COLLABORATIVE NATURAL BIRTHING – NURSE-MIDWIVES, DOULAS, AND DOING IT YOUR WAY: AN INTERVIEW WITH DEBORAH FRANK
Deborah Frank is a board certified nurse-midwife (CNM) with over 32 years of experience caring for women and their families. With degrees from Duke University and Yale, she was the first CNM to be granted privileges at Cedars-Sinai hospital in Los Angeles. Having attended more than 2,500 births, Deborah is a leading voice in the fields of childbirth and women’s health.
Alanis.com: Deborah, you are true pioneer in the field of nurse-midwifery. Where and how did your extraordinary work begin?
Deborah: It was the early 70s. As a young woman, I started out in undergraduate school and went for two years. At that point, nothing had captured my attention as a path I wanted to pursue, but I had a compelling desire to find a path that I could feel very passionate about. So I ended up withdrawing from college, and in the five years after that I met and married my husband and had two children. Starting my own family was my first exposure to birth and midwifery care and that whole world. And it was something that I truly felt interested in and curious about.
We lived all over the world during that time, and I had the opportunity to see healthcare models besides the American model. In many parts of the world, midwives are the primary care providers in a system that involves collaboration and cooperation with other healthcare providers.
One of the big turning points for me was a period when we were living in San Juan, Puerto Rico, and I was working with an obstetrician who attended births at home—he was originally from Peru. I also started writing literature about breastfeeding and childbirth. So that was, essentially, the beginning. And when my children were 2 and 4 years old, we moved back to the united states.
With a growing passion for maternal-child health, I considered going to medical school to become a nurse. That decision led me to working in a small community hospital in Pennsylvania as a nursing assistant. I had been there for just a short time when a group of nursing students came through. I was flipping through one of their textbooks and it described what nurse-midwifery was about. It totally clicked with my interests in a more holistic approach to healthcare in general, and birth, more specifically. So that was the path I took. I completed my nursing degree at Duke University, and then I later received my Masters degree in nurse-midwifery from Yale.
While I was in nursing school, there was a practice in Durham, North Carolina that had an English-trained midwife, and I had the great opportunity to learn from her. The training she had received was much more interested in promoting normal birth and health maintenance, as opposed to the medical path of obstetrics, which is understandably well-schooled in pathology as well as normal birth. It is just a difference of focus.
I am always so grateful to my physician associates because when I need their expertise, I certainly need it. I need them to be very knowledgeable about complications and managing them. But I think that when you immerse yourself in pathology and complications as opposed to normal birth, it colors the perspective you bring to the day and to the birth.
After I finished my formal education, I came to California and started my nurse-midwifery practice, which I practiced here in southern California for 32 years. I just recently retired from clinical practice.
PAVING THE WAY FOR GREATER CHOICE IN THE BIRTHING PROCESS
Alanis.com: What is the distinction between a midwife and a nurse-midwife?
Deborah: Right now in the U.S., there are nurse-midwives and then midwives. There is a national board certification, but each state has different regulations. To use California as one example, here there are nurse-midwives who have nursing degrees and then go on and get master’s degrees.
There is another mechanism to become a licensed midwife in California by apprenticing with another licensed midwife, assisting a certain number of births, and also taking an exam.
I think it would be helpful if there was one credential that applied to all, but that is not how it is right now here in California. While the standards to become a nurse-midwife are pretty consistent at the national level, the standards to become a licensed midwife vary from state to state, which makes it a little complicated for the consumer.
Alanis.com: Given that you have traveled widely and seen how certain other countries handle birth and midwifery, what is your biggest concern about how we’re doing it in the United States?
Deborah: In most places in the world, midwives are the primary providers for basically healthy women, as we were discussing earlier. And the skills of an obstetrician are utilized appropriately for caring for woman with more complicated pregnancies. It goes back to the collaboration and cooperation I mentioned. There are healthcare systems that encourage this collaboration, where midwives are very much integrated into the system, regardless of where they are attending births—at home, at a birth center, or a hospital. It is a cooperative effort by all the providers to ensure the optimum care for a pregnant woman, and I see that as the ideal.
I think that in the U.S., we’re not there yet. We spend a tremendous amount of money on all aspects of healthcare except maternal-child health. And we don’t have outcome statistics that are as good as parts of the world where there are fewer resources.
