Our New Prenatal Vitamin

Megan Barnes, Registered Dietician and Nutritionist, joined our practice at the end of 2013 and has been an incredible addition to our clinical team. Her knowledge-base is astonishing. Those of you who have sought consultation with her will agree! She is a recent Purdue graduate and currently enrolled in a graduate program for functional medicine and nutrition. (Yes, I know, I am equally ecstatic that she has chosen to work with our midwifery team. What an incredible blessing.)

So… as you can imagine, I take every opportunity to pick her brain. Today she allowed me to conduct a little interview of sorts and I wanted to share that with each of you.

Megan, why did you decide to create your own, unique prenatal vitamin?

Many of the prenatal formulations are not really optimized for pregnancy care. The bulk are, quite simply, just glorified multivitamins. Vitamins are not typically formulated in a manner that optimizes absorption whether created specifically for pregnancy or a more standard multivitamin.

The supplement market is sort of an interesting thing in that when vitamins were initially synthesized it was decided that it was cheaper to synthesize synthetic versions, and now we’re learning that these aren’t well absorbed or utilized by the body. In fact, we are learning that there are circumstances in which this can be detrimental, even at normal levels.

Megan states, “I really wanted to create a prenatal vitamin that provided nutrients in their best forms, which would be the form found in nature, and in appropriate amounts. If you’re going to take a prenatal vitamins, you might as well get the most benefit from it.”

How did you come up with this specific blend for your prenatal vitamin?

Megan spent a great deal of time researching prenatal vitamins in effort to find a brand she could recommend for our boutique. In doing so she became increasingly concerned with the minimal value of prenatals available today on the market. Nearly all are formulated in a way that the body is unable to utilize, so even when spending more money for what was thought to be a better brand, women are essentially excreting their investment because their bodies simply can not utilize the formulations.

For example, if you look at the label of this respected brand of prenatal vitamins [unnamed], the B vitamins are synthetic, there is no activated folate, the vitamin D is D2 rather than D3, there are a number of minerals in formulations which are hard to absorb, and there are a number of ingredients for flavoring and coloring which I believe could be avoided. My disclaimer is that not everyone needs a prenatal. They should get what they need from a healthy diet, with a probiotic supplementation and a high grade cod liver oil.

Megan and I both felt it was urgent to create a proprietary blend that we could stand behind and recommend to our own clients. While Megan states she might continue to perfect the formulary, this blend has so much more to offer pregnant women than what can be found elsewhere. We are most eager to update the design of the label and discover a perfect name!

Megan further discussed the importance of utilizing the best forms of vitamins and minerals, and doing so in a manner that complements each other. Folate and B12, for example, are dependent upon each other like two turning gears. Both are required in appropriate forms for either to work. Often what you’ll find, in various supplements, are components which are not well utilized by the body, and so in trying to convert them, the body is overwhelmed and then poorly converts other components of the vitamin. Proper form and proper amounts is vital for utilization within the body.

Our new proprietary prenatal blend additionally offers both versions of vitamin K, and a full spectrum of both vitamin E and vitamin A. Typically vitamins offer only one form of each, which again, are not well utilized by the body. Certainly, more benefit is obtained from the full spectrum of each.

Iodine, from kelp, is added, one of the greatest deficiencies among women today, and various minerals which are not considered trace but we know women aren’t getting sufficient quantities are also included to our new proprietary blend. Choline, Megan explains, is a trace mineral not often included in prenatal vitamins but is frequently under consumed, but so very important for fetal brain development.

What is not added to our new proprietary prenatal vitamin is artificial colors, flavors, and unnecessary fillers.

Discuss for me the important difference between Folate and Folic Acid?

Folate is a chemical that is synthesized in a cycle so four various forms are created, with the most active being 5 methyltetrahydrofolate. This chemical is important for cell replication and regulating DNA, so certainly it is vital for fetal growth and development. When expert clinicians and researchers realized a folate deficiency was a contributing factor for neural tube defects, such as spina bifida, it was quickly added to all prenatal vitamins and is now fortified in many of our foods. This campaign was so successful in fact, that folate deficiency is one of the more uncommon deficiencies in childbearing women within our country today.

Unfortunately, while there is clear epidemiological evidence that folic acid supplementation has improved outcomes, as many as forty to fifty percent of the population lacks the necessary enzyme for converting folic acid into folate. These women simply don’t receive the same benefit and are therefore, at increased risk of pregnancy complications.

Folic acid is very inexpensive and easy to make so it continues to be utilized in essentially all prenatal vitamins on the market today. Change is slow and not completely because of cost issues, but also because new knowledge circulates exceedingly slow within the profession.

You were quite eager to add the new Butter and Cod Oil blend to our boutique. Can you tell us more about this blend and how it benefits our clients?

Yes, this cod liver oil is awesome! It is a blend of cod liver oil which has been fermented to high grade butter oil. Extraction of oil by fermentation is the most natural form of extracting oils. Rather than utilizing harsh chemicals or damaging mechanical processes, fermentation breaks down the cell walls over time, extracting the oil while also offering the benefit of high quality bacteria to the blend.

The butter oil in this blend is very concentrated and of high quality. “Butter has really gotten a bad rap in our culture lately,” says Megan, “but it actually has a lot of nutritional benefit when it comes from cows that have been raised well and fed well.” These cows have been allowed to pasture, are predominantly grass-fed, and aren’t given antibiotics so they have a high population of bacteria in their cuts. This provides for byproducts in their milk which is very beneficial to us, including high quality vitamin A, vitamin D and K2. The latter, K2, is not produced by our bodies as it comes specifically from bacteria, so a high grade bacteria from the milk of happy and healthy cows is an incredible resource for optimizing health.

Megan talked a bit about the concentration of the butter oil, explaining that butter is already the fattest part of the milk and where all the fat-soluble vitamins are found, so when you concentrate butter by removing all the proteins and solids, you get a really concentrated nutrition.

Megan also shares that, “This butter and cod liver oil blend also offers all of the omega oils balanced perfectly.” It is important to understand that this butter and cod oil blend is a whole foods supplement. Traditionally people would ferment their vegetables in animal fats for their supplementation. We don’t do this today, but it was widely used and is therefore, not a new idea.

