Nicole Greene shows off the tattoos on her upper right arm — two placentas, each roughly the size of a softball. A midwife by trade, Greene made the decision to get stamped after every 100 babies she catches.
If her career goes as planned, one day she’ll have a full sleeve: a whole gang of placentas for the world to see on the dominant arm that’s the first thing to greet a newborn.
“How awesome would it be to be an old, wrinkly, tattooed woman with 2,000 births and 20 placentas on her sleeve?” she says. Right now, the 29-year-old is sitting at 245 childbirths.
Greene didn’t always dream of becoming a midwife. She graduated from the University of Iowa at Iowa City in 2008 with an art degree, which explains the symmetrical, tree-like placentas she designed for her tattoos.
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The leap to women’s health care happened, she says, “sort of by accident.”
Greene was always interested in pregnancy and birth. When women around her began having intervention-heavy birthing experiences — C-sections and instrument deliveries with forceps and vacuums — she says she asked herself, “How many years have women been having babies? It just seems like such a natural process. Why did they need all of this intervention?”
She hit the public library and devoured everything she could find about birth and the differences in birthing practices across different cultures, and eventually, in 2010, she decided to become a doula.
A doula essentially provides support for women in childbirth, so Greene had no medical training at that point.
Eventually she wanted to be more involved in the birthing process. She became a birthing assistant, which meant taking a more active role in participating on the medical side of a birth, as opposed to a doula who provides emotional support only. She assisted a midwife in Shawnee, a move that brought her from Iowa to the Kansas City area. And during the six to nine months she worked as a birthing assistant, her boss tried to convince her to become a midwife herself. Still, Greene refused.
“I had no real interest in becoming a midwife at all,” she says. “It was way too much responsibility for me. I didn’t want to be that reliable or liable, and I just had no interest.”
Until she beat her boss to a home birth.
The woman in labor was advancing quickly, and Greene was the only one around. “I never felt nervous,” she says. “I just walked in the room and I knew that the baby was coming out, and so I thought, ‘OK, I need gloves.’ ” She caught the baby (Greene says she never “delivers” a baby; the mother does that) and held him to the mom.
“I remember our foreheads touching, I was sitting so closely to her on the floor. And she was so tense that she couldn’t really hold the baby, because it was just a lot, and so I was holding the baby on her, and she’s just crying,” Greene says. “It was emotional and beautiful.”
On her drive home that night, she decided to become a midwife.
In 1989, the first year for which data is available, midwives were the lead care providers at just 3 percent of births in the U.S, according to the National Center for Biotechnology Information. In 2013, the most recent year for which statistics are available, that number was close to 9 percent, according to the Centers for Disease Control and Prevention.
There may be a specific group to thank for the surge in midwifery. An increasing number of expectant mothers are millennials, and with that comes the tendency to turn to the Internet for information, good or bad, about all things — including birthing options.
Cathy Bonderer, the senior director of maternity at North Kansas City Hospital, says this research helps mothers feel more confident in their birthing choices. The hospital system brought in a midwife to collaborate in a physician’s practice a few months ago — with another to follow in February — and Bonderer says it’s in response to patient requests and needs.
The most popular request, Bonderer says, is for less intervention. Women want more time to labor and be active during labor rather than being confined to a bed. “I think they look to the midwife as that more supportive and that one-on-one relationship, whereas sometimes when they see physicians, it’s usually a group kind of thing.”
Kim Anderson is the midwife recently brought on by North Kansas City Hospital. After being a labor and delivery nurse for 16 years and watching practices that require women be in stirrups, to push when they’re told to push and to give birth on their backs, she says she decided to become a midwife.
“I wanted … to allow for the birth process to be a natural birth process without all the intervention that seems to be done when women go into a hospital,” Anderson says.
She worked home births for two years before switching to a hospital setting, where epidurals are a possibility and the latest technology is on hand in case of an emergency. That hasn’t changed her emphasis on maternal care.
“Just because the technology is there doesn’t mean we utilize it,” she says. “We follow and encourage normal, healthy childbirth for women and for families, which means labor starts and progresses on its own. Women are allowed to eat and drink during labor. They are mobile during labor. We encourage any position they choose to assume for pushing — whatever gets the baby out works.”
Anderson says she sees a shift in labor preferences — and younger moms are leading the charge. She believes millennial moms are less likely to take the doctor’s word for it, wanting more information before making decisions.
Eva Shay, a labor and delivery manager at Shawnee Mission Health, echoes the thought. “They are very educated consumers, the millennials, and so they come really knowing what options are available to them and with a pretty specific plan in mind.” She notes that Shawnee Mission is definitely seeing preferences shift toward natural labor.
