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Midwives changing the world one baby at a time

HT team

With Global Citizen focusing on maternal health this month, I thought it would be awesome to get some perspective from a professional Midwife. Luckily, my family happens to know an incredible Midwife in the Bay Area, so I decided to reach out. She was kind enough to take time from her extremely busy schedule to explain to me the ins and outs of Midwifery, share her personal journey, and discuss her thoughts on the gaps in maternal healthcare - both in the developed and developing world. My biggest takeaway? This lady is my hero.  

Her name is Gina Catena, CNM, NP, MS and she is a Certified Nurse Midwife and Nurse Practitioner with a Master's degree from the University of California San Francisco (the hospital where I was born!) Beginning as a struggling teenage mother, she enrolled in community college at the age of 30 while raising her three children and eventually earning three degrees with honors. Pretty badass if you ask me. For the last twenty years, her career has been focused on working with inner city women in California, working in public clinics and attending births at home, a birth center and in tertiary care medical centers. She has also provided volunteer medical care in both Guatemala and Indonesia.

MH 4 Gates Foundation .jpgImage: Gates Foundation

Here is what I learned from our interview. First things first..

NP: What exactly does being a midwife mean?

GC: The legal definition of midwifery varies in different parts of the world, covering everything from an illiterate traditional birth attendant (TBA) to a PhD prepared advanced practice nurse with national certification and licensure. In the USA, most Certified Nurse Midwives (CNMs) have Master’s degrees with advanced training from a graduate nursing program or through a medical school- which enables them to provide full scope women's healthcare including gynecology, contraception, prenatal, labor & birth, postpartum and menopausal well-woman care.

CNMs can practice at home, in birth centers or in hospitals - depending upon their choice of practice venue. Other midwives, such as Licensed Midwives or Certified Professional Midwives, are trained for only normal maternity care to practice only in out-of-hospital settings.

The system in other developed countries varies a bit from this.

In my mind, a midwife's first job is to support, educate and help assure the health of women and their children. This differs from medical practice because medical education is directed to detecting problems and intervening when they occur. Of course there is overlap. In the USA, the maternal mortality rate is rising - one of the worst in the so-called developed world, despite the access to technology and that the majority of births in the USA are attending by medical doctors. Whereas other countries with better maternal-infant outcome statistics use midwives for the majority of maternity care.

NP: Sounds like a pretty awesome job! How did you get into this profession?

GC: Thirty eight years ago, I was a teenage mother living on welfare with limited access to healthcare or medical care. However, I was determined to learn everything I could. I checked books out of the library, took childbirth classes, exercised and breastfed my children in an era when that was considered radical. Since I lived in a low-income neighborhood, I saw the majority of others in my former demographic had bigger hurdles to overcome than I did. Many were abused, had addictions in their home, did not know about healthy eating, or were intimidated by the professional world. Many felt victimized by society, and just accepted the little that fell their way.

After birthing my daughter shortly after my 19th birthday, I continued learning and applying everything I could to the best of my limited ability. I believe that well-begun is half-done. By helping pregnancy and birth to go well, I hope to help breastfeeding and family life begin well. That in turn, can help the next few  years, and beyond that. There's a saying on a refrigerator magnet at my house "Midwives changing the world one baby at a time."

My profession is immensely gratifying. I'm blessed to help families through monumental changes -  as they welcome new life. It's an honor to share such intimacy and support strong family bonds.

Baby Image.jpgImage: UK Department for International Development

NP: As an expert on the subject, what would you say the advantages and disadvantages of midwifery are?

GC: A good midwife supports a family to grow strong, provides education, health care, provides medical assessments and helps a woman (family) to birth a new child. I am fortunate, as are many other Midwives and Nurse-Midwives, to have close collaboration with skilled and supportive obstetricians for situations that require medical or surgical intervention. Working in the Bay Area of California, my clients have access to needed blood tests and other prenatal diagnostics.

Some midwives elsewhere lack access to supportive obstetricians, either due of geographic distance, political issues, or because of limitations by obstetricians' malpractice insurance policies. It would be dangerous to practice without access to necessary medical intervention or emergency services when needed.

The only disadvantage for midwifery would be a situation when a woman is very attached to the idea of natural birth without intervention, when intervention is actually appropriate. It's important that a midwife identifies variations from the normal and refer appropriately before a situation becomes a full blown emergency situation. Unfortunately, some inadequately trained people claim to be midwives and hurt the reputation of our profession. And there are some clients with unrealistic expectations.

It's ultimately the responsibility of each mother to take care of her health. Each woman should interview her health care providers, whether midwife or physician, ask about appropriate weight gain, labor preparations, express preferences, learn about danger signs, ask her provider about the place of birth and who will attend, and understand the criteria as well as risks and benefits if a cesarean section is recommended.

now-is-the-time-to-put-mothers-first.jpgImage: Flickr-Heinrich Plum

NP: What have your experiences been working in developing countries?

GC: I worked in rural areas of Guatemala with comadronas (illiterate birth attendants), teaching skills, and listening to their wisdom from years of delivering babies on dirt floors without medical access. I also worked in Bali, Indonesia to help establish an NGO that provides pregnancy, birth and other health care services at no cost. That NGO is now well known, as Yayasan Bumi Sehat run by Robin Lim, who was voted a “CNN Hero of the Year” for 2011.

