cancer, death, and moving forward

alright. it's been about a month since i last wrote anything. 

this last month. well last 5 weeks have been challenging to say the least. 

to start out with. saying publicly for the first time. my mother has cancer. shit fuck motherfucker (excuse the profanities, but i think they are justified). 

i found out a few weeks ago while i was at school. needless to say. i can't really remember that session. the diagnoses. she has colon cancer. so i guess if you are going to have cancer it's one of the ones you want, right? apparently it's been growing now for 3-4years. not sure how they actually know that, but well this is what has been told to me. so again, it's slow growing. non-invasive right? this is a good thing. my mantra. 

she is having surgery the end of the month. allegedly having 12" of her colon removed. it's fucking killing me. so much conflict. on call for about five births. i'm going home. when. i think i've finally figured that out. after the surgery though. better not fucking die during surgery. seriously. anxiety. morbid? maybe. but when you are dealing with the mortality of someone in your family, particularly your mother. it's hard not to be.

this has pretty much consumed me for the last two weeks. which also included a stint in new york visiting old loves and returning home to move. ack.

so death. you may be thinking i was referring to my mother, but no. i haven't mentioned this. i haven't written about this other than a vague post last month. 

on march 12 i attended the birth of a beautiful boy that was born quietly into this world. his mother is writing her story about her feelings on dealing with the loss in a way that i can't imagine touching on.  

this has been one of the most powerful experiences of my life, not just midwifery life, but so far. i hadn't ever contemplated the notion of attending a stillbirth. i don't know why. it was nothing i was prepared for. 

march 8th i got out of the dentist and had a call from my midwife saying that she was meeting one of our clients at a colleagues office to check for heart tones, after the mother had reported feeling decreased fetal movements. 

i drove as quickly as i could over, but they were leaving. they hadn't found heart tones and were on the way to the hospital for an u/s to confirm that baby was no longer with us. i could use phrases like "we went to confirm the fetal demise" but like some medical terminology we use in midwifery, it is not something i feel comfortable with. this situation was not something i felt comfortable with. but what was i to do? 

when we got to the hospital the parents already had the u/s. we all just sat there and cried. the next five days are somewhat of a blur. working with two midwives means off call doesn't really happen. regardless of what is going on. i kept getting called to births. i was in and out of the hospital and between births for five days. little sleep, little to eat, so much emotion.

it's hard to let something like a baby's death not affect you when you are attending other births. i think i did OK, outwardly. but i know on the inside when one mother in particular was having a tough go of a labour she thought would be "easy", i felt resentment inside of me. thinking...if she only knew. she should be grateful, she should relish the fact that her baby is alive. i know that is horrible. but i also think it is normal, as meanwhile this beautiful family was in the midst of an induction that just kept going.

for five days this family sat with this stillness as copious amounts of drugs and attempts were made to stimulate her body into labour. finally on the fifth morning the time had come. i had just gotten home from a birth about four hours before the phone rang.

i laid in bed for about a half hour before getting up. i called the director of my school. i needed some guidance. i was not equipped to counsel a family though something like this. i was reassured that if anything it was my presence. my midwife had also said the same thing. 

as i got up and got ready i had no idea what was about to transpire, what to expect. there was no way of preparing myself. i merely put one foot in front of the other. 

when i got to the hospital they were waiting for the doc to come in and check her. she had been on an epidural all night long labouring and was complete. 

i don't even know how to articulate the rest. as she birthed we were all by her side. the strongest i have ever seen a woman. even through tears. all of us tears. conner david was born breech and placed on his mothers chest. he was wrapped in a blanket and we could see his perfect tiny hands and feet. after the placenta was delivered conner was taken by his dad into the next room to be bathed and dressed. 

we spent the rest of the morning sitting together, in conner's presence. a professional photographer came in, as well as his older sisters and grandfather. i spent most of the time with the girls. talking to them. sitting with them. occupying them. i think i may have needed them more than they needed me. though i know it was appreciated, but caring for them. 

it is heartbreaking to think back on. but as the weeks have passed, sleep has gotten easier and remembering not as triggering. 

for weeks afterwards i couldn't sleep. that first night i had taken a sleeping pill and drank a bottle of wine. sure, not the picture of clean living, but i needed to sleep. i needed to dull the pain. 

life doesn't stop. i'm not sure how much i have processed everything and now with the news about my mother....i just want to scream and hide. i'm struggling not falling back into depression. i prone to it. the sunny days have helped. i've laid in the grass feeling the warmth of the sun bathe me. seeing babies and mothers and friends help. i moved in with my midwife for the summer and being around her family i think is good for me. despite the energy of a 2, 7 and 10 year old. i feel love. i feel family. 

time moves forward. 

Day 2: midwives as primary maternity care providers and inter-professional collaborative care

yesterday was intense. it was a long day and we had powerful discussions, the day culminating in the language of racism that exists in "white neo-midwifery".

i'll talk about this concept later as it is a big topic. one that is distinct from what i see as the intention of this conference. but one that is important in order to address the disparity in maternal and neonatal mortality rates in the united states.

a discussion that leads to more questions than perhaps answers. 

