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Denise Punger MD FAAFP IBCLC
David Stuart's Prenatal Care
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My Prenatal Care

Many birth stories focus on labor and don't share any of the anxieties women have throughout pregnancy. I am 36 weeks. My impending birth and subsequent birth story would not be complete without the details leading up to it. I became the client with needs unable to be met by birth teams, which I attribute to different cultural customs and routines taken for granted. These differences have been a major stress point in my third pregnancy.

My Birth Plan was simple: To give birth surrounded by my midwife and doula friends in the comfort of my house.

Considering my friends are in the birth field, my plan is not that complicated. I thought about birthing this way before I was pregnant. As circumstances would have it, my family moved out-of-state. It was tough to leave my friends. Even with phone and email the distance seemed enormous.

The  the new community  was vastly different from Florida. The small town culture was not expected. After all I trained in this state; I lived in this state longer than anywhere else, but this town  was so different than the other ocations that I lived-- I would have never believed it even if someone had tried to explain it.

Making friends in  the birth community was one of the first ways I attempted to make new contacts. A few weeks before the move, I searched yahoogroups and found a birth community and introduced myself. I was welcomed before I even left Florida. This gave me something to look forward to even as I grieved what I was leaving behind. Meeting on-line would eventually turn out to be different to meeting in person.

This difficult move became even more challenging when I became pregnant a few months later. I could continue the e-mail and telephone communication, but would not have the familiar prenatal care or birth plan I hoped for. I was going to have to recreate a birth plan or find meaningful friendships quickly. As soon as I knew I was pregnant, I sent email to my doula friends in Florida. Their initial replies were exciting. I felt special. They made it so exciting for me that I wanted to tell everyone else I knew that same day. Since I had family all over, and several Internet communities of friends, e-mail made it real easy to share the news.

I was taken back a bit by the cumulative responses in my new  birth community. First, "Congratulations. I am shocked. I don't know what to say." This is from a midwife-hopeful who I knew socially and couldn't wait for me to be in her locale; she previously claimed that she was deprived of a birth network living out in Mayberry. She had claimed before that she could never tire of talking about birth and babies, yet she was speechless over my news. A few days later, I ask her for the name and number of her midwife. She says that she'll look it up and try to get back with me. She had just given birth: she had to try and look for this number? Her responses made me uncomfortable. I didn't get it. Was this a communication gap that I misunderstood? Why was she shocked? Because I just moved, because I was looking for a new practice situation, or just my overwhelming personal family issues. I felt judged and realized she wouldn't be good prenatal or labor support with the tone set. I found the midwife's number without her help before she got back to me days later.

Next I had run into a doula at my boys Martial Arts Class. I shared my great news. She didn't say much, again confusing me, but a few days later I found out she was  dreading leaving the area and wouldn't be around for my birth. I obviously knew how it felt to move and I thought I should be sensitive to her needs rather than to brag about my pregnancy, birth, and desire to have a doula with me. This was frustrating. I really wanted to share my excitement with someone in person.

My doulas in Florida are still sending me notes of enthusiasm and encouragement while I made contact with the recommended midwife. I told her she came highly advocated by several local moms  and I'd look forward to my first prenatal in a few weeks. Being in the birth community, I was thinking ahead, being courteous and letting the midwife know when I was due. Somehow this offended her. It was her policy to have a "consultation" first not an "initial prenatal." She stated that just because I wanted her, did not mean she wanted me wanted me as a client. Whoa. Low blow. Why would she not even want to meet me before coming out and saying something so humiliating? This made me really second guess myself. Where was the support in this community? I had participated whole heartily in the natural childbirth movement, supporting midwives, and she responded like I was unworthy. To keep from being depressed, I could only think that it was cultural issue. What if I did say "consultation?" Did I come across too sure of myself? This was such a let down. I thought I was a good home birth candidate. Now, I wasn't so sure. After thinking about it a few days I decided I should not have to feel obligated to prove myself to her. I could find another midwife.

While I was searching for another, I also discovered the midwifery "is not legal in this state, but not prohibited either." It is legal in Florida. More adjustments! What this means is that there is no state licensure for midwives. A midwife could obtain a national license or credentials, but this is a personal choice and not recognized by the state. The midwife takes the risk. Perhaps this is why the midwife was cautious, but I did not realize her huge responsibility at the time I called. For the birthing family they can birth anywhere they want without legal consequence. It also means that midwives could not order labs and medications. This part did have an advantage. I was not contrived in to having unnecessary testing, especially amniocentesis, or coerced into taking medication I did not want. I'd have to make the effort to go to a physician if I wanted these "extras."