NP: What would you say are the major gaps between the developing and developed world when it comes to maternal healthcare?

GC: Many books and studies are produced annually about this. To make it simple, in my humble opinion, wholesale access to quality health care and education for women and children is in direct proportion to two things : A) The value that a society places on its women and children, and B) The resources of that country. Inequitable distribution of resources in both the developing world and the developed world creates poverty, more ill health, abuse, morbidity and mortality.

Scandinavia, the UK and most of Europe have a socialized medical program that emphasizes midwifery care for maximizing maternal and infant health at a lower cost than in the USA. All their women and infants have access to care.

The USA's system, on the other hand, is the most costly maternal health care and has some of the worst outcomes. Many women cannot access overcrowded underfunded clinics. And women need more than quick clinic visits to assure the health of themselves and their children. They need safe shelter, education, nutrition, clean water, and safe streets.

It's interesting to note that in developed countries, homebirth is primarily chosen by upper middle classes people who can afford personalized boutique care throughout pregnancy, birth and postpartum. While poor women in developed countries universally receive care by whoever happens to be at the hospital upon their arrival. It’s exactly the opposite in developing countries - where poor women usually give birth at home or small birth centers and wealthier women with ressources travel to a hospital to give birth with the best technology and specialists they can buy. Kate Middleton and Prince William, Duchess and Duke of Cambridge broke these molds with the recent birth of their princess daughter. Kate Middleton gave birth in a maternity hospital attended by the same midwives who delivered their son two years ago. A team of surgeons stood by, ready if needed.

The differences between maternity in developed world poverty vs developing world poverty is evident with different types of illnesses, and access to technology.

Baby & Mother .jpgImage: Gates Foundation

NP: Can you compare and contrast your experiences working in developing countries with your experiences working with at risk inner city women in the Bay Area?

GC: After scratching beneath the surface veneer, there are many challenges shared by poor women in developing countries and poor women in the developed world. Mothers and parents from all walks of life want the best for their children. They want their children to be healthy, happy, have an education, grow with love and have the ability to provide for their own families when they grow up.

In both worlds, poor women often lack support, lack resources, and lack a vision of a better life for themselves. Many struggle with racial and religious prejudices that limit access to education. Most impoverished people live in areas with a dearth of educational and employment opportunities, making crime an enticing livelihood for their children. Life surrounded by high crime and violence adds an untenable level of constant stress and PTSD. Many migrants struggle with culture shock and lack knowledge to navigate their adopted homeland.

To make gross comparisons, maternal poverty in the developing world generally has higher rates of infections, starvation, and hemorrhage. Many women in these situations are aware of the risks of death with childbearing. They have seen loved ones die in childbirth and are grateful for helpful health care providers.

In the developed world, maternal poverty exhibits high rates of complications from obesity, diabetes, hypertension, street violence, smoking, alcohol and drug abuse. Many have witnessed loved ones die from drug overdoses and street violence. Many poor women in the USA are unprepared for the physical labor and risks inherent in childbearing. Many incorrectly expect to give birth quickly (having seen 30 seconds of a birth on television) and think an epidural or a risky cesarean section on demand would spare them from physical discomfort.

Many poor women in both the developed world and developing world feel disenfranchised and intimidated by educated professionals. They are usually relieved and appreciative when treated as human equals having a challenging and monumental life experience. Sometimes they lack access to contraception and have many children - 7, 8, 9 and more, with the inherent risks of having so many children. For some who are so disenfranchised as to be illiterate, childbearing may give them an identity. I’ve met some incredibly intelligent illiterate women. Some are dependent upon the men in their lives. One woman explained to me that she, "must satisfy him regardless" of her own wishes, and have more children than she would choose otherwise.

The litigious attitude in the United States impacts attitudes around childbearing. Obstetrics is the most frequently sued medical specialty - and carries the most expensive malpractice insurance.  Whereas, after delivering a dead baby on the dirt floor to a family in rural Indonesia, the family brought a multi course dinner to the home of the lead bidan (midwife) to thank us for doing our best to care for village families. They had prayer rituals to protect the soul of the departed baby, and were grateful that the young mother's life was safe, even in mourning. Maternal-child poverty in both settings usually lacks access to safe housing, nutrition and education for the next generation, thereby denying the next generation of opportunities to break the cycle of poverty.

NP: What do you think needs to be done to improve maternal health care?

GC:The health and education of women and children should be a priority - to assure the strength of society and our future. This should be a global priority. It is extremely short sighted to cut funds for education and health care. Societal costs will be much greater down the road - from expensive interventive medical care for neglected problems, poverty, anger, sick families without resources and homes.

Education and maternity care are inseparable twin concerns. Appropriately trained midwives with access to physicians and tertiary care medical centers are usually the most cost effective and efficient providers of first line women's health care. Even a recent CNN story reveals midwifery care produces better outcomes than standard medical care alone.

Midwife Photo for Body .jpgImage: HTeam

NP: As a midwife, what is your message to global citizens?

GC: Nutrition, exercise, education, social support, love, -- these are the basics of health for each person, society and our planet.When those basics are not supported - the delayed cost is much higher. A society that values the future provides accessible maternal-child health care and education for all.