Ticking the "Home" box

A former client recently emailed me, asking me to write a post about home birth. Was she searching for information for the ongoing debate with her husband? Even though it is the woman who must ultimately make the decision about her birth setting, it is imperative that her partner is included in the process of informed choice, and comes to understand and support her decision, without fear.

Since I'm known as the research-oriented and pragmatic doula, I'd better throw in some evidence. So, here are a few things I want you to consider:

1. When you are presented with two equally effective treatments, then "best practice" requires that you take into account the patients' preferences (that means HER).

2. The Province of British Columbia Ministry of Health fully funds care by registered midwives, both at home or hospital.

3. A 1986 World Health Organisation report concluded that “home is the most appropriate birth setting for most childbearing women. Women (and their attendants) choosing this option must be provided with necessary diagnostic, consultative, emergency and other services as required, regardless of place of birth.” See College of Midwives of British Columbia.

4. In 2002, the "Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia" was published in the Canadian Medical Association Journal. The results showed that "women who gave birth at home attended by a midwife had fewer procedures during labour compared with women who gave birth in hospital attended by a physician." "Comparison of home births with hospital births attended by a midwife showed very similar and equally significant differences." The final interpretation of the study was that "there was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife."

5. In September 2007, the UK National Institute for Health and Clinical Excellence issued clinical guidelines (The NICE Intrapartum Care Guidelines) on intrapartum care of healthy women and their babies during childbirth. Under ‘‘key priorities’’ it stated: ‘‘Women should be offered the choice of planning birth at home.’’ Information suggests that for ‘‘women who plan to give birth at home or in a midwife-led unit there is a higher likelihood of a normal birth, with less intervention’’.

After attending almost 800 births in my 21 years as a doula, I can now say that I'm most comfortable (and I feel most safe, actually) at a home birth, with a client who has come to this decision freely, who is autonomous, who is radiantly healthy, whose midwives (there are always two present) are trusted and respected by all of us, and who has a partner who fully supports her decision without fear. But that's me...now.

I can't squish a woman into that mold. I would never want or expect everyone to be "that woman". A woman must go on her own unique and challenging journey to trust birth that much. I trust each woman to make the decision regarding the best place FOR HER to give birth, and with whom to give birth. I support each woman without reservation, no matter what her choice. In order to give birth at home, a woman has to gradually grow into the person who can make that decision. I know I didn't reached the point where I would have chosen home birth until I was 31, after giving birth to two children, and after attending over 100 births (many at home). Until then, I simply didn't have enough information to make an informed choice about home birth myself, even though I HAD made the amazing, and life-changing, leap to midwifery care for my second birth!

So, to the couples who are spending evenings debating home birth (she wants it...he's not sure...grandma says "over my dead body"), please do your homework. The research is clear. The more difficult task is to deal with the images swirling in your heads - images born of myth, misinformation, and fear, fueled by society's expectations and the media's lopsided representation of birth. You need to talk to people (call me - my clients would love to share!) about their personal experiences of home birth, watch movies which include home births (like The Business of Being Born or Le Premier Cri), and understand that choosing home birth doesn't lock you into that option. It just means that you can now include another option in your choice of birth places - you can now tick the "home" box.

When asked where she was planning to have her baby, one family doctor with four children would always say, "Wherever it wants to come out!" (In the end, she had #1, #3 and #4 at home, and #2 at the hospital) Because...on the big day, if you've given the body and the baby both options (hospital AND home), their final choice is always loud and clear!

Now, if I could only let you into my head to see the images of the home births that I've attended...but that's for the next post...

- Jacquie Munro, Vancouver Doula

Baby at the Breast

Sorry...shamelessly proud mum here. My daughter Sarah painted this Warhol-esque breastfeeding baby (acrylic on canvas) as part of her final Breastfeeding Counselor project. Love it!

