Transcript

[EPISODE 1: WELCOME AND INTRODUCTION]

PODCAST INTERVIEW

Anne Nicholson Weber: 01:10 Welcome to a new episode of the birth guide podcast. Today, we are learning about a wonderful option for many families, which is to give birth in a freestanding birth center. Two of my grandchildren were born in this setting and I’m a big fan. With me to talk about this are three Certified Nurse Midwives who have all had experience caring for families in the birth center model. First is Sarah Stetina, who is a Certified Nurse Midwife and currently the Director of Midwifery at the Burr Ridge Birth Center, which is a new birth center in the Chicago area. My second guest Jen Jae. Jen is currently serving as the Director of Midwifery at the Birth Center of Chicago, another new option in the Chicago area. And my third guest is Jeanine Valrie Logan, also a Certified Nurse Midwife and a Certified Lactation Specialist. She’s a birth justice activist and often speaks publicly on breastfeeding, birth justice and midwifery in the black community. She is currently working with activists to open a birth center on Chicago’s South Side. So welcome to all three of you. I’m so happy to have you here to talk about the model of care offered in freestanding birth centers. Let’s start with this question, which is what are the key cultural differences between hospital and birth center care? And maybe Sarah, you could start us off.

Sarah Stetina: 02:34 Sure. So,  I would say that the culture at birth centers is an understanding that birth is inherently a normal physiological process, and we use techniques to support physiology while hospitals maybe tend to view birth more pathologically and use more medical interventions. I would also say that hospital culture from my experience has been very paternalistic, and the understanding of client autonomy, shared decision-making  is not really modeled well. I think the concept that birthing people are patients there rather than clients — that’s a really huge difference in my opinion. A birth center is — from the design of it, to the visit length, to the education that we provided, the tools that are available — everything about a birth center is designed to be family-centered and client-centered. Which is not easy or convenient. And the hospital model is definitely about what is convenient for the providers and the nurses. And that makes all the difference in the world. I think.

Anne Nicholson Weber: 03:39 Great. Jen, maybe you could give your answer to that same question. Are there things you would want to add to that?

Jen Jaume: 03:49 I think the big thing that’s different is that midwifery is the standard of care in a  birth center. So it just changes what it looks like to be a midwife because you’re providing the expert care, and there’s not a tension between what you think is appropriate in terms of waiting and watching and being attentive and how much time you want to spend in a room. And everyone on your team is on that same page. So that is a really wonderful way to practice midwifery and to be able to provide care. We want to make the experience everything that they are dreaming it would be, so that they can really let go of some of the . . .  cause it’s always gonna have some level of anxiety and not knowing. And so how can we make the environment prepared so that they can just focus on the labor?

Anne Nicholson Weber: 04:40 So what I think I heard you say is that hospitals are more the domain of the OBS and midwives are functioning within that culture, but have less autonomy to practice the way that they’re trained to practice. Is that a fair characterization?

Jen Jaume: 04:57 Yes. And that’s highly variable from institution to institution. So some places are doing it better than others, for sure.

Anne Nicholson Weber: 05:06 Yeah. Yeah. So Jeanine, is there anything else you would want to add to that — maybe contrast your experience from the midwives’ point of view and also from the client’s point of view being in a birth center versus a hospital?

Jeanine Valrie Logan: 05:19 Yeah. When I think about birth center care, I think that is the epitome of slow living, right? So a lot of people are like, I need to slow down, take time, you know, smell the roses. I really love birth center care as you said as a consumer, but also as a midwife. It’s really one of the only places where you can actually practice the art of midwifery. Like Jen said, you slow down and you watch labor, you labor sit, which is a rare privilege that I get to do in the hospital because you have just so many things to do. You have so many people to see and calls to answer and triage to take care of.  Like there’s small moments where you can actually labor sit and provide physical and emotional support. And so I think that’s one of the biggest things about birth center care is like . .  you’re actually slowing down and preparing the space to invite —  you know, in my culture, we say the ancestor is returning. That is the space where, you know, you can really prepare that space for that sacred experience.

Anne Nicholson Weber: 06:28 Mm-hmm. So from the point of view of a family considering where they want to have their baby, what would be some of the most important considerations that you would suggest they take into account if they’re considering a hospital versus a birth center birth. Sarah?

