07:06.160 --> 00:07:09.760 of mine who about like twenty years ago spearheaded this 122 00:07:09.800 --> 00:07:14.440 effort to change the unit policy so that all babies 123 00:07:14.440 --> 00:07:17.360 were sort of handed directly to their moms after birth 124 00:07:17.440 --> 00:07:20.760 rather than being separated. So like skin to skin and 125 00:07:20.760 --> 00:07:24.520 delayed cord clamping are really common in midw free care, 126 00:07:24.600 --> 00:07:27.440 and I think now they're even becoming more common in 127 00:07:27.640 --> 00:07:31.320 centric care because in part because midwives have really like 128 00:07:31.400 --> 00:07:32.840 pushed for policies like that. 129 00:07:33.680 --> 00:07:35.840 Yeah, you guys were out ahead on both of those things, 130 00:07:35.880 --> 00:07:40.760 which have quite good evidence behind them. So I want 131 00:07:40.800 --> 00:07:45.640 to talk about who, from an individual standpoint, how people 132 00:07:45.680 --> 00:07:50.960 would think about choosing a midwife versus an obstetrician for 133 00:07:51.040 --> 00:07:55.360 their individual birth, because this is a question that comes 134 00:07:55.440 --> 00:07:57.320 up from many people. You have to choose a provider. 135 00:07:57.360 --> 00:08:00.760 These are different kinds of providers. Sense is that for 136 00:08:00.840 --> 00:08:05.400 a lot of people, their perception is a midwife is 137 00:08:05.480 --> 00:08:08.880 appropriate if I want to have a baby at home, 138 00:08:09.480 --> 00:08:15.000 or if I'm committed to no pain medication. I let's 139 00:08:15.040 --> 00:08:19.400 just start with the question of are those stereotypes accurate? 140 00:08:19.880 --> 00:08:24.400 Well, I do feel that people who want to have 141 00:08:24.440 --> 00:08:28.120 an unmedicated birth are really great candidates for midwif free care, 142 00:08:28.240 --> 00:08:30.840 and I think they're likely to get the support that 143 00:08:30.880 --> 00:08:33.319 they want during their birth. But I do not think 144 00:08:33.320 --> 00:08:36.880 they're the only candidates for MIDWI free care. And I 145 00:08:36.920 --> 00:08:40.080 mean personally, you know, I work with a patient population 146 00:08:40.240 --> 00:08:44.000 that really isn't like seeking midwif free care per se, 147 00:08:44.880 --> 00:08:47.720 but they do great with us. Like I think most 148 00:08:47.720 --> 00:08:50.440 of my patients come to my clinic because it's, you know, 149 00:08:50.480 --> 00:08:53.600 a bilingual clinic that accepts Medicaid insurance, not because they're 150 00:08:53.640 --> 00:08:59.400 seeking some certain kind of birth experience. But you know, 151 00:08:59.480 --> 00:09:03.920 because mostly receiving care from midwives, they do have lower 152 00:09:04.000 --> 00:09:08.960 epidural rates. I think that there's a whole lot of 153 00:09:09.000 --> 00:09:12.840 women who probably fall into this category of somewhere in 154 00:09:12.920 --> 00:09:16.760 between someone who wants a lot of medical medical intervention 155 00:09:16.840 --> 00:09:19.400 and someone who wants none, and so you know, I 156 00:09:19.400 --> 00:09:22.640 think midwives were really great providers for those people as well. 157 00:09:23.240 --> 00:09:24.880 One of the things we talk a lot of people 158 00:09:24.960 --> 00:09:27.320 talk about is the idea of midwives as appropriate for 159 00:09:27.400 --> 00:09:28.880 low risk births. 160 00:09:29.240 --> 00:09:30.960 What does that mean? Is that true? 161 00:09:31.040 --> 00:09:31.280 Yeah? 162 00:09:31.320 --> 00:09:36.080 Good question, Good question, because I mean I really don't 163 00:09:36.120 --> 00:09:38.800 love the sort of high risk low risk ditotomy because 164 00:09:38.840 --> 00:09:42.760 in my experience, so few women fit neatly into one 165 00:09:42.840 --> 00:09:45.319 or the other. I mean, there's probably like a small 166 00:09:45.320 --> 00:09:48.040 percentage of women that just have zero risk factors whatsoever, 167 00:09:48.080 --> 00:09:50.560 they're very low risk. And then there's women who are 168 00:09:50.559 --> 00:09:53.480 obviously very high risk. But I would say most people 169 00:09:53.559 --> 00:09:56.439 fall into like what I would call a medium risk category. 