I am glad you mentioned fatty acids, because my next question was about omega oils. Can you talk about those and what you mean by “balanced perfectly?”

It really just means they come in a natural balance, and it is not that they are all equal, but in amounts that our body needs them. Omega 9 is not technically essential, but it is really important. Our body can make 9, but if we aren’t getting enough of 3 and 6 we can’t do that.

Omega 3 and 6 are really important, and most people get 6 fairly well from their diet because they are already enriched in all of our processed foods, and nuts, but omega 3 is much harder to come by. We really need a good ratio of those, with the recommendation 1:1 or 1:2, although it is estimated that most people are getting a ratio of 1:15 or 1:20 (omega 3 to omega 6). This is problematic because while we need both, they actually funnel through the same enzyme pathway, meaning they compete for those enzymes. If you are getting a ton of vitamin 6 and some of the precursors for omega 3 (flaxseed, walnuts and other plant-based sources), because they are competing, then we are never going to get to the active ingredient our bodies need because we have overwhelmed the system. The animal version of omega 3 from animals, such as fish oil, is so important because it does balance out the omega 6 that most of us are already getting in our diets.

Tell me about sourcing and testing of the fish oil.

Sourcing and testing is important. We have to consider where the fish come from, what have they been eating, what have they been exposed to, what waters have them been in… and with the brand of cod liver oil we are recommending, the fish are Norwegian where the water is cold, clean, and very, very low in pollution and as we talked about, no chemicals are used in the extraction process.

They also test their product vigorously. Every lot of the Royal Blue Butter & Cod Oil blend is tested for PCBs, metals and etceteras… and every small run is tested three times for pathogens (standard food screens). They also direct other standard tests not required so they can accumulate information for better understanding of the product. All testing is done by third party labs and per FDA regulations for food and safety.

Cod fish however, is not one of the fish varieties that have demonstrated high metal contaminates, with one qualification, it should be wild, not farm raised. All of the fish utilized in this brand is caught wild.

Many years ago, at a midwifery conference, a well respected epidemiologist had shared that the only omega supplement she would recommend would be Udo’s Oil. What are your thoughts on that?

Udo’s oil is a great brand, and one we carry in our boutique. However, this is exclusively a plant-based product. Only the vegan or vegetarian should be recommended this product, because we do need omegas from animal sources. Cod liver oil is safe and incredibly beneficial for optimizing health.

We have a few other omega oils in the boutique and they are a good basic option. What one should understand is that most supplements have fish oils, but they aren’t omega’s or they aren’t in sufficient ratio. The Carlson’s fish oils and doTerra are two brands we carry with good formulation, but they lack fat soluble vitamins and I am unaware of their processing method.

Schedule a Consult with Megan TODAY!

Read about what Megan can offer here and book an appointment or call our office at (317) 434-2229 to schedule in either the Lafayette office or Carmel. Megan can provide consults to men, women, and children.


Negative Commentary

Being a business owner in the social media age, especially in a field with such emotional investment, is an exceptionally vulnerable endeavor. I certainly couldn’t handle the personal attack our legislative leaders undergo, or the witch hunt our celebrities endure. What our young high schoolers go through today on Facebook, I simply can’t imagine. I am learning that what some require is a little more understanding of the personal trials of extending midwifery. I’ve resisted this in the past, because first of all, this is a service oriented field. Midwives and nurses are willing to sacrifice, which we’ve learned especially this week with nurses contracting ebola after committing to care for a sick patient with a deadly disease. This happened too when AIDS was new to our culture. People ran in fear, but nurses stayed and cared for those in need. The irony of being both a nurse and a business owner is that like most business owners, we get punched in the gut with complaints, and the fact that I just sacrificed my time, my family, and my own health escapes them.

The other reason I have skirted away from sharing some of the hardships of this role is because it is a bit disheartening to clients. It allows one to assume that we aren’t grateful, that we don’t appreciate the honor of being called to one’s birth or recognize the privilege of being asked to take the responsibility of extending primary care. Women develop deep and sincere relationships with their midwife, and us to you. It can cheapen the experience to later whine about what one had to invest in it. For those who are reading and walking away with that impression, please forgive me. I am taking a risk here, and pray the Lord allows my words to land in your heart with grace.

The Black Sheep

Most anyone within the natural birth community in Indiana is well aware that this practice, and more specifically, myself – Dr. Lane, is not well accepted among the homebirth midwifery circles. This has occurred for a few reasons. The primary reason, and the one so many fail to appreciate, is because ten years ago my husband and I choose to birth at home with a prominent midwife in the area and my son lost his life. This was a planned homebirth, after two cesarean sections and was a planned vaginal breech birth. I researched. I prayed. My husband prayed. We sought counsel from several providers. The night before I went into labor, I received an email that my midwives were not willing to take the risk and attend my birth. They argue now that they felt there was too much medical risk, but I know and their email was clear, what they feared was prosecution. I had attended a vaginal breech birth with these midwives previously, and my son had been persistently breech throughout my pregnancy with ultrasound confirmation. The plan to birth at home was consistent. I even have a sticky note, ten years later, of the script we were asked to tell the hospital in the event of a transfer, in effort to protect them.

After receiving their email, I contacted several nursing and midwifery friends for counsel. Being a weekend, I wasn’t able to connect with a new provider. My option was to simply walk into the hospital in labor and then lay down for a cesarean, or pray my sweet baby slides out like butter, transferring with any little indication of trouble. After several nurses (some also direct entry midwives) committed to attending me, and a significant amount of prayer along with my husband’s full support, we continued with our plans to birth at home. We had bags packed and the phone prepared for a transfer to the hospital just ten blocks away at the first whisper of need.

My son was born, after a steadily progressive labor, and he failed to breath. My attendants failed to assist him. Recognizing I likely had the most expertise and they were simply intimidated, I began mouth-to-mouth on my son and asked for the resuscitation equipment. They couldn’t find their supplies and their oxygen tank had been left on and was now empty. I then told my husband to call 911. He and I worked together to breathe for our son. The team of midwives at my birth, all except one, packed their bags and left. They left my son there to die. The image of my husband resuscitating our little boy will forever be burned into my brain.

