Rebecca Dekker:
Hi everyone. On today’s podcast we’re going to talk with Melissa Anne DuBois about shifting from the role of hospital labor and delivery nurse to home birth advocate.
Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.
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Hi everyone. For Nurses Week this year, I’m so excited to share a replay of one of my favorite episodes here at EBB, and this is an interview with registered nurse Melissa Ann DuBois about shifting from hospital labor and delivery nursing to becoming a home birth advocate. Before we get started, I do want to give you a brief trigger warning. This podcast episode does discuss obstetric racism and includes graphic descriptions of obstetric abuse.
And now I’d like to introduce our honored guest, Melissa Ann DuBois. Melissa Ann is an experienced perinatal nurse living in central Massachusetts in the US. She graduated summa cum laude from the University of Massachusetts Amherst School of Nursing in 2006 and has worked in a variety of perinatal settings since 2007, including inpatient labor and delivery, high risk obstetrics, outpatient OBGYN, a home birth practice, and postpartum home health. Melissa Ann became a childbirth educator in 2011 and a lactation counselor in 2014, and currently teaches childbirth classes for babiesincommon.com. Melissa is also the mother of three children.
In today’s replay, you’re going to listen to Melissa tell her birth story, including her unique perspective on labor and delivery nursing, which came out of her own traumatic birth experience, and how she witnessed obstetric violence and obstetric racism for many years as a labor and delivery nurse. Seeing outdated procedures being performed in hospital settings, Melissa went on to have a healing birth at home, and she tells us that story, as well as how she got involved in advocacy for expanding home birth options for families. And at the end of today’s podcast, I will share with you a brief, exciting update as to what Melissa Ann is up to now.
So, Melissa Ann, happy Nurses Week and welcome to the Evidence Based Birth® Podcast.
Melissa Anne DuBois:
Thank you so much for having me, Rebecca. I’m excited to be here.
Rebecca Dekker:
I will never forget when I first got an email from you. You had just read Babies Are Not Pizzas and you said, “We have a lot in common.”
Melissa Anne DuBois:
That’s true.
Rebecca Dekker:
And we do. We both have three kids, we’re both nurses, although you specialized in labor and delivery, whereas I never worked on a labor and delivery unit, but we both had really strong feelings about nursing and the nurse’s role and the nurse’s dilemma in the hospital.
Melissa Anne DuBois:
I want to thank you for writing your book because I devoured every word and I don’t know if you remember back when I sent you that email, I had stayed up ‘til three o’clock in the morning [laughs].
Rebecca Dekker:
That’s right, you told me you wrote me the email in the middle of the night. Yeah, I remember that now.
Melissa Anne DuBois:
I did. You know how it is as a mother, you never know when you’re going to get a chance to sit down and actually write. So at 3:00 AM with a nursing babe asleep on me I typed you this email on my phone, because I’ve read a lot of childbirth education and maternity care books. So when you came out with yours I put it on my Amazon cart but I had wrongly assumed that it was just another pregnancy preparation book, and really as you’ve described many times on your podcast and on your blog, it’s your story in large part, and it was just absolutely fascinating and it spoke to me on so many levels. So I’m just so thrilled that you’ve asked me to be on your podcast and I appreciate it.
Rebecca Dekker:
Yeah, it’s great to be able to continue this conversation. So what was it that brought you to nursing as a career?
Melissa Anne DuBois:
So like many young adults who find their way into healthcare at some point, I originally started off as a biology pre-med student in college, but very quickly realized that medical model of care, and at this point it wasn’t even maternity care, it was just kind of the diagnosis and treatment of illness, was not what was drawing me to healthcare. I kind of briefly toyed around with the idea of being a physician’s assistant and a friend of mine that was in some of my classes said, “What about being a nurse?” And at first I kind of blew off the idea. I didn’t know any nurses, a lot of people find their way into nursing because they have family members that are nurses or they had somebody that was sick and the nurses really made an impact on them caring for their loved one, but I never had any experiences like that.
So I kind of just poo-pooed the idea, but she said, “Why don’t you take nursing 101? It fulfills a general education requirement and just see if you like it.” And from the very first day I took that class, I still remember the professor’s name, her name was Genevieve Chandler. She really just explained how different nursing is than any other field of healthcare, and I was hooked.
What drew me to nursing was the large emphasis on not just caring for patients and families, but educating patients and families and really teaching people how to take care of their own health and advocate for others that can’t advocate for themselves. So, that’s how I started in nursing.
Rebecca Dekker:
Yeah. A lot of people don’t realize that a big focus in nursing school and in the nurse’s role is supposed to be on health and wellness, promoting health through basic health education of people, teaching them how to take care of their bodies and their health. It can be life changing too. I know I’ve watched … That’s what inspired me to go into nursing, is watching my mom, who was a nurse, do some basic health teaching that saved a life.
So can you tell us what was your professional experience like when you started working in labor and delivery? Did you start there right after you graduated from school?
Melissa Anne DuBois:
No. I actually took a job as a float pool nurse because the hospital that I had applied to was not accepting new graduates into labor and delivery, which is fairly common. While I don’t think you need general medical surgical experience to be a good labor and delivery nurse, I do think that it did enrich my practice, because while most people who are pregnant are healthy low risk people, there’s lots of people who come into pregnancy with chronic illnesses, and learning about the whole body systems was definitely something that helped me, specially since my first job in labor and delivery was high risk obstetrics. So the hospital that I took my first float pool job at, which basically meant that I worked on every single floor of the hospital, except labor and delivery, really proving to myself that labor and delivery was exactly what I wanted to do. But I took a job at that hospital because they had the largest labor and delivery unit in Central New York, which is where I was.