Ours became a very physician-dominated system over time, and then midwives began to be slowly added back into it. It has taken time to train new midwives. And we’re just beginning to make that transition to realizing that there is a host of others with valuable roles to play, like nurse-midwives, nurse practitioners, and physicians assistants. Instead of it being a competitive environment, ideally (hopefully) we will move toward a more cooperative environment.
Alanis.com: Is there a particular healthcare organization leading the way in creating a system of cooperation?
Deborah: One example of how nurse-midwives have been successfully integrated into the system of healthcare in the U.S. would be the Kaiser system. In their model, almost all of the normal births are attended by nurse-midwives, and this has been the case for at least the past 40 years. Kaiser demonstrates a lower c-section rate, lower complication rate, and lower intervention rate. In that setting, there has been a good allocation of resources. Kaiser is research-oriented and cost-oriented as well, so they have actively looked for alternatives that would provide good outcomes at a lower cost and found it in nurse-midwives. They also found that consumers were satisfied and happy with that care.
Alanis.com: As a nurse-midwife, and one relocating to California, what did it take for you to become an integral part of the medical establishment?
Deborah: When I did my training to be a nurse-midwife on the East Coast, nurse-midwives had clinical privileges at hospitals in that region. When I came to Los Angeles, I just assumed that would be the case here, and it literally took me 25 years to get clinical practice privileges at a hospital in Los Angeles.
I don’t think it was about legality. I feel that it was about economic competition. Physicians dominated the hospitals for many, many years. I think that the concern was “If you open the door to nurse-midwives, what are we going to do?” But this has become much less so.
Alanis.com: Did the hospital privileges you acquired give you the freedom to attend births both in homes AND in hospitals—to have the legal ability to go back and forth between the two, depending on what your clients needed and wanted?
Deborah: In my own professional journey after arriving in California, for the first 12 years, I did home births exclusively. When I first came here, I thought I would offer home births as well as hospital births, but when I went to Cedars-Sinai and applied for privileges, I was told very definitively that they were not accepting application for nurse-midwives.
At that juncture in my life, I was very fortunate because I always had some avenue of clinical practice that was very satisfying, and so I had a busy home birth practice and was enjoying what I was doing. I had an excellent system of backup, so if I needed to transfer a woman to the hospital, I had a physician who was willing to accept them and willing to collaborate with me in making decisions during the pregnancy. So I chose never to take any kind of legal action or fight that battle.
I also worked at an out-of-hospital birth center. It was a really beautiful center that at one time was associated with UC Irvine, and started by D.J. Snow, a real pioneer in midwifery. It was one of the first birth centers in the country to have a cooperative relationship of that kind with a learning institution, which was really great because the residents in the medical training program were trained in our birth center. We had an effective system for those instances when someone needed to be transferred over to the hospital by ambulance, which was just a mile away. So I had exposure to how well that system worked.
I also had the opportunity to teach there, which was very exciting. I was able to do a lot of different things professionally over many years without having hospital privileges, but I was committed to seeing that happen in Los Angeles. In such a huge urban area, it was really unfortunate that a woman couldn’t choose to go to a hospital and have a baby with a nurse-midwife.
The number of women having home births in the U.S. is increasing, yet it is still an exceedingly small number compared to other countries. It’s less than 2%. So the other 98% should have access to midwifery care within hospitals.
Alanis.com: During these developmental years, was there a particular breakthrough moment?
Deborah: UCLA eventually started a nurse-midwifery education program. And once a hospital has credentials of a particular category of healthcare professionals, they are not able to deny another qualified professional of practice privileges. So once that education program was set up, I then put in an application for hospital privileges and did get them at UCLA.
Eventually, the same thing happened at Cedars as they recognized what nurse-midwives had to offer. They also needed nurse-midwives in terms of the labor force, because most physicians just can’t possibly come and sit with their patients when they’re in labor—when you have an office practice and are doing surgery. So as an adjunct to the nurses caring for the woman in labor, they hired a staff of certified nurse-midwives to help.
The nurse-midwives also became involved in the education of the obstetrics residents, which was great because the residents were able to learn about normal births from the nurse-midwives, and the nurse-midwives could learn about handling complications from the physician affiliates. So, with nurse-midwives now on the Cedars staff, I applied for privileges a second time and received them as well.
