The Return on Your Midwifery Investment

The Return on Your Midwifery Investment

KeoniThe beginning of October found us celebrating “National Midwifery Week”, and the posts on social media about midwives and the personal care that they provide to so many moms and families got me thinking about the investment that midwifery care requires, on the part of both midwives and clients. Of course, one of the biggest investments that clients make is the cost involved. Sadly, many insurance companies are not willing to cover the costs of midwifery care, especially when it comes to delivering at home. This means that families have to weigh the costs, and determine if they can afford care out-of-pocket.

Oftentimes, it is easy to see the price tag (midwives are good at giving you all the costs up front, so you know what you are paying for at the beginning!), and think that a midwife must be making pretty good money.  But I wonder, have you ever stopped to think about all the “hidden costs” that are involved with midwifery? It’s easy to think that the only time the midwife is investing is the time you are with her…your appointments, your birth (and maybe you’re one that has quick births, so it doesn’t seem like THAT much time!), and a handful of home and postpartum visits. In communication with other midwives, I have realized that many clients don’t realize all the “behind the scenes” time and costs that a midwife incurs in order to offer safe, up-to-date, competent  & individualized care to each of the families she serves. So here’s an attempt to help you realize how much you are actually receiving in return when you choose to invest in midwifery care:

  • TIME: and not just the time you see her for your appointments and birth. On average, I spend about a minimum of 20-24 hours total with a client in-person (8-10 prenatal visits, 3-4 postpartum visits, and the birth…and of course, this amount of hours can be much more than this depending upon many factors!). However, there

    After-birth paperwork

    are many hours spent on each client that you don’t see: writing notes about your history and ongoing care, filing paperwork for records, birth certificates, & tests, research when clients have questions or develop issues, answering questions via email, text & phone, submitting reports when required, attending state-required conferences, creating handouts with updated information, and the list goes on…

  • ONGOING TRAINING: if you stop and think about it, you don’t want to trust your life and the life of your baby to someone who practiced something 10 years ago, but has never reviewed her training OR has not continued learning, right?? But ongoing training takes time & money, especially when it oftentimes requires traveling for classes. Maintaining current CPR, Neonatal Resuscitation Certification and accumulating the needed CEU’s to keep your NARM certification current, CPM re-certification fees, and regular peer reviews are all ongoing commitments and costs that a midwife must stay on top of.
  • COLLABORATING CARE & NETWORKING: When a client develops a complication the requires more medical intervention, it can take a number of hours to locate medical professionals willing to see them, copy and fax records, contact the proper offices, and obtain referrals.
  • COMMUNITY RELATIONSHIPS: Another aspect of good midwifery care that is oftentimes overlooked is that of having good relationships with the local midwifery community. In order to have back-up arrangements (both for planned trips AND for unpredictable emergencies, which will occur at some point in a midwife’s career), a midwife MUST have a solid relationship with other midwives, and facilitating these relationships doesn’t just happen. Another aspect of community relationships is the side of the local medical community. To facilitate good transports when needed, a midwife needs to have a good relationship with local care providers.

    Grateful to have good relationships with my back-up and colleague, Rose Marie!

    This translates into taking the time for peer reviews, staff meetings, staying up to date on local situations and politics, taking the time take thank you gifts and notes personally when services are received, and so much more. Having a positive relationship with local hospitals and doctors translates into better, quality care for clients, so it is a very worthwhile investment of the midwife’s time and energy.

  • OFFICE FEES: These costs are more obvious, but real nonetheless. You want to be able to reach your midwife anytime, ASAP, right? So she must maintain cellphone service and a working phone. Then there is the fax service that most medical offices require for sending/receiving medical records. Internet for research, copier for providing records for other medical providers & clients, ability to print forms, handouts, etc. I might also add that most midwives are doing all of their own office work, too, so time to order supplies, keep track of bills, payments, answer inquiries and all the paperwork that is required to run a business has to happen at some point!
  • EQUIPMENT & SUPPLIES: quality equipment must be purchased and maintained in order to provide excellent, safe care. Dopplers, birth stools, testing machines, ability to sterilize instruments, repair of equipment when needed…all of these go into maintaining a midwife’s supplies.

