A Love of Labor

Nurse midwife Nancy Degennaro demonstrated straddling positions on a large exercise ball for Rose Gallegos, an expecting mother sitting next to her. “Sometimes we would have her sit on it this way,” Degennaro said, squatting on the ball, opening her legs wide, acting out Gallegos’s possible future delivery. “Sometimes we have her lean on it this way,” she said, moving to rest her flat tummy on the ball. “We just get creative.”

Getting creative is part of the birthing philosophy in Yale’s midwifery department, located at Yale–New Haven Hospital’s St. Raphael campus on Chapel Street. An alternative to the OB/GYN maternity ward, the department staffs midwives, who are licensed to deliver children and provide holistic birth-related care. Mothers are encouraged to take ownership of the birthing process. Instead of lying flat on their backs in a hospital bed, they move around, play birth playlists, and order takeout. There are exercise balls used for sitting and bouncing to open the pelvis, a bar that allows for pushing while in a squat position, and tubs and showers for hydrotherapy. Mothers can decide to labor on all fours in a large, lavender-scented tub, though they must give birth outside of them.*

Dana Oakes-Sand is a doula, meaning that she is trained to provide emotional support before, during, and after birth but does not have a medical degree. “I had a patient play Skrillex while giving birth,” she told me. “That was an experience.”

***

Mothers are encouraged to take ownership of the birthing process. Instead of lying flat on their backs in a hospital bed, they move around, play birth playlists, and order takeout.

With warm lighting, ambient instrumental music, and large photographs of newborn babies, the midwifery department looks and feels a little like a womb—comforting, quiet, red-tinted. During a tour of the department for October’s National Midwifery Week, nurse-midwife Erin McMahon reached up to brush a crumb off my sweater, a bracelet inscribed with “Kindness Changes Everything” sliding up her arm. Traditional boundaries of personal space seem to melt away. Nearly every midwife, nurse, or doula would nudge me to make a point, or let their hands rest on my arm while we laughed. Someone even grabbed a pen from my back pocket while my hands were full.

Although OB/GYNs meet with patients many times before the birth, the visits tend to be physical exams. Nurse Katie Brady, who has been at YNHH for thirty years, sees midwife care as a more holistic alternative. “The difference between midwifery care and the, how shall I say it?” she asked, turning to her co-workers, “the traditional medical model? … It’s more supportive, a more calming environment.”

***Founded in 1956, Yale’s professional midwifery program is one of the oldest in the country. It was born during a period of decline in midwifery, as OB/GYNs replaced midwives as the primary caregivers for pregnant women in the 1950s. Practicing nurse Michelle Telfer attributes the shift away from midwives to changing attitudes toward women’s health in the early twentieth century. “Pregnancy came to be seen more as pathological, more as a disease to be treated, more as a danger to women’s health,” she said. As birth became clinical, midwives’ traditional approach led to the stereotype that they were “unclean witches with gnarled hands,” said associate professor of nursing Heather Reynolds.

Women and couples covered by the Yale Health Plan seeking midwife care have two options: give birth with an OB/GYN or pay out of pocket.

OB/GYNs delivered almost all American babies until the feminist revolution of the 1970s when, Reynolds said, “women started to look for alternatives to heavy sedation and started to demand a family birth experience.” This shifted OB/GYN practices—fathers were allowed in the delivery room for the first time, and caregivers began to emphasize nutrition, cultural needs, and the physical changes of pregnancy. This change in attitudes also led to an uptick in midwife-assisted births. (According to the Centers for Disease Control, between 1975 and 2002, the percentage of midwife-assisted births rose from less than one percent to 8.2 percent.)

Midwives try to maintain an air of unique approachability. The word “midwife” comes from the Germanic Middle English root of “mid” (meaning with) and “wife” (meaning woman): “with-woman.” The etymology reveals the their role as one of accompaniment and support. As explained to me by Richard Jennings, the only male nurse-midwife on the Yale team, “midwife” refers to the gender of the mother, rather than the healthcare provider. “What do you call a male midwife?” he asked me. “A midwife?” I answered, confused. “No,” he joked. “A delivery boy.”