As one or two hospitals begin to include nurse-midwives, more people in a given community become familiar with nurse-midwifery—professionals and laypeople. It becomes easier. So when I applied at Saint John’s hospital in Santa Monica, although there were no nurse-midwives there yet, they were very welcoming. And I think Saint John’s is a great place for a nurse-midwifery practice because it’s a smaller, more community-based hospital.
Kaiser, on the other hand, has a great staff of midwives, but essentially whoever is there on the day you come in would be your midwife. So while it’s not quite as personal, it is still excellent care based on the midwifery model.
So now those doors are open at all those different hospitals, and I think more and more nurse-midwives are going to be applying for privileges … and we will see how it goes!
Alanis.com: For those who may be interested in training to become a nurse-midwife but who don’t live near a school offering that type of program, is there a quality distance learning program?
Deborah: Yes, the Frontier School of Nursing out of Kentucky. I was involved in the development of their distance learning nurse-midwifery program, which was the first of its kind in the U.S. In fact, theirs was the first midwifery program in the U.S., period. And then they later went on to create the distance learning program. They also offer a doctoral program, which allows for more in-depth experience and research related to nurse-midwifery.
In general, there aren’t a lot of training programs for nurse-midwives, so that is another aspect of why it hasn’t really become the standard of care—because we haven’t been able to train as many as are potentially needed.
I delivered Kendra and then Kendra’s baby – a first for me.
PREPARING FOR BIRTH – EMPOWERING PERSPECTIVES AND RESOURCES
Alanis.com: When you had your own children, what was your experience of having a midwife support you?
Deborah: I was very fortunate. With my first child, I did have some complications and needed to go to the hospital. And we had a good system worked out beforehand for transfer of care. If care was needed beyond the scope of a midwife, I knew early on that it would be readily available to me.
The second time, I had a midwife who was going to be with me, but unfortunately she had to move away right before the birth. So I did end up having a hospital birth with a physician. But I basically delivered so quickly that nobody did much of anything! I had a really long labor the first time and an exceedingly short labor the second time, which went very fast and easy.
Alanis.com: Are natural births in hospitals just as beautiful as natural births at home?
Deborah: Absolutely. I think you can have a beautiful birth in either of those settings. I really do. But it is a matter of planning for it, doing the legwork to find a care provider that is philosophically aligned with you, and checking out the hospital to see if it is going to support the things that you’re looking for.
In my practice, I did very few things differently in the hospital than I did at home births.
I think that the best place is the one where you feel the most comfortable and at ease—and that is where you are going to do the best. Some people feel more comfortable in the hospital. Conversely, If you are choosing to do a home birth just because you have fear about the hospital, I don’t think that is really the best reason to choose it.
Alanis.com: What would you say to women who are afraid (or more than afraid) of home birth?
Deborah: First, I would say it is your birth. And I always encourage people to dig deeply to know what is most important to them. And then to know that there are certain criteria to meet. I believe home birth is about everything being normal—familiar. If you are willing to keep it normal while adhering to guidelines and having a good plan for transfer if needed—care, if needed, beyond the scope of what’s available at home—I think it is a very reasonable and safe decision.
We have to recognize that giving birth has some element of risk. Things can happen in the hospital that would never happen at home. Things can happen at home that could be better handled in the hospital. The likelihood that there could be a serious problem at home that could be better handled in the hospital is about 1 in 1,000. But, overall, the woman is going to do best wherever she and her partner feel the most at ease and comfortable.
Some women want to have their babies in the hospital because they want access to options for pain management that aren’t available at home. I’ve had women interview me and say, “Are you going to be upset if I choose to have anesthesia?” And my reply to them was always “No, not at all. I am here to support you to have the kind of birth that you want and to ensure the safety and the health of your baby and of you.”
As a nurse-midwife, I was trained and equipped with a skill set that empowers women with the option to give birth without anesthesia—using lots of techniques for comfort and for the management of discomfort—but I never felt like it was my job to keep women from having pain medication. I felt my job was to help them have the kind of birth that they wanted, and I think that is just so important.
Alanis.com: Is there a particular key to empowerment that stands out for you?