Sarah Stetina: 06:46 I guess the first things that come to mind are they should consider any safety concerns that they have. So if someone feels unsafe in a setting, regardless of what that setting is, that’s going to make them anxious. That’s going to affect the labor process and their experience. So if someone feels inherently unsafe in a hospital, then that is not the place that they are going to have the most positive experience possible. And that could also go for a birth center or a home birth. If someone is  truly feeling like home or a birth center is incredibly unsafe — you know, there are ways to debunk some of those fears — but inherently at the end of the day, internally, if that’s something that carries fear for them then that’s not the right setting for them..

07:38 And then the other thing that I would think of is their pain medication plan. So epidurals are not an option at a birth center. So if that’s a main focus point of someone’s birth plan — which is a valid option — then a midwifery-based hospital practice maybe would be a better fit. And then ultimately understanding the pros and cons of the proximity to emergent services. So birth center midwives have the same skills and access to most of the same equipment needed to treat most emergencies  in obstetrics. But there’s the consideration of time that it takes to get from a birth center to a hospital if it’s needed. So there are a few emergencies that truly benefit from proximity to the O.R., such as a cord prolapse, where time is of the essence. And most birth centers drill for this very frequently. And we have really great community partners and we have what’s called a decision to incision time of 30 minutes. It’s our goal. Those are the things that come to mind when thinking about all the settings.

Anne Nicholson Weber: 08:39 So thinking about risk, because that’s obviously something that every family considers when they’re deciding where to have their baby, Sarah has pointed out that there are a very few instances where the fact that you have to transport from a birth center to a hospital could impact outcomes. What, Jen would you say, are you balancing against that? What are the risks that you run in the hospital that you don’t run in a birth center?

Jen Jaume: 09:06 I think knowing the team that’s going to care for you. So at the birth center, it’s usually a more intimate team and you’ve met everyone likely before you show up that day. I think that when you’re hearing advice on an emerging situation, it’s easier to hear from someone you trust. And so I find that what makes a birth good isn’t always what actually happened that day, but it’s about how connected you felt while whatever happened happened. And so I’ve cared for clients in birth centers and at home and in the hospital. And it’s all about that connection. And that’s something that you get in birth center.  And at the hospital it’s not as predictable.

Anne Nicholson Weber: 09:53 And is that because so much of labor is attended primarily by the nurses in the hospital setting, who you may or may not know —  is that what you’re referring to, or something else?

Jen Jaume: 10:04 I think if you — you won’t meet your nurse likely until that day. There’s a lot of variation in nursing care. The other thing is that you’re caring —  the provider is caring for more clients than they’re caring for at the birth center. And so it is sometimes difficult to care for everyone in the way that you would like to, not because you don’t know how, or you don’t want to, but just you can’t be in three rooms at the same time. Because it is a business where you don’t know <laugh>, who’s coming when. And that’s much easier to manage at the birth center..

Anne Nicholson Weber: 10:43 So that goes back to Jeanine’s point about the pace in the hospital. There’s just more of a sense of a rush or an urgency that you don’t have, it sounds like, in a birth center. So Jeanine, are there other risks that you take in the hospital that you don’t take in a community birth setting?

Jeanine Valrie Logan: 11:02 So looking at it from a larger perspective, we have created a system where that does not, that doesn’t work, right. We can look at outcomes in the community. We can look at people’s — like Jen said — emotional experiences, to what has happened during their labor. And it doesn’t, it doesn’t work. And so some of the risks that people are facing:  you’re risking not being listened to. You risk your options being questioned, what you intuitively know that’s going on with you and your body and your baby. You risk finding things that you normally wouldn’t find. You know, like you have this one test that might lead you to another test that might lead you to something that you weren’t interested in knowing about to begin with. So  there are many different risks in choosing to have a hospital-based birth that might not necessarily be anything about you physically, but you know, it affects your experience and your heart and your mind. A lot of people leave the hospital having had, you know, great births, like nothing happened to the mother or baby, but they just still don’t feel adequate or competent in caring for their child when they go home.

Anne Nicholson Weber: 12:21 And that goes back to Jen’s point that what makes a good birth may not be that it plays out exactly the way you expected, but that you felt throughout it that you had a connection with the people caring for you and that you were respected and listened to.

Jen Jaume: 12:35 Something I just want to say, something I think that was missing from hospital care is, like, the magic. Like, it’s not there. And they’re always coming up with initiatives to make birth better, and it’s always missing the mark on the time and attention. It’s a lot of checklists and more huddles or whatever, but it’s never — I’ve never heard the solution be, “be with your client more, listen to them more.”