170 00:09:56.960 --> 00:09:59.040 And you know, I take care of a lot. 171 00:09:58.960 --> 00:09:59.880 Of those patients. 172 00:10:00.679 --> 00:10:04.000 Like, for example, as a midwife, right, I take care 173 00:10:04.040 --> 00:10:07.559 of women of all different body sizes, all different ages. 174 00:10:07.720 --> 00:10:10.160 You know, I've had patients as young as thirteen and 175 00:10:10.200 --> 00:10:14.240 as old as forty seven. I take care of patients 176 00:10:14.240 --> 00:10:17.360 who have risk factors like you know, complications in a 177 00:10:17.400 --> 00:10:23.040 prior pregnancy. You know, people who have had a preterm birth, preclamsia, 178 00:10:23.080 --> 00:10:25.280 who had a c section for their last birth. That's 179 00:10:25.280 --> 00:10:28.960 a really common patient for me to care for. And 180 00:10:29.000 --> 00:10:31.960 then there's some people with you know, risk factors that 181 00:10:32.040 --> 00:10:35.760 develop during pregnancy where I have I can take care 182 00:10:35.760 --> 00:10:38.400 of them as long as I have access to a 183 00:10:38.440 --> 00:10:43.240 collaborating physician, So that would be things like gestational diabetes, 184 00:10:43.400 --> 00:10:45.240 especially if it's still diet controlled. 185 00:10:45.360 --> 00:10:46.880 I do take care of those moms. 186 00:10:47.760 --> 00:10:51.200 I've taken care of moms who have substance use disorder 187 00:10:51.320 --> 00:10:55.680 and are on suboxone because they're addicted to opiates. I've 188 00:10:55.720 --> 00:11:00.000 taken care of moms that you know, had mental health 189 00:11:00.080 --> 00:11:03.120 health disorders and just really needed a lot of extra 190 00:11:03.200 --> 00:11:07.120 TLC for that reason. So again I think, you know, 191 00:11:07.200 --> 00:11:10.720 midwives were great care providers for people that need a 192 00:11:10.760 --> 00:11:16.000 little extra time and TLC to like process a challenging 193 00:11:16.040 --> 00:11:18.880 birth that they had last time, or to deal with 194 00:11:18.920 --> 00:11:22.880 you know, stressers they're experiencing during pregnancy. You know, as midwives, 195 00:11:22.880 --> 00:11:25.520 we really it's like a big focus of ours to 196 00:11:26.240 --> 00:11:29.480 care for the individual as a whole. And so, you know, 197 00:11:29.559 --> 00:11:31.320 we tend to spend a lot of time with people 198 00:11:31.440 --> 00:11:33.960 both during prenatal care and birth. 199 00:11:34.400 --> 00:11:38.000 Can we talk about that time because one of the 200 00:11:38.040 --> 00:11:42.200 biggest complaints might be a little strong, but concerns that 201 00:11:43.080 --> 00:11:46.320 women expressed to me about their prenatal care and birth 202 00:11:46.360 --> 00:11:48.600 experience is a lack of time. You know, I was 203 00:11:48.640 --> 00:11:50.840 in the doctor's off I didn't get a chance to 204 00:11:50.840 --> 00:11:53.959 ask my questions. I forgot something, you know, the appointment 205 00:11:54.000 --> 00:11:57.120 was very short. This comes up all the time, and 206 00:11:57.720 --> 00:11:59.480 you talk now, and we've talked. You and I have 207 00:11:59.520 --> 00:12:03.400 talked in the asked about the the value of time 208 00:12:03.480 --> 00:12:05.719 and the fact that that in midwif frey care there 209 00:12:05.800 --> 00:12:07.200 is more of that time. 210 00:12:08.000 --> 00:12:11.840 Yeah, for sure, I think you know, it probably varies, 211 00:12:11.960 --> 00:12:14.959 you know, again based on physicians, and