    Birth supplies ready during a labor

    Medications also need to be purchased in order to always have them on hand (even if you don’t use them frequently, you want your midwife to have them-and many of these items are not cheap!). Keeping emergency supplies to deal with the unexpected is also a real cost, as these things need to be keep up-to-date, which mean some items need to be purchased regularly, whether they are consumed or not.

  • RELIABLE TRANSPORTATION: You want your midwife to be able to get to you anytime…which means she needs a reliable vehicle in working order. Just last month we replaced all the tires on our vehicles, as my husband felt they were getting too thin to count on them during the winter weather. We also pay more to run an AWD vehicle as we have lots of snow & ice in PA. A midwife always needs to keep her gas tank full, and regular maintenance is a must.

    A flat tire meant new tires for the vehicle had to be purchased ASAP!

    Oftentimes a midwife will routinely drive a separate vehicle to events in order to be able to leave at a moment’s notice, instead of driving with friends or family. This is additional expense she must pay for!

  • HOME & FAMILY COSTS: Another aspect of midwifery life, especially if your midwife has a family, is that of having reliable and available babysitting at a moment’s notice. Meals that can be prepared quickly, or household help during times when mom has missed lots of sleep attending births are also very real costs. A family certainly must work together in order to let mama help other families, and I am blessed to have this type of support from my husband and family. But we do pay for it-bringing in food/eating out at times and getting regular cleaning help are two ways our family has made midwifery life sustainable.
  • ON CALL STRAIN: The last item I will mention on this post is the physical, emotional and mental strain of being on-call. While most midwives stay in this field because they genuinely love serving families as they bring their babies into the world, there is the very real downside of always being on-call. If a midwife has a small, independent practice, this generally means that she is the one who always answers the phone unless she has arranged back-up. No matter how much you love what you do, there is a toll that it takes on your body to always be available. You honestly never know when the phone will ring, and you will need to totally re-arrange your plans and be ready for whatever is at hand, day or night. Most midwives’ friends get used to all plans being made with the contingency of “unless I’m at a birth”, but the honest fact is that sometimes it’s not a birth. Sometimes a client has an emergency right when you’re in the middle of a much-anticipated event, or right as you closed your eyes after being up for 40 hours, or…you name it! I’m not sure how one can put a price tag on this aspect, but it’s well worth whatever your midwife charges!

My hope is that this post can encourage families that they are making a wise investment when they utilize midwifery services, and perhaps give you a greater appreciation for all your midwife is doing to ensure that you receive quality, informative, excellent care. I’d love to hear your thoughts as you’ve read through this. If you’re a midwife, what would you add to this list (I know I haven’t covered everything!)? If you are a client who has benefited from midwifery care, what would you add or comment? Did any of these factors surprise you? Thanks for sharing your comments!

Birth Photographers: Local Options!

Birth Photographers: Local Options!

If you’ve been following the Gentle Delivery Facebook page (go like and follow here), you’ll remember seeing some photos this month of adorable newborns. April has brought some really cute babies! And there is something so precious and amazing about how these babies look in the first minutes and hours that can’t be captured at any other time. I am personally SO grateful for the dear ladies who took photos during those initial moments with my babies (one of my highlights of my baby born last year!), and it’s been something that I wish more women could have access to.

However, when I moved to State College, I was quite surprised to find out that birth photography itself isn’t a “thing” in this area. There are some great photographers willing to do newborn and “Fresh 48” sessions, but there’s not options for the mom who wants professional photos taken immediately before, during and after delivery. Now, to be fair, birth photography is a challenge-you’re asking someone to be on call, drop what they’re doing whenever you call, and to commit without knowing when, how long, and all of those details that make planning challenging.

