Fourth Trimester Podcast Episode 4: What is a Certified Nurse Midwife? Midwife vs OBGYN
Timmi Pereira is a dear friend of ours. She is also a Certified Nurse Midwife (CNM). CNM credentials are recognized nationally in the USA. So, what is a CNM?
Certified Nurse Midwife
According to the American College of Nurse Midwives, “Midwifery as practiced by certified nurse-midwives (CNMs) and certified midwives (CMs) encompasses the independent provision of care during pregnancy, childbirth, and the postpartum period; sexual and reproductive health; gynecologic health; and family planning services, including preconception care. ”
Opting for a midwife vs OBGYN is not an uncommon choice. In case you didn’t know, you can have a hospital birth with a midwife. Working with a midwife can be cost effective, and come with other benefits such as home visits after the birth. Midwives can also provide home birth options. Midwives and doctors can be part of the same birth care team. There are many options available.
“An obstetrician-gynecologist, or OB-GYN, is a healthcare professional that specializes in female reproductive health. People trained as OB-GYNs specialize in both obstetrics and gynecology: obstetrics involves working with pregnant women, including delivering babies” (source: medicalnewstoday.com)
Some differences: Midwife vs OBGYN
Timmi points out that there are far fewer medical interventions for women working with midwives as compared to women working with an OBGYN. This makes sense – OBGYNs are trained in surgeries related to birth, while midwives are not. Midwives are seeking to help women and families avoid interventions that aren’t necessary.
“Collaborative care is something that is a goal to shoot for. And now we have midwives training doctors in their residency programs, to some extent to try to show what a normal birth looks like and that the less you do [in terms of intervention] is actually what allows the process to unfold in a supported way.”
— Timmi Pereira, Certified Nurse Midwife
Connect with Esther Gallagher esthergallagher.com
Resources mentioned on this episode Becoming the parent you want to be by Janis Keyser
Sarah Trott: [00:00:46] Hi welcome back to the fourth thermistor podcast. I’m here with Esther Gallagher today and I’m very very honored to say that we have a guest with us today and we’ll let her introduce herself. But Timmi has tons of experience and knowledge and we’re again just so honored to have her here. So Timmi why don’t you give us a quick overview of what it is that you do.
Timmi Pereira: [00:01:06] My name is Timmi Pereira. I am a nurse midwife by training and I work in a collaborative practice with six midwives and nine obstetrician gynecologists and two family practice physicians in Santa Cruz. We do births at two hospitals. We don’t do home births and we also do of course prenatal care postpartum care and well women gynecology.
Esther Gallagher: [00:01:37] Timmi since this is the first trimester podcast, Can you talk to us a little bit about what the postpartum care you provide your patients looks like.
Timmi Pereira: [00:01:49] Well yes and I think what we’re gonna get to is that traditional postpartum care in today’s medical environment is sorely lacking. We attend the births and then stay for a few minutes to hours after the newborn is born. Nurses will be attending to the mom and baby’s needs and then we come back the next day and each morning until the family goes home. to our credit nurse midwives will sit down at the bedside, we’ll assess how the child is breastfeeding, how the mother’s pain levels are and something about her emotional state. But the postpartum visit lasts maybe 20 minutes and then we don’t see them again for six weeks. And that’s an office visit.
Esther Gallagher: [00:02:39] How long is it between when they leave the hospital and you see them again? Just to repeat six weeks six weeks. And you know you and I both had children Sarah has a child. We’re aware of what goes on in those six weeks and that some of what goes on especially in the first few weeks is pretty dramatic in terms of hormonal changes, establishing breastfeeding, that mom will probably be bleeding for several days after delivering.
Esther Gallagher: [00:03:14] Do you have anything to say about what you think people need when they go home?