Now that we're on the topic of breastfeeding... A lot of women mistakenly believe that they will automatically receive incredible breastfeeding support at the hospital and during the initial weeks at home with the baby. Sadly, this is just a myth. Read about the resignations of local lactation consultant extraordinaire Renee Hefti, and then sign up for the breastfeeding courses that she offers in the community (604-733-6359).

Shameless promotion here - but it's truly necessary!

- Jacquie Munro, Vancouver Doula

Do you need a doula? (or...I am your Sherpa)

I was debriefing with a second-time client yesterday. She wanted to tell me how important it was that I was by her side at her second birth. “This time, lots of people said I didn’t need a doula - that you’re not a midwife...that the doctors and nurses would be there to help me. But I knew that you’d be there just for me - and I trust you. I knew you were there in my corner - always.”

Her husband thanked me for being there again - for helping to create such a positive experience. He put it all down to what he calls “the Jacquie magic”...the fact that everyone in the hospital treated them differently because they were with me.

It’s sad, but true. The hospital staff do treat patients differently depending on their caregivers. They’re human - they have their favourite doctors, nurses, and doulas. I really would love a world where everyone walking through hospital doors was treated equally. But, right now, it doesn’t happen...so if I can do anything to make my clients feel more autonomous, more respected...then I will. Petty “wars” can be waged between overworked and under-respected staff, and I do everything in my power to prevent my clients from being a witness to negative behaviour. Preventative magic helps.

It all starts prenatally. We cover every possible scenario in our talks over the phone, in person, via email. We discuss the woman’s hopes and fears, interspersed with stories of her life. We talk about how the couple works together, what their strengths and weaknesses are, how they face challenges separately and as a couple...even how they’d react if they were bumped from an important overseas flight. We discuss family dynamics, setting boundaries, postpartum planning. The prenatal preparation isn’t about following a prescribed path - its about finding how each woman’s life experience has uniquely prepared her for this particular birth. Whether she needs to do soprano vocal exercises in labour, or relive that amazing underwater night dive in Fiji, conquer the West Coast Trail’s ladders once again, or run the Paris marathon with each breath during labour - we will uncover her own history that will carry her through to birth. My job is to protect her from outside disturbance without her ever noticing (it’s kind of like trying to be the best server possible).

Luckily, since most clients are referred to me by their caregiver (and others), I know that there is a web of security and trust between us all. I may have known a woman’s midwife for 15 years (from the wonderful “community midwife” days)...or have been the family doctor’s own doula...or have known the doctor-on-call with the extremely dry wit (who my client has never even heard of) for 20 years. I know their style, their particular sense of humour, how they react when they’re tired, how they react when they’re sad, and most especially, how we can all work in concert to provide the very best care for my client. We often know each other well enough that very few words need to be spoken. This helps the woman to stay in her birth trance, without interference or complication.

At home in labour, after the client has spoken to the caregiver, I can offer additional information. The other night, in between contractions, I only had time to say...”Hi! Second baby, just vomited, some bloody show, some pressure, we’re coming in. Oh, and she’s GBS positive but doesn’t want antibiotics.” “Fine,” said the doctor, because he knew he could trust me that this baby was coming fast. I called the hospital and spoke with the assessment room nurse, who said - “Hi, Jacquie. We’re short four nurses because they called in “sick” on the long weekend, so no Cedar (the fancy rooms with windows) tonight. But we have a room for her.” When we reached the hospital, the nurse and I exchanged glances as soon as we walked through the door. “Hey Jac...pushy?” The couple didn’t really have to say anything - they could stay in “the zone”. We went straight into a birthing room - no stopping in the assessment room. She stayed standing by the bed. No “please lie down, put this gown on, etc. etc.” Her wishes were honoured without debate (the nurse and I had had the GBS-decision discussion a few weeks ago, so there was no need to belabour the fact on this night).