My son arrived at the hospital within minutes of birth. The paramedics swooped him up and he was out the door. We literally lived that close. He never required heart compressions. This was a respiratory issue. During the ten days of his life, on the respirator, we learned who our supporters were and who just wanted to be part of the gossip or judge, and who our haters were. Yes, there were haters. My midwives disappeared, never to reappear and I didn’t perceive their absence at first, then assumed they were simply trying to avoid legal trouble. I wanted to protect them too. I told the medical staff I had friends at my birth, to avoid their being arrested for practicing midwifery.

The hospital informed my husband and I that we did not have parental rights. They explained that we could visit our son, but he could not receive my breastmilk and we could not make decisions in his care. He would be moved into a nursing home and could not come home with us. The details of all ten days now are etched in my mind as if they happened yesterday. At the time I rode through each moment as if my body was robotic and my mind was numb. I remember a moment at his bedside with my sweet husband, and our son having webbed toes, he mentioned how cute it would be to see him grow up and wear flip flops. My husband’s toes are also webbed and he is self-conscious of this fact, but on our sweet baby, it was endearing. We laughed. I later read in his medical record that the “mother sits at the bedside laughing, uncaring that her son is in critical care.”

We were interrogated. Lectured. Blamed. Hated. We were prayed for and told that we must discern who we had wronged, and fix it so the Lord could hear our prayers and save our son. We were told if we just believed enough, he would be raised. We were told that we cared more about having a homebirth, than our son’s life. In fact, to this day, and having learned all I know now, while I may not make the same decision today, I whole-heartily believe we made the best decision for our son with the information we had at the time. I also have every bit of confidence that I was obedient and felt the Lord was directing us in our decisions. Ten years later, I am beginning to see why we had to endure this trial.

I became the subject of a police investigation. The prosecutor pursued me with reckless homicide, child endangerment and medical neglect. Our supporters became sparse and our midwives sought legal counsel. They crafted their defense and in all accounts, I was the one to blame. There aren’t many willing to go to jail for another. These midwives had children, spouses, lives. If the police were willing to blame me, it was easy to make me the scapegoat. We retained counsel and I hid in my home, fearing every car that came around the corner was coming to handcuff me. We feared having our older children removed from our home. I questioned every decision we’d made. I questioned why I had to endure, where had I not discerned the Lord’s direction. I watched the midwifery internet circles I had just days prior sought refuge within, thought they were friends, speak horribly about me, even comment that I deserved what I got. I printed every comment but sat quietly.

Our attorney had advocated for us at the hospital, realizing our parental rights had been removed illegally. In fact, a judge had ordered that we were completely within our rights and all rights should be returned to us two days after his birth, but we were oblivious to this. My son was given artificial breastmilk through his feeding tube as I pumped my breasts at his bedside. They violated us both. They ignored our basic human rights. He underwent multiple brain scans and had very little brain activity. He was not brain dead, but he was a vegetable. In the ten days he laid in that bed, he deteriorated quickly. I was a nurse. I could care for him. I could dedicate all my time to caring for that sweet child. I knew though, if I were his nurse, I would want him set free. My husband made the decision for us, to remove life support. This was a brief moment, because we had a small window of time. The ethics committee might argue.

Our son was perfect. He was saved. He need not suffer. If he had been older and needed to accept the Lord for eternal life, we would have prayed indefinately and waited for a miracle. I asked the nurses if I could please pump my engorged breasts before we took him off life support and scurried away. When I returned, they had already done so without me present and we weren’t provided a room to hold him as he passed in private. I am so angered by the lack of compassion and the punishment the nursing staff made us endure, but I think often of the poor family beside us, and later directly outside the cubby we were squished within, who watched our son die in front of them and the trauma they too, certainly suffered.

After an hour of my baby gasping in my arms and within my husband’s arms, he took his last breath. We were not allowed additional time. I suppose the hospital staff felt we got what we deserved. After all, I was too educated to choose to birth at home. We had chosen to donate his heart valves and corneas, which are the only few options when one is not brain dead and therefore, must die of anoxia. We met with the organ transplant team and had a tiny glimmer of light that some good may come of his life. Someone would be helped from our tragedy. We soon learned that the coroner refused these families opportunity because he too, was angered. Our transplant team said he was simply “being a jerk and trying to punish us.” The law allowed for this injustice.

Our son’s burial was the hardest of all. What was suppose to be a closed casket turned into finding my son naked, wrapped in hospital blankets. The clothes we provided were thrown away. Still I have thoughts of digging my son out of the ground to wrap him in warm clothes and soft blankets. There were many days that I had to lean hard on the Lord to maintain the simplest of sanity.

Weeks after my son’s birth and death, and thick into the hatred we received from the community, from Indiana midwives, from my previous hospital associates and from my family, we received his autopsy report. My son had suffered multiple brain injuries during my pregnancy. He had no capacity to breath. I was devastated that my son, while cradled in my body was being harmed. I remember my husband’s relief at the news and I simply couldn’t relate. I was so unaware of the moment my son suffered within me. I felt as if I failed to protect him and then lived my life oblivious to his suffering.

I called the pathologist at the state’s lab for more information. That man, I literally pray for daily. I can’t remember his name but it wouldn’t surprise me to learn he was an angel, a true messenger of God. He spent a great deal of time talking with me, comforting me and protecting me. He was a great physician. He shared that the prosecutor had made the hour trip to his office to threaten him into making clear my son’s death resulted from murder. He said because they were so determined to charge me, he had my son’s brain flown to Florida, to be given a second opinion by another pathologist. He too found evidence of multiple brain injuries – one months prior to his birth and one weeks prior. The second was the most ominous and left his brain completely foam. He said, “When they charge you. Please call me. I will defend you, and so will the pathologist in Florida.”

We had no reason to share these findings publicly. People had already made up their mind about me. They never sought truth. They wanted to find me guilty of neglect, of recklessness. Midwives especially, because if this were my fault, then it meant that they could remove themselves from the possibility of ever having to face a similar situation. Death is a reality we can’t except for babies. No one wants to recognize that some breech babies are breech because they haven’t the neurological development to turn cephalic. They were already compromised. His five foot cord is thought to be the cause.