Deborah: It’s about trusting your intuition; about knowing what’s going to be best for you—not having a home birth because your best friend said it was the best, or not having a hospital birth because your parents said it was the best.
Self-trust also sets the tone for what comes after your child is born—because that is the BIG step, really. It is just so important as you step into the next phase, which is parenting. It is a whole new journey.
And that self-trust also helps you in learning how to have that flexibility in your soul—the flexibility that will make all the difference as you respond to the child you’ve been given and some of the hurdles that inevitably come up as you parent.
Alanis.com: What words of wisdom or advice would you give to a woman who finds herself feeling attached to her birth plan and not really looking at options?
Deborah: My experience has been that when a woman is rigidly attached to a birth plan, it often doesn’t go as planned. So that is why I would always encourage a woman to explore the thought process early on involving how you’re hoping your birth will go; what kind of things are important to you.
I always had the luxury of having time to spend with my clients, and it takes time to have those kinds of conversations. I always wanted to know what was important to them and to help them move towards that. That was the time when I would have the conversation about the things we’re discussing here: Creating a great first plan; encouraging flexibility; and, if it doesn’t go as planned, how to handle that so you come out the other side feeling you did the very best you could.
Of course you want to do whatever you can for the safety of your baby, which sometimes means having a cesarean. Sometimes as mothers we have to sacrifice what we want for the sake of our children, that is just how it is.
Alanis.com: How much of your work as a nurse-midwife has involved counseling women and couples around the emotional, psychological, and spiritual aspects of preparing for the birth process and becoming parents?
Deborah: When I engaged with someone, I wanted them to have a sense that I was really there. There was a tremendous amount of emotional support involved. I was there to help them have a kind of birth that they wanted. But I also didn’t want someone to put too much thought into me. The bottom line was, I was there to help them have a safe birth and to be respectful of their wishes, but I didn’t have any special powers. If I felt like someone was deeply fearful or had issues larger than I felt prepared to cope with, I would encourage them to seek out additional support from a counselor or therapist, because I didn’t feel that that was my role.
Alanis.com: Are there specific childbirth preparation classes that you recommend?
Deborah: Yes, especially for first-time moms. First, I really encourage them to consider all different kinds of classes. In addition to the important techniques they learn, the classes also give women and couples exposure to others who are going through the same thing. I think they can learn a lot from each other and lend support to each other as well.
I recommend looking into Bradley classes, Lamaze classes, and hypno-birthing classes. They all have a lot to offer. My big interest is in mindfulness-based childbirth preparation and parenting classes.
What has happened recently is a lot of teachers have studied a variety of childbirth methods and integrated them—taking the best of everything and creating an eclectic preparation class. So I encourage people to call the teacher (or teachers) they’re most drawn to and talk with them about what their particular class is like. Usually, there is a method that will resonate with you personally.
Choosing a childbirth preparation class is a part of assembling a toolkit—gathering the things that you think might be helpful to you in labor. And then when labor comes upon you, you try the different techniques, and something you might have thought beforehand was going to be so helpful might not be on the day. Something you didn’t think was going to work might be the thing that helps you the most. So, again, it’s approaching the birth with flexibility and having a lot of tools that you can use to assist with coping with the sensations. On the day, you just try them and see what works for you.
THE DEEP COMFORT OF HAVING A LABOR DOULA
Alanis.com: In preparing for childbirth and gathering together one’s support team, can you also tell us about doulas?
Deborah: Surrounding yourself with those who you believe will be supportive is so essential—and having that element of trust. And yes, labor doulas can be an important part of this. They are relative newcomers to childbirth preparation and childbirth itself, within the past 10-15 years. As physicians have less and less time to be at the bedside when a woman is in labor, or in the Kaiser setting, for example, where one nurse-midwife might have to care for three or four women concurrently, the labor doula has really stepped in as a supportive female presence to be with a woman in labor.
The presence of the labor doula has demonstrated to be very powerful in terms of decreasing anxiety, decreasing the need for pain management, and also decreasing rates of intervention. So there is something deeply comforting about having another supportive female at the bedside even if she isn’t medically trained. Initially, there was a lot of resistance to doulas on behalf of the medical staff, but now they’re beginning to appreciate them in a new way. And they’re becoming much more accepted.