But today I’m delighted to introduce you to some local options for birth photography that have very recently surfaced in this area! So, if you’re interested in hiring a photographer for your birth (one that can take lovely photos instead of the inexperienced shots that your midwife and her assistant get!), hopefully this list can help you by giving you some leads. If you’re wondering what all is possibly entailed in having a birth photographer at your birth, or what types of photos, etc., I would highly recommend you check out the sites of a few birth photographers that work in other areas of the country. A few of my favorites are T. Marie Photography , Monet Nicole, and Lyndsey Stone.

Catherine Malizia: Catherine recently contacted me, telling me of her interest in the area of birth photography. She stopped in my office for a visit, and I had a delightful time chatting with her and hearing about her vision to capture the amazing and special moments of birth for families. She is acquainted with birth in various settings, especially after spending some time serving with Midwives for Haiti. I think Catherine would do a beautiful job of respecting a family’s space and wishes in a birth setting-she definitely had the type of rapport that I think many moms would connect with. If you’re interested in hiring her, I’d recommend getting in touch and asking questions…she may be running some specials as she gets her “birth side” of her photography business off the ground! Besides her website (linked in her name), you can also contact via email:

Denae VigilanteDenae also works as a doula with the Doulas of Central PA agency. I had the privilege of attending a birth with Denae, and was impressed by her kind, gentle mannerisms. Birth photography is something Denae is doing more of these days, and you can check out some of her albums on her website!


Photo Credit: Denae @ Vilgilante Photography

Sara BloseSara has recently joined the State College community, and is exited to offer the option of birth photography to her photography options beginning with due dates in November. I’m looking forward to meeting Sara in person, but am glad that there is yet another option for families in this area.

Are you planning to hire a birth photographer for your birth? Or are you local to the Central PA area, and you used a birth photographer? I’d love to hear about your experiences, how you chose your photographer, and what you’re looking forward to the most, or what you appreciated the most about utilizing a photographer. I’m sure other families would love to hear of your experiences, too, so thanks for sharing!!

Some Recommended Reading

Some Recommended Reading

As we’ve headed into a new year, I’ve been taking the time to update old records/files/paperwork, etc. One of the fun things I’ve updated is my current library list. While the internet can be an excellent resource for many topics, I still enjoy a good book that can stay on my nightstand, or be read while I nurse baby (one of the best things about having a nursing baby is getting guilt-free time to sit and read a book!). This past year I was introduced to a number of books that I had not read before, and I thought it’d be fun to share a few of those titles to you, in case you’re looking for something new to read!


One of the library shelves in my office

  • Ina May’s Guide to Breastfeeding by Ina May Gaskin: I found this jewel at a thrift store this summer, and picked it up just because of Ina May’s name. It’s a great resource to have on hand if you’re wanting some extra help or information on breastfeeding issues. One thing I appreciated was that she actually dove into the issue of tongue-ties causing nursing difficulties, which is something that many manuals on breastfeeding overlook. Overall, this book was a great easy-to-read book that I would recommend adding to your home library!


  • Pushed: The Painful Truth about Modern Maternity Care by Jennifer Block: This book is not your “feel-good-warm-and-fuzzy” type, but if you’re in to making informed choice, and understanding the politics and protocols that go on behind the scenes, especially here in the US, this is an eye-opener. Jennifer explores the history behind different changes to the maternity care scene, how insurance companies dictate much of hospital’s protocols, how our lack of understanding our bodies and understanding the normal function of birth contributes to the rise of interventions, the limitations in so many areas of good alternative care options, and more. While it can be a bit depressing at times, it was definitely educational, and helpful in understanding risks vs. benefits of different medical choices.


  • The Official Lamaze Guide: Giving Birth with Confidence by Judith Lothian: While this one has been around for awhile, I had never taken the time to pick it up and read through it. I found that it really wasn’t all about a particular “method” for birth, but more about understanding how your body works, and how to work with it. Clear, concise information written in an easy-to-read style, with birth stories to boot.