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i attended two break away sessions yesterday.

take away message from both:

"the right care at the right time in the right place by the right people"

the question is - what does this look like and how do we get there?

in the two sessions, the first on midwives as primary maternity care providers, the second, collaborative care. 

Amy Romano discussed what a primary maternity care provider is and the concept of a maternity care home. These concepts are the outcomes of the 2020 Visioning and the Blueprint for Action.

some interesting distinctions that she made, which we can see happening in other countries, is the difference between midwifery care and midwife-led care. it is this concept that midwives need not necessarily be limited to low-risk women, but that midwives work with women, in a collaborative relationship with other healthcare provider to meet the individual needs of pregnant women. the midwife essentially coordinates a woman's care. 

this can work in conjunction with the concept of a maternity care home (which i discovered was not necessarily a discrete physical place - though it could be). 

Elements and features of maternity care home

-        primary maternity care providers assigned to each women

-        individualized care planning guided by

o      standardized risk screening

o      evidence-based guidelines

-        linkages with community resources

o      behavioural health services

o      mental health services

o      parenting services

-        preventative care

-        access to self-care information, reseources, and tools

-        accessto a higher level of care, as needed

-        shared decision making and clinical decision support

-        coordination of care

-        performance measurement and reporting, continuous quality imporovemnt

-        new payment models, eg. bundled payment, pay for performance (including “patient experince”)

-        community outreach to foster access to care

-        newborn care and breastfeeding support/promotion

the second part of implementing a system like this is by facilitating effective inter-professional collaborative care.

this is huge. 

Debbie Jessup talked about the MOM's for the 21st century act - HR2141 (122th)/HR5807 (111th), a large component of which involved the development of a core curriculum that is essential to providing high quality maternity care. one with a public health focus, incorporated cultural sensitivities, supports physiologic birth, and includes an interdisciplinary curriculum. 

emerging from the homebirth summit, statement six addresses the idea of interdisciplinary education. 

"effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings. to achieve this, we believe that all health profession students and practitioner who are involved in maternity and newborn care must learn about each others disciplines and about maternity can health care in all settings."

Practical application of inter-professional education (IPE) in maternity care

-  focus on expanded understanding of roles, responsibilities, skills and training or maternity care providers

-    focus on expanded understanding and appreciation for varied birth settings

-    focus on promoting more integrated approaches to supporting women across all birth settings both in selecting sites for care and in movine from one care setting to another as needed/desired

Lisa Kane Low, CNM involved in the interdisciplinary education workgroup made an important argument that the cross training can and should begin between CPM's and CNM's. that we should be welcoming each other into our practices and spaces. learning from each other, gaining knowledge from each others expertise. 

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so were does this leave us?

Day 3 - today we focus on where we want to go.

i have a lot more to say about the discussions from yesterday, and this is where i want to focus my attention. what i see as important in addressing the maternity care disparity in this country. 

we will see what emerges. 

Day 1: Setting the Stage

millennium development goals, blueprint for action, government initiatives - strong start, AOC's, innovative awards. but how do midwives access these? how do CPM's access these? 

there has been an increase in homebirth --> amongst white, non-hispanic women. 40% of maternity care covered by medicaid. in 26 states midwifery is legal. in 14 states medicaid covers midwives. where do we go?

do midwives want to be primary maternity care providers?

what does this mean? how does this look? what does it imply?

education: skills in health promotion, public health, collaboration....

individual responsibilities of midwives to foster these relationships at a local level. don't stop fighting just because midwifery is legal. a system that requires mother to go between midwife --> family practice doc --> specialist is inefficient.

women will be lost, particularly if we are trying to mitigate the disparity that exists. 

do we as white midwives feel guilty because of the colour of our skin? most women don't seek healthcare providers. most women only see healthcare providers during their pregnancy. 

what tools do we as midwives have to meet the needs of these women?

are we turning our backs on them? do we even see these women and their needs?

do we want to be primary maternity care providers or do we want to be midwives (continuing to serve the same women we have been serving)?

i thank the midwives that came before me, that fought for the white, non-hispanic women to have the options that they do. but it's time to move forward. we need to reframe the discussion around midwifery care away from homebirth and refocus it on to what is important. serving women during their pregnancies - not only white women, but all women. 

sure birth can be a spiritual journey, but today is that what is important? when women and baby's are dying, what is important?

the above may not actually be a summary of all that came out of yesterday, but the above is how i've processed it. where i see the discussion.

lobby day

the beginning of the 2012 NACPM Symposium started with a bunch of midwives occupying capitol hill.

there were about 45 of us crowded into a small room at the health policy source office this morning, being prepped for our meetings with senators and congressmen, advocating for the mission of the MAMA campaign and HR 1054.

the bill, if passed would include CPM's in the list of providers that would be reimbursed by medicaid for out of hospital midwifery services. right now there are only about 14 of the 24 odd states where midwives are licensed that receive medicaid reimbursements.

our WA state contingent was strong, about fourteen. much of the information that we provided the representatives comes from data collected from our home state (yes, yes. i'm not from washington, but for all intensive purposes, why not).

over the next four days we will be filled with information, my aim is to try and blog throughout.

i should be proud. there are only a handful of students that are present at this symposium. i'm amongst some pretty powerful midwives and the energy is high.

numb

little one. you left too early.