#37 | Hospital To Home: A Midwife's Perspective: Interview with NYC Midwife Chloë Lubell

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth

Chloe Lubell is in New York City based midwife who spent the first part of her career working in a hospital based practice. As much as the hospital sought to support all people, Chloe didn't see that happening very much in practice. She also felt while hospital administrators are coming from a good place, there were limitations imposed that weren't necessarily in the clients best interest. What she found was the only way to truly fulfill her life's work was to open her own home birth practice.

In this episode, Chloe shares more about what went into that decision and why home birth makes so much sense for the clients she serves. We're really excited to speak with you because we know you've been a hospital based midwife in New York City for a number of years. And you've recently made the decision to switch into home birth midwifery after experiencing your own home birth. So we'd love to start off today just by hearing what went into that decision.

I love being a midwife, and I've been a midwife in a number of different locations. I've been a midwife in a freestanding birthing center that had an alongside hospital unit where I was able to transfer my clients back and forth between the two. I've been in a public hospital for a number of years. And then most recently, I was in a private practice at a hospital that had an in hospital birthing center that most recently closed. You know, my commitment to hospital birth started with my commitment to making sure that midwifery care is available for all of the people who need it, especially people who are in low resource settings or even people here in New York City where I within work who are undocumented, uninsured, low income, because midwifery care can offer so much to someone who is otherwise underserved.

So My original thought on the matter was that I wouldn't be able to provide home birth midwifery to those people, because those are the people who are giving birth in hospitals. So that's why I was there for now six years. But most recently, I've been working in a private practice. And even though we have committed to accepting as many Medicaid clients and under under insured clients as we can, I'm still not seeing all that many people who are outside of the realm of normal common midwifery clients, which might mean in New York City means most of the people seeking out midwifery care are white, well educated middle class sis heterosexual women. And so it got to a point for me where I realized that I wasn't providing the care that I wanted to, to the people that I wanted to and it's to work in a hospital in New York City, there's a lot of drama between four different people in the mix the doctors and the midwives and the nurses and mostly the administration. And so I am really looking forward to being able to step outside of all of that and just focus on providing the care that I know my clients deserve.

Can you speak a little bit to what the barriers were in the hospital to the kind of care that you wanted to provide as a midwife and what was working for you and what wasn't? And were there any specific things that really stood out as just like major blocks to being the midwife you want it to be? each hospital has its own pros and cons, from the different places that I've worked.

The hospital that I've been in, has a long standing culture of midwifery care that slowly over the past few years and being chipped away at so There's the history of beautiful midwifery, low intervention, physiologic birth culture. The nurses understand that the doctors understand that. But as a new administration has taken over, it's changed the culture now things that used to be expected, like intermittent monitoring or access to hydrotherapy during labor, showers, baths, those things we now have to argue about, and that's not everyone at the hospital. It's just as you come in, if it just so happens that you have arrived on a day when a certain doctor or a certain nurses working, we have to have the conversation about policies over and over again, and just we address what is the policy because there isn't any administrative backup on that.

You're actually seeing in the hospitals that it's Working the opposite way that instead of further supporting those protocols, you're getting more resistance to them.

Yeah. New York City is a strange place for birth. There's very little support for out of hospital birth. And in the hospital, there's very, very little support for midwives, other places in the country. This is not the case. And in fact, other places in New York State, this is not the case. But what I've seen in New York City is sort of surprising because we would expect New York City to be a leader in all things including midwifery care, and evidence based maternity and but we don't see that, unfortunately.

So I'd love to ask you a question that my clients asked me very frequently. Why if the you know, the evidence based data is so available, we know quite clearly that intermittent auscultation, for example, is associated with better birth outcomes. Why are you or couples ever put in the position of having to defend those practices? What is happening at the administrative level? Where is it that they're uninformed? Is it that they view it as some kind of obstacle to their profits or their practices? What is the issue? Why is this so difficult? What's your insight on that? You know,

that there's nothing malicious behind it. That's the important thing to remember. It's absolutely no one is there saying, oh, how can I make more money here? I'm gonna have more c sections. You know, it's definitely people with different opinions, thinking that they can support their clients best in the way that they know how, and they may simply not have the most up to date information, but they're also not that willing to learn. I think that's a major issue is that even as per example, eating during labor becomes not only common but recommended by all of the professional organizations, the organizations for the obstetricians for the nurse midwives, and certified midwives. And also for anesthesiologists, there are still many anesthesiologist who are practicing who say Actually, no. When I give you an epidural, you can't eat because of the risk associated with aspiration, which we all know is ridiculous, but it's something that we continue to come across. It's that really dangerous phrase that everybody loves, which is that the way we do it here.