At the hospital, I know NEVER to show up at the end of a shift, when tempers are frayed - you will either be left to wait for the next shift, or be caught in the vortex of emotions borne out of 12 hard hours. If the vibe is weird in the assessment room (like it was a couple of weeks ago), I know the nurses well enough to whisper, “What’s up?”, and be trusted enough to be told the truth - that everyone’s on edge because an obstetrician wrote an incident report after a woman was sent to Cedar without allegedly fulfilling the criteria (long story). A war is brewing. We negotiate, and figure out a way (enlist the dad’s aid) to have my client go upstairs to Cedar without it causing a problem for the nurses in assessment (diplomacy in action). We’ve been through enough that we’ve built up a trusting relationship, and are able to work together collaboratively, seamlessly, so that my client doesn’t even suspect that we averted a petty war on the hospital floor.

I’ve worked with clients giving birth at home and in the hospital for over twenty years. I’ve quietly built bridges with midwives, physicians, and hospital staff. I’ve worked to earn the trust of each nurse and each unit clerk (these women have their finger on the pulse of the place). The amazing thing is, each new client reaps the rewards of the cumulative history of all these births, and all of the experience gained from those who have gone before her.

I’ve learned to chatter less and listen more, to teach by example, to foster trust in each woman and her baby, to soak up every lesson, to read voraciously, and to constantly tend the bridge of trust and diplomacy with all caregivers. Because I am autonomous, and not affiliated with any group or hospital (no affiliation = no baggage), I can focus on each individual client’s needs and wishes without prejudice.

I’d love there to be a day when I could trust that each and every woman in labour could be autonomous and free to give birth undisturbed, that her history would be one of complete trust in the body, that no doulas would be needed. But, that’s not possible in today’s society, within the current health care system. Each woman still has her labour, her own history, AND the system to negotiate.

Each woman in labour still needs a navigator (one midwife recently said that I have to add "Even with a midwife!"), or as I laughingly say at times, “Just think of me as your Sherpa,” as I carry the bags up the stairs. Each woman climbs her own mountain, while I quietly deal with the bureaucracy, the logistics, climbing up the stairs behind her, all the while chanting like Barack Obama...”yes you can, yes you can...”

- Jacquie Munro, Vancouver Doula

Change

Change. Is it always good?

In the next month or so, obstetricians at BC Women's will be changing their provision of care at the hospital. Rather than having three call-groups providing an in-hospital rotating OB consulting service (24 hour call, with each physician or midwife being able to choose one of the three available OBs, if a consultation is warranted, depending on the case at hand), there will be two obstetricians on hand (one primary and one secondary) at all times, each working 12-hour shifts, drawn from the combined pool of 20+ obstetricians that used to make up the three smaller OB groups at BC Women's Hospital.

When I heard about the change, I asked if caregivers would have a choice of obstetrician if they required a consult during labour. "No," said the head nurse, with a quizzical look. So, you'll just get who is available, not who might be the best "fit" (clinically and emotionally) for the client on that day. Even if an OB has been consulted during the pregnancy, if a family practitioner or midwife needs OB assistance in labour, they will be not be able to choose between the 2 OB's in hospital, but will only be able to consult the one who is designated for consultations. And remember, there will be one less OB in the hospital at any time. Hmmm...

I know that other hospitals have been using this one-OB-fits-all approach for years (e.g. St. Pauls - but they have a small pool of OBs, and a low-tech high-touch philosophy that seems to work well from the patient's perspective, and their nurses are given quite a lot of autonomy). At first glance, this change at BC Women's might appear to signal a departure from patient-centred care. But, apparently, improving patient safety was the primary motivating factor. So, it may be a good thing in the long run - the 12-hour shifts might result in more energetic OBs providing more focused patient care. But, the shorter work day (and the inability to chose the OB) could result a loss in continuity of care for the labouring woman. Could the positive working relationship between a family physician and a small OB call group be lost in this reorganization, causing further internal conflict? Who knows.