  • Cut, Stapled, and Mended: When One Woman Reclaimed Her Body and Gave Birth on Her Own Terms After Cesarean By Rosanna Rosewood: This one deserves a disclaimer-while the story was fascinating, I don’t recommend or agree with everything this mama pursued in her quest for a VBAC. However, this book helped me to understand many of the challenges that brave VBAC mothers must make as they recover, heal, and prepare for birth from an emotional, spiritual and physical standpoint. I found it valuable as I seek to help mothers who desire a VBAC without having personal experience.


Besides the mentioned books, I’ve encountered a few new resources that I would heartily recommend:

  • Spinning Babies DVD’s: The Parent Workshop & Daily Essentials. Gail Tully, the instructor of these DVD’s and the brains behind the Spinning Babies website, has so many tips, suggestions and information to offer-and it all helps to make pregnancy more comfortable, understand your body, and encourage baby to be in good postion…which ultimately helps your labor, birth and recovery to go so much smoother! If you haven’t spent time on Gail’s website, it’s worth looking in to!


  • VBAC:Know the Facts by Jen Kamel: Jen has compiled an immense volume of research and facts surround VBACs, and presents them in a fascinating seminar that can be taken online or attended live. This 6+ hour seminar addresses subjects such as myths, actual research results, how and why different hopsitals have different protocols, what complications can increase risks (and how to avoid some of them!), and the list goes on and on. If you are considering a VBAC and have questions, or just want to learn more about the subject, this would be a very worthwhile investment. I learned so much from it!



More books…and they don’t all fit here, either!

This past year I had a friend who contacted me-she was newly pregnant, lived in another state, and wanted to know where to start in figuring out what she wanted for her pregnancy, birth, caregiver, etc. What a list of questions! And where do you start?!? So I’ve been on a quest to find factual, evidence-based information to help new moms in making decisions and sorting through all the myriads of opinions and information. If you have a resource that was particularly helpful to you, I’d love to hear about it! Feel free to comment (below), leave a message on the facebook page, or send me an email at: I’d love to hear from you!

And if you want to check out my updated Recommended Reading/Library List, feel free to look at it here:  Remember, clients have access to this library as part of their maternity care package!


Making an Informed Decision on Epidurals

I wrote this article on epidural anesthesia while I was in school, and I thought someone may find it helpful….it’s always important to consider ALL aspects of the information available!

There is much debate today over the use of epidural anesthesia during labor and delivery. On one hand they are reported to bring miraculous relief from labor pain, and yet on the other hand many different risks and complications have been reported. How much do we know about this method of pain relief? For how many years have epidurals been used? How is it administered? What are the possible risks and complications? How does it affect other facets of labor? What are the benefits? Let us take some time to look at the issue from the perspective of researchers who are representing both sides.

The history of epidural anesthesia:

According to one source, the epidural block was first introduced unsuccessfully in 1901. (1)  At that time, administering an epidural through the caudal region was being experimented with, but was a complex technique that required extreme skill. In 1921, Fidel Pages from Madrid, Spain, first reported on his successful results using the epidural space for insertion of anesthesia. As this method became more familiar, and new discoveries were made in the invention of better needles and equipment along with further understanding of anesthesia and its effect on the human body, the epidural block has become part of the modern medical world. (2)

How is an epidural administered?

Before administering an epidural, the patient must first be given an IV of crystalloid solution (in order to counter-act the hypotensive effect of the medication), and it must be determined that she is in active labor. The anesthesiologist will take a full history and determine if there are any contraindicating factors. Ideally, he will also talk with the patient about the possible risks and benefits of the procedure. Then she will be instructed to lay on her side, in a curled, arched position so that he can reach the vertebrae and insert a needle into the L3-4 or L4-5 area. (3) The patient must hold extremely still, as the epidural space is only 3-5 mm deep, and it is easy to accidentally puncture the dura, which can cause major headaches and other side effects. (4) Once the needle is inserted, it is replaced with a catheter, and a test dose is given to make sure that the dura has not been punctured and that the patient will not have an adverse reaction to the particular drug used. She must continue to lie on her side to prevent aortocaval compression and hypotension that results from being on her back, and the remainder of the anesthetic is injected. Some evidence of pain relief should occur within 5 minutes, and full effect should take place within 8-15 minutes. The catheter is then taped to the patient, and remains inserted so that more medication can be injected as needed for the duration of the labor. (5)

How does the epidural work?