So it's the unwillingness to change. It's the unwillingness to learn or the lack of access to the information. So I mean, I know as a midwife, myself that we come from very different backgrounds of education, there's medical school, and there's midwifery school, and one teaches physiologic birth and one teaches pathologic birth for the most part, and so we're coming at it from really different places to begin with. And then if you have a culture in a work environment where those two areas aren't really willing to work together, this is how it goes.

So in planning your own home birth, what surprised you?

So I didn't find all that much different in the prenatal care itself. There's a difference perhaps in the way that we approach the normalcy of birth as a hospital based midwife, even in a private practice. I know it's so healthy and normal to go past the due date. But as we get to that point, I start to see the shadows of the hospital around me and I want to best protect my client as well as I can. And I know that I protect them by helping them to avoid it. induction and therefore, medical intervention. And in my hospital, we talk about inducing labor at 42 weeks. So if, if my client is getting closer and closer to that cut off, I'm doing everything I can to get her to go into labor. Whereas my home birth midwife as I went past my due date, and as I started to really lose my grasp on reality, because I was so done with being pregnant, kept saying to me, it's okay. We don't need to do anything. We don't need to touch you. We don't need to do a membrane sweep. We can just wait. I find myself in the hospital. And describing myself to people oftentimes is sort of like a birth bouncer. I'm standing in the doorway between my clients and the rest of the hospital. And I'm midwifing both  my clients through their labor through their birth and, and helping them and then sometimes I'm doing things that I wouldn't If we were at home because I know that that's the best way to get my patient as close as they need to be to the birth that they want.

So for example, if it's a question of, you know, if we were at home, I wouldn't check you right now. But here if I check, you can then go outside to talk to the on call attending the nursing staff and explain to them what's going on. So in an intervention in the hospital, that I wouldn't do out of the hospital, not because of any need, but because it then allows everybody else to come down and and allows the birth to progress further in the direction that we want it to.

Is there any point at which your home birth midwife would have suggested inducing you if you had gone past 42 weeks. It would have been a conversation at all steps of the way and honestly, I don't know that I would ever be right. I don't know that I would have felt trouble going past 42 weeks, but it would have been a discussion, there would have been ultrasounds to evaluate my placenta function and amniotic fluid level and to see how I felt, I probably would have chosen induction at that point because I was really, really done with being pregnant, but it was reassuring to have someone so fully trust in in my body.

Were you always committed to the idea of a home birth? Or was that something that changed over the course of your pregnancy where you knew you were going to have a home birth from before you got pregnant?

How did that How did you come to that? I was pretty sure I was gonna have a home birth or wanted to have a home birth from before I got pregnant. I felt really reassured in the fact that unlike the average person in New York City, choosing home birth, if I had to transfer I knew I could transfer to my colleagues. I knew that basically any hospital in the city that I ended transferring to if I had to, I would have someone there that I knew. which is not the case for most people choosing home birth in the city.

And that's one of the biggest challenges of home birth in general, both for the client and being the midwife is how you are received, when it's time to make a transfer and is your care going to be appropriate or is it Are you going to be criticized for coming to the hospital? Are you going to be welcomed? Are you going to be supported? What do you anticipate that is going to look like for you being a home birth midwife in the city?

I hope that it's okay.

My goal is to transfer to places that I know will be accepting and hopefully be able to transfer smartly. That's the whole goal. As a new home birth midwife. I don't have the drive to stay home at all costs. I am comfortable transferring to the hospital, even in situations where a more experienced midwife might not. My goal is to be safe. If the worst thing is that I transfer when maybe I didn't need to. That's not a bad thing.