I don't want 212 00:12:14.960 --> 00:12:18.360 to stereotype or say that everyone practices a certain way, 213 00:12:18.559 --> 00:12:22.720 but I do know from talking to obstetrician colleagues that 214 00:12:23.000 --> 00:12:27.000 they're often seeing just you know, many patients in a day, 215 00:12:27.080 --> 00:12:31.040 let's say, like twenty five to thirty five. In contrast, 216 00:12:31.040 --> 00:12:33.280 you know, the midwives that I've talked to and myself, 217 00:12:33.320 --> 00:12:35.520 you know, it's more common for us to see maybe 218 00:12:35.600 --> 00:12:38.680 between fifteen and twenty patients a day, so there's just 219 00:12:38.760 --> 00:12:42.160 more time. I also think, you know, midwives tend to 220 00:12:42.200 --> 00:12:45.680 spend more time with patients in labor. I can't speak 221 00:12:45.720 --> 00:12:49.440 for every midwife, but myself and the midwives in my practice. 222 00:12:50.520 --> 00:12:55.439 We're in hospital for call, which means that we have 223 00:12:55.600 --> 00:12:58.560 time to sit with people in labor. I think that, 224 00:12:58.920 --> 00:13:00.920 you know, it's really important to me to be with 225 00:13:00.960 --> 00:13:04.200 anybody who is sort of laboring without an epidural, and 226 00:13:04.240 --> 00:13:07.280 then when someone's pushing, I am with them for the 227 00:13:07.400 --> 00:13:10.400 entire time, like whether it's thirty minutes or four hours, 228 00:13:10.440 --> 00:13:14.720 I usually am not leaving the room for that pushing phase. 229 00:13:14.800 --> 00:13:17.920 And that's a difference that I hear a lot of 230 00:13:17.920 --> 00:13:20.360 women talk about, you know, and I know this as 231 00:13:20.360 --> 00:13:21.520 well from being a labor. 232 00:13:21.280 --> 00:13:22.120 And delivery nurse. 233 00:13:22.360 --> 00:13:24.720 You know, the idea was to call in the doctor 234 00:13:25.160 --> 00:13:28.480 at the last minute to catch the baby, so that 235 00:13:29.640 --> 00:13:31.880 you know, you weren't kind of wasting their time. 236 00:13:34.000 --> 00:13:38.520 Why is it useful to have can you It's it's 237 00:13:38.559 --> 00:13:40.960 such an ambiguous question. Because we're gonna I think we 238 00:13:41.000 --> 00:13:42.400 can talk a little bit about the data, and we 239 00:13:42.400 --> 00:13:44.160 can talk about the data on birth DODCRAM. You've talked 240 00:13:44.200 --> 00:13:46.520 about the data on epidurals, and I think this is 241 00:13:46.559 --> 00:13:50.439 a place where the share of people who are having epidurals, 242 00:13:50.480 --> 00:13:53.680 even if you're pulling in a population who is not 243 00:13:54.400 --> 00:13:56.960 particularly coming and intending not to have an epidurol, you 244 00:13:57.000 --> 00:13:59.920 are going to have a lower epidol rate with midwifery 245 00:14:00.280 --> 00:14:02.720 than obstetrics. I think that shows up in the data. 246 00:14:03.320 --> 00:14:06.839 But do you have a sense of why, Like, what 247 00:14:07.559 --> 00:14:08.319 are you doing? 248 00:14:10.280 --> 00:14:11.679 Oh, that's such a good question. 249 00:14:12.000 --> 00:14:15.960 I mean, I'm just gonna say it, like labor support 250 00:14:16.000 --> 00:14:20.000 is key, Like birth is really freaking painful, and if 251 00:14:20.040 --> 00:14:22.600 you don't have supportive people in that room helping you 252 00:14:22.640 --> 00:14:28.320 through it, it's nearly impossible. I would say, you know, 253 00:14:29.040 --> 00:14:31.760 I'm not I'm not against epidurls. I think they can 254 00:14:31.800 --> 00:14:34.240 be a really useful intervention. I even have times that 255 00:14:34.280 --> 00:14:36.760 I recommend them to people, you know, people who've been 256 00:14:36.760 --> 00:14:39.040 in labor for days, people who are just at their 257 00:14:39.040 --> 00:14:42.000 wits end. I don't think it's a bad choice. I 258 00:14:42.040 --> 00:14:45.560 think there are very good reasons to get an epidol sometimes. 