My sweet husband and our son, Lyric Bram.

My sweet husband and our son, Lyric Bram.

The National Advocates for Pregnant Woman came to my defense and ended the pursuit against me, but not after weeks of interrogation by my attorney who continued the abuse already initiated by the hospital. He did his job and I am grateful. However, he clearly thought I was an idiot. While defending me in what the prosecutor thought was an unassisted birth and gave him grounds for reckless homicide and medical neglect, I shared that I did in fact have a team of direct entry midwives. They were my friends and so in effort to protect them, I didn’t share they were medically trained. He wanted records from the midwives who had cared for me through my pregnancy, and the physician we were consulting with when planning a vaginal birth at home. Then he asked how much I paid them, and I shared, $1,200. He said, “Well, I think you got your money’s worth.” I was stunned into silence.

Sadly, I had to remain silent on all details of my birth because under the eye of the prosecutor, if I shared I had hired direct entry midwives, while it might protect me from reckless homicide and medical neglect, it would open me up for charges of conspiracy to commit a crime for hiring someone to commit a felony. My birth story was incriminating no matter what I said and in my silence, I witnessed the character of everyone around me unfold. If you don’t give people a story, they will make one up.

It seems much of my first year I was in a fog. I couldn’t care for myself, or the kids. My husband and oldest daughter carried the burden. I was so fearful. So very betrayed. I was terrified to live in a country that could violate someone so horrendously and have no recourse. So many others reached out to me with similar scenarios. Women abandoned by their midwives and they too lost their babies. Some had been violated and manipulated by the hospital, their children removed from their home simply for not following protocol. I lost hope. I scoured legal briefs about birth, breastfeeding and parenting. I further researched vaginal breech birth, vaginal birth after cesarean and poor birth outcomes.

Donating my milk was a comfort for me and after ten months of pumping and sharing, I now have a number of babies and adults who benefitted from the milk my son was never allowed. I found refuge at Witham Hospital as a staff nurse. The nurses and physicians there listened to me, and not simply out of curiosity, but with sincere compassion. They healed me and supported me through my next pregnancy and birth, a beautiful, all natural water birth. Frontier Nursing University held my hand through the remainder of my studies and supported me as I defended my innocence legally. As a private school, they easily could have rid themselves of the controversy and dismissed me. They recognized that I was making the best decision for my family with the options and resources I had at the time. They welcomed me back for my doctorate and I will forever be grateful.

High Standards

Which brings me to the second reason I am an outcast in the homebirth community, I work darn hard to set high standards. This is a calling for me. I have been victim to poor midwifery care. I know the price one pays. When I worked to open my practice, there were no other legally practicing nurse-midwives in Central Indiana. Another opened at the same time as myself, but we laid new ground. She had refuge among the direct entry group and I worked against the persecution. New couples would interview each of us and most all shared they had met with the other midwives, and had been warned about me. I watched social media outlets speak about my being reckless and having lost my own son’s life. It was said that I had no experience, and while I was a new midwife, I had attended more than 2,000 births within the hospital, birth center and home. I was a very good nurse and established a very well respected midwifery practice in a short amount of time and with little to no support. After two years, I was awarded by the Indiana State Board of Nursing for my work.

I was isolated. I was set apart. I knew this was God’s will. I wanted to create something different. I wanted to offer excellent care that wasn’t found in the hospital, and based on the number of homebirth families being abandoned, it wasn’t happening at home either. It is easy to stand by women when births go well, but they don’t pay thousands of dollars to you to celebrate with them after they did all the work. They hire you for the hard births. That is where we must excel as midwives.

I think a combination of urban legend and self-protecting midwives surrounding my son’s birth and death, and then later sheer intimidation at my growing practice in spite of complete lack of support from the home birth committee continued to solidify my being the outsider. As the years past, the Lord validated my trial as necessary. If my son’s life was going to be short no matter his birth setting and if I had a heart for homebirth, I needed to learn the weaknesses so that I could improve them. I also needed to discover my allies.

There were times that I was asked to support the direct entry bill in Indiana. I was conflicted. I had many direct entry midwife friends outside the state who taught me a great deal and who I respect. I was concerned about their professional group, and was concerned about their grievance policy. At the time, if I wanted to file a complaint, I would have to share my concern within a group of local midwives (of which my midwife was the leader and would be present) and then I would be asked to leave while she defended herself. Her group of peers (and friends) would then determine her discipline. Even if she was found purposely negligent and this was the direct cause of his death, which I couldn’t argue, the most strict punishment was loss of certification for a single year. Why endure the pain of sharing? I was confident that the Lord would do His will, in His time, in His perfect way. I had a calling that now demanded all my time. I stayed focused on my path.

I also taught within a direct entry midwife program to help support our family as my practice grew, and although MEAC certified, this program did not meet high school standards in my opinion. References were not required for written work, even at the graduate level. Plagiarism to the point of coping and pasting directly from published literature was not disciplined anymore than requesting the student to talk with someone in the writing lab. Courses were taught based on midwifery tradition and the cycle of the moon, rather than evidence-based midwifery data. Again, I felt women deserved better. It was and continues to be my opinion that midwives can work to the best of both science and art while still honoring the midwifery-model-of-care. We can extrapolate all that is good and share this with families so they can determine their own course of action. The point is offering respectful and compassionate care.

It seems ironic to me that I have a reputation of despising direct entry midwives when I have always practiced legally and could easily have reported each of those who have practiced outside the law. I don’t report. I don’t speak ill. However, two years ago, I did testify against the direct entry bill. Why? Because when I testified in front of the House, the bill only required a high school diploma. Midwives do not simply catch babies, and they do not simply handle birth emergencies. They are primary care providers that must have the clinical expertise to determine a woman an appropriate candidate for homebirth. How can this be done without the skill set of providing a physical exam? My primary objective in testifying was to make our legislative leaders aware there already was a legal option, and it would be wonderful if they could get behind nurse-midwives!