This part of  the state doesn't have an abundance of midwives, but I did finally find one. She was a lay midwife, without formal training, credentials, or a state or national licensure. My husband and I do value formal education and accepting this difference was also challenging. I value the initials after my name. It is another one of those things I didn't understand. Even if the state didn't recognize it, why wouldn't you want to show the world you could do it! And show the state this profession was worthy of being legal. Some people think I am just proud because it is an "M.D." after my name. I am equally proud of the IBCLC initials. I feel like it shows my patients I am committed to helping them breastfeed and differentiates me from other physicians who support breastfeeding with lip service, but don't keep up with the information. I was so uncomfortable with the no-credentials thing; I hated to ask her how she felt about it. I feared being alienated by another midwife. Not asking, however, did not help me resolve my issues. I did eventually ask other midwives in "legal, but not prohibited states." Jan Tritten, editor of Midwifery Today, explained to me how complicated this issue is and deserves its own dissertation. I may not understand it all now, but can respect the difficult situation for midwives.

On the phone initially my midwife warned me that she has a distributorship for vitamins and would highly recommend all sorts of vitamins from her company. I felt like my pregnancy was a racket for her other business. She really meant it, too. I made it clear to her by the second visit that I will eat well and I will take cheaper vitamins. I thought it was unnecessary for anyone to buy the most expensive vitamins and I wouldn't be buying hers. "Look at me. Do I look deprived of food." I rarely have taken vitamins in the past and what I am taking already is a big compromise on my side. I didn't take too many vitamins my previous two pregnancies. I had started them this time because I had lost eight pounds initially and I questioned if I was eating enough. She told me she had a big problem with my decision not to take her recommended vitamins. "Other clients of hers who felt poorly with previous pregnancies, find that they feel much better with the current pregnancy when they take her all-natural megavitamins. If I didn't want to take them, I could just continue to feel tired." If birth providers weren't limited, she would have been told to leave. She did retract a little bit when I pulled out all the different teas and vitamins and shakes I had and was willing to take. I must say it is hard to accept being talked to like this when I have been around so many empowering doulas and midwives. Words can have a powerful effect. I read Gail Hart's timely article in Summer 2003 Midwifery Today summarizing this in reference to why woman choose to birth unassisted, "Are we so untrusting of birth that we must carry and recommend a bags of herbs and medications, put our client on special diets ... do we horrify them with our talk of risks, consequences, worries, fears..." In my own article, Reflections of my Obstetrical Training, I referred to the family practice department I trained with being more open minded compared to the obstetrics department. One of the points the family practice faculty made was not to force horse pills down the throats of our nauseated first trimester patients: give it some time. A point was made that with good nutrition many of our healthy patients could do fine without vitamins, whereas, for the high risk obstetric patients it probably was better to get them on a compliant vitamin schedule. So hearing the midwife endorse a certain brand and tell me that I needed those specific MVI, calcium, Vitamin C, B12 complex, and alfalfa really was imposing on my training that was freeing me from rigid OB routines and also conveyed it to me that my body could not labor naturally if I didn't follow her recommendations. If I didn't feel so scolded, perhaps, I could have fully explained this. Funny, she barely mentioned raspberry tea. Her company must not sell it. This is what I did take: four gummies or Flinstones daily, raspberry tea, which I really did enjoy drinking hot or cold, Ovaltine or Noni shake, and eventually Vitamin C. I have heard good things about alfalfa reducing post partum bleeding, but my gag reflex was strong this pregnancy and I found it very unpleasant to swallow the large tablet.

I had also given her copies of my stories that has been previously published or soon-to-be published in Midwifery Today. I told her these topics I wrote about were more important than what I could tell her clinically. To this day, I am not sure if she has read my birth story. After several months she commented on the Reflections of my Obstetrical Training. These were not very long stories. You'd think she be curious about what I would have to say and want to talk about my feelings. I did not feel very valued as a client. I did not bother to pull out my artwork --pregnancy photography-- to share or my belly mask. I did not sense an interest.

I really want to be able to promote birth choices in my new community, a role I am very comfortable with, but I didn't like how things were going, for myself, let alone to be recommending these choices to other woman. I felt gypped of my chance to brag about my pregnancy and my well-thought out decision to not birth in a hospital. I did not feel like I was making a well-thought out choice.

As far as labs go, I didnt have much of a problem if she couldn't order them. It was my third pregnancy; some things just dont change. She did request a blood count. My husband wanted a triple screen for reassurance, even though I knew I wouldnt pursue an amniocentesis no matter what the results. I took it casually; Get the test and he'll be off my back. What a surprise to see that it was positive test for Down's and Spina Bifida. I cant tell you how much anxiety this provoked in my husband, and myself and even the midwife. I finally came to terms with how many times this particular test gives false results and could put it behind me. As I looked at the calculations and values that went into getting the results, I saw plenty of room for error. I can't say I recommend this test routinely or lightly.