“This is their labor; this is their birth; and they need to be participate in those decisions,” Anderson says. “And we firmly believe that women should be empowered to make those decisions.”
The maternal mortality rate in the U.S. is one of the highest in the developed world — each day one to two women die of pregnancy-related complications. The American Congress of Obstetricians and Gynecologists maintains that these deaths (usually related to hemorrhage, blood clots, infection, high blood pressure, stroke, amniotic fluid in the bloodstream and heart disease) could be prevented if women had better access to quality health care. The U.S. infant and maternal death rate dropped by more than 90 percent in the 20th century, and the ACOG attributes this, in part, to increased access to safe deliveries in hospitals.
Nicole Greene doesn’t work in a hospital. As a CPM, she works strictly in the homes of her clients. (“We call them clients because they’re not sick. Pregnancy is not a disease. They’re not sick women.”)
This isn’t to say that expectant mothers are guaranteed that no hospitals will be involved when they choose a home birth, but Greene has only had two emergency transports in her career. Only women with low-risk pregnancies are candidates for home birth, says Greene, noting that most women fall into that category. If something goes wrong in labor, Greene gets the mother to the closest hospital, unless there’s enough time for other options.
She accompanies the mom to the hospital and continues to support her through the delivery, ensuring continuity of care.
But, Greene emphasizes, a hospital doesn’t often come into play. When everything goes as planned, she arrives at a client’s house when she goes into active labor — usually meaning she’s been doing some early, light contractions on her own or with the support of her partner or birthing coach. She does a full exam on the mother and then settles in to support her. She monitors the baby’s heartbeat with the home-birth equivalent of the machine that Hollywood often depicts.
She does not, however, administer pain meds at any point. A home birth delivery is synonymous with an all-natural birth delivery. Greene can’t administer an epidural.
“I have had people call me, just like a blind call, thinking, ‘Oh, I’ll have a midwife. If you can give me all the same stuff, I’ll have the baby at home,’ ” she says. “And then, ‘Wait, you can’t give me an epidural? This is not going to work. Goodbye.’ ”
Almost every mother gets to the point where she wants an epidural, Greene says. “When you get to the point that you don’t think you can take anymore, that’s it. That’s the end. That’s when you meet your baby.” She emphasizes that childbirth is a normal body process. “So it’s not going to get bigger than you. It’s not an injury.”
After the birth, it takes her about two to three hours to finish her assessments and clean up. She says she usually makes the mother a protein meal, something like scrambled eggs, and then clears out of the home. “I tuck them back in bed and say, ‘Goodnight, and see you in 24 hours.’ ”
The next day she sees the mother for a postpartum visit, and she comes bearing gifts. “I always bring them lactation muffins that have just a lot of Omega 3s, a lot of healthy oils and a lot of good things to encourage good breast milk production.”
Sometimes she brings a handmade baby blanket, depending on the amount of free time she’s had leading up to that particular birth.
Kayli Surls of Kansas City will use Greene’s services, and Surls is due April 6.
“Hospital birth was never really an option for us,” she says of the decision that she made with her husband, Jeremy. “When I think hospital birth, I think fear. It’s all scary. It’s all medicalized.”
With a home birth, the couple can control the atmosphere during delivery. “When I think midwife, you get to choose your own environment,” Surls says. “You get to have your birth go the way you want. … We always knew we wanted a midwife. We never considered anything else.”
The goal is to provide women with a new norm for childbirth: one where a woman can confidently make and enforce her own decisions.
“There’s nothing like the birth of a baby and caring for women,” says Greene. “Giving power to women is really what it’s about.”
Two kinds of midwives
Certified Nurse Midwife (CNM)
Certified Professional Midwife (CPM)
A CNM like Kim Anderson must have a master’s degree in nursing or public health and pass a test credentialed by the American Midwifery Certification Board. A background in nursing is necessary.
Nicole Green became a CPM after apprenticing under a CNM for two years. She received her credentials via the North American Registry of Midwives. She also spent time in birthing centers in Haiti, China and Texas in addition to her apprenticeship.
A CNM can do full scope gynecology and prescribe medication.
A CPM cannot prescribe medication.
A CNM has to have a collaborative agreement with a physician and see clients in the practice.
A CPM has no partnerships and works strictly in the homes of clients.
Epidurals are an option if the mother feels that she needs one.
CPMs cannot administer epidurals.
CNMs are reimbursed by insurance companies just as the physicians they partner with would be.
Greene has a contract that allows most insurance companies to reimburse her. She says most of her clients have health insurance coverage and she offers a self-pay package for $3,000, if insurance isn’t an option.