There was argument that legalizing direct entry midwifery would allow for regulation. There were adversaries to midwifery in support because they felt it would give them the ability to prosecute and at the time there was no such avenue. I testified that this belief was false. In fact, practicing midwifery without a license was a felony. Practicing medicine without a license was a felony and we had case law for both of those. However, the attorney general’s office and most of our county prosecutors simply aren’t aware of this. In fact, the attorney general had been unaware of nurse-midwifery until a client of mine reported me for what she called abandonment. We provided our version of the events and the attorney general’s office not only ruled in our favor, but asked if I could be a liaison for nurse-midwifery in Indiana. We did not abandon. We referred the client to another provider when our continued care would have been inappropriate. This is our responsibility.

This I shared during my testimony, as well as the fact that two direct entry midwives were under investigation because it was evidence that if a direct entry midwife was reckless, she would be investigated and held accountable under the current law. One of those cases I had been consulted on, and that midwife was convicted after the deaths of two babies in this state. The other case fizzled out. I am not loyal to midwifery or homebirth to a fault. I am loyal to safe care. I have offered such expertise in a number of legal cases, and am currently working on three cases out of state – none of which I am even aware if I am working for the defense or the prosecution. My testimony remains the same either way, because it is driven by evidence.

Setting Boundaries

My good midwifery friend, Kate Shantz, once told me that I had a boundary disorder, meaning I don’t draw them well. When I first opened my practice, I just wanted to serve families in whatever way they desired. This too often meant I was taken advantage of and when I started to draw boundaries, clients were upset. Why would I demand to be paid, when I had offered free care for so long? I also learned that those who don’t pay, don’t value my service but if I give it out free, they will continue to accept it and criticize me along the way. No matter how I try to please, I will always fall short. I have given more free care away at this point, than what I have been paid. This is a challenging boundary to draw but will ultimately allow us to better serve our clients.

Many feel that hiring a midwife means they are hiring a best friend. While we are available to you 24/7, this doesn’t mean you can demand attention continually and for all things that your best friend would not even tolerate. I learned to under promise and over deliver, but in doing so, I disappointed clients who had created inappropriate expectations. I’ve had many staff believe too, that when joining the practice, they now have a midwife at their finger tips to answer any and all questions and while I would sincerely like to meet these needs, it is hard to sleep when you are not allowed to silence your phone or ignore a single text because anyone could be a momma in labor. Staff have struggled to draw boundaries and become bitter when I have to do that for them.

Most always we realize we aren’t a good fit, whether staff or client, within the first few visits. It surprises me the level of anger that can boil up from just a few encounters. Women are emotional while pregnant, and sometimes we are the victim of the emotional roller coaster, especially postpartum. I will forever adore the women who are humble enough to admit they were victim to these negative emotions and were overly critical or hostile, and return to us with complete forgiveness. When negative commentary hits Facebook, I rarely comment. I observe. I don’t send out my troops to defend which is common within the midwifery community. In fact, my long-term clients aren’t the type to engage in such scenarios. They appreciate intelligence, professionalism, and high moral character. They would excuse themselves from negative commentary. Other times, it is a client who felt wronged, and I know exactly who they are and the facts of the story. I also know the Better Business Bureau has told them their complaint was invalid and so has the Attorney General, because you can bet if they are speaking openly on Facebook they are angry and have already taken measures to report me to everyone who will listen. These clients also know I can’t defend myself so they can add to their story and get compassion from the crowd in effort to validate their story. Thanks again to those who know my character well enough to know these attacks don’t hold merit.

If you’ve read this far, you’re likely concerned that we have a plethora of angry clients and staff. It feels that way sometimes. As most can relate, one upset client can feel like a legion of angry warriors and as a woman who is earnestly trying to meet and satisfy every single client in our practice, each less than absolutely thrilled client is one I take very personal. The reality of being a midwife and a business woman is that although we are only of very few practices in the country that offers three highly trained personnel at each birth, and can offer genuine primary healthcare with very low transfer rates, clients don’t often recognize the level of expertise and clinical skill they have in hiring our practice. We have excellent relationships with collaborating practitioners. We have made a very good name for ourselves within the community. We serve with a great deal of commitment, but we do draw boundaries.

We quite possibly make it all look so easy, that it is easier to complain. My heart spills for you here. This job is hard. Being a midwife is very hard. It is self-sacrificing. It requires the sacrificing of our family. It was commented this afternoon by a previous client that we turn over staff quickly, that working for me must be an exceptional challenge. Yes, it is. I demand a high standard of care. I take the responsibility of caring for your wife and baby very seriously. I expect my staff to train, to answer when I call, to show up and perform well, and to dedicate themselves to being a professional. If their skills aren’t competent, if they can’t make the commitment, if they don’t understand their role then I don’t keep them employed. This does cause for some bitter departures. It is what you expect from me when you hire me as your midwife. While I have upset many more than I would ever desire, we always, always, always draw the line at safe care. We are very, very good at what we do. That may intimidate. That may frustrate. You may vent on Facebook, but I am here to tell you, I draw these boundaries because I have seventeen years experience. I know my role well. I know the cost if we don’t do it well. I am on a mission and I am accountable. This is my son’s legacy.


No Longer Working for Free

As our practice has grown, so has our administrative expenses, especially because we strive to meet every Indiana statute and exceed every professional standard. It can be difficult keeping costs at a point that clients can invest, while still covering costs. For the first several years of our practice, we participated in the Medicaid program and accepted payments from third party payers. Indiana Medicaid reimbursed a single prenatal at $30, and not often prior to 32 weeks because nurse-midwives are not primary providers within our state (violating Federal law, but that is another matter). Moving to a cash only practice was one of smartest decision we’ve ever made and was crucial in establishing a thriving practice.

At $30 a prenatal, the hourly rate of my nurse-midwife is not even compensated, not to mention the wages of our assistants and receptionist. No supplies were covered, no equipment, no payment for space, heat, phone or administrative costs. Medicaid is a huge loss to midwifery practices, unless such practices are willing to take clients late in pregnancy, offer very few visits and for very brief sessions, and include a number of procedures which are high ticket items. This opposes the midwifery-model-of-care. Midwives value time intensive and low interventive care. Unfortunately this does not turn a profit when working within the Medicaid program or when contracted with third party payers and consumers seeking the midwifery-model-of-care do not always appreciate the reality of this concept so seek care elsewhere.