Labor doulas come recommended in different ways. The midwife or the obstetrician might suggest a doula, but there is also a lot of networking among pregnant woman. Childbirth classes are great for sharing ideas and information, including suggesting doulas.
Years ago, in all probability, your mother would have been with you in labor. But now, so often, that’s just not possible—and sometimes having a non-family member is really good!
In my practice, I was mostly able to provide one-on-one support when I was with a woman in labor, but not everybody has that luxury of time.
Alanis.com: What was it like for you to be available to your clients one-on-one and have a full life of your own?
Deborah: Most of my years of clinical practice I was in solo practice. And there were periods of time when I worked in partnership with one other person. I had a wonderful professional life, but there are some sacrifices you make to be on call 24-7 for the women that you take care of. As a lifestyle, I could see how working at a place like Kaiser, where you have a 40-hour week and you know what days you’re going to be there, is probably a lot easier for your own personal life. But I also think it’s great that there are different ways of doing it.
I would always plan my vacations way ahead of time, so when someone came in to interview me and they asked, “Are you going to be there for sure?” I would say, “I have a vacation planned six months from now, and I’m going to be gone for two weeks. During that time (especially because I was the only one doing the hospital births), my backup doctor will be with you. And if you’re ok with that, I would be happy to care for you. If that doesn’t work for you, I completely understand it.”
I do think that as a healthcare provider, if you’re wanting to encourage the women you care for to take care of themselves, you have to model how you do that—even with basic self-care like exercise and eating habits. You have to take some time to nourish yourself. And I think you figure it out over time. We all make choices in our lives about how to create balance. And I had the good fortune of having a profession that I was really passionate about and really engaged with. There are some other things that I didn’t get to do then, but I am getting to do them now.
PRENATAL CARE RECOMMENDATIONS
Alanis.com: What are your general recommendations for women around prenatal care?
Deborah: Ideally, in the best of all worlds, a woman begins meeting with a midwife before she even gets pregnant—to begin the conversation. While some people will already have an exercise program and healthy eating habits, for others, it really is a time to change it up. And preparing for pregnancy is a real impetus for doing that.
I focus on healthy foods as opposed to lots of supplements and following basic guidelines for a diet that is very nutrient-rich, whether a woman is vegan, vegetarian, or omnivorous. Sometimes, of course, there are women with special needs based on factors like being underweight or overweight, and in those cases there are excellent nutritionists whom I recommend.
I also strongly recommend that women do some kind of exercise for their whole pregnancy. If someone hasn’t routinely exercised, getting out for a 30-60 minute walk everyday is really great. Labor is a test of one’s stamina. And if you haven’t done any exercise, it is likely going to be very challenging. Whereas if you’re used to doing some kind of regular exercise, or if you get in the habit of doing it, it will really help with the labor.
In addition to walking, I recommend yoga and swimming, both are such great stress relievers. I don’t feel like any one exercise is THE exercise. The best exercise is the one that a woman likes and is therefore more likely to do.
POSTPARTUM RECOMMENDATIONS
Alanis.com: What are your main recommendations for women during the postpartum period?
Deborah: This is an interesting topic. As much as I would like to be able to prepare women more for what comes after, I think that developmentally it is hard for them to see beyond the birth. Understandably. At the same time, the birth is but a day in a woman’s life—and then the real work begins. And it goes on for a really long time.
Postpartum is a really critical time. So for example, after a woman had her baby (at home or at a hospital), I would have her come back and see me at 2-weeks and at 6-weeks postpartum. Sometimes, I would determine that she needed a little more attention and would have her come back more frequently.
I think it is often shocking to a couple when the new baby comes. They think: How can this little baby take up the time of two adults, 24/7? And the lifestyle changes that accompany it are often pretty challenging. I think some women are able to cope more easily with the interrupted sleep, whereas other women really find it difficult. So I do chat about it beforehand and encourage them to reach out to all the resources they have to help them at that time. If your friends come over to visit the baby, ask them to bring a meal. If you have a nice relationship with your mom and she’s able to come and help with some of the cooking, laundry, etc., that’s wonderful.
The more supported the mother is, the better she is going to do mothering her new baby.
We talked a little bit before about labor doulas, but there are also postpartum doulas. And if someone doesn’t have a family member or a friend who can help them, I encourage them to get a postpartum doula who can help with what needs to be done—and also be that quiet, reassuring, motherly presence that says, “The baby is fine. This is normal. This is what babies do.”