Timmi Pereira: [00:03:21] Well I want to speak a little bit to some history because when I had my children 39 and 37 years ago there was no kind of concept of postpartum care whatsoever because of the ruptured traditions from living in an extended family groupings to living in isolated family groupings. And the fact that many women’s mothers had no idea what breastfeeding was right. I was fortunate because my mother did understand that and she had successfully breastfed three children but she left after two days. So I realize even you know thirty nine years ago that there was a huge need for postpartum care. As a home birth midwife at that time We would do visits at one day, two days, four days, seven days of life and then depending on the needs of the family see them again at least once more before six weeks. And even that would be inadequate to most women’s needs. But in the current obstetrical environment women are just sort of dropped off.
: [00:04:28] And I talk about postpartum care during prenatal visits but I don’t think all the colleagues do. And I talk to them about what family resources they have, what they think they’re going to need, and what I could suggest that they might need. and then it’s another matter altogether whether or not they’ll find the resources right. Well my perception is that most families will be looking forward with a lot of trepidation and focus to the birth process. And in many cases sometimes especially for first time parents bringing up the topics of postpartum falls on deaf ears. They don’t seem to understand what I’m talking about. I’ll talk about it anyway.
Esther Gallagher: [00:05:13] Timmi and I were actually postpartum together. We spent our fourth trimesters neck and neck with two developing babies and partners who were mostly not home to support us and extended family that were completely not available. Your mom had two days, my mom had a whopping three. And so since we’ve known each other, Towards the end of our pregnancies we did manage to start spending a little time with each other once we came out of the cave of early early postpartum and that certainly was a major blessing for me because it meant that in my journey to be a breastfeeding mom there was somebody else to share that journey with me.
Esther Gallagher: [00:06:05] And just to kind of bounce baby development back and forth with. what else do you remember about that period, Timmi?
Timmi Pereira: [00:06:13] Well I remember a sense of emotional resource that would have been really lacking if I would subtract your presence out of my experience. And that friendship was developing. We hadn’t known each other for a really long time but we were very fortunate. And one of the things I talk about with my clients prenatally is whether they have close friends who are at home with small children and whether they have a network with that and also because many of them don’t. They may be the first mother in their circle then how they might access getting to know other new moms. and how might they be in your community?
Timmi Pereira: [00:06:56] I live in Santa Cruz. Both of our hospitals have postpartum wellness groups, support groups and lactation support, individual appointments and groups. So in one sense we could say that it’s a pretty well resourced small community. Also I really encourage people to either get to know people in their prenatal preparation classes or by just being a little bit creative and reaching out amongst their peers and getting to know people like they will encounter other pregnant women, so how can they develop or cultivate that.
Esther Gallagher: [00:07:37] Yeah. I mean you know the nice thing about pregnancy is it shows. So if you aren’t extremely shy you might be able to make some friends at the cafe. Right. And especially like if that’s your Neighborhood cafe. That means these are going to be the people who live near you perhaps and that will make for a nice connection. You don’t have to trundle off to a meeting across town to find friends again. We were fortunate we lived on the same street, right. Yeah. Yeah. So yeah. Try to find it where you can.
Sarah Trott: [00:08:16] And I would like to add that I’ve had a lot of success finding other moms through online groups. For example here in the Bay Area there’s the Golden Gate mothers group. There are a few online clubs but there are also free resources to meet other people. There’s a new app called Parenthoods. I know they’re expanding to other cities. That’s a fantastic resource and I’m sure there are similar apps and websites that new moms can go to meet other new moms. And it’s certainly been wonderful for me just to have conversations with other moms that are having the same questions that I am and who want to talk about their babies and a lot of those nuances because it sort of takes one to know one. I would say and feel comfortable having a lot of those conversations.
Esther Gallagher: [00:09:03] Yeah I’m not sure about this but I get the feeling that not just new moms but new dads are also kind of experiencing this social networking boom in our culture as one that can and has the potential to draw them in a little closer to all this experience. I think it’s fair to say that when Timmi and I had our children the reigning cultural norm was that dads didn’t get involved much. You know maybe for birth they would be at the birth which their dads didn’t do but they weren’t intimately involved in breastfeeding for instance or you know it wasn’t their job to feed new moms for instance or anything really.