Anne Nicholson Weber: 13:09 Mm-hmm. I think we’ve in a way skipped a really important predicate to this discussion, which is the difference between obstetric care and midwifery. I think when we talked about the culture of the hospital and the culture of the birth center to a large extent we’re talking about the difference in culture between obstetrics and midwifery. So maybe Sarah, you could talk a little bit about what is the core of that difference?

Sarah Stetina: 13:35 You know, there are exceptions in obstetrics and in midwifery, but as a general rule, I feel like midwives approach their client’s care in any capacity with a holistic view of shared decision making and equal partners in this care. And the obstetric model traditionally has always been that the doctor holds the power and they know what is best, and they will present what they would like to do. And that model doesn’t work for most people. And the reason we see some of the disparities and the poor maternal outcomes in general, I feel like that is the root of it. And midwifery is very much holistic, it’s human, and it takes time, as Jen has said, to do that. You cannot learn about someone in five minutes. You can’t.

Anne Nicholson Weber: 14:31 So what are the kind of practical, concrete differences that that difference in philosophy results in. what will actually be different in my care if I’m going through the midwifery model, as opposed to the obstetric model? Jen, maybe you could attack that one.

Jen Jaume: 14:50 Longer visits. Lots of discussion about what are considered routine aspects of care. And so I think when a client is considering community birth, it’s worth considering:  do they want to do the legwork to think about some of these things? Sometimes I see a client and they want me to just tell them what to do. And that’s not always a good fit for this kind of care because it does demand some like — okay, I’ve reviewed all my options and this is what I want to do. And so there is some responsibility-taking on the part of the client for their participation. Sometimes it looks like more family participation. So I feel like I’m having as much discussion with the client as I am having with their support people to make sure that everyone’s agreeing to the plan or feeling involved.

Anne Nicholson Weber: 15:39 That’s interesting. Yeah.

Jeanine Valrie Logan: 15:41 I want to just say that a lot of times when people seek community care, they’ve had children before, or this might be actually the first time someone asked them to consider, to make decisions about their own body. Right. I see people all the time and I’m telling them things or talking about, you know, these particular labs or these particular interventions. And they’re like, I don’t know, doctor, what do you think? First, I’m not a doctor and I have to remind them what a midwife is. Don’t call me that please <laugh>. And then they’re like, “I don’t know, like I’ve never had to think about  . . .  I’ve never owned this particular vessel. Right. So now you’re asking me to think about what I want to do with it. I have no idea.” So that is really telling about not only, you know, socially —  what people are bringing when they come to me for care: they’re bringing all their lives and all their traumas and their experiences — but also creating an avenue for self empowerment or self-determination. You have to decide what you want to, you know, take away from this experience.

Anne Nicholson Weber: 16:56 So as Jen is talking, I’m thinking, right, and there are people who want someone who’s going to tell them what to do and feel safer if someone else is in charge. But Jeanine, you’re raising an interesting aspect to that, which is if you’ve only ever been, kind of told what to do, and you didn’t know that you could have ownership of these kinds of decisions, then you may not know that that’s something you want. It’s interesting to me because when I pitched the question, “what’s the biggest difference between obstetrics and midwifery?”, all three of you have gone much more to the patient autonomy, the slowness, the time to be. I do think it’s important also, though, for someone who is coming into this — a first time mom who may, you know, really not know about the difference between midwifery and OB and is trying to figure out where she and her family are going to be most comfortable — she needs to understand that it’s not only this core difference in kind of values that you’re talking about, but it’s also actually a difference in style of practice. Which obviously grows out of some of what you’re talking about.

Anne Nicholson Weber: 18:31 But that hands off element to midwifery leads to some very different ways of dealing with the same situation. And maybe a good way to get at this might be to talk about a common presenting situation where there’s a choice:  whether or not to do something medical. And maybe Jen, I’ll let you come up with that. What would be a good scenario that would kind of pinpoint some of the differences in the way that a midwife versus an OB might approach it?

Jen Jaume: 18:36 I think the intervention I encountered the most was artificial rupture of the membranes, and this is strongly encouraged. Everyone needs it at the hospital. And I always — for me, it’s such a beautiful moment when it happens spontaneously for the birth giver. They’re like, Ooh, and now this has happened! And then they can understand why the next contraction will be so much stronger, because they’ve had this experience. And so it’s really like tying their physical and emotional experience just from the forces of their own body. And, and so this is intervention, this to me is like where I differed the most often. What’s the rush?

Anne Nicholson Weber: 19:28 So just to kind of clarify, you’re talking about when the bag of waters breaks and that normally will happen — I mean, that’s going to happen sometime in the labor if nobody does anything. But you’re saying that it’s very typical in the hospital for that to be done artificially. Jeanine, do you have either more to say about that example or another example that you think would be telling?