Recently we trained a new administrative assistant in processing birth certificates. She entered the number of prenatal visits with one of our clients as 22. The system kicked back a response that this was entered in error because it was outside the standard. She sought advice and one of our midwives confirmed that this was an accurate number. This particular client was determined as high risk and so was provided close monitoring through her pregnancy. She was diagnosed with gestational diabetes and had a high risk finding in her blood screen. She was also at an advanced maternal age. The obstetrician we consulted for opinion on her blood screening felt she should be risked out of midwifery care entirely and offered a primary cesarean section at 38 weeks of pregnancy.

We offered the option of transferring to a medical practice and offered to continue as her primary providers with our own strategy. The benefits and risks of both were discussed, as well as our experience and expertise in working with the issues she was currently facing. She and her husband chose to continue in our care and so we extended twenty-two nurse-midwifery consultations and nearly as many nutritional consults, and we had a successful homebirth at 41 weeks of pregnancy. All of this – all her prenatal visits, nutritional consults, twice weekly non-stress tests, labor management, birth with two nurse-midwives and an assistant, postpartum home visits, and neonatal care through six weeks for total fee of approximately $5,500. This pregnancy would easily have exceeded 50 thousand dollars in a medical practice. We were honored to care for this family and are motivated to continue doing what we do because of outcomes such as this.

Did we push our luck? No. Our care extended the same management she would have had in any traditional practice, but because we invested heavily in her pregnancy and because she committed to optimizing her pregnancy, we succeeded in maintaining a very stable diabetic without any additional co-morbidity issues. This allowed us to approach her birth with minimal intervention. Extending a high level of care is not about the birth setting, but about the team. Technology travels. We live in a modern society. Investing with great expertise is the key.

Back to the point of this article, while midwifery care can offer a significantly lower cost than the standard medical model, should we work for free? Consumers have become accustomed to free healthcare, either while covered by Medicaid or by a third party payer. When insurance companies reduce their reimbursement, clients are unaware because they are seemingly unaffected. It is standard for homebirth-based nurses to be denied payment when claims are filed, or for various supplies and medications to be reimbursed below cost. The midwife in private practice must share her “professional earnings” to cover the cost of the entire team and its overhead.

Interestingly, while a large number of midwifery practices are working on a cash-only basis and more physician practices follow suit, some are recognizing the multitude of ways they give away their services for free. An article in the Houston Chronicle in February of 2003 (yes, more than ten years ago) discusses the expectation consumers have of phoning their provider for advice, a prescription or a work release but don’t want to pay for this service. In comparison, they appreciate when calling their attorney, during business hours, they will be billed by the minute. They have no expectation of obtaining such advice after hours.

A few years ago, our office reached out to a contractor for a service required in our practice and while the spouse worked to correct our issue after office hours, one of our nurse-midwives sat and talked to his wife. This started as a simple, friendly discussion and ended with the nurse-midwife diagnosing a medical concern, ordering labs, and providing a pharmaceutical at no cost to the wife. Without hesitation, the husband left a bill for several hundred dollars for his work. No one batted their eye at the irony, because one expects a plumber, electrician, or computer technician to charge for their work, but a midwife… well, we are expected to do this out of the kindness of our hearts.

I’ve toiled with this irony my entire career. We know this when we enter the field. We recognize we will be overworked and underpaid. We enjoy serving and don’t seek to become rich. As a business owner however, we must cover our expenses if we are going to continue to offer our services. Telemedicine is the new buzz word among Indiana legislature and certainly not a concept our practice is very familiar. This new and innovative concept seeks to extend care to clients via Skype or Go To Meetings. Some practices have started charging for email responses, or $5 a minute for phone calls. This Houston (2003) article states, “I think the patients know that if they are going to take a doctor’s time, they are going to have to pay for it,” Dr. Allen M. Dennison of Barrington, R.I. Is that really true?

Published more than a decade ago, this article states that the administrative costs of running a medical practice has grown tremendously (spoken even prior to the implementation of electronic health records) and “most primary-care doctors now spend on average of two to three hours a day on tasks for which they are not compensated, such as returning phone calls and filling out insurance forms,” (na, 2003, Houston Chronicle).

“If you call your attorney at 4 o’clock in the afternoon on a Friday, they are going to send you a bill. I don’t understand why I shouldn’t send a bill if someone wakes me out of a dead sleep at 4 a.m.” Dr. Paul Williams, past president of the Pennsylvania chapter of American Academy of Family Practitioners

There is the perception that if a practitioner charges for their time, we are “nickel-and-diming” our clients. At the same time, as operating costs increase and our resources are stretched, clients expectations don’t change. They still expect every call to be returned on their time table, prescriptions to be called in immediately, advice to be given freely so they are inconvenienced with having to visit the clinic, and medical records to be transferred same day. When we fail to meet these demands, complaints increase. Charging appropriately for our work would allow us to better meet the demands of our clients, and ultimately increase customer satisfaction. However, how does a midwife offer homebirth services to all who desire it, in all financial classes, and still meet the needs of all her clients?

Another irony that is commonly ignored is the fact that the high dollar incomes of physicians allows for a stay-at-home wife or a nanny and housekeeper. When a midwife, who are predominately all female, work outside the home and keep the hours required of a midwife, how does she satisfy the needs of her family and home when her income is less than what she made as a bedside nurse? After seven years in practice, and as the owner of this business, Dr. Lane has yet to earn what she did as a bedside nurse working only twenty-four hours per week, with full medical and retirement benefits.

This post offers no answers. The solution escapes us quite frankly. How does a practice offer the highest standard of care for nearly a year per client, twenty-four hours a day, with exceptionally well educated staff and a high staffing ratio, and with equipment that rivals a level one facility at a cost lower than the price of a website build, a set of orthodontic braces, a semester of college, or a nice landscaping job?