That doesn’t mean that they wouldn’t have or didn’t. Some did but at least in my work I experienced more of an array of fatherhood and kind of intimacy in that postpartum process which is gratifying to see. it’s still very much the case that dads are saying to me, gee we had no idea how helpful this would be and in particular you know we were committed to just kind of getting through and working it out and we thought that that would be fine. But now that we’re having this other layer of resource it feels really good. We’re understanding that we’re not struggling to sort things out from one day to the next and that that’s a blessing. So you know that’s a nice thing to be hearing back from dads these days.
Timmi Pereira: [00:10:46] Esther I have a question for you. When you’re consulting prenatally with a couple, What sorts of resources do you suggest to them either for reading or for getting their minds around the reality of a newborn in the home?
Esther Gallagher: [00:11:05] Well I’m not the best read postpartum Doula I don’t think. I know kind of a smattering of what’s out there. I’m not really keen on most of it, to be perfectly frank but this subject does come up because people do ask that question. And there is one book. And you know what it is Timmi. I think Sarah knows what it is too and it’s called Becoming The Parent You Want To Be by our dear friend Janis Keyser and Laura Davis her co-author and it’s about child emotional social development in the first five years and parenting — being the parent.
It’s about being that parent and it’s just a really warm, reader friendly guide and support. And so that’s really the only book that I suggest to parents. I find and Sarah can chime in on this that most parents have more than enough resources when it comes to what to read. I tend to be guiding them away from the scary stuff if I get the chance. Sarah was there anything that you particularly thought was good to read Prenatally that was actually a preparation for parenting.
Sarah Trott: [00:12:27] I enjoyed that book that you recommended and as a small segue before I answer your question I would say it’s really helpful for the newborn portion but also for the phase I’m going through now which is thinking about caregiving. When someone’s preparing to go back to work. I mean that book has a wealth of information. In fact it pretty much wrote my interview script for talking to new caregivers. I would say that I value the classes at the hospital quite a bit. Those were pretty good. I mean they were basic but that’s what I needed.
Timmi Pereira: [00:13:06] I have a couple more things to talk about before we move into my direct experience with Esther’s postpartum care and that is to say that if anybody who’s out there listening has the opportunity to be involved in a centering pregnancy group; our group in Santa Cruz is embarking on that; it’s only five months old, which means that the first cohorts of parents haven’t delivered their babies yet.
But this is a model of group participation. And rather than a teaching didactic model it is an informal facilitated group prenatal program and what I mean by that is where we are midwives and doctors are facilitating groups. Many places it’s only midwives and then we have a co-facilitator whose normal day to day role would be a medical assistant or a nurse. And women come in and they weigh themselves, they take their own blood pressure, the provider will do a quick tummy check in a quiet corner of the room and then we spend the remaining time which is about an hour and 45 minutes talking about topics directly related to wellbeing in pregnancy, preparation for birth and preparation for parenting.
And I absolutely love it because what I’m understanding or coming to know or re-know because I remember this now from when I was very young, is that when people embody their own knowledge base and they share and learn by example from each other there’s a whole new level of richness and it removes a lot of the fear.
Esther Gallagher: [00:15:05] It’s the model of hey we’re in this boat together let’s paddle right let’s see where we’re going and compare notes and all of that. Like you and I experienced a lot of.
Timmi Pereira: [00:15:15] Yeah and one of the topics for instance in the sixth or seventh session is that these sessions last throughout pregnancy from 12 to about 40 weeks with a reunion of course with all the babies. That is a very guided discussion about what is your expectation. We’re assuming there are two people in the family, two partners. What do you think your partner’s going to do and what do you think you’re going to do. We try to have it be fairly neutral by giving cards for different tasks. And it is an amazing conversation starter because people get to look ahead at what their assumptions are and go Oh well I thought you were going to do every single speck of baby care and oh I thought you were going to help with the diapers and the food.