***In America, most babies are still delivered by an OB/GYN. In almost every other country, midwives, both male and female, deliver most children, with OB/GYNs only involved when complications occur. According to Oakes-Sand, American women fear birth and labor pain more than women in other cultures. She pointed to a study in which scientists asked women in Japan whether they were afraid of childbirth, and their responses indicated that they seemed surprised that anyone would be. Describing her sense of the prevailing attitude in Japan, she said, “I might be afraid of a tsunami, or a volcano, but birth? Why would I be afraid of birth?”

For many American women, childbirth is pathologized—an event of hospitals, screaming, and white-coated doctors. “We are taught to fear pain,” practicing nurse midwife Michelle Telfer said, “but labor pain is different.” Many OB/GYNs try to eliminate pain with epidurals, which numb women from the waist down. Though midwives offer epidurals, they prefer to use alternative methods of pain management. “It doesn’t mean she has to go through it unmedicated,” said Telfer, “but our bodies work, and it can be a very powerful experience for women to go through that process.” Back in the labor room, Degennaro pointed to a tank of nitrous oxide, or laughing gas, which some women use to alleviate pain and relax. Animatedly, she told of one woman’s birthing process in which, “We laughed her baby out.”

“Laughing a baby out” constitutes a radically different image than the conventional one of an American soon-to-be-mom: sweat-drenched, screaming, flat on her back. Looking around at the props in the labor room, giving birth with a midwife seems more like a new exercise class fad than The Most Painful Experience Ever.

***Yale’s health care plan does not cover birth through midwifery for undergraduates, graduate students, or faculty. The only option available under the Yale health plan is an OB/GYN birth. Among American health care plans, this is fairly common.

Still, the ubiquity of OB/GYN births in the United States can come as a shock to people from other countries—most international health care plans do cover midwifery care. At Yale, Telfer said, the response of many foreign faculty and graduate students is, “What do you mean, we don’t have midwife care?”

When I met Sarah, a young Israeli doctoral student, she was bouncing her nine-month-old daughter, cooing to her. Sarah, whose name has been changed at her request, delivered her daughter with an OB/GYN via cesarean section. As C-sections go, she said, she had the best possible experience, but she would have preferred a vaginal delivery.

Though these procedures are routine and low-risk, a cesarean section is, as Telfer described it, “major abdominal surgery” that should be used only as a last resort. The CDC reports that 32.7 percent of American women gave birth via C-section in 2013, more than double the recommended regional rate of the World Health Organization. As one nurse, who wished to remain anonymous, said, the mindset of many in the medical field is such that “one intervention”—such as an epidural—“leads to another,”—such as an episiotomy, the cutting of the vagina to allow the baby more room—“to another,”—a C-section. Midwives, who generally employ fewer interventions, have C-section rates of six percent.

Sarah believes that she could have avoided a C-section had she worked with a midwife. “I just thought the C-section was unnecessary,” she said, shrugging. “I had perfect conditions: I am big, I had a small baby, I had full dilation. I pushed and pushed and pushed and for three hours, she didn’t come out. I am sure that if I would have been moving…” Sarah trailed off. But believes that the alternative tactics of midwifery, like walking, would have allowed her to give birth vaginally.

“our bodies work and it can be a very powerful experience for women to go through that process.”

Women and couples covered by the Yale Health Plan seeking midwife care have two options: give birth with an OB/GYN or pay out of pocket. This often proves too costly—according to the pregnancy website What to Expect, a birthing center birth costs about three thousand dollars. Telfar explained that many of her patients who pay out of pocket choose a home birth, which can cost as little as fifteen hundred dollars. “It’s cheaper overall,” she said, “but for women who don’t feel comfortable with that, they don’t have much of an option.”

“I would have come here, [to the midwifery ward] if it had been covered,” Sarah said. “I tried. I asked if I can, they said no, and so I just accepted it.” Sarah intends to purchase another health care plan to have her next child at St. Raphael’s midwifery department.

Though women like Sarah turn to midwives to gain more control over their births, midwifery remains unpopular among New Haven residents and Americans alike—hence the need for tours like the one in October. As I packed my camera away and readied myself to leave, nurse-midwife Melanie Albright shrugged. “We help them write their own stories,” she said of the mothers she and the other Yale midwives have helped. “Anything we can do to get the word out.” With that, she turned to show another small group around the floor.

*A previous version of this article incorrectly stated that mothers could give birth in labor tubs.