I wanted a job there, I wanted to see everything. I loved being a OB-GYN nurse, I knew I wanted to dedicate my career to this field from the very moment I first witnessed the power, strength, beauty and intelligence of pregnancy labor birth, bonding, breastfeeding. I always say in childbirth class, our bodies are very smart. So it’s still a miracle to me every day that I witness pregnancy and birth, because even though I understand the science behind it, it still seems like magic. So I wanted to learn everything about it, and I took a job at this, it was a tertiary care center with a attached medical school that had a residency program and we took care of the sickest nit people and babies in 13 counties in Central New York. We did about 4,500 deliveries a year, so I saw a lot there. I saw a lot there that I’ll probably never see again in my rest of my career, but it’s important for me to also say that none of my passion for birth and reproductive justice, evidence-based practice or family centered maternity care was fostered during my labor and delivery training.
It really wasn’t at all part of nursing school obstetric rotation, it wasn’t part of my orientation as a labor and delivery nurse. It was something that I had to kind of come about on my own.
Rebecca Dekker:
So you started off in a high risk obstetrics unit and you really felt like in order to educate yourself on evidence-based practices, on reproductive justice and other issues you had to do that outside of work.
Melissa Anne DuBois:
Yeah. I mean, like almost all of my contemporaries and even our 20th century predecessors, right? I was initially indoctrinated into the for-profit position monopolized medical industrial complex that is the United States maternity care system. It wasn’t until I watched the 2008 documentary,” The Business Of Being Born,” a year into my labor and delivery career that my eyes were really opened. I had never heard of home birth. I did work with midwives, I worked with some certified nurse midwives, but I didn’t know of any other type of direct-entry midwife, and I know that that documentary has since garnered some criticism from activists for neglecting to bring awareness to the role of institutional racism and how that played in the literal formation of the field of obstetrics and how the medicalization of childbirth has disproportionately affected Black, Indigenous and other people of color and marginalized communities. But regardless, viewing it was a pivotal moment for me that forever changed the course of my entire career, because up until that point I was essentially the star pupil, right? For the medical model of maternity care.
As a new nurse it’s hard not to get caught up in trying to prove yourself by following in line and going with the tide. I don’t know if you remember in nursing school feeling similarly, but learning the vocabulary and the lingo of medicine was exciting. It made me feel like part of an exclusive club. When you can talk shop with the big kids like elderly gravida six, para one, habitual aborter, history of secondary infertility. Admitted today for induction for labor for gestational diabetes noncompliant. Artificial rupture and Pitocin, like that kind of stuff, it makes you feel-
Rebecca Dekker:
I love how that just comes out of your mouth.
Melissa Anne DuBois:
Yeah, right? Oh, it does, right? Vacuum-assisted vaginal delivery for poor maternal pushing efforts, failure to progress, right? It’s all alluring.
Rebecca Dekker:
So you were an insider then.
Melissa Anne DuBois:
Yes, definitely.
Rebecca Dekker:
And you were very much, like you said, a pupil. You were soaking up everything, this model, this institutional model was teaching you about the failure of women’s bodies, about all of these things. So you must have, when you watched that documentary then, must have experienced some moral distress from realizing-
Melissa Anne DuBois:
Oh, absolutely.
Rebecca Dekker:
… that you were playing a role in this system.
Melissa Anne DuBois:
Yeah.
Rebecca Dekker:
What was that like?
Melissa Anne DuBois:
I just was under the impression that we were saving mothers and babies, right? So it was a regular occurrence that we were rushing down the hall for a stat emergency cesarean, heart pounding for fetal distress, NICU team called and it really felt all very important, right? The physicians that were teaching the residents would talk. I mean, this isn’t an editorialization, this is literally the physicians would say things like labor and birth are inherently dangerous, right? They would speak like that.
Rebecca Dekker:
They would say that to the residents in training?
Melissa Anne DuBois:
Yes, absolutely. And so we…So, it’s not that medical vocabulary and medical intervention doesn’t have its place. I am 100%, 1000% grateful for living, working, birthing in modern America 2020 with access to all the life saving technologies that we have, but as the research is very clear that when we utilize medical interventions as a matter of routine, we do more harm than good. That’s why the United States has some of the worse maternal and neonatal morbidity and mortality statistics out of any other industrialized nation, right?
So my introduction to obstetrics was working in this large tertiary care academic medical center that basically served two populations. One population was middle class and wealthy White families that were affiliated with the university next door in some way, and most of them lived in the suburbs. The other population was essentially disenfranchised, predominantly Black, Medicaid ensured inner city youth. A lot of 16 to 24 year old families, right?
Rebecca Dekker:
Mm-hmm (affirmative).
Melissa Anne DuBois:
And at this hospital, it’s interesting because the nurses were actively prevented from exercising basically any autonomy over the care of their patients, because doing so was considered, and this is a direct quote, “Taking learning opportunities away from the residents.” I mean, we were strictly prohibited from performing vaginal exams, even if a patient was starting to spontaneously bear down. We had to call the residents for literally everything. So, that led to a huge amount of unnecessary medical interventions. In fact…
Rebecca Dekker:
Because everything was a training opportunity for the residents.
Melissa Anne DuBois:
Absolutely, yeah. In fact, there was a worksheet that was when we closed out the chart and brought the patient to postpartum there was a billing sheet that we had to fill out, the nurses did, that we had to check all of the medical intervention that that patient had received and send it to the billing department. So this was everything from artificial rupture of membranes, internal monitoring, Pitocin infusion. I have never seen so many pudendal blocks in the entire 14 years of my career as I saw at that hospital, because that was again, another charge. We had these patients that had gotten all the way to fully dilated, who were spontaneously bearing down and did not want an epidural, were not wanting anesthesia who were held down by residents and given pudendal block.
Rebecca Dekker:
Can you describe what that is for people who aren’t familiar with that?