259 00:14:45.960 --> 00:14:48.360 But I also think that you know, women are just 260 00:14:48.440 --> 00:14:53.320 inherently capable of childbirth, and for women that don't want 261 00:14:53.360 --> 00:14:55.640 an epidurl, and there are really good reasons to not 262 00:14:55.680 --> 00:14:59.040 want an epidol, you know, it's my job to support them. 263 00:14:59.600 --> 00:15:02.160 And I think what unfortunately happens a lot in hospital 264 00:15:02.200 --> 00:15:05.440 birth is Number one. The staff are just not used 265 00:15:05.440 --> 00:15:09.400 to accompanying women who are giving birth without an epidurl, 266 00:15:09.520 --> 00:15:12.360 so they're not very skilled in helping them through that. 267 00:15:13.720 --> 00:15:18.560 And like number two, it's like, to be honest, it's 268 00:15:18.560 --> 00:15:21.000 a lot easier for the staff if a woman just 269 00:15:21.040 --> 00:15:24.760 gets an epidural because then she's sort of laying in bed, comfortable, 270 00:15:25.240 --> 00:15:28.960 not needing as much hands on care. So, I mean, 271 00:15:29.600 --> 00:15:33.080 I just kind of feel that if someone's in labor 272 00:15:33.120 --> 00:15:36.240 without an epidural, like her way of coping is her 273 00:15:36.320 --> 00:15:38.240 way of coping. Like, I don't care if she screams, 274 00:15:38.280 --> 00:15:40.800 if she cries, if she drops the string of f bombs, like, 275 00:15:40.840 --> 00:15:43.680 I'm okay with that. I just kind of view it 276 00:15:43.680 --> 00:15:45.360 as my job to help her get through that really 277 00:15:45.400 --> 00:15:48.840 difficult moment. And I do see a lot of value 278 00:15:49.000 --> 00:15:53.440 in getting through labor without an epidural. It tends to 279 00:15:53.480 --> 00:15:56.880 make the labor shorter. You know, you avoid certain risks 280 00:15:57.000 --> 00:16:00.680 like epidural headaches because they can puncture the Super Bowl's 281 00:16:00.720 --> 00:16:04.360 final column and have fluid leak out. Anyway, There's just 282 00:16:04.480 --> 00:16:07.720 there's reasons that epidurals also have some risks you know, 283 00:16:07.760 --> 00:16:10.560 there's also the bill for the epiderral. You know, some 284 00:16:10.600 --> 00:16:13.320 people have deductibles and you're gonna get, you know, a 285 00:16:13.360 --> 00:16:16.200 couple thousand dollars bill that maybe you could have avoided 286 00:16:16.280 --> 00:16:18.640 if you could avoid the epidurl, which I'm hoping isn't 287 00:16:18.640 --> 00:16:21.360 the reason people make that decision, but in American healthcare, 288 00:16:21.400 --> 00:16:22.440 it is possible. 289 00:16:22.760 --> 00:16:25.080 Unfortunately, it is, it is possible. 290 00:16:25.560 --> 00:16:28.640 We talked recently and I had I had sent you 291 00:16:28.640 --> 00:16:32.000 something I wrote in which I used. It was about midwives, 292 00:16:32.040 --> 00:16:34.520 and I use the phrase delivered. The midway can deliver 293 00:16:34.600 --> 00:16:36.680 your babies. I'm like, and you wrote back and you said, 294 00:16:36.680 --> 00:16:38.360 you know this, well, here's here are some comments on 295 00:16:38.360 --> 00:16:39.880 this piece. And one thing is I you know, we 296 00:16:39.880 --> 00:16:44.360 don't say delivered. We say attending birth. The midwife attends 297 00:16:44.360 --> 00:16:46.640 the birth. And I thought that was such an interesting 298 00:16:48.400 --> 00:16:55.400 linguistic turn and and like but but underlying such a 299 00:16:55.440 --> 00:16:57.760 different attitude to like, what is your job? 300 00:16:58.560 --> 00:17:01.120 Yeah, yeah, that's a really good point. 301 00:17:01.200 --> 00:17:03.280 I you know, I think I'm not gonna say I 302 00:17:03.360 --> 00:17:06.720 never accidentally slip up and use the word delivered. But 303 00:17:07.080 --> 00:17:09.400 you know, as midwives, we really do prefer to say 304 00:17:09.480 --> 00:17:10.280 attended birth. 