Protected: Book Review: Modern Essentials

This content is password protected. To view it please enter your password below:

Cultural Diversity & Midwifery

We had a mother a few years ago whose pregnancy duration far exceeded standard pregnancy parameters and it was an emotional event for a few of our nurses. Two in fact, no longer wanted to participate in her care and this became evident to the family, because ultimately we had to terminate our relationship with nurses not capable of supporting our practice model. The parent’s of this young pregnant mother assumed their discomfort was related to her being a teen mother who became pregnant outside of marriage. I was distraught that I had to let really great nurses go that were fearful of the repercussions of our litigious society and failed to recognize that this family felt judged for reasons many of us personally empathized, and genuinely desired to support. It seems through the years, I’ve been quite surprised by those who felt they had to ask if they would be “allowed” within our practice because of their culture, race, religion or sexual orientation. It is quite disheartening to think that any of those reasons would cause someone to think they may be excluded. We once had an African American couple ask if we would care for a “black family” and flabbergasted, I asked why they would even question that. Their response was that Thorntown is a small community and sometimes they are not welcomed to similar communities. My good friend who practices in Florida has shared with me that she’s had women of color in her practice share that their friends poke fun at them for birthing at home, claiming its “such a white thing to do!” A few times a year we get calls from same sex couples and again, to think one would be excluded for who they are is a bit astonishing to me.

There is well-documented racism within the healthcare community for which we must not remain naive. Most notably, the 1932 U.S. Public Health Services Tuskegee Syphilis Study on Untreated Syphilis in the Negro Male, in which federally funded investigators withheld available treatment from African American men with syphilis. This history of racial discrimination in fact, has created a reluctance among African Americans to participate in medical research or even to trust researchers and clinicians. Authors Boulware, Cooper, Ratner, LaVeist & Powe (2003) sought to discover if African Americans or white healthcare consumers were more distrusting of clinicians and hospitals. Overall, respondents did trust their physicians (71%) and trusted hospitals (70%), although fewer trusted their health plans (28%). Interestingly, black respondents were less likely to trust their physicians than whites, but more likely to trust their insurance plans. Black participants were more likely to report concerns about personal privacy and the potential for harmful experiments (Boulware, Cooper, Ratner, LaVeist & Powe, 2003). Similar findings were discovered by researchers Cohin (2003) and Corbie-Smith, Thomas, & George (2002).

The staff of Believe Midwifery Services, LLC are committed to serving a diverse population and are regularly educated in world views, cultural trends, and ethnic differences so that we may extend the most sensitive and respectful care available. Every single woman deserves safe and satisfying healthcare.

Boulware, L., Cooper, L., Ratner, L., LaVeist, T., & Powe, N. (2003). Race and trust in the health care system. Public Health Reports, 118, 358-365. Click here to view this article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497554/?tool=pubmed

Cohen, J. (2003). Disparities in health care: An overview. Academic Emergency Medicine, 10(11), 1155-1160. Click here to view this article: http://proquest.umi.com.ezproxy.midwives.org/pqdweb?index=0&sid=1&srchmode=1&vinst=PROD&fmt=6&startpage=-1&clientid=51766&vname=PQD&RQT=309&did=452629321&scaling=FULL&ts=1309535589&vtype=PQD&rqt=309&TS=1309536000&clientId=51766

Corbie-Smith, G., Thomas, S., & St. George, D. (2002). Distrust, race, and research. Archives of Internal Medicine, 162, 2458-2463. Click here to view this article: http://archinte.ama-assn.org/cgi/content/full/162/21/2458

Book Review: Clinical Aromatherapy by Jane Buckle

Jane Buckle has offered a second version of the book, Clinical Aromatherapy. This is one of the few evidence-based books for clinicians, but sadly the copyright is more than a decade old without a newer version available. For those looking for more than a simple pocket guide with suggested essential oils for various ailments, this is still a helpful resource. Jane Buckle holds a PhD and that mindset is evident within her book.

UnknownThe first few chapters are an introduction to aromatherapy and basic plant taxonomy, chemistry, extraction, biosynthesis and analysis, with subsequent topics on toxicity and contraindications. However, chapters four through twenty-five review various body systems and apply aromatherapy principles to the treatment of ailments within each system.

Each chapter offers an introductory discussion regarding the system itself and a review of the standard of care offered as of a decade ago from the worldview of modern medicine. The remaining portion of each chapter explores the available evidence available on the system under discussion. The endocrine chapter for example, offers a basic discussion of the intricacies of the body’s hormonal system, then discusses medical management and available resources, and finally presents a discussion on aromatherapy as it relates to premenstrual syndrome, menopause and diabetes.

The author clearly identifies evidence from anecdotal information, and when discussing either, she is thorough in her discussion. Anecdotal information for example will offer a history and most often, trace the origin of such recommendation to its rightful owner. While reading the text, there were certainly times where it was evident that the information printed is no longer valid and on only rare occasion, information within is quite simply, inaccurate. For example, the author defines the sexually transmitted disease, trichomoniasis, as a bacteria; when in fact, this is parasite. Details that may seem insignificant, but nonetheless, remind the reader to avoid using this single text as a Bible for directing how they may recommend essential oils within their own practice.

As a nurse-midwife with a passion for essential oils, this book was a wonderful find in that it is one of a limited number that offers scientific rationale for its recommendations. An intelligent discussion is offered, with a plethora of resources. It is not a book that offers recipes or gives suggestions on application, but as an educational resource for the healthcare practitioner seeking to expand their essential oil knowledge-base, this text is a good resource. It would be a true treasure if it were updated and if that day presents, I’ll be on the waiting list for purchasing my own copy.

Essential Oils for Hormone Balance

Premenstrual syndrome (PMS) and the symptoms surrounding peri-menopause are directly related hormone to hormone balance, or lack thereof, and many of these discomforts can be ameliorated with certain essential oils. Fluctuation in estrogen alone, occurring after ovulation and during menopause, can lead to profound mental and physical symptoms.

Premenstrual Syndrome

While it can sometimes be hard to admit, women have known for generations that for a few days each month, just prior to menses, many can become irrational, irritable, weepy and occasionally, violent. While the phenomenon is somewhat of a mystery, it is understood that the woman’s brain actually changes during this time leading to reactions she can not control (Alexander, 2001). The area deep within the limbic system involved with mood control has more estrogen receptors than other parts of the brain, which makes it more vulnerable to changes in estrogen levels. Interestingly, Alexander (2001) discovered that depending on the side of the brain more significantly effected, symptoms can alter. The left side often produces symptoms of depression and irritability, while the right side is associated with anger and negative emotion.