Melissa Anne DuBois:
So a pudendal block is, honestly I don’t even know what the statistics are, if this is even done anymore, but it’s essentially an incredibly long needle that is probably as long as your forearm that is basically inserted into the vagina and you inject a numbing agent, like lidocaine, into the infiltrate around the pudendal nerves. So before we had epidurals, for example, this was something that was done to try to numb the perineal floor, the perineum for birth. This was done while the babies were trying to crown.
So sometimes the doctor would push the baby’s head back in and insert the pudendal needle to numb the patient who is actively pushing to have the baby, right? This was not something that even provided her any relief. There are risks to pudendals, including nerve injury and tissue damage. They’ve fallen out of favor for a number of reasons, epidurals being way more effective for one, but also because they’re not very effective for providing pain relief. They’re just simply not that good. Yeah, so that was just something else so that they could check off, right? That was something else that the residents could put in their book as far as something that they had performed.
So this might be hard for people to hear me talk about, but this is something that didn’t happen that long ago and are things like that that still continue to happen and still continue to happen every day around this country, right?
Rebecca Dekker:
So you said a large part of the population giving birth there were Black. Did the labor and delivery nurse staff reflect that population or were your colleagues mostly White?
Melissa Anne DuBois:
Yeah, absolutely not. So our labor and delivery staff was exclusively White. I think in the three and a half years that I was there maybe we had one Black nurse that was a travel nurse, but it was all predominantly White. They all lived in the suburbs. I was the only one that actually lived in the city. The only Black employees on our floor were either scrub techs or housekeepers. We were never provided any type of anti-racism or implicit bias training, and in fact the work environment was seething with both covert and overt racism and microaggressions, right? So phrases like “welfare queen,” and “my tax dollar is paying for that baby,” were things that were in heavy rotation at the nurses station. As I’ve already described, there was a lot of obstetrical violence perpetrated to all patients, even the White middle class and wealthy patient. They were not protected either, but certainly it disproportionately affected the Black patients, especially since they were very young. They were mostly younger women.
My cultural competency training is pretty laughable. The only thing I remember learning in nursing school about cultural competency was basically heavily based in stereotype. One thing that sticks out to me, and of course this is like 20 years ago now, was that “American Indians are often distrusting of White men,” right? Like, really? Overly stereotypical, not at all helpful, kind of “Latina patients are more likely to dramatically express pain,” right? I remember that being another one. So pretty unhelpful, pretty-
Rebecca Dekker:
Racist.
Melissa Anne DuBois:
… dated. Racist, yeah. I mean, it was totally, totally unhelpful. As far as the physicians, there were about 35 attending OBs and all of them were in private, almost all of them were in private practice, which meant there was absolutely no accountability or oversight for the intervention rates. Because of that, they performed a lot of elective procedures. I remember one physician once would, he was pretty classic for the nurses had to take the induction bookings. So when a physician would call we’d have to take down the patient’s name, and he would routinely book people for inductions for post dates that were only 39 weeks pregnant. That like really … I mean, I don’t think you can get any more blatantly misleading than that, right? Something post dates for a patient who is literally before her due date.
There were also two clinics that serviced basically the low income inner city population. One clinic was called the Perinatal Center and it was primarily run by the residents and the medical school. The other clinic was called the Community Center, and it was run by two Black physicians and one Black midwife. The staff at that center was also predominantly Black. The contrast in the care that was provided at each center was striking. I mean, I’ll let you guess which center had better intervention rates and more culturally competent care, right? And in fact, that midwife was one of my favorite providers to work with. I learned a ton about the midwifery model of care from her and she was a big influence on my continuing education as far as providing family centered evidence-based care.
Rebecca Dekker:
I can only imagine too what it must have been like for them working in that essentially White supremacist culture environment, every day trying to protect their patients must have been very difficult for them as well.
Melissa Anne DuBois:
Yeah. It was striking. I mean, it wasn’t, like I said, these things were blatant, right? So there were times when the community center doctors were on vacation or needed practice coverage. So they would have the perinatal center providers cover, right? And I remember because the perinatal center wasn’t going to get any more money for those deliveries, those patients were often left to labor without … I mean, they were ignored. They were essentially ignored. They would admit somebody for labor and then they would ignore them for hours instead of doing what they routinely would do, which was break everybody’s water on admission and then after two hours you didn’t dilate two centimeters they would pit you. Then if you got to fully dilated they would shut off your epidural and make you start pushing immediately, which of course led to an increase in pain and decrease in ability to cope for these people. If you couldn’t push your baby out in two hours, you were given a cesarean section. I mean, this was a baby factory, right?
But the community center patients, because they weren’t going to get any extra money, they were just simply covering them, they were ignored, but it actually worked out in their favor because they had higher rates of spontaneous vaginal delivery because they weren’t actively managed, they were expectantly managed. So it actually worked in their favor, but that’s just another illustration of the stark contrast between the levels of care.
Rebecca Dekker:
Mm-hmm (affirmative). So what was your next career move after that?
Melissa Anne DuBois:
So I was in Upstate New York because my husband was in graduate school. So he graduated, we moved back to Massachusetts. So I deluded myself for a little while into thinking that the only reason why the problem with maternity care was just big tertiary care teaching hospitals and residents, right? So if I went to a community hospital it would be better. I took a job at a community hospital in the North Shore and it was, just to be brief, even worse, because it was a small hospital where there was a very small amount of providers that were running it. The hospital was so desperate for the deliveries that these providers were bringing to their hospital that the providers called all of the shots, and the intervention rates, if you can imagine, were even higher. We had a 40% cesarean section rate, and these were predominately healthy, young, middle class professional families, and they had 40% cesarean section rate.