To top off our communication problems, she talked about  issues in a way that made me feel very uncomfortable. It's hard to pinpoint exactly what bothered me, everybodys entitled to have their own opinion, but I think it was that she made assumptions that I shared the same beliefs. There was no open end for me to  express my own thoughts. I couldn't be myself, and when I finally did tell her otherewise, it was awkward. I felt like I was the first person ever that didn't share her agenda; Even if I did share the same views coming from an international diverse back ground (South Florida, Atlanta, New York and medical school) you learn to not make assumption about people and respect their opinion. It was just one more communication barrier blocking me from fully enjoying my prenatal care. Other woman from the area probably would have been excited to find a midwife with the typical regional values and presentation and not have found this to be a difficulty at all.

I always envisioned prenatal care with a home birth midwife to be laid back, enthusiastic, and encouraging. My appointments with her continued to be quick, uncomfortable, and somber. I dreaded them. I kept holding on to the hope that towards the end our weekly appointments-- we would get to know and understand each other better. It effected me physically, too. When she checked my blood pressure it was often on the high end. I checked it on my own several times and it was always on the lower side.

I still had a problem of not having a local doula either. When I was about 32 weeks another  doula who is 45- minutes away posted to the yahoogroup that she desperately wanted more birth experience. She seemed to beg for someone to take her under their wing. I thought she could be a good match for my birth needs. I responded to her post. Without even calling me to get details, she determined that I lived too far. Frustrating.

The one good thing is that my friends in Florida continued to provide the optimism I needed. I was actually enjoying this pregnancy despite all this. It was suggested several times that I look into unassisted birth. Mistakenly it was assumed because my husband and I are physicians we could handle it. Going back to my birth plan, I thought birth was a time to be shared, not go into isolation. Woman who had unassisted birth often had above-average-supportive husbands. My husband and I mutually agreed that he did not fit this role. I wanted to know if I was alone for a long labor who would help me change positions, take photos, watch my other children, explain to my children what was going on, make phone calls, get snacks, help clean-up, do laundry, and comfort me. I certainly could not do all that. A planned unassisted birth was not for me. I want a strong birth team.

Several of my doula friends expressed sincere interest all along in coming to me for my due date. It was so hard to believe this could come true. I was a long ways away. At the 35-weeks, I went down to Florida to visit. I was proud to flaunt my pregnancy around people who cared. A midwife and several doulas were interested in caravanning to me  got together for a meeting while I was visiting to work it out the plans. I was with four women who made me feel on top of the world. I felt like my birth was the most important birth in the world. I felt like my family and needs were important. What a high! All childbearing woman should feel this way. They were actually excited to come to me and stay awhile with me around my due date. This was beginning to look like reality, not just a dream. No one knows how much their enthusiasm meant to me. I could be happy about this and enjoy the last month of my pregnancy! It wasn't too late to change providers.

Shortly after my visit to Florida, I had a 36-week prenatal appointment with the local midwife. She routinely went through her questions and fetal exam. She gets through quickly with minimum conversation and says this just gets to be "cut and dry." I guess she was trying to minimize her haste and her mutual discomfort. I felt like shouting to the midwife, "Cut and dry? I am 36 weeks pregnant. You bring a birth kit. We are supposed to be planning my birth. My sons are attentively watching you. I am thrilled with their curiosity. You're suppose to be telling me how exciting this is and how wonderful my birth will be. You are supposed to give me positive affirmations. Will my birth be cut and dry too?" When I told my husband about this, he thought that she just treats me more formally because I'm a physician, others probably get more pampering. (I want to be pampered!) She is bringing her partner to meet me the next appointment. Not that it matters anymore, but it is a let down realizing she did not make it a priority for us to meet earlier then full term. I asked to meet her at the first appointment. The mundane routine and undermining was not what I chose midwifery care for. If I was this uncomfortable, I couldn't even imagine what she thought of me. She couldn't be at ease either. How could I surrender to the joys and pains of birth if we had no relationship?

She left. I took A few deep breaths and decided to vent and e-mail my Florida birth team. I could relax. I knew help was on the way. How could childbearing women from my Florida home take the birth support in that community for granted? They are so lucky to have birth choices.

The manuscript, Responding to Cultural Diversity in Womens Health, published by the Royal Womens Hospital and the University of Melbourne, Australia, defines "culture as a way of life; it may encompass, spiritual beliefs, and practices, values, language, customs, diet, and styles of communication [and] there is considerable diversity among and within cultures, including relation to age, marital status, socio-economic or educational backgrounds, religious beliefs, ethnicity, levels of urbanization, regional variations, and duration of residence." I identified with all the defined criteria.

37 weeks-- A Poem

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Denise Punger MD FAAFP IBCLC
4640 S. 25th Street
Ft. Pierce, Florida, 34981
Copyright 2005