Will notice of this change be given to each woman prior to her decision regarding her primary caregiver for pregnancy, so she can make an informed decision about prenatal care? Now, this is a tricky question. Pre-conception information regarding "the caregiver decision" is already lacking in B.C., with many women making their decisions based on non-B.C. books or the internet. For example, many newly pregnant women don't know that B.C. midwives are covered by BC Medical (practicing in both home and hospital), or that the BC Women's "Birth Docs" are there for women whose family doctors don't provide obstetric care, or that, in B.C. (unlike the U.S.), obstetricians are not intended to be the primary caregivers of "low risk" women, but are consulted after a referral by a family doctor or midwife, if the pregnancy becomes "high risk".

As a doula, part of my role is to inform clients about their choices, their rights and responsibilities, and to help them to retain their autonomy. I'm also there to quietly remind them that birth is a normal life process. I do my best to provide my client with comprehensive information in a balanced and thoughtful manner, working in concert with their caregivers (many of whom I've known for 20 years). I certainly don't have all the answers to the questions that I've posed in this post, but a general wariness of change (I'm a Taurus, through and through) made me sit down to write this. Despite my feeling of unease, I'm going to have to sit on the fence with this one, and wait to see how it all works out.

To the obstetricians, it might look good on paper. But we'll just have to see how it works in reality....for the labouring women.

(Update June 11/08: The new system has been in effect for a while, and, while the obstetricians are well-rested and seem to have a new lease on life, I have witnessed some dangerous gaps in continuity of care when an OB is the primary caregiver of my client.)

(Update March 2009: Obstetricians are still voicing their concern about the 12-hour shift. Yes, they are well-rested and able to perform better in the OR, but some women have fallen through the cracks due to a lack of continuity of care. Some women may have three of four different OBs looking after them in labour, each with a different approach. No solution so far...)

Renee takes it to the community!

Renee Hefti-Graham, lactation consultant extraordinaire, offers wonderfully information Breastfeeding Classes and Consulting in Vancouver.

I encourage all my pregnant clients to book a private or group breastfeeding class with Renee. She also offers an additional in-home breastfeeding consultation and phone follow-up service, if needed. Renee's comprehensive service provides incredible continuity of care, a vital ingredient in breastfeeding success.

Please call Renee at 604.733.6359. - Jacquie Munro, Vancouver Doula

("Maternite" by Paul Gauguin)

Meet Carly

As a doula, I am invited into the homes of so many wonderful and creative people. This past year's client list has included an amazing collection of writers, artists, counsellors, dancers, environmental crusaders, yoga instructors, entrepreneurs (and lots of lawyers.)

I love watching my clients' postpartum transformations, as they find ways to reconcile mothering with their "pre-baby" careers. Many former clients become consultants or start new businesses, and others strike out in entirely new directions. I support and applaud their efforts to find balance in their lives.

One such former client is Carly Fleming. She has recently branched out on a career path that I believe will fill a gap in perinatal services in Vancouver. I encourage you to call her if you feel in need of expert counselling assistance during the childbearing year - and beyond.

Carly provides pre-conception, prenatal, and postpartum counselling to women and men who need some additional support as they travel through their childbearing journey. Her services are aimed at individuals who are having difficulties coping or adjusting to pregnancy and parenthood or who are experiencing emotions that are preventing them from moving forward in a productive and fulfilled way.

She offers clients the choice of having her come to their home to conduct the counselling session or meeting with them in a private counselling office (locations are Kits and downtown).

Keep her contact info handy:
Carly Fleming, M.Ed., RCC
Prenatal and Postpartum Counselling
604-808-9587
carly.fleming@gmail.com
www.carlyfleming.ca

L'Arbre et Le Fruit

Here's a little excerpt from an article by Dr. Michel Odent, noted French obstetrician.

"According to traditional wisdom in rural France, a baby in the womb should be compared to fruit on the tree. Not all the fruit on the same tree is ripe at the same time. A fruit that has been picked before it is ripe will never be fit to eat and will quickly go bad. It is the same with a baby. In other words, we must accept that some babies need a much longer time than others before they are ready to be born. If you have some apple trees in your garden, you will listen to your common sense and choose an individualized and selective approach: you will not pick all the apples on the same day."