So I only lasted there for three months. I needed to get out of there. Then I took a job at the advice of a friend at a hospital closer to Boston that had a huge midwifery population. Even though it took me over an hour to drive there and drive home every day, my three years working for that hospital was incredibly transformative. About 40% of the patients that deliver at that hospital are delivered by midwives, midwives catch 40% of the babies. Because they are one of the largest autonomous midwifery practices in New England, they managed their own patients. They consulted with physicians when medically appropriate and there were guidelines for that, but there was a huge trust between the doctors and the midwives, and there was a lot of congeniality between the doctors and the midwives. So the midwives were allowed to practice a midwifery model of care, and because there was such a large midwifery practice, that hospital really attracted physicians that enjoyed working with midwives, because if you didn’t like working with midwives and covering midwives then you didn’t last there for very long. So I met some phenomenal providers there that even as obstetricians really practiced a physiological model of care.
There were also a few other things about that hospital that really lent itself to evidence-based care. For one, all the providers that were part of the call group basically just divided up the money made from the deliveries every month equally, no matter how many deliveries were done. The thinking being it’s kind of luck of the draw whether you’re going to have a busy night or a slow night, and everybody wanted to kind of not have to take a huge pay cut because they lucked out in not getting a lot of deliveries certain night. So there wasn’t a incentive to get people delivered before your shift was over. They also had to be in-house at all times. So many hospitals the providers can go home if there’s nobody in labor, but our providers had to stay in-house. So other things like that that really just lent itself to expectant management, just allowing a physiological process of childbirth. So I learnt an incredible amount from the providers that I worked with there, and also the doulas. That was the first time that I really met any doulas and got to work with doulas. The hospital was very doula friendly.
So I learnt a ton about labor support as a labor and delivery nurse from the doulas and the midwives that I got to work with. I did not learn labor support as part of my nursing orientation. I learnt it from experience with midwives, and doulas, and conferences, and workshops, and reading, and it was all on my own time and my own dime. I was the nurse that raised my hand and said, “Me, me, me, me, me.” Every time somebody came in with a birth plan for an unmedicated birth because I wanted to get experience in supporting people through an unmedicated birth experience and get an opportunity to use those skills.
For somebody who is, for example, looking for an unmedicated birth, or just wants to know that the people taking care of them have experience with hands-on labor support, I always recommend looking at the epidural rate of the hospital. It’s not necessarily because the epidural rate, if it’s high means that you’re going to be coerced into an epidural, though that absolutely does happen, but think about if you are a labor and delivery nurse and you work at a hospital with a 90% epidural rate and the only unmedicated births that you’re seeing are mostly precipitously delivering multips that are coming off the elevator with a head crowning between their legs, right? Then you do not get really any opportunity, even if you want to. You don’t get any opportunity to learn or practice the skills of labor support. So that’s where I really got to expand my expertise in that area.
Rebecca Dekker:
Mm-hmm (affirmative). In the meantime did you have any children of your own yet by this point?
Melissa Anne DuBois:
Yeah. So I ended up leaving that community hospital because I got pregnant in 2012 with my first son. I realized, thankfully I had some foresight to think that doing a day night rotating 12 hour shift with a two plus hour commute was probably not going to work out as a new parent. So I actually took a job with a doctors group, a group of obstetricians that delivered at the hospital I was working at, they asked me to be their office nurse. So I left when I was like 32 weeks pregnant and I started working for this OB-GYN practice, which was wonderful. They were an incredible group of OB-GYNs. I learned so much from them. They treated nurses like a part of the interdisciplinary care team with our own expertise. It was awesome.
So I had my first at the hospital that I was working at, the community hospital, with the midwives that I was working with. Although that was a very, very long and arduous 36 hours of back labor, 27 hours of which I did unmedicated before I asked for an epidural because my cervix was starting to swell because I was having a premature urge to push. It was a very empowering and positive birth experience because I felt very cared for. I loved the midwifery care and I felt that the medical interventions that I ended up needing, including the epidural and a small amount of Pitocin towards the end of my labor for my very exhausted uterus. I felt like they were appropriately timed and I felt part of the decision making. So it was a wonderful experience.
So, when I was working at the OB-GYN office a couple years later, about three years later, I got pregnant with my second. At that time I had a three year old, and I was living in Central Mass, so driving to the Boston Area for prenatal care with my three year old who got car sick was just not something that I was interested in. So there’s two hospitals in the Worcester area. One was a smaller community hospital that was a Catholic institution, and for a number of reasons regarding reproductive justice I did not want to deliver at that hospital. So the other one was a large tertiary medical care medical center, and even though I had worked for one and I know how that machine works, I had kind of deluded myself into thinking that the ease of the prenatal appointments and the closeness of where I would give birth in relation to my house was going to be worth having to fight a little bit.
I thought I just have to fight a little bit for the birth I wanted. I felt like if I was experienced, a labor and delivery nurse with 10 years under my belt that I, of all people, would be able to advocate for evidence-based care, would advocate for the birth that I wanted and I found a provider that had a really good reputation with the nurses that worked at that hospital as far as OBs. They all felt that he was very hands off and low intervention and compassionate, and I found that to be true, but of course he went on vacation the week that I had the baby. So my experience was actually pretty horrible. In a nutshell, I was not believed to be in labor, even though I was a multip and a labor and delivery nurse. I was given unnecessarily aggressive vaginal exams. I was coerced into an epidural at nine centimeters that I didn’t want and didn’t need. They actually ended up giving me a spinal because I was so far along. Then because I was completely numb from the waist down I was subjected to pretty aggressive perineal stretching during the delivery that I’m actually grateful I couldn’t feel because it actually made my husband lightheaded and he had to sit down at one point.
I almost received Pitocin, but I delivered too quickly. As the doctor walked out of the room after she ordered the epidural she said, “Start pit when you’re done.” But there was no conversation with me about starting Pitocin. I almost had a vacuum delivery, but the baby came out before they could put the vacuum on the baby’s head. Again, it was less than 10 minutes of pushing and the baby wasn’t even in distress. So it was a pretty traumatic experience, and all the while I was terrified that if I spoke up they would do something to hurt me or my baby. That was the state of mind that I was in, that if I asked them to stop stretching my vagina the way that they were doing it that they would maybe cut an episiotomy, or et cetera, et cetera.
