If your idea of a midwife is a quirky old lady who’s stuck in the ’60s, than you need to meet Cara Muhlhahn. Muhlhahn is a Certified Nurse Midwife with over thirty years of clinical experience. She is also a mother, a jazz singer, a salsa dancer and a multilinguist. Featured in the eye-opening film The Business of Being Born, Muhlhahn is a vocal advocate for homebirth and for redefining the role of the midwife in American culture. Here, we discuss stereotypes about midwifery, what she takes issue with in the film, and what she really wanted to call her memoir. – Lindsay Armstrong
I heard that since The Business of Being Born was released, women have started scheduling their pregnancies around when you’re available. What kinds of reactions have you’ve gotten to the film?
[Laughs] I haven’t heard that particular fact yet, but all of the homebirth midwives’ practices have pretty much doubled since that film came out – in the New York City area, but not only there. Everybody is busy, busy, busy! Women who had not previously considered homebirth are definitely being inspired by it.
When you first considered taking part in the film, you were wary of how midwifery might be presented. What stereotypes do you usually encounter about midwifery?
People look at me and say, “You’re a midwife?” And just from one look, I know what they’re thinking. The visual stereotype of a midwife is someone who is old and overweight and kind of quirky, not a modern person. That distinction stands, I think, even in the educated person’s mind. The other stereotype has to do with the idea that midwives don’t know how to make clinical judgment calls. It’s very harmful and not true.
The other night, for example, I had a mom at home. She was only in labor for about three hours when she started having some very subtle signs that something was going wrong. I put an IV in, walked her to the car, and drove her to St. Vincent’s Hospital. In fifteen minutes flat she was in the labor room and she later had a Caesarian section. Everything was fine, but she needed the C-section, so I made the right judgment call.
That’s what I was so happy about in the film. There were many midwives in that movie and each of us looked like modern, scientifically and clinically prepared medical professionals, but hopefully ones with a lot of soul! [Laughs.]
The Business of Being Born has generated some very strong reactions, both positive and negative. One of the experts interviewed in the film implies that women who have C-sections may have a harder time loving their children. Many of us at Babble were surprised and offended by that. What is your take on his comment?
It feels like a dis, I think. I’ve never seen anyone who had a Caesarian have trouble loving her child. It can interfere with early bonding, but the maternal/child bond . . . those maternal instincts persist until you die, probably. The person who said that was a man and I respect him in a lot of ways, but he’s never known those exact feelings. I understand what he’s talking about in terms of saying that we need to do everything we can to promote vaginal birth both for safety and maternal bonding, but that’s it.
You know, some of my women have C-sections as well. I have a four percent C-section rate. It’s often hard, especially for moms who have planned to have a natural birth but end up needing a C-section. They sometimes have undeserved feelings of inadequacy. The last thing I want to do is to reinforce those feelings.
So your C-section rate is four percent, while most New York City hospitals have a section rate above thirty percent. Is this an advantage of home birth? What do you see as the other advantages?
The major advantage is that for women who are not afraid to give birth at home and are comfortable with that setting, they really enjoy the freedom to behave as they would normally. When women go to the hospital, even if they’re planning on a hospital birth, their labors often slow down because they’re changing places. We take them out of a normal comfort zone where they can flow in labor, to an unfamiliar place, so that’s an advantage of being at home.
For women who want to have a natural birth without pain medication, it’s also good not to have the drugs readily available! [Laughs.] When I was in labor, I begged to go to the hospital to get an epidural, but I was at home. I’m grateful that I didn’t get one; but if someone doesn’t feel that way about epidurals and interventions, then homebirth is not necessarily going to be for them.
The other thing is that we let women’s bodies have the opportunity to go into labor on their own. We give them more time before we induce, and if we do induce, we use things like castor oil instead of pitocin. A lot of the tools that we use to get babies out are simple tools that don’t have to do with machines or medicine. They have to do with walking, lunging, sleeping when you’re exhausted. It’s simple, simple stuff, but it works. They don’t use those tools in the hospital. The tools that they use in the hospital are not as effective at preventing Caesarians as our tools are.
How does this differ from the average OB/GYN and hospital experience?
Most women are not really aware of how clinical judgment calls are made in the hospital. Most women are not really aware of how clinical judgment calls are made in the hospital. They usually just give that role up to the practitioner. There are physicians who give good informed consent, but it’s more typical during obstetrical visits for all of the testing that’s available to pregnant women to be presented to the woman as though it’s just routine.
At my visits, if a woman is thirty-six, I’ll introduce the topic of an amniocentesis. I’ll explain why I’m presenting this option of testing to her and give her a cost/benefit analysis a month before she’s eligible for her amnio. Once she’s had a month to think about it, then I feel like she feels responsible for making that decision, having consulted with the expert, rather than the expert just saying, “Oh, you’re thirty-six. You need an amnio.”
It’s a subtle thing and it’s insidious, but a lot of women in that position, it’s not as if the doctor is intimidating or berating them, but the woman feels that the doctor probably knows better and maybe she doesn’t need to ask questions or shouldn’t say anything even if she wants to. It’s not like all doctors are autocrats; I don’t mean that, but the relationship implies a certain hierarchy that I do my best to reverse.
In the film it seems difficult, once you’re in the hospital, to necessarily get your ideas and preferences about the birth process heard. Do you agree?
Yes, and a lot of times women feel resentful afterwards, like they’ve lost their voice, which is not a good thing. It’s better to empower women so that if they go along with these decisions during the visits they can have a satisfying experience in the hospital. If they feel empowered, the institution won’t intimidate them.
The other piece of that, because I don’t want to vilify physicians, is that everything changes when you’re in labor. I am the homebirth midwife who begged for a Caesarian. I almost called my book that! [Laughs.] When you’re in pain, you just want to get out of it and you don’t necessarily think about how you’re going to feel afterwards.
Your job is very intense. What do you consider to be the best part of it?
People when they ask me that, they usually guess at the answer and say, “Bringing life?” That’s part of it, but that’s kind of the romantic view, because I don’t feel like I’m bringing life. The woman is giving birth and that’s a very clear distinction for me. I am facilitating a woman’s process by not getting in her way. I’m there so that when she’s afraid, I can present hope. When she’s desperate and wants to get out of it, I can encourage her. I can be her vision to let her know that she can do it. Even if I’m tired, or frustrated, or things are not going great, if I can have keep her best interests at heart throughout that then I know, at the end, I’ll feel a serious reward glow. It’s an empathetic one, because she’ll feel the same thing. She’ll say thank you to me and the appreciation is so heartfelt, because you can’t even measure what we did together. That’s what keeps me fed. That’s my soul food!
You develop stamina. It’s not that hard for me, really, to sleep two hours a night in my car. You’ve mentioned your own labor a few times here. How old is your son now?
He’s thirteen. Can you believe it?
You have a stressful job and a thirteen-year-old son! How do you stay centered?
I’ve grown and developed my survival techniques over time. I’ve psychologically adapted to being on call, and the more years I do this, the more comfortable I get with the fact that a potentially unpredictable or risky situation is always just around the corner. In terms of the schedule, it actually works for me. I don’t know, I guess you just develop the stamina. And it’s not that hard for me, really, to sleep two hours a night in my car.
You have a new memoir called Labor of Love.
A lot of my life – both positive and negative – and struggles and achievements are in that book. It’s revealing. It’s personal and I’ll just have to live with that. I’m an imperfect human being! [Laughs.] What can you do?