A recent client was concerned that she would be induced, as she had been in her first pregnancy. I had the confidence to tell her that her physician would not induce labour, even if she reached 42 weeks, as long as she and the baby were well. I could say that with confidence because I have been working closely with this particular group of family doctors for almost 20 years. This gave her peace, and she was able to relax. Soon after, she went into labour on her own, well after the typical "10 day limit" imposed in most North American hospitals. All was well. She could hardly believe the wonderful difference from her previous, induced, labour.

I live in a bubble, working as I do with midwives and family doctors who respect the current research, dare to challenge hospital protocols, and fully respect their clients' rights. I am fortunate to work in collaboration with caregivers who dare to wait, who only induce women if it is truly medically indicated (even if it causes a fuss with other staff!) In reality, this means I rarely see a woman face induction.

I am glad that I only work with caregivers who follow the best care practices. We work in concert with each woman and her body. Labours start on their own, women dance and move freely, women are continuously supported, women do not face regular interventions, women give birth standing, kneeling, or wherever they choose, and the women reach to pull the babies to their breasts. (Left brain dominant? Click here.)

In birth, we are not the keepers of the power, each woman's body is. Yes, we have to do our homework and ensure that everything we do is supported by the best evidence. But, after a while, the 21st century knowledge is only a backdrop to the ancient truth of birth.

So, if a woman's body is the tree, then the apple will fall, as it should, whenever it is ready, and will rest on soft safe ground. And the orchard keepers will be sitting, as they should, with their hands beneath them, in the shade of the tree. - Jacquie Munro, Vancouver Doula

"window children/with protective parents/sit and watch/other kids go out and play"

When I had my daughter, obstetric ultrasound was relatively new. My British obstetrician proudly told the story about the Glasgow obstetrician who saw the potential in ultrasonic testing for cracks in submarine hulls. I had one scan late in my pregnancy because the obstetrician suspected that my baby was quite small. The images were unsettling – at 28 weeks, her body was too big to completely fit on the screen, so it appeared as if her legs, arms, and torso were unconnected. I left the room, shaken. After waiting for the results for a day, I heard that the verdict was in – she was growing normally. (Her birth weight was a decent 8lb 8oz.) Even with the good news, it was hard to reconcile those images with the feeling of her inside me.

To reconnect, I would press my belly against my husband late at night, so that he would be able to feel the baby move against his body. We would talk about who this baby might be, based on the clues that we had – the vigorous movements, the tumbling and dancing. We worked hard to leave the disconnected ultrasound images behind.

During my second pregnancy, I chose to be cared for by midwives who were part of a pilot project at Grace Hospital, and, as part of the project policy, I had to be seen once by a physician. His main focus seemed to be to convince me to agree to an ultrasound. “You’re not one of those midwifery patients who’ll argue with me, now, are you?” I remember my 3-year old daughter looking at him, warily, when he said that. “Oh, of course not!” I heard myself saying, submissively, while thinking, “I wish I was strong enough to opt out.”

Over the years, I followed the progression from 2D to 3D and 4D ultrasounds. During research trials of the 4D equipment, clients would describe the experience as eerie, like they were seeing something that they weren’t supposed to see. When I didn’t hear anything further about 4D scans, I assumed the newest models were being used under strict guidelines in medical diagnostic settings. But, when I started to hear that one of the newest pregnancy trends is the “Bonding Scan,” I couldn’t help being reminded of the trend to X-ray customers’ feet in shoe stores in the 1940s and 50s.

For some reason, the 3D and 4D ultrasound images have always made me feel mildly nauseous. It feels like the baby isn’t comfortable being scanned – moving away from the transducer, covering her face. But, after talking with many clients this week, I’ve found that I’m not alone. Each woman that I’ve spoken with (perhaps we’re all in agreement because, well…they are my clients) talked about a little voice in her head that said, “It’s like we’re looking at a mystery without permission.” “There’d be a porthole if we were meant to see this!”