So that was a very eye-opening professional experience for me because if that happened to me, somebody who for all intents and purposes should be the most able to advocate for themselves, what is happening to the birthing families all around this country who are not in the same position as me?
Rebecca Dekker:
How did you recover from that? It sounds like a very traumatic birth.
Melissa Anne DuBois:
Well, I talked to a therapist. I think that’s important for anybody who has had a traumatic birth experience. I’ve actually been doing a lot of trainings, professional trainings with Krysta Dancy at the Birth and Trauma Support Center, and learning all about the brain and how it processes trauma and how that first six weeks of neuroplasticity after you have a traumatic event can learning how to process it in a healthy way can be the difference between basically post-traumatic stress symptoms and healthy mental emotional recovery.
So I did talk to a therapist and I channeled that into more advocacy. At that point, a few months after I had my second, I ended up trying to juggle two kids and still commute to the Boston Area, even though it was set schedule it was really difficult. So I took a job at a community hospital closer to my house and I took it with reservations because I knew that this community hospital had a high cesarean section rate and did not have the best reputation in the community for providing evidence-based care.
However, I felt like I’m in a different position now as someone who at that point had, again, 11 years experience. I was in a different position than I was when I was 24 years old at that hospital in Upstate New York where I didn’t have the same voice. So I took a job there, but as expected, the three years that I spent there was pretty traumatic professionally as well. The amounts of obstetrical violence and coercion that were occurring on a regular basis were horrifying, and the pandemic only made it worse.
So when I got pregnant with my third, that’s when I decided that if this was my last baby I was going to do it my way, and that’s when I hired the home birth midwifery team that I ended up taking a job with a year later that I work for now, Embrace Midwifery.
Rebecca Dekker:
So you had a home birth with your third baby then?
Melissa Anne DuBois:
Yeah. A home water birth. I call her my mermaid baby.
Rebecca Dekker:
And how did that contrast with your prior experience?
Melissa Anne DuBois:
Night and day. As you know, I know you had some home births too, Rebecca. There is nothing that compares to the home birth midwifery care. It’s concierge care, right? You really get to know your midwife team. They really get to know you. They care not only about the physical health of your pregnancy, but your mental and emotional health as well, whole body wellness. I had never had an OB-GYN recommend things like chiropractic care, or herbal supplements, or probiotics to me before, and all of these things were things that dramatically improved my comfort during my pregnancy, and those are things that the midwives had recommended to me.
So my labor experience was, I mean, it was hard work, don’t get me wrong. It was the hardest thing I’ve ever done in my life, but it was also kind of like a dream. I mean, I labored in my brother’s outdoor swimming pool, my brother lives across the street from me. So I labored in his swimming pool from four to eight centimeters. It was July and it was a beautiful summer day. Then I went straight from the swimming pool to the shower, and then I went straight from the shower to a warm birth tub in my dining room and pushed her out in less than 10 minutes of pushing and it was a 12 hour labor. It was unreal.
I mean, like I said, unmedicated birth is hard work. They call it labor because it’s hard work. If it was easy they would call it picnic, right? So it wasn’t a picnic, but I felt cared for, I felt safe, I felt loved and supported. The midwives didn’t lay a hand on my body without my permission ever. I felt part of the decision making. I never once thought to myself, “I really want to get in the car right now and drive to the hospital.” Maybe when her head was coming out I thought, “Can we have a time out? Maybe I changed my mind.” But then she was out, so after that I stayed in my own home. I was cared for in my own home. The midwives came and visited me at day one, day three, day seven at two weeks. It was unbelievable, and everybody deserves that care.
Rebecca Dekker:
Mm-hmm (affirmative). When was this baby born? What year?
Melissa Anne DuBois:
So my daughter Marceline was born July of 2019. So she just recently turned a year old.
Rebecca Dekker:
Okay. And you still continued working at that hospital for a little bit longer and then the pandemic hit. The United States started locking down in March of 2020. What problems did you see over the next several months in your job as a labor and delivery nurse during the height of the fear of the pandemic?
Melissa Anne DuBois:
Sure. So, to kind of set the stage with a couple examples, I mean, the hospital that I was working at before I left in patient care, there were doctors that when patients would for example just ask in childbirth class, we talk about using your brain, what are the benefits, what are the risks, what are alternatives, right? When patients would ask things like, “Well, what are the benefits and risks of a cesarean or an induction?” The providers would literally say things like if “you don’t, your baby will die,” right? So this is the state of informed decision making, or lack of I should say, that was the place that I was working at.
So, that was the foundation. Add the pandemic on top of that and of course everybody was very fearful. We didn’t know a lot about COVID-19, we didn’t have an ability to test for it. Nurses were afraid of patients, patients were afraid of nurses. All of a sudden that big part of why many nurses go into nursing, that human touch and connection, that spending time with people, we were being discouraged from spending any time in patients’ rooms, which was a culture that I was trying very hard to change. One saving grace of this hospital, so one of the main reasons why I stayed there for three years was because of the nurse manager and the nurse educator. They were phenomenal. They were very much into evidence-based practice and family centered care, and informed decision making. The nurse educator was one of the most incredible educators that I had ever worked with. She worked her tail off to do biannual, we call them “educations days,” where she would bring information from the AWHONN conferences, and journal articles, and create drills, and presentations, and workshops for best practice.
So I was working a lot with her to kind of change the culture of this hospital, from being the nurse that labors people at the desk, right? And watches the monitors, to providing these nurses with hands-on tools for helping troubleshoot dysfunctional labors and provide labor support. The nurses were thrilled. I mean, nobody was a bad person, they didn’t know any better. Most of the nurses that I worked with had only ever worked at that hospital, and again, when you have a high, excuse me, epidural rate, you don’t necessarily get the opportunity to do hands-on support.