I'm curious. Right now there seems to be a strong movement toward home birth, in part because of where we are in the world right now with a global pandemic and people being very fearful of hospitals and very fearful of separation of mother and baby if they go to the hospital exposure to the virus. Can you help our listeners understand a little bit about why they might choose home birth or who might not be a good candidate for that we are just we get a lot of questions about Should I make this change? And I think home birth is going to be forever changed after this as people start thinking about it differently. But people have so many questions about safety of home birth and who's a good fit and who's not. And what does it look like?

Right now, my main opinion on this is that I think the most important thing to pay attention to is that home is not the place to be if you're scared of the hospital. And the truth is that the hospital was never free of disease.There's always been disease there in the labor and delivery floors in the labor and delivery rooms.

We have always done our best to separate contagious diseases from the rest of the hospital, but it's always been that that's where sick people go. And the beauty is that when you're there, you have access to all sorts of interventions that might be necessary. So if you're choosing to go to hospital right now. It's not all that different from how it has been previously for labor delivery. It looks different. Everybody's wearing hats and goggles and masks and gowns and gloves and they look like they're about to, you know, get on a spaceship to the moon, but the attitude around birth is the same. When it comes down to what do we do now in this labor that has, you know, the contractions are spacing apart. It's not going to change what we do the fact that there is Coronavirus elsewhere in the hospital.

I think when you are choosing to be at home, you have to be really committed to it. You have to really know that you don't want to be outside of your home that you feel safe in your home and that most of all you trust your care provider. home birth is safe when the providers are experienced. And well trained. So it's most important that you find someone that you trust, and that you click with. I think finding a provider that you want to give birth with is more important than finding the location.

I've always said the same thing, choose the provider more than the facility because they're your they're your protector, for one, they are going to have more responsibility than just random hospital policy. Right. But who you hire is the first important piece of that decision before location.

Absolutely. Yeah, that's definitely what I would say because it's, you know, there are there are lovely midwives, there are brilliant midwives and then there are midwives that are just phoning it in just like every single other line of work. So it's important to find the person that you you trust will always have your best interests at heart, even if things don't go the way that you want them to. So if you have an OB That you trust to have your best interests at heart when they say actually, I think it's time for you to give birth by cesarean. You know that they're doing it because they've exhausted all other options, not because they're trying to get home to their, you know, golf game or whatever.

Yeah, I talk with clients a lot, because many times they come for education because they don't want a C-section. And I try to make clear at the beginning that what we're looking to avoid isn't a cesarean section. It's an unnecessary cesarean section, because it's safer to avoid an unnecessary cesarean section. But when do you know you need one, you actually can switch over to feeling grateful for it. So that's the nuance it's, it's too easy to say no to a cesarean section. It's too easy to get hell bent on one type of birth and to cut off other options but in childbirth, we can't do that. We always have to keep those options open. So what does it come down to? comes down to trusting your gut in that relationship,

that's also why I, this is a little controversial, I guess. But I don't. You know, when when my clients are talking to me about birth plans, I don't think they're important. I don't necessarily think a birth plan is a good use of anybody's time. But I think a communication plan is hugely important. Because a lot of times people will say to me, in their birth plan, it'll say, I don't want you to break my waters unless it's medically necessary. And of course, I'm not going to break your water unless it's medically necessary. But what do you want to happen when I walk into the room and I say, Hey, I think we should break your water. Do you want me to step out so you can talk it over? Do you want to have your doula have a pre written list of questions to ask me? Do you want your partner to be the one to speak up? You know, how do you want that conversation to go so that you feel as if the decision was made with, with your input as much as you can in the middle of labor and and for your best interest. And then, you know, maybe we'll end up with breaking your water or maybe we'll try something different. But that way, you know, the most important thing is figuring out how the conversation is going to go down.

In my experience doing home birth, it was very rare that anybody ever wrote a birth plan, because the birth plan was developed throughout the entire nine months of prenatal care, those conversations about erythromycin about when we transfer about how long my labor can go about how far I can go past my due date, all those things that you would sort of outline in the birth plan, were happening in half an hour to 45 minutes to an hour long prenatal visits. So there was no need to have a written plan at the time of birth. Everything was understood that we were on the same page and that we had a trusting relationship and that I would look out for your best interest should any of these things that we've discussed come up at the time of birth. And that's ideally the way it would be. Whether you're giving birth at home hospital birth center anywhere.

