Between a Rock and a Hard Place: Practicing with Integrity as a Midwife Doula

I have attended a little over 100 births. The majority of those births have been in an out of hospital setting and I was in a midwife role, whether as the primary midwife or assisting in the birth team. I have been a doula at eleven births in hospitals here in New York and in New Jersey. Before I became a midwife, I was aware that there was injustice occurring in hospitals to birthing individuals, and that people of color were suffering the brunt of that abuse. I felt powerless in certain respects – I was taught to be advocate for my clients but warned against being antagonistic towards the hospital staff. I constantly reminded myself that I was not the healthcare provider and that I could not intervene, even though my intuition was telling me otherwise. In the first couple of births a doula attends, she is often getting out of her own way to serve the person they are assisting. Becoming a midwife changed my entire perception on what I thought about birth, as well as human rights and self-determination. The births I have attended as a doula after that training have caused a lot of conflict that could be compared to cognitive dissonance. Knowing what I know as a trained midwife and being a doula challenges my integrity.

I chose to be trained in an out of hospital setting intentionally. Though I had only seen hospital birth, I knew in my spirit that I needed to experience birth as close to how my ancestors did before the medicalization of birth. Making this decision meant that I was putting myself in a position to not be able to practice in New York City when I returned from my studies. I chosedirect-entry midwifery, which is an independent practitioner educated in the discipline of midwifery through apprenticeship, self-study, a midwifery school, a college, or university-based programdistinct from the discipline of nursing.

If I were to be certified and licensed, my certification would be a Certified Professional Midwife (CPM). According to theNorth American Registry of Midwives (NARM), a Certified Professional Midwife is a knowledgeable, skilled and professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM) and is qualified to provide the Midwives Model of Care. The CPM is the only midwifery credential that requires knowledge about and experience in out-of-hospital settings. This certificationhas not been embraced in New York State as legitimate. Midwives in NYS must have a master’s degree and be either a Certified Nurse Midwife (CNM) or a Certified Midwife (CM), with the former having more respect in certain ways than the latter.

With the awareness that I was professionally hindering myself and would not be able to legally practice in NYS, I still decided to purse direct-entry midwifery. I learned the non-allopathic way, or non-mainstream methods that are herbal and holistic, to manage birth. I was taught to study the entire person, from their disposition to their body language while also learning how to interpret laboratory values, draw blood, document a person’s vital signs, understand the medications necessary in hemorrhagic emergencies and maneuvers to assist the birth of a child. Not only did I gain skills and knowledge about the scientific and medical side of birth, I also learned how to help a person through their birth and encourage them to trust their body to move and birth in the way they feel called to. There is a freedom in out of hospital birth that does not exist in hospital birth. I knew before I began to practice again as a doula that this would be difficult to integrate.

I feel called to serve birthing individuals who give birth in hospitals here in New York City because I know my experience is valuable and because it is the only way up until now that I can safely and legally be a part of the birthing process. It has come with a lot of frustration and heartache – frustration at the things I’ve seen hospital staff and providers do and suggest to the heartache that I could not fully protect some of my clients from being abused. Of course the solution would be to pursue a master’s degree in midwifery so that I could be a CNM or a CM, but that also comes with its own host of dilemmas. As a CNM, the easiest place to practice financially would be in a hospital. Ethically, I would have to work under pressure and still under obstetricians; this is counter-intuitive for me, as a midwife by nature is an autonomous healthcare practitioner. Though there are midwives needed in hospitals, and they help many women in that setting, I personally would be depleted from working within that system.

New York State is not a friendly environment for homebirth midwives as a whole; there are pockets within the state where some homebirth midwives may feel supported by the community they practice in. However, there are midwives that I personally have spoken to about the struggles they have faced in making transports to hospitals in cases of minor emergencies. I say minor emergencies because out of hospital midwives are trained in identifying emergencies and responding to them; usually, and here I speak just from my own experience in my training, when a transport happens, the person is still stable but for safety reasons, the birth or postpartum is better continued in a hospital. Additionally, some midwives in New York and New Jersey have experienced a decrease in their income because insurance companies have become increasingly more difficult and less cooperative with out of network providers.

The last birth I attended was particularly difficult to witness from a human rights standpoint. In few words, and to protect the privacy of my client, there was coercion and blatant disrespect from the hospital staff. I was appalled. I felt that I had to be antagonistic when being polite no longer got my client’s needs met. After, I felt bad for being so confrontational but I shuddered to think of how the birth would have turned out if someone was not protecting that birthing person. I know too much about how a respectful birth is managed to stay quiet in these situations. Being a doula in a hospital, particularly when serving people of color, can be like going to war. I try my hardest not to see the hospital staff as the enemy, which is what allows me to bring peace with me and address the staff with all the respect I can muster. My struggle is that I feel sometimes that I am out of integrity because I cannot share everything I know, from prenatal advice to natural ways to induce labor, because I am not licensed and I want to protect my client. Conversely, I am always tempted to share more than what is appropriate because I want to protect my clients from being coerced and also supplement the prenatal care they do get, which for many leaves a lot to be desired.

Ultimately, as a professional, these are struggles that I work out daily to continue to be of service. I know the path and the decisions I need to make to be able to be more autonomous. But the truth is, being a midwife doula is challenging on a mental, emotional, and spiritual level. I can’t unlearn what I know about the history of experimentation on people of color for the sake of medical advancement. I can’t forget the reasons why so many births end in Cesarean sections and over-medicated. It is impossible to turn off the voice that tells me that the birthing person needs to get off their back, eat and drink whatever they want, and move in the ways their body asks them to so that they can get through their labor pains in a dignified way. To interface with hospitals, which are built on the subjugation of human rights for the benefit of technology, capitalism and patriarchy is exhausting. With all that said, I am willing to struggle through my own conflicts to continue to share the information I can share, nudge my clients to ask their providers questions and do my best to support birthing individuals in having births in which they are respected and honored.