305 00:17:10.400 --> 00:17:12.120 In fact, I submitted. 306 00:17:11.680 --> 00:17:14.760 An article to a journal and they responded it was 307 00:17:14.800 --> 00:17:16.800 a Midwiffree journal, and they were like, go back, and 308 00:17:16.880 --> 00:17:20.080 every time you said delivery, change it to birth. So 309 00:17:20.119 --> 00:17:23.000 it's not just me. I mean it is parlance right 310 00:17:23.040 --> 00:17:25.080 in midwif Free speak that we don't like to use 311 00:17:25.119 --> 00:17:27.720 the word delivered because I think it gives a little 312 00:17:27.720 --> 00:17:30.159 too much credit to the provider and not enough to 313 00:17:30.200 --> 00:17:34.040 the mom. Because you know, this baby's here, because this 314 00:17:34.160 --> 00:17:36.280 mom did a ton of work, right, like just staying 315 00:17:36.320 --> 00:17:37.680 a baby, pushing on a baby. 316 00:17:38.080 --> 00:17:38.840 It's no joke. 317 00:17:38.960 --> 00:17:40.359 And so for me to just show up at the 318 00:17:40.400 --> 00:17:45.840 last minute and say I deliver it to you your baby. 319 00:17:44.760 --> 00:17:45.400 It's Amazon. 320 00:17:45.440 --> 00:17:48.399 It's like Amazon, you know, it's like same day, right. 321 00:17:50.200 --> 00:17:50.440 Yeah. 322 00:17:50.440 --> 00:17:53.200 I just feel like it kind of devalues everything she did, 323 00:17:53.480 --> 00:17:57.320 which is most of the work. Like I think of 324 00:17:57.359 --> 00:18:00.600 myself sometimes like almost like the cox of a boat, 325 00:18:00.760 --> 00:18:02.720 you know, like as a midwife. 326 00:18:02.760 --> 00:18:04.960 Like I'm not the one rowing the boat. I can't 327 00:18:04.960 --> 00:18:05.680 make the boat go. 328 00:18:05.720 --> 00:18:09.000 Faster, but I do have like a pretty clear view 329 00:18:09.040 --> 00:18:11.520 of the finish line and a pretty good view of 330 00:18:11.560 --> 00:18:13.399 the conditions. You know, I can tell if the waves 331 00:18:13.400 --> 00:18:17.400 are getting choppy. So I think it's like it's definitely teamwork. 332 00:18:17.400 --> 00:18:19.000 I'm not going to say that I don't have an 333 00:18:19.000 --> 00:18:23.040 important role, but I would not give myself the credit 334 00:18:23.119 --> 00:18:25.480 by saying, like, oh, I delivered this baby. That's why 335 00:18:25.760 --> 00:18:29.960 you'll hear a lot of midwives like we'll talk colloquially, 336 00:18:30.040 --> 00:18:32.359 kind of like I caught babies, Like how many babies 337 00:18:32.359 --> 00:18:33.359 did you catch this weekend? 338 00:18:33.400 --> 00:18:34.720 That's kind of how we talk to each other. 339 00:18:35.480 --> 00:18:38.240 Yeah, when you're speaking about it officially, we'd like to 340 00:18:38.280 --> 00:18:42.399 say I attended a berth, not I delivered a baby. 341 00:18:43.320 --> 00:18:48.400 Okay, So I want to talk about data because there 342 00:18:49.160 --> 00:18:54.040 is some data on the impact of midwif free care 343 00:18:54.200 --> 00:18:59.080 on birth outcomes, and I think you and I differ 344 00:18:59.200 --> 00:19:02.920 a little bit and how in what kinds of data 345 00:19:02.920 --> 00:19:05.199 we would want to rely on there, And so I 346 00:19:05.280 --> 00:19:06.639 want to set the stage a little bit and then 347 00:19:06.640 --> 00:19:08.920 we can, like, then we can sort of talk about 348 00:19:08.960 --> 00:19:12.119 where we where we agree, and where we disagree. 349 00:19:12.200 --> 00:19:14.760 So sure, one thing one. 350 00:19:14.720 --> 00:19:18.720 Might imagine doing is comparing women who have midwife to 351 00:19:18.960 --> 00:19:22.639 women who have an obstetrician. And that, like, as a 352 00:19:22.920 --> 00:19:26.639 general approach, if you don't do any other adjustments, doesn't 353 00:19:26.640 --> 00:19:29.840 really work because the kind of women who are selecting 354 00:19:29.840 --> 00:19:31.360 into MIDWIF free care are. 355 00:19:31.160 --> 00:19:32.640 Going to be different on average. 