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In my current practice as a hospital birth midwife, I'm able to spend time I have 30-45 minutes, even an hour appointments available for all of my clients, which allows us to really go through what they can expect in the hospital and throughout the course of their labor and birth. There are midwives who are not able to do that because they have really short 10-15 minute appointments and you can't get into detail during that time. I think the main difference when it comes to home birth, in prenatal care is that we're really following the lead of the client. I phrase it that while I am a guide in this journey, I can tell you what I think you might want to know It can show you the different pathways, but you are always the one in charge and you are always the one making the decision at the end that allows you to have all of the information that you need and make your own decisions. There's a famous phrase about in nursing. The nurse is there to do for the patient, what he would do for himself if he had the knowledge and the means. And I've always taken that really to heart that I am here to help you get to where you need to go, where you want to go, no matter what that is. So if it is that in the end, your goal is to have a calm, non traumatizing birth experience. That might mean choosing an epidural, because it might take out the panic, it might take out the intense sensations that are disconnecting From your body that are making it so that you have to dissociate. But if you're able to take those out of the equation, you can come back into the room and back into your body and be really well supported. So in that scenario, I am helping you to have an epidural to have the birth that you want to have received the same thing and HypnoBirthing the goal is to become an in control. And if getting an epidural, is what helps you to become in control, then that's the right course of action. The vast majority of women don't because they're learning the techniques. But one of my very best friends had an incredibly long labor and about 24 hours into it. She was just waving a white flag, like, Hello, I need help. I need to rest I need a break. And she got an epidural for just a few hours and rested. And it's in such stark contrast to a woman who is told Oh, believe me, you're not going to be able to do this. You're not going to want to do this and when one goes, oh my god My god, that's not where we want to come from with this.

Even for women who are choosing home birth, the number one reason that women end up having their babies in the hospital or transfer from home to the hospital is for that rest for that reason for for an epidural so that they if their labor has been going on too long, and they need that support, they still have the birth experience they want. But that would be the reason that 10% of home births transferred to the hospital.

It's been said, and I firmly believe this that the enemy in labor is not pain, it's exhaustion. The people that I see in labor are rock stars, they're unbelievable, so strong and so committed and able to you're able to deal with anything and then they get tired because they've been dealing with it. Everything for 24-36 hours. And when you get that tired and that exhausted, you simply don't have the reserves to continue dealing with anything. And that's the point at which people can really really use the support of an epidural addressed. So they get that moment that that break that little rest, like you said, and then they're able to tap back in and come back at full strength. We forget that we're still human beings with basic human needs like sleep, and water, and food. And these things tend to be either impossible during labor or taken from us. If we're birthing in the setting that's not following evidence based birth and saying we can't drink we can't have water. We can't have food Of course you can. The hospital policy can't stop you from doing those things, but it makes women feel very unsure of themselves when it's hospital policy because it fall asleep. implies to them that that's the safer course of action when in fact, it isn't. But we do forget, we just have those basic needs. And I even tell birth companions, the same thing. You part of your role here is to take care of yourself. Be well rested in the last weeks of pregnancy, take care of yourself, because you need to be there for this birth. And you can't do that. If your reserves are low. If you're tired, if you're not eating and drinking and taking care of yourself, we forget all of that.

What is beautiful about home birth is that everything that you need in your daily life is right there because you're at home. So your bed all of the food that you could possibly want. It's all right there and you're able to rest and and move through the early parts of labor, at least getting as much support from your own daily life as you as you want. Even through the early parts of labor. You are able to go through those contractions or perhaps in between contractions, whereas if you had gone to the hospital right away with the first few contractions, you, you might not be able to get any rest during that time because the lights are on the machines are beeping, the nurses are coming in check your blood pressure. It's a very different scenario.