At the onset of one’s monthly cycle, levels of estrogen and endorphin interact with neurotransmitters serotonin, dopamine, and norepinephrine to keep mood fairly stable. When estrogen levels first begin to drop, immediately after ovulation, serotonin receptors are primed. Prior to menstruation, estrogen levels drop even further and the brain registers a withdraw of serotonin. During premenstrual syndrome, there is a fluctuation in the levels of endogenous opioids and serotonin which modern medicine treats with selective serotonin reuptake inhibitors (SSRIs). Women have found chocolate to also be an effective remedy, which has also been found to increase serotonin.

Aromatherapy for PMS

clary sage vintageEssential oils for the treatment of premenstrual syndrome are usually those which are thought to have an estrogen-like property, such as fennel, sage, or clary sage. Scotch pine and myrrh are also thought to have hormone-like activity. An old remedy for female hormone balance included sage, thyme and geranium. Aniseed is another essential oil found helpful for treating PMS.

Hormone imbalance can take several months to remedy, so essential oils should be applied daily for several months. When additional issues arise, women may benefit from individualizing their blend by adding specific oils for specific complaints to those previously suggested. Bergamot for example, can improve symptoms of depression and weepiness or angelica can improve violent and irrational behavior. Either of these could be added to a blend of fennel, thyme and geranium.

A study by Tzeng et al in 1991, suggested that the aqueous extract of geranium (Pelargonium graveolens) can inhibit platelet aggregation and therefore reduce extensive clotting which is common to peri-menopausal women. Another study by Han et al (2003) indicated that clary sage applied to the abdomen can reduce dysmenorrhea (several menstrual cramping). Aromatherapists have anecdotally found success with tarragon for women who display aggressive PMS.

Aromatherapy and Menopause

Depression is a major symptom of menopause, motivating many to seek hormone replacement therapy (HRT). Others fear the sequela of osteoporosis, while others are optimistic HRT will treat their hot flashes. Hormone replacement therapy has its own set of consequences, some more severe than others, but weight gain, bloating and breakthrough bleeding are common reasons for discontinuation.

Cessation of estrogen and progesterone production does not happen overnight. The interim imbalance can be tumultuous. Essential oils such as rose, cypress, or clary sage can be helpful when used in a spritzer around the face, neck, and shoulders during a hot flash. A few drops of peppermint added to the mix is wonderfully cooling. Essential oils that could be used for estrogen support include fennel, sage, and aniseed. Cypress can be helpful for night sweats, and angelica or lavender for insomnia. Juniper can reduce breast tenderness and fluid retention. Red clover supplements and black cohosh can also help tremendously as these phytoestrogens can help balance wildly fluctuating hormones.

Similar to PMS, using essential oils for balancing hormones during the peri-menopausal transition is best when done daily. It is suggested that rotating calming and estrogen-supporting essential oils, simply to prevent a reduced response over time.

Nurse-Midwives and Women’s Health

Nurse-midwives adore catching babies, but our speciality isn’t so limited. We are primary care providers for women and can assist in managing hormonal imbalances common to the monthly cycle and assist women who are transitioning into menopause. Make an appointment with your local nurse-midwife to discover how her counsel may optimize your current health.

Food For Thought

Food for Thought

"It is much more important to know what sort of patient has a disease than what sort of disease a patient has."

Sir William Osler

Food for Thought

"Happiness is underrated and critically important to health. Seriously! Unfortunately, many people just have no idea how to be happy."

Aviva Romm

Food for Thought

"Physicians simply do not have time to be what patients want them to be: open-minded, knowledgeable teachers and caregivers who can hear and understand their needs."

Snyderman and Weil

Food for Thought #1

"They say that time changes things. But you actually have to change them yourselves."

Andy Warhol

Food for Thought

"To think is easy. To act is hard. But the hardest thing in the world is to act in accordance with your thinking."

Johann Wolfgang von Goether

Food for Thought

"Birth isn’t about avoiding one set of realities in favor of another. It’s about embracing all facets of birth--contradictory, messy, or unpleasant as some might be--as vital to the whole."

Rixa Freeze PhD

Food for Thought

"Why I appreciate being a certified nurse-midwife, as opposed to choosing another route for midwifery: I feel learning the science is vital so the art of midwifery is safe and effective."

Dr. Penny Lane, nurse-midwife

Food for Thought

"When the debate is lost, slander becomes the tool of the loser."


Food for Thought

"To accomplish great things, we must not only act but also dream; not only plan, but also believe."

Anatole France

Food for Thought

"Science and uncertainty are inseparable companions. Beware of those who are very certain about things. There are no absolute truths in biological sciences - only hypotheses... 'We need to train medical students and residents more in the art of uncertainty and less in the spirit that everything can be known or that it even needs to be known.'"

Grimes (1986)

Food for Thought

"American physicians are rewarded for doing things to patients, not for keeping them well."

Grimes, 1986

Food for Thought

"The false idol of technology. 'Having a widget screwed into one's scalp has become an American birthright.'"

Grimes, 1986

Food for Thought

"Between 1985 and 1987, a hospital instituted a successful program to reduce its cesarean rate. The rate fell from 18% to 12%, losing the hospital $1 million in revenues - no small sum in those days."

Goer & Romano, 2012, p 37

Food for Thought

"Obstetricians are much more likely to perform a cesarean when they wrongly believe the baby weighs 4000 g or more based on sonographic estimates than when the baby actually weighs this much but the obstetrician did not suspect it."

Goer & Romaro, 2012, p 35

Food for Thought

"If you play God, you will be blamed for natural disasters."

Marsden Wagner (2006)

Food for Thought

"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you know and what you don't."

Anatole France

Food for Thought #3

"Birth is not only about making babies. Birth also is about making mothers - strong, competent, capable mothers, who trust themselves and know their inner strength."

Barbara Katz Rothman PhD (1996)

Food for Thought #4

"Believe there is always, always, always a way. When you have exhausted all possibilities, remember this: you haven't."

Thomas Edison

Food for Thought #5

"All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident."

Arthur Schopenhauer

Food for Thought #2

"Yet you brought me safely from my mother’s womb and led me to trust you at my mother’s breast."

Psalm 22:9