Jeanine Valrie Logan: 19:47 Yeah. I am a hospital midwife and I think it’s so funny when people come into labor — and I’m lucky to be able to have a lot of autonomy where I work at — and people come into labor and you know, they might be a couple centimeters, but they’re having contractions and they’re like, “so what are you gonna do Jeanine?” I’m like “nothing”. <laugh> Like “nothing. Let’s just see what happens.” Yeah. You know, what are we rushing for?

Anne Nicholson Weber: 20:18 So that goes back to that trust in the physiological process that, if you just leave it alone, for most women labor will work. So Sarah, could you talk a little bit about C-sections? We all know that C-section rates are very high and pretty much everybody agrees across the board who does maternity care that they are too high, that more women can be giving birth vaginally than are. What are C-section rates like at a birth center compared to comparably low risk populations who give birth in the hospital?

Sarah Stetina: 20:54 Yeah, you definitely want to compare apples to apples as far as low risk clients. We track our cesarean birth rates for clients that, you know, transfer out of the practice at any point, even antenatally — meaning during pregnancy — and if they transfer out during labor and end up having a cesarean birth. So when a birth center tells you cesarean rates, it includes all of those things. And so even just receiving care at a birth center prenatally, regardless of where you end up birthing, seems to have benefits as far as decreasing those cesarean birth rates. So most birth centers have very low cesarean birth rates in the single digits, typically under 10%. It can be as low as 3% or 4%. Where if you’re comparing that to a low risk hospital setting, it can be in the high 20s. And we’re talking about, you know, hundreds of thousands of people who aren’t having unnecessary surgery, if they had chosen a birth center experience for their care.

Anne Nicholson Weber: 22:07 So it sounds like if I’m a pregnant woman trying to decide where to have my baby and avoiding a C-section is very important to me, birth center care would make a lot of sense,

Sarah Stetina: 22:18 Absolutely.  93% of people who receive care at a birth center, regardless of where they end up birthing, go on to have a vaginal birth.

Anne Nicholson Weber: 22:28 I guess another thing you might want to talk about is natural childbirth. If avoiding a C-section is one part of wanting to have a natural childbirth,  obviously there’s much more to it . . . an unmedicated birth, a physiologic birth is another term that people have used. So Jen, first of all, sometimes I think a woman who has an instinct that she wants to birth naturally also feels like she’s being naive. Could you talk about that?

Jen Jaume: 22:56 Yes,  I think sometimes people are scared to commit to the fact that they want an unmedicated birth so that they won’t disappoint themselves. And so I’m always, it’s a tricky conversation because you want to leave room . . .  I don’t know what kind of labor this person is gonna have. So I want to leave room for all the possibilities without shame. And so how to boost confidence that you can do it, I know you can do it, but you may not want to do it at some point in your labor. And that that’s okay too, because I don’t have a crystal ball. She could have a 48 hour labor,  maybe pain management is a good decision for her. 

Anne Nicholson Weber: 23:56 So what are the alternatives to an epidural in the birth center setting? You don’t, you can’t offer that. What can you do to help a woman manage the pain of labor?

Sarah Stetina: 23:51 Universally, midwives use hydrotherapy —which is using a bath,  basically a bathtub — at some point in labor. Nearly every client at the birth center and most of my clients, even when I practiced in the hospital, opted for hydrotherapy at some point. And it’s a really awesome tool for pain relief. It really promotes relaxation and comfort and many clients go on to just stay in the tub and have a water birth. So that’s, I would say, the hallmark of a birth center as far as pain relief goes. But we have other options as well. We provide nitrous gas that helps with just kind of taking the edge off some of the pain, especially during really intense parts of labor, like transition.  We can do sterile water papules, which is a great evidence-based intervention for back pain when babies are malpositioned. And then just having a culture and a space that’s designed to promote movement. It can’t be understated that moving your body and labor really helps cope with the discomfort. And then ultimately continuous labor support. So from the midwives, from the birth assistants, many clients hire doulas.  And continuous labor support, physical, emotional support from experienced compassionate people can really improve pain and just overall birth satisfaction. Having someone tell you you can do it makes all the difference in the world.

Anne Nicholson Weber: 25:29 So currently in the Chicago area there are three birth centers. There is the birth center at PCC in Berwyn, which is the first, the pioneer. And then the birth center, Sarah, that you’re now running, the Burr Ridge Birth Center has opened. And then Jen, your birth center is the Birth Center of Chicago, which is exactly where?