Esther Gallagher: [00:16:12] Yeah right. So you know when I’m talking prenatally with couples or even trios or whoever the family looks like that I get to talk to prenatally, I’ll ask the question and usually these are birth clients, they haven’t signed on for postpartum care but I’ll ask the question, “So what are your plans Postpartum?” the answer I get is almost always my partner or if it’s the partners speaking I will have X number of weeks off from work period right then that’s all they say. It’s not, I love to cook and I plan to cook nourishing meals five times a day or you know or whatever they think they’re going to do.
It’s just that I have that time off. There is no plan. There is no even vague understanding of what those days might entail what they might look like what they might feel like why it might be a good idea to Know a little bit about it in advance and prepare for things to go a certain way and why it might not be a great idea to have some very experienced ongoing day to day care not 24/7 just couple of hours each day where somebody experienced and knowledgeable is going to support you, answer your questions, help you sort through the newness of it all, nourish you and move on till tomorrow, which is at least an outline of a plan. So yeah that’s very common.
Sarah Trott: [00:17:55] Timmi while we have you, I wanted to take the opportunity to ask you for an overview of the differences between midwives and OBs or doctors.
Timmi Pereira: [00:18:03] Okay. So that’s a great question. Midwives are specialists in women’s health care with a perspective that all phases of a woman’s life cycle from adolescence through menopause are normal processes. So we view pregnancy and childbirth and the postpartum time as normal and we are the guardians of normal. At the same time, I call it wishful midwifery. We don’t want to practice that. So if complications arise or even deviations from normal arise we want to take things in hand early and offer supportive measures to get things back on track. OB-GYNs have gone to medical school and gynecology is a surgical specialty.
So they are trained in surgery before they are trained in birth in Med school. They might have a smattering of exposure to obstetrics but not much about clinic or prenatal care and in their surgical residency they may very rarely see a normal birth. So actually having realized that that’s somewhat of a problem, there was a collaborative statement by the American College of Nurse midwives and the American College of Obstetricians saying that collaborative care is something that is a goal to shoot for. And now we have midwives training doctors in their residency programs, to some extent to try to show what a normal birth looks like and that the less you do is actually what allows the process to unfold in a supported way. Does that make sense Sarah?
Sarah Trott: [00:19:51] That makes perfect sense. Thank you.
Esther Gallagher: [00:19:52] Would you say, Timmi, that you’re describing that postpartum care that midwives give in the hospital and that you know your patients in a clinical setting aren’t going to see you for six weeks. Is it your experience that your patients will reach out to you for clinical care if anything is frightening.
Timmi Pereira: [00:20:14] Yes. Yes. And I’ll speak for my physician colleagues as well. We encourage people to call and we basically, the nurses, go over it and the provider that comes to see them before they go home goes over it and it’s written. What are the deviations that suggest that they should call for an earlier appointment? Headache, fever, pain that’s increasing instead of decreasing. We refer to the lactation consultants for breastfeeding problems so they know we’re available. But the fact of the matter is they’re not going to see us unless they reach out with a problem.
Which would lead me, without you guys really asking, into the heart of this discussion, which is what comprises postpartum care from a doula and there are going to be a lot of variations in that. But I know what my friend Esther offers and offered in particular to my daughter. And I’m going to back up and say that my daughter had had a birth experience, her first, which involved a baby being in the intensive care nursery for close to two and a half weeks. And she didn’t have postpartum care during that time.
She had support from me and she visited her baby in the hospital but it was very difficult for her to be around the hospital environment. So knowing that she was going to have a huge transition when that baby came home I suggested to her that she avail herself of some postpartum care. And I believe she interviewed a couple people and the person that she hired apparently understood the care to mean that she would be helping take care of the baby and maybe helping with breastfeeding.
And Esther can chime in here because she knows more directly what my daughter said to her after the second baby was born. But in any case after a few visits my son-in-law was uncomfortable with the person being in the home. And they weren’t deriving much benefit. And fast forward four years when they were expecting their second child. And as the mom was saying I really want you to consider postpartum care. I know it can be different. I know it could be very valuable to you and your family. And the concept of what the person does was really foreign to both my daughter