356 00:19:33.119 --> 00:19:36.639 True, there is then a version of studies like that 357 00:19:36.640 --> 00:19:40.280 that tries to hold more things constant across women, so 358 00:19:40.320 --> 00:19:42.679 it tries to compare more comparable women with different. 359 00:19:42.480 --> 00:19:43.760 Kinds of care. 360 00:19:44.040 --> 00:19:46.199 And then there are randomized trials in which people are 361 00:19:46.240 --> 00:19:49.919 randomized into MIDWA free care not And I am always 362 00:19:50.160 --> 00:19:53.600 going to be of the I am generally of the position, 363 00:19:53.680 --> 00:19:55.920 let's say always maybe a little stronger, I'm generally of 364 00:19:55.960 --> 00:19:58.919 the position that I want to rely on the randomized trials. 365 00:19:59.040 --> 00:20:01.760 When you look at the randomize trials, there definitely are 366 00:20:01.880 --> 00:20:05.840 some benefits to MIDWIF free care. 367 00:20:06.400 --> 00:20:08.240 They are real, but in. 368 00:20:08.480 --> 00:20:12.160 Magnitude relatively small, So something like a reduction in cesarean 369 00:20:12.200 --> 00:20:15.480 section but like one or two percent, you know, an 370 00:20:15.520 --> 00:20:18.879 increase in the chance of a spontaneous vaginal birth, so 371 00:20:19.000 --> 00:20:21.520 vaginal birth without four steps or epidural but maybe a 372 00:20:21.560 --> 00:20:22.880 five percent increase. 373 00:20:22.560 --> 00:20:24.320 So real numbers. 374 00:20:24.359 --> 00:20:27.960 And certainly there's nothing that would suggest that MIDWIF free 375 00:20:27.960 --> 00:20:30.320 care was less good. But if you asked, you know, 376 00:20:30.640 --> 00:20:32.520 is this a little bit better? 377 00:20:32.600 --> 00:20:33.200 A lot better? 378 00:20:33.440 --> 00:20:37.960 The numbers are relatively are relatively small, and I think 379 00:20:39.280 --> 00:20:42.120 you're well, I don't want to put words in your mouth, 380 00:20:42.280 --> 00:20:46.399 but I think that you're more optimistic about some of 381 00:20:46.440 --> 00:20:50.639 the positive impacts based on some of the non randomized data. 382 00:20:50.680 --> 00:20:53.200 So I'd love to just dig into that a little bit. 383 00:20:53.080 --> 00:20:55.960 And tell have you tell me how you read how 384 00:20:55.960 --> 00:20:57.800 you read the evidence on these outcomes. 385 00:20:58.480 --> 00:21:01.240 Yeah, I mean, I'm not a to like the idea 386 00:21:01.240 --> 00:21:01.919 of an RCT. 387 00:21:02.359 --> 00:21:04.359 In fact, I think it's kind of crazy that that's 388 00:21:04.400 --> 00:21:06.160 not been done in the United States. Like, I mean, 389 00:21:06.480 --> 00:21:08.720 that would be a fascinating result to see, you know, 390 00:21:08.800 --> 00:21:11.200 in the US. You know, when if we randomize women 391 00:21:11.280 --> 00:21:13.359 to either op centric or midw free care, like what 392 00:21:13.480 --> 00:21:15.399 kind of outcomes are we going to get? But I 393 00:21:15.440 --> 00:21:17.760 really wouldn't hang my hat on that result because I 394 00:21:17.800 --> 00:21:22.120 think people just behave differently when they're being watched and 395 00:21:22.400 --> 00:21:23.320 like in an RCT. 396 00:21:23.680 --> 00:21:26.119 Yeah, tell me more about what you mean by that. 397 00:21:26.720 --> 00:21:29.680 Well, I mean it's like, you know, supposing we have 398 00:21:29.760 --> 00:21:34.080 this hypothetical RCT where people are either being cared for 399 00:21:34.160 --> 00:21:37.560 by obsentricians or midwives, Like those care providers are both 400 00:21:37.600 --> 00:21:39.199 going to be working really hard. I mean, they know 401 00:21:39.240 --> 00:21:41.040