Jen Jaume: 25:55 It’s in the North Center neighborhood, it’s near Irving and Lincoln is the closest big intersection.

Anne Nicholson Weber: 26:02 And then Jeanine you’re involved — you currently are doing hospital births, but you’re very engaged in trying to get a new birth center that would be on the south side of Chicago. Can you talk a little bit about your vision for that?

Jeanine Valrie Logan: 26:16 Yes. Over the last year we worked really hard to expand the numbers and the type of birth centers that can be in this area. And I’m happy to say that that licensure passed. Yeah. And so that is the hope, to offer this kind of birth option to folks on the South Side, particularly where many of the OB units have closed. Like I said earlier, this what the systems we currently have in place are not serving — not serving us collectively and specifically women of color and black women. So the hope is to have a culturally safe and competent place for women on the South Side to go to have love shared with them during their prenatal care and postpartum care. And to be able to have that in a midwife-led, nonprofit birth center.

Anne Nicholson Weber: 27:21 Great. Mm-hmm.  How far away can you live from a birth center and safely choose to give birth there? In other words, how far is it safe to travel during labor? What do you advise your clients

Jen Jaume: 27:33 So, first time moms can travel further.  But I think something that —  it’s not always just that labor travel time, but coming to every visit. I say that if it’s more than an hour away, it can become burdensome, especially in the early postpartum period, since those visits are a little bit tough that first time you leave the house. And so obviously I’ll take clients that are coming from much further than over an hour away, but I’m always trying to balance; I want to make sure that they’re taking care of themselves.

Jeanine Valrie Logan: 28:06 I live pretty far from the birth center and in my third labor, it was like, the minute I felt I was in labor, I had to call the birth center midwives. Like “I’m on my way. <laugh>, I’ll be there in two hours maybe, but I’m on my way.”

Anne Nicholson Weber: 28:22 You know, we’re lucky in, in Chicago, in the Chicago area, there are a lot of options. There are many good hospitals including hospitals where you can experience the midwifery model of care if that’s what you’re attracted to. But there are some people, I think, who might live further out, who don’t feel comfortable with the kind of care being offered at the hospitals near them. And Jeanine, it sounds like you were willing to travel two hours — did I hear that right? — in order to get this kind of care. And I think all of you are saying that’s safe, by and large. There’s no reason why, if you are that far away and this is something you’re really attracted to, you should, you know, not consider it. So there are, I think, risk profiles that can preclude freestanding birth center care being appropriate. Sarah, maybe you could talk about some of the common conditions that would risk you out of birth center care?

Sarah Stetina: 29:23 For the most part, anyone that has chronic health conditions that need medical management. So things like preexisting diabetes or preexisting high blood pressure, other organ systems like liver disease or lung disease, those would be really an indication for having a hospital birth. Things that come up during pregnancy that we look for as providers, as midwives, and we screen for — part of the reason prenatal care is done — and so that’s things like gestational diabetes that needs medication management, you know, hospital birth is a better option, a safer option. And same with things like high blood pressure, preeclampsia that develops. Twin pregnancies, typically birth centers do not do multiple gestations. But like we’ve mentioned, most people are candidates for birth center birth if that’s what they want.

Anne Nicholson Weber: 30:20 So you’re saying that don’t assume you’re too high risk. If you’re interested in this model of care, consult and find out whether you would be a candidate,

Sarah Stetina: 30:29 Absolutely. Consult with a birth center midwife.

Anne Nicholson Weber: 30:33 Jeanine, what are misconceptions that you hear about birth center care? Like people say, oh, I wouldn’t want birth center birth because . . .  What kind of things do you think are misconceptions that are common?

Jeanine Valrie Logan: 30:47 I think one of the major misconceptions is just not understanding the different roles that healthcare providers have.  I see a lot of people that —  I see them throughout the whole pregnancy, and then we’re again reviewing like visitor policies and when to call the midwife and then they ask me, “so when do I call the doctor?” <laugh>  I’ve been seeing you this whole time,  I’ve explained to you what a midwife is <laugh>. And so particularly when you’re having out-of-hospital birth, whether that be home birth or birth center, I think people just don’t understand the full scope of what midwives are trained to do. You know, they just don’t understand what it really means to have that kind of care. And so people will choose just to do what the majority of people in their lives are doing — you know, going to the hospital, getting an epidural —  because they don’t, they don’t see themselves in that space.