Certainly, ultrasound images can reassure parents. They can see the fingers and toes and be sure that everything is “all right.” But, isn’t it a false sense of security that we’re being given? We can never ever be sure that everything’s “all right” in life. Ultiimately, we have to accept that there are hidden dangers, potential concerns, around every corner. Life can never be risk-free. As parents, we have to let go at some point, do our best to keep our children safe, and hope for the best. Certain things are beyond our control. This is the hardest challenge of parenting – to trust that we will do our best to ensure the safety of our children, teach them to keep themselves safe, then, eventually, let them go out into the world.

Perhaps my negative feeling about the “bonding ultrasounds” is my gut telling me that we have to trust our bodies and our babies. It doesn’t mean that we have to turn our backs on technology, just use it judiciously, mindful of the false sense of security that it gives us.
- Jacquie Munro, Vancouver Doula

778-883-9851...vancouverdoula@gmail.com

All my previous clients have the correct spelling of my name "Jacquie Munro" and my email address. But doctors who've run out of my brochures resort to scribbling down my name for their clients... Oh, dear, just look what happens then...

Yes, I think it's time to send out more brochures when:
1) Clients try to google my name but have been given the wrong spelling,
2) A client sees an article about me, phones up the newspaper, then has to convince the editor to release my phone number (very resourceful, but could have resulted in the end of the search),
3) Old-school clients look for me in a phone book (no, it's not there!), and poor Jack Munro or Jackie Munroe, etc., still get the odd message about "wanting a doula" on their voicemail, or
4) One potential client googles "Adoula" thinking it's my name...nope...my name is not Adoula Munro.

People can always find me by googling "Vancouver" and "doula", since I'm "Vancouver Doula". Plus my email address is vancouverdoula@gmail.com.

But I still think I'll head down to the printers for some more moo cards...so the midwives and docs can still hand out my cards with the pretty photos...

- Jacquie Munro, Vancouver Doula

An Education in Care

If you want to get the inside scoop on birthing practices in BC, stand outside a kindergarten classroom just before the end of the school day. You’ll find a group of young mothers, with babes in arms, waiting to pick up their 5 year olds. They’ve been through the system - probably a few times - and are only too happy to share their hard won stories. Ask about their first birth experience, and you may hear stories of disillusionment, loss of dignity, overcrowding, or lack of continuity. They’ll tell you they wish they’d been better informed, and had known enough to find great caregivers.

Then there will probably be one woman in the group who shares her second birth experience, and shyly admits to feeling joy. “What a difference my second birth was!” she’ll say. “It was like night and day!” You might hear her talk about empowerment and laughter. What was the difference from her first birth, you ask? “Oh, I changed caregivers...and I hired a doula.”

Sadly, the majority of us stumble onto our maternity caregiver. Perhaps our family doctor doesn’t provide obstetrical care any more and refers us to a local obstetrician. Perhaps a friend gives us the name of the doctor who performed her D&C last year. Since there is often an element of surprise involved in the discovery of our first pregnancy, very few of us have the luxury of time to research the variety of available care in our area.

We are also victims of American media, watching their TV shows and reading their books, and mistakenly believe that an obstetrician will provide us with the best care possible. The system in BC is quite different from that in the U.S. The obstetrician doesn’t necessarily provide the best care for our particular needs (this is quite separate from being a good caregiver) - and most assuredly does not provide the greatest continuity of care. Many of the obstetricians that I work with will be the first to admit that their skills are best utilized by those who truly need them, those at high risk, and not by the average normal healthy pregnant woman. “You don’t want to see me walk back into this room,” said one obstetrician to my client the other day, after consulting with the woman’s family doctor. “I’m the surgeon.” Happily, this woman’s labour ended smoothly, without further consultation from this wonderful obstetrician.

Here’s the explanation provided by the BC Women’s Family practice Maternity Service: “In BC, family physicians, registered midwives, and obstetricians are all licensed to provide maternity care. Women can see any of these three caregivers: however, obstetricians are specialists with extra training in surgical skills and management of complicated pregnancies. They typically see women with complex pregnancy issues. Most women see either a midwife or a family physician. While both midwives and family doctors provide excellent care for the expectant mother, choose the caregiver that makes you feel most comfortable.”