The anesthesia of choice (usually a combination of two or more of the following: lidocaine, bupivacaine, mepivacaine, chloroprocaine) is injected into the epidural space (6), which surrounds the outside membrane of the spinal cord. Since the spinal cord carries signals to the brain, the nerve sensations can be numbed or blocked by filling the epidural space with anesthesia. This affects the areas just above and below the insertion spot. The amount of pain relief depends upon the type of anesthesia used, and the amount that is given. It is possible to have all sensations blocked so that the patient has no feeling from the waist down, or to have just enough pain relief to “take the edge off” and yet still allow the mother to be mobile. (7)

Advantages of an epidural:

Advantages of using an epidural block include:

–    Completely pain-free labor and birth experience is possible, while allowing the mother to remain aware of what is transpiring. (8)

–     Pain relief is constant for whatever length of time is desired.                                                                                                                  –     During a long, difficult labor, it can bring about needed relaxation to help the mother progress and give her strength by providing a chance to rest. (9)                                                                                                                                                                                  –     Should a cesarean become necessary, the entry route for anesthesia is already established, allowing the mother to remain awake during the surgery, thus enabling her to be a part of the birth and postpartum periods.                                                             –     If the mother is having trouble coping with labor pains, an epidural can help her to relax and enjoy the process. (10)

Disadvantages and possible complications:

–     Complications are reported to occur in about 23% of women. (11)

–     Safety to the baby is not proven.

–     Restricts the mother’s movement, as she must remain on her side in order to prevent complications and allow the catheter to stay in place. (12)

–     Lowers the blood pressure, which may make the patient feel nauseas and possibly vomit. This also affects the baby due to the reduced amount of blood flow through the placenta. (13)

–     There is a 15-20 % chance of the patient developing a fever, in which case further testing must be done in order to make sure the baby is not being negatively affected.

–     Changes the normal progress of labor, many times lengthening the second stage. (14)

–     Increases the possibility of other interventions: urinary function can become impaired, necessitating a catheter; second stage may be prolonged, indicating a higher incidence of oxytocin, episiotomy, forceps, and/or vacuum extraction. In addition, continuous fetal monitoring is indicated, and the mother’s vital signs must be closely observed. (15)

–     It can influence the baby’s heart rate. In one study, 8-12% of the women who used an epidural experienced low fetal heart decelerations, indicating fetal distress. (16)

–     The actual strength of the uterine contractions can be concealed, which can increase the possibility of uterine rupture, especially when oxytocin is involved. (17)

–     There is an 8% incidence of the dura being punctured during insertion of the catheter. This results in extreme headaches, which can last for up to a week, with some patients experiencing long term chronic problems. (18)

–     Occasionally there are women in which the epidural does not take, which can cause further discomfort and pain, along with subsequent loss of expectations. Some women experience numbing on one side and not the other, or in certain areas, which is a frustrating experience. (19)

–     The drugs do reach the baby, and depending on the degree in which he was affected, his muscle tone and reflexes can be altered and he may be excessively drowsy for his first hours of life. (20)

–     Many women experience long term backache, sometimes as a result of unknowingly straining muscles during labor, due to lack of feeling in the area. (21)

–     Paralysis can last for up to several days (this occurs in 1/500 women). (22)

–     Postpartum problems including a higher increase of jaundice in the newborn, and an increased difficulty with breast feeding have been reported. (23)