Sarah Stetina: 31:49 I would add to that that safety is a big concern that I think people have.  That if birth is not in the hospital, then it’s probably — or definitely –not safe. But there’s plenty of data that shows that birth centers might actually be one of the safest models when you look at outcomes. And we did talk a little bit about the time of transferring to a hospital, but even with that consideration, even with transfer rates, our outcomes are still great. And so you don’t have to exchange safety for a positive experience. You can have both. And I think that is what I spend the most of my time doing at consults — is showing people the data on what safety of a birth center actually is. Because the cultural or societal kind of understanding is that the only place to stay safe is in the hospital. And that isn’t true for everyone.

Jen Jaume: 32:51 I feel like what I get a lot is, this is a low intervention environment, but people are surprised that we do things like IVs and administer medications, and know how to resuscitate newborns. And so that’s where that safety piece comes in. But I get a lot of questions about, “You do IVs?!”.  And it’s like, “Yes! It’s within the scope of everyone who provides care here.”

Anne Nicholson Weber: 33:16 Maybe one last thing we could just try to define is: What is the midwife’s expertise?

Sarah Stetina: 33:23 A lot ! <laugh> Midwives are experts in, obviously, pregnancy and birth and labor and the immediate postpartum period. But our scope and our expertise can extend really far from there. So at the birth center, we provide newborn care for the first two weeks of life. And that’s a great thing to do because caring for the birthing person and the newborn together makes a lot of sense for looking at that holistic model again, and looking at them as a couplet, as a unit. But we also do, like Jen said, we’re capable of putting in IVs, of doing procedures, of, you know, administering and prescribing medications, ordering testing, and imaging. It’s not like you miss out on all of the testing and screening options when you do need an intervention, just because you selected a midwife. You get all of that. You just don’t get it routinely in a way that isn’t individualized.

Anne Nicholson Weber: 34:23 Okay. Anything that anybody feels like it’s important that we add to this? What have we missed?

Jeanine Valrie Logan: 34:30 I feel like I really want people to be able to —  with confidence —  say that whether I’m in the hospital, whether I’m in the birth center or whether I’m at home, I have autonomy and I’m going to be listened to, and I’m going to feel safe. Because we practice in all those settings. So, you know, I want people to be able to choose where they want to get their midwifery care. And vice versa. I would like providers to have birth centers and even home birth as an option. So when you see someone and you know, that’s not your setting, but you ask them, “What are your hopes and dreams for your birth?” And they say, “well, I really want to be at home.” Then say, “Hey, these are home birth midwives you should talk to before you come back and see me.” Especially with a lot of new ideology that providers are starting to adapt around birth justice or community birth. Like that is really what that looks like.

Anne Nicholson Weber: 35:27 I think something that families struggle with is the norm. I mean, the norm is a hospital birth with an OB. And when you go outside the norm, it feels a little scary. Like if everybody, you know has done it one way and you have some instinctive desire to do it a different way, you’re going out into unexplored territory and you also are likely to be subject to some judgment. There’s a lot of judgment around birth, which I think is so unfortunate. So I think some of this is about giving people the courage to understand that just because it’s not what everybody does doesn’t mean that it’s irresponsible, that it’s not safe. It’s just a different choice because you might have different values or different priorities for your own birth.

Sarah Stetina: 36:13 I would add to that too, that it is the norm in other places. Midwifery care is the standard of care and the entry level of care in many other countries that have much better outcomes than we do. And one way that I sometimes explain it to clients is just that when you go to see your family practice doctor for an annual checkup, that’s where you start, you start with your family practice doctor, and if they find something abnormal with your heart, they refer you to a cardiologist. And so midwifery is the same way. You should start with a midwife and, if something becomes complicated or high risk, then we refer you to the obstetrician. But in our country, you start with the specialist.

Anne Nicholson Weber: 36:55 I think that’s a thing that’s hard sometimes to accept —  that what seems like more sophisticated interventions in birth are actually not improving outcomes. That’s just the fact. So how do we address that? And I think freestanding birth centers is one fantastic option for families for whom it’s the right kind of care. Thank you again for your time. I’m so grateful to you for joining me. 

Jeanine Valrie Logan: 37:19 Thanks Anne.

Sarah Stetina: 37:20 Thanks Anne.

Anne Nicholson Weber: 37:22 This episode of The BirthGuide Podcast is sponsored by The Birth Center at PCC, a homelike facility in Berwyn Illinois, where patients give birth without medication in the care of PCC’s Certified Nurse Midwives.