In terms of continuity of care, your own family physician, if skilled in the area of obstetrics, might perhaps be your choice. This person would have prior knowledge of you and your family, be able to care for you during your pregnancy, both obstetrically and medically, and provide postpartum, baby, and family care afterwards. However, this “small-town” approach is rapidly disappearing.

Many family doctors these days have withdrawn obstetrical services due to time constraints, increasing insurance costs, or lack of experience in this area. Increasingly, family doctors refer their pregnant patients to another caregiver. It is worth doing as much research as possible before accepting a referral for maternity care. Know your options, then make an informed choice about your maternity caregiver. This decision will determine the standard of care for your birth experience, perhaps one of the most important experiences in your life. So take your time.

Regulated in BC since 1998, midwives are experts in healthy pregnancy, normal birth, and well babies, and are respected members of the BC medical system. Midwives attend births both at home and at hospital, following strict protocols governing safety. Their services are covered under the BC Medical Services Plan. The Midwives Association of BC website includes listings of midwives in your area. The College of Midwives of BC website provides more in-depth information on the model of care, standards, and education.

For those women whose family physicians no longer provide obstetric services, BC Women’s Hospital, Royal Columbian Hospital, and Lions Gate Hospital all have family practice maternity services. The doctors at these clinics are general practitioners who specialize in obstetrics. These doctors work in rotation to provide prenatal and birth care. At St. Paul’s hospital, there are some more informal groups of family physicians who will accept referrals for care during a woman’s pregnancy.

If pregnancy complications arise, both the midwife and family physician consult with other medical personnel, but remain involved in your care. If either the midwife or family physician requires an obstetrician’s consultation, then they are often able to select the caregiver most compatible with your personality, and most competent to deal with your particular concern on that day. This part of their service is particularly critical these days, with hospitals being stretched to their limits.

So, what are the odds of having your own midwife or doctor attend your birth? Midwives generally work in teams, with perhaps two or three midwives working in rotation. At a home birth, there are always two midwives in attendance. Continuity of care is of great importance. Very few doctors take all their own calls. The majority of family practitioners work in call groups of up to six doctors, working shifts of 24 hours. Some attend their patients’ births during the week, and rotate call on weekends. Many of the groups have “Meet the Doctor” nights, where you can visit with all the doctors in the call group, and listen to them talk about their philosophy.

If your pregnancy is complicated, or becomes complex, you may be working with an obstetrician through your labour. Remember that all obstetricians work in large call groups (of 8-20+ OBs), and are on call for 12-48 hours at a time. During that time, each obstetrician is responsible for his or her own patients, plus the patients of the other physicians in the call group. Because of the surgical work load, and for teaching purposes, an obstetrician relies on an obstetric resident to provide care for the woman in labour. Either the resident (junior and/or senior) or the obstetrician (or all) will be present for all procedures, and at the birth. At these more complex births, the nurse’s role and the doula’s role are critical. Since the physician who you have seen in your prenatal visits is unlikely to be present for your birth (or busy in the OR), the nurse and doula are left to provide continuity of care, and to work closely together to complete a multitude of tasks. Highly technical births need that extra bit of human touch, and we must all work diligently to make you feel honoured and empowered during this more challenging experience.

In all cases, whether you work with a midwife, a family physician, or an obstetrician, I will work with your caregivers to provide continuity of care. I will act as “translator,” working to facilitate open communication between you and the medical staff. I will provide physical and emotional support for you and your family, and make sure that you are provided with all the information so that you can always make informed decisions. I do my best to help you feel empowered by the process, to feel safe.

And I hope that, when you are that mum standing outside the kindergarten classroom, you will share your birth story and be able to smile and say, “I’m so glad I had such great care...and my birth was great - it was challenging, but it was amazing!”

- Jacquie Munro - Vancouver Doula, Slow Birth, Slow Planet