In closing, it must also be considered that pain can be a good thing. Research shows that the pain and stress of normal labor trigger the release of adrenaline and noradrenalin, which are necessary in preparing the fetal lungs to breathe air and helps to utilize the mother’s energy. Pain can be an indicator of progress, as well as a safeguard to keep the mother from assuming a position that can be harmful. When the nerves of the pelvic floor are numbed, the body is not able to make the same supply of oxytocin which causes the pushing urge. Thus the body’s natural mechanisms are altered.  Along the same lines, stress hormones cause the release of endorphins, creating a natural form of painkiller. These give the mother a type of “high” enabling her to do the work needed throughout the laboring process. (24)                                                                                                 The decision whether or not to use an epidural must be the choice of the mother, after she has been informed of all of the pros and cons on both sides. Any type of intervention is not without its risk, as we can see from this study. However, there are times when intervention is necessary, and it is important to know what the risks are when evaluating your choices. For a mother who has had a long labor without progress, and is getting tired and worn out, and epidural may be just what she needs in order for her to have a vaginal birth. At these times we are extremely grateful for medical invention and progress, but we must not forget that a woman’s body was designed to give birth, and for thousands of years this has happened without epidural anesthesia. As with any medical advancement, we must exercise caution and make wise, informed decisions concerning what is placed inside of our bodies.


  1. 1. Mandabach, Mark G., MD; article entitled “The History of Epidural Anesthesia”. Accessed on August 29, 2007, at:;jsessionid=AEA7FF46297392A08B32A41CD6976656?year=2000&index=14&absnum=506
  2. 2. Franco, A.; article entitled “Current Anesthesia & Critical Care”, accessed in August, 2007, at:
  3. 3. Article entitled “Epidural”, accessed in Aug. 2007 at:
  4. 4. Article entitled “Epidural”, accessed in Aug. 2007 at:
  5. 5. Oxhorn, Harry, Human Labor and Birth, pg. 461
  6. 6. Oxhorn, Harry; pg. 461
  7. 7. BUPA’s Health Information Team, article entitled “Epidurals for Surgery and Pain Relief”, accessed in August, 2007, at:
  8. 8. Kitzinger, Sheila; Complete Book of Pregnancy and Childbirth, The, pg. 242
  9. 9. Oxhorn, Harry;  pg. 462
  10. 10. Sears, William, MD; The Birth Book, pg. 177
  11. 11. Marsden, Wagner,MD; Born in the USA: How a Broken Maternity System Must be Fixed to Put Women and Children First, pg. 54
  12. 12. Sears, William,MD,  pg. 177
  13. 13. Kitzinger, Sheila, pg. 243
  14. 14. Wagner, Marsden, MD,  pg. 54
  15. 15. Wagner, pg. 55; Goer, Henci, Obstetric Myths Versus Research Realities,  pg. 250
  16. 16. Wagner, Marsden, MD, pg. 55
  17. 17. Oxhorn, Harry,  pg. 463
  18. 18. Various authors, article entitled “Epidural Anesthesia and Analgesia Are Not Impaired After Dural Puncture With or Without Epidural Blood Patch”, accessed in August 2007, at:
  19. 19. Kitzinger, Sheila, pg. 243; Sears, William, MD,  pg. 176
  20. 20. Cohen, Nancy, Open Season,  pg. 98
  21. 21. Sears, William, MD, pg. 175
  22. 22. Wagner, Marsden, MD, pg. 54
  23. 23. Goer, Henci, pg. 255; article entitled “Epidural Birth May Negatively Affect Breastfeeding”, accessed August 2007, at:
  24. 24. Goer, Henci, pg. 252

Check out the new pages!

This post is to bring to your attention two new pages that have been added recently. The first is a short History of Midwifery article, which may help to explain some of the differences between the midwifery care model, and other forms of midwifery care. The second page provides you with more information about some of my assistants, and the people you may meet throughout your pregnancy. Enjoy!