So Chloe, I just want to ask you because I know that we get this question a lot and our listeners listening right now this might be running through their head, but just like the basic question of who is right for a home birth, how does a woman know if home birth is right for her? Or how does a couple know if home birth is right for them?

There are certain things that quote unquote, risk people out of home birth right off the bat and those are complications of the pregnancy or of their health in general. Things were when we looked at at the grand picture, we realized that there's a much higher likelihood that that person would be able to have a safe, healthy birth in the hospital. All different midwives have different levels of comfort. But there are some basics. For example, in New York State, midwives support baby between 37 and 42 weeks of pregnancy, when those babies are singletons, so it's just the one baby in a in a uterus with their head down. Now, certain midwives might feel comfortable moving outside of those recommendations, but those are the basics. And if you would like to be home, or if it's even sort of like a thought in the back of your mind that oh, this might be something that I'm interested in, it's probably best to just start talking to some midwives. So that You can know whether or not that sounds good to you.

What do you think are some of the biggest fears that women have around home birth or reservations that they have around choosing home birth?

I mean, the two big ones that I hear are, what happens if something goes wrong? And what if I want an epidural? And the answer to both of those things is we transfer. home birth is not in opposition to hospital birth, I sort of think of it as a stepping up of levels of care. Not that there's less care provided at home, but it's less interventive. And so if your goal is to start with a low intervention birth, then start with that. And then as we discover that there are things that need intervention will transfer to the next level of care, which is the hospital.

I think one of the common misconceptions people have is that when things go wrong in childbirth, that it Sudden and emergent and there's very little time. And while those things can occur in childbirth, they're exceptionally rare. And most of the complications that arise in childbirth are something that are more slowly developing or there could be categorized as urgent, not emergent. So it's not emergency, but it is something that's more urgent and needs attention. And that's where having a skilled home birth midwife who can make the decision of when it's time to transfer is so important. But I always found in counseling women and families about home birth at that, that fear of the unknown of  the just like the total disaster was so prevalent in people's minds.

The number one reason why people transfer is for epidural for a long, slow birth. But that's not even all that common. It's just the number one reason because all of the other reasons are so much where they do happen, but they're really uncommon because by and large birth
is healthy and normal and goes straight forward. But like you explained, there are ways that as trained midwives, we see something coming. When I worked in the public hospital, I loved accepting the home birth transfers, because I was always so impressed with really smart decisions that the midwives were making, where they would start to see something that wasn't even necessarily wrong. But they would transfer and by the time that patient arrived at the hospital, they were a severe preeclampsia or whatever the situation was. But this is what home birth midwives do is they pay very, very close attention. They're constantly running through the scenario and thinking everything through and making sure that each time they reevaluate the situation Everybody's still safe and healthy at home. That's exactly right.

So when we started off this interview, we asked you about why you made the switch to home birth. And you alluded to the fact that there are other issues at hand that are close to your heart. So would you like to go into what those may be?

Well, one really lovely thing about the way that I've been able to set up my home birth practice is that I am able to truly provide informed consent and respectful care that is, at every step of the way. trauma informed trauma informed is sort of a buzzword, but what it means to me is just that I have zero interest in and I'm actively working to avoid any traumatizing touch or conversation or interaction at each step of the way. And that is really useful for anyone who's had a history of trauma in their lives, but also people who just
don't want Want to be traumatized. And when I talk about my clients, I'm speaking not just about cisgender women, so people who were assigned female at birth and identify as women, but also transgender men or trans masculine gender non conforming people who have uteruses and want to be able to grow their family by giving birth to a baby. And they, by and large, are choosing home birth because it's a place where they know that they can be safe. And they don't have to expose themselves to potential dehumanizing interactions with with other folks who don't understand the scenario. So I'm really glad that I'm able to make that happen. Since this is my own practice, and I am my own boss, I get to decide who I want to accept in and make sure that care is available to them. That really fills me with joy and and so I'm able to pass that joy on to everybody that I'm working with.

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In fact, so far, every single one of my clients is on Medicaid. That's not my goal, but it's just been that I'm making a space for people who might Not be searching out home birth otherwise and are finding that they're able to afford it when they come to work with me. And that really fills me with joy which allows me to pass that on to everybody that I'm working with.