So I was working really hard to change that culture there, and then the pandemic hit and all of a sudden it was don’t touch your patients, don’t spend time in their rooms. Give them an early epidural so in case that we had to do a emergency cesarean we won’t have to intubate because that would aerosolized an asymptomatic patient if they have Covid. It was just like a twilight zone. I mean, they were doing … And then of course there are some practices that because you don’t have all the information about Covid you have to be cautions, and I understand that, but there are other things that just simply didn’t make any sense. So for example, we had an increase in elective inductions cited for Covid, right?
These are people that didn’t have COVID-19, they had been quarantining at home because they personally did not want to be exposed or expose their baby, and they were being convinced by their providers to come in at 39 weeks for an elective induction because of “Covid,” and that doesn’t make any sense. I mean, then they were turning around and they were pushing these people to be discharged within 24 hours of a vaginal delivery, 48 hours of a cesarean birth because they didn’t want them to be unnecessarily exposed to the hospital environment for longer than they had to. Yet they were bringing them in for a three day induction that was unnecessary. So I mean, that doesn’t make any sense.
They took away nitrous because there was a fear of it possibly aerosolizing an asymptomatic Covid positive patient, yet when we started universally testing everybody for Covid on admission to the hospital they weren’t allowing people who tested negative to use nitrous, even though there are other hospitals in our region that have higher risk populations than ours that were.
Same thing with taking away doulas. Originally at the beginning of the pandemic hospitals all around the country said no visitors, partner only, and then I believe it was June, the Department of Public Health in Massachusetts put out a memo saying that we know more about COVID-19 now, we’ve got a better handle on things, and so a hospital patient should be allowed one visitor at the bedside, and for maternity patients the spouse or support person is not considered a visitor. So it’s a human right to have somebody with you and not have to labor alone. So the spouse or partner is not a visitor, and so they should be allowed to have somebody like a doula, and yet there are still hospitals all across our state that are not allowing a second support person.
Then of course there was the compulsory separation of mothers and babies that was explicitly against the World Health Organization. That’s eventually what was the straw that broke the camel’s back. I made a desperate plead to the chief of pediatrics about the separation of mothers and babies, and these were the separation of not just Covid positive mothers, but anybody with a fever or symptoms in labor, including things like chorioamnionitis or an epidural fever, which we know can cause fevers as well. So a woman with no risk factors for COVID-19 would, and a 1,000 risk factors for let’s say chorioamnionitis would spike a fever in labor and then the written protocol was to strongly recommend separation, as per the original press release from the American Academy of Pediatrics, and only if the parent protested, allow the baby to stay, but the baby would be placed in an isolette on the far end of the room and the parent would be discouraged from taking the baby out of the isolette except for feedings. So that was it, that was the last straw.
I had a patient who did have chorioamnionitis, got a fever in labor and I looked right at the chief and I said, “I’m not going to rip a baby out of a mother’s arms.” And I gave my notice the next day, I gave my two week notice the next day and I never looked back.
Rebecca Dekker:
Wow. That is very an emotional journey I’m sure, to walk away from a hospital career in labor and delivery. But I understand that you now have a new career. Can you tell us a little bit about what role you stepped into? Because you didn’t just say goodbye to that role, you really were saying hello to something new. What is your new role like? What are you doing?
Melissa Anne DuBois:
Yeah. So right now I work for actually the home birth practice that cared for me during the birth of my daughter, Marceline, last year. They’re called Embrace Midwifery. They’re run by two fantastic midwives, Rachel Blessington and Marianne Pelletier. We service women in Worcester County, which is Central Massachusetts primarily, or the towns surrounding. They had kind of toyed the idea around with me. Hey, if you’re ever interested in leaving the hospital, you know we could always use a nurse that does postpartum visits. When I was working at the hospital and I had of course a new baby, I was trying to think like how am I going to make that work still having to do shifts at the hospital and whatnot. But when I gave my notice and I hang up the phone, and I called the midwives, and I said, “I’m all yours.”
So now I primarily do their postpartum home visits. So I see patients who have delivered with our practice at home. I go visit them on day three and at the two to three week mark. So I provide the home care visits and also during, my husband is a teacher, so during school breaks I also am on call for them to be a birth assistant because the practice is overseen my Marianne Pelletier, who is a certified nurse midwife, and in Massachusetts I can work under her as a registered nurse, and that’s how I can work as a birth assistant.
Rebecca Dekker:
Yeah, so you’re able to go to home births then and be the nurse basically alongside the midwife?
Melissa Anne DuBois:
Yes, exactly. I love it. I get to give good care. I get to form relationships. Home birth is so uninterrupted. I mean, when I’m teaching childbirth class and talking to new parents about advocating for bonding time, for example, I’m trying so desperately to help them advocate for one hour of uninterrupted skin to skin, right? We call it the magic hour. That’s what I’m trying to drill home and advocate for that. In home birth everything is uninterrupted. Your labor is uninterrupted, your postpartum recovery is uninterrupted, your bonding, breastfeeding. Parent and child are kept together, and we work around you. So my particular practice is unique, I think, in the home birth community too because all three of the midwives that work with, two of them are certified nurse midwives, one of them is a certified professional midwife who is in school to become a certified nurse midwife, but they were all labor and delivery nurses before becoming midwives.
So while I don’t think that is a requirement, and I know personally so many incredible direct entry midwives in Massachusetts that provide exceptional care, I think that it makes us different because we’ve really seen what it’s like on the other side. The experience of the reality is that even if you are the busiest home birth midwife, there’s only so many births you can see in a month or a year, but we’ve all seen hundreds and thousands of people give birth and all different types of scenarios. So I think that gives us a unique perspective as far as how to care for you in the home birth environment, but also when is it appropriate to consider medical intervention or transferring of care, right?