Most women in our country right now, when they have their first baby, have never taken care of a baby before. And suddenly they have a totally different rhythm to their days as well. Most woman work and are used to getting through their checklist everyday. Having a new baby is, honestly, a lot of repetitive tasks. If it can all be thought of as a Zen-like exercise, and if there can be some additional support for that time, I think it is tremendously helpful.
Alanis.com: Are labor doulas and postpartum doulas often the same people? And are they formally trained, like nurse-midwives?
Deborah: It’s a mix. Some doulas do both and some focus only on labor or postpartum. And there are formal training programs that people can go through to become certified as a doula. I also know doulas who were already trained nurses and now work very happily as doulas. But there is a certification process that they go through, which is very good because they’re educated to know the signs of postpartum depression, what are normal infant behaviors, how to help with breastfeeding, how to burp the baby, and more. And of course the doula would always encourage a new mom to call her pediatrician or call her medical provider when a question or concern necessitates that, but they have a lot of experience with the day-to-day aspects of mothering a newborn.
There are others levels of support as well. Right now, I am living in Ojai, California, and there is a parenting center here, The Nan Tolbert Nurturing Center. Their mission and purpose is “supporting secure beginnings” for children pre-birth to five-years-old. And they’ve just started a program for community members, comprised primarily of older women who have had kids themselves and are very much at ease with babies. They visit new moms in the community and do things like hold the baby so the mom can take a shower, make a meal, handle their email and phone calls, and those kind of things. The little things can make a big difference. And sometimes with a crying baby, it’s nice to have someone else to hold the baby just for a little while. It’s another way to not only have your family supporting you, but to have your whole community supporting you.
Alanis.com: Do these sorts of organizations and centers welcome women to help who haven’t had children of their own but have strong maternal instincts?
Deborah: I am sure they are really happy to have the support of women who, although they haven’t given birth, have so much to offer … a different perspective.
Alanis.com: What is your view on bio-identical hormone use for women?
Deborah: The use of bio-identical hormones is a very big conversation. In general, I am a strong proponent of bio-identical hormones. It is just common sense that if you are going to use hormones, you would always want to use the ones that are most like your own body’s mix.
In pregnancy, we don’t really use hormones unless someone is having fertility treatments. They occasionally come into play postpartum. I think this is a body of science that is still in development. I think that the traditional anti-depressant medications need more research as well.
Alanis.com: Would you share some thoughts on postpartum depression?
Deborah: I feel that it is very real and is probably mediated by hormonal changes. There are brain chemicals that change, and especially with our changing sleep patterns. So I always try to be very alert to the potential of postpartum depression, which is another reason why I connect woman with other good resources who might help these moms.
In terms of the identification of it, it has become a nationally recognized issue. As with any kind of depression, the longer it goes on, the longer it takes to reverse it. What I like about the midwifery approach is that it is multifaceted: It is about family support, community support, personal hygiene, sleep hygiene, and also the potential use of medication if needed—and often it is short-term use.
MINDFULNESS – A “NEW” FRONTIER IN BIRTH AND PARENTING
Alanis.com: In the field of childbirth, what are you personally most interested in or excited about right now?
Deborah: One of my current interests, something I’m going to train in, is the mindfulness practice for childbirth and early parenting preparation that I briefly mentioned earlier.
One of the things that I have noticed over the years is that you can plan for the birth, you can get the people that you feel are most philosophically aligned with you, you can do your best, but there is that affect of nature that no one has control over. So I think it is important, beforehand, to realize that you can have the perfect group for your home birth, the perfect hospital, you can have it all worked out—but one of the most important things that you can bring to the day is the flexibility we talked about … because we don’t have control over it. If you don’t bring flexibility to the day, and if the birth isn’t going quite the way you planned, it can kind of throw you off the tracks. So I’m excited about the practice of mindfulness for bringing presence and peace in the midst of everything.
Alanis.com: Beautiful. Deborah, thank you so much. We want to extend a deep thanks from all of the women whom you have supported in welcoming their children into the world. You are a symbol of support and certainty and a miracle for so many. God bless you.
Deborah: Thank you, too. It has been a pleasure.