Rebecca Dekker:
Mm-hmm (affirmative), yeah. So it sounds like you’ve kind of stepped into a new role that is more aligned with your beliefs and your perspective right now and less moral distress then when you go to work.
Melissa Anne DuBois:
Oh yeah. The panic attacks have stopped [laughs]. I now am excited to go to work. That’s for sure.
Rebecca Dekker:
What advice do you have for parents who are birthing in the hospital setting, especially during the pandemic? I mean, you painted a pretty grim picture of some hospitals. One thing I also noticed is just the variation from hospital to hospital, all within the same state. You have some hospitals really doing horrific things, others doing a pretty good job, and then even in some of the hospitals where things aren’t good you have some providers doing a great job, others abusing women. So there’s a lot of variability is kind of the takeaway point. There’s no hospitals are all bad or hospitals are all good. It’s a mix, and it kind of depends on where you are. What advice do you have for anybody who is listening right now who might feel anxious from listening to your stories? What could you tell them? Especially for people who maybe can’t choose a home birth for whatever reason, it’s not an option.
Melissa Anne DuBois:
Absolutely. Yeah, and I’ll say it again just to be clear, I’m not anti medical intervention or obstetricians. Some of my closest friends and most influential mentors are obstetricians. Home birth can’t be the answer to our broken maternity care system because not everybody is wanting an unmedicated birth, right? I think wanting an epidural is a perfectly reasonable birth plan, right? I certainly benefited from the epidural that I had with my first. I’m not anti epidural, and also some people just need medical intervention. They have a higher risk pregnancy, so home birth cannot be the only answer. But the reality is it’s really hit or miss out there, like you said.
So I have a few things, few pits of advice. One is take a childbirth education class. Knowledge is power, hands down. Number two is hire a doula. I had a doula for all three of my births, even though I was a labor delivery nurse and had a very supportive partner, and my mother was there with me, and she has four vaginal deliveries of her own. In fact, at my first birth I had the opportunity to hand pick the midwives and nurses that were taking care of me, and I still hired a doula. So hire a doula, find a way to hire a doula. There’s always a way to hire a doula.
Then after you do those two things really sit down with your partner and your birth team and think about the type of birth that you want, and then determine how important that is to you, right? If you would consider it really important, right? Then transfer your care to a provider who already offers that as the standard of care, right? I’ve heard you talk about this before, Rebecca. I love the way you describe it, you call it the “golden ticket,” right?
Rebecca Dekker:
Mm-hmm (affirmative).
Melissa Anne DuBois:
So to do anything less, and I know this is a provocative way to phrase this, but it’s very important to me to say it this way. To do anything less is to potentially participate in your own abuse, right? Because there are so many providers out there, and I’m not saying that these are bad people, but that’s just the way that they were trained. They were trained to view labor and birth as inherently dangerous. They were trained to make the decisions, they were trained to actively manage your care aggressively, and if that’s not what you’re looking for, then transfer your care. Even if, like your friend Christen, it’s the day before you have your baby. It’s never too late to transfer you care. I mean, take it from me. Even as an intelligent, very well researched, strong, outspoken advocate with 10 years experience as a labor and delivery nurse, someone who literally stood up to doctors every day, I was powerless to stop my own abuse at the hands of an obstetrical team that wanted to dictate my care, right? They just wanted me to be complicit in their machine. And when you are in labor, it’s hard to be in your logical part of your brain. You’re in your mammal monkey part of your brain, you’re in “labor land.” Fear can negatively affect your labor experience physically and emotionally.
So, so many people I tell them in childbirth class, they ask me for advice and I say that it sounds like the provider that you’re seeing or the hospital that you’re planning to deliver at isn’t supportive of your plan of care and they feel to overwhelmed with the possibility of changing, and I understand that. I decided to choose the convenience of the hospital location over the quality of care that I knew I was going to receive, and I paid for that, right? I paid for that. Birth is something that you’re going to remember for the rest of your life. So you only get to give birth to this baby one time, and so you deserve to have the birth experience that you desire, or you at least deserve to feel like the cards were stacked in your favor and you were listened to and heard and were given quality care.
Rebecca Dekker:
I love the advice you’re giving about transferring care. I was curious if you have any last words of advice about how to get the nurse on your team or find the right labor and delivery nurse for you. There is someone I follow on Instagram, Dr. Stephanie Mitchell, doctor_midwife, and she always talks about the care and labor and delivery nurse. She says, “I’ve been a labor and delivery nurse for 30 years.” And does things their way and refuses to listen to you, and I don’t want to set it up as adversarial, but in our childbirth class at Evidence Based Birth® we really coach parents on how to build a team, a mutual trusting relationship with your nurse, but how sometimes you just have to get a new nurse. Do you have any words of advice for building a connection with your nurse so that the nurse is on your team and is ready to go to bat for you and to advocate for you or when it’s time to ask for a new nurse?
Melissa Anne DuBois:
Absolutely. I think that that part of your Evidence Based Birth® childbirth education classes is vitally important. I think that’s giving somebody tools to advocate for themselves, giving the birth partner literal vocabulary for how to advocate for the birthing person, as is outlined in your classes, is a vital part of any quality childbirth education program. So if you are taking a childbirth class and that is not part of your course, then take another class, because childbirth class shouldn’t be about just learning how to be a compliant patient, right? But I would recommend, I mean, it’s not going to be a guarantee, nothing is, but when you get to labor and delivery, either before you’re placed in a room or while you’re in triage if it’s a bigger hospital, mentioning to the person that’s taking care of you or mentioning to the receptionist at the desk, was there any way I could get the nurse that loves natural childbirth? Even if you’re planning an epidural. If you get the nurse that loves natural childbirth, then you’re probably going to get someone who has done their fair share of research on evidence-based practice and providing evidence-based care. So that’s definitely something. I mean, there’s no…
Rebecca Dekker:
And they probably have a lower cesarean rate because they know how to really support people during labor.
Melissa Anne DuBois:
Absolutely.
Rebecca Dekker:
So like you said, even if you’re planning on an epidural, asking for the nurse who loves unmedicated childbirth, and then go ahead and ask for your epidural when you get in the room, but that way you-
Melissa Anne DuBois:
Exactly. Yes, exactly. And who knows? Maybe even if you’re planning an epidural she might have a couple suggestions for you before or …
Rebecca Dekker:
While you’re waiting.
Melissa Anne DuBois:
So, that is definitely one option. Then, the other thing I would say is, and I know that you talk about this in your classes as well, how to fire your nurse. A lot of us are taught to not make waves, to just follow medical advice blindly, and my advice would be don’t worry about offending anybody, because you’re never going to see these people again. You don’t have to eat Thanksgiving dinner with this nurse for the rest of your life, right? And if you stick a thorn in her side by asking to be cared for by another nurse, then there are going to be no long-term consequences of that, even though it might be awkward, even though you might feel a little bit embarrassed. The way you deliver this baby can have effects on your future health physically, emotionally, fertility, for the rest of your life, right? The way you deliver this baby can affect the way you deliver every other baby. So just don’t worry about offending anybody. You are important, your comfort is important, your mental health is important. Feeling heard and listened to is important. The research shows that the number one predictor of birth trauma is not emergency birth, or epidural birth, or unmedicated birth, or cesarean birth, it’s feeling a lack of control, feeling not listened to and heard. So don’t let politeness get in the way of the birth experience that you desire. There is no downside.
Rebecca Dekker:
All right. So you fully, wholeheartedly agree with asking for a new nurse if you need one, if you feel like you’re not being supported. The way I typically teach parents how to do this is to ask for the charge nurse. You could go out to the nurses’ station, ask to speak with the charge nurse. That might not be possible in Covid. You could say, “Can you have the charge nurse stop by my room?” And then when they come in the room you could say, “I feel like it’s really not a good fit with our labor and delivery nurse. We’d like to request a new nurse.” And that’s all it has to be, you know?
Melissa Anne DuBois:
Yeah.
Rebecca Dekker:
It’s pretty simple. Two sentences.
Melissa Anne DuBois:
Absolutely. Honestly, if you’re not jiving with that nurse, they’re probably not jiving with you. As a nurse myself, nobody wants to take care of somebody who doesn’t want them to take care of you, right? So if you really are not doing well with this nurse’s care, do her a favor. If you have to think of it as doing her a favor, think of it like that, right? Nobody wants to take care of someone who doesn’t want them there, so I completely agree. Just ask for the charge nurse, whether you ask your nurse to come in, to send her in, or you go out to the desk if you’re allowed, or a lot of hospitals have if you press the call bell, somebody comes over a speaker and talks to you.
Rebecca Dekker:
That’s true.
Melissa Anne DuBois:
You can just ask the person that answers the speaker, “Could you please ask the charge nurse to come in? We would like to speak to the nurse in charge.”
Rebecca Dekker:
Yeah. Then of course we were talking about kind of a worst case scenario, if you have to switch nurses, although it’s not really worst case. But if you do have to, there are other ways that we teach how to connect with your nurse, and just getting to know them on a human level. Just asking them about themselves. “Where are you from? Do you have any kids of your own? Where did you go to school? Are you a Cubs fan?” I don’t … What do they ask in Massachusetts?
Melissa Anne DuBois:
We would talk about the Red Sox, we would talk about.
Rebecca Dekker:
Are you a Red Sox fan?
Melissa Anne DuBois:
Exactly.
Rebecca Dekker:
Here where I live it would be, do you follow UK basketball? So yeah.
Melissa Anne DuBois:
I agree. I’ve heard some advocates be upset at this advice, that you shouldn’t have to endear yourself to someone to get quality compassionate care, and I totally get in an ideal world you shouldn’t. You should be able to act however you need to act and be however you need to be, and ask for whatever you want, right? But you and I are in the business of trying to help people get the best care in a broken system. So in a broken system, yeah, endearing yourself to the nursing staff by asking them a little bit about their family and their favorite basketball team is definitely a way to kind of bring down that fear, the informality of meeting somebody new.
Rebecca Dekker:
Yeah. It’s all about building connections. I don’t think there’s anything manipulative about wanting to have a connection with the human who is going to be there at the birth of your baby.
Melissa Anne DuBois:
Agree. It’s a life changing experience.
Rebecca Dekker:
Yeah.
Melissa Anne DuBois:
I feel connected to the people that I’ve taken care of forever. I feel like there’s a connection forever when you’re with somebody during something like that, so I agree.
Rebecca Dekker:
Yeah. Well thank you Melissa Anne so much for sharing your wisdom and your journey with us. What’s the best way for people to follow your work?
Melissa Anne DuBois:
Yeah. So you could read more about me and the team that I work with, the home birth team in Central Massachusetts at embracemidwifery.care. I also have a podcast with my colleague at Babies in Common called the Babies In Common Show. We do podcasts for expectant families and new families on a variety of topics. So you can find us on Spotify or Apple Podcasts, or babiesincommon.com.
Rebecca Dekker:
All right. Thank you so much.
Melissa Anne DuBois:
Thank you so much, Rebecca. It’s been wonderful.
Rebecca Dekker:
This podcast episode was brought to you by the book, Babies Are Not Pizzas: They’re Born, Not Delivered. Babies Are Not Pizzas is a memoir that tells the story of how I navigated a broken healthcare system and uncovered how I could still receive evidence-based care. In this book you’ll learn about the history of childbirth and midwifery, the evidence on a variety of birth topics, and how we can prevent preventable trauma in childbirth. Babies Are Not Pizzas is available on Amazon as a Kindle, paperback, hardcover, and Audible book. Get your copy today and make sure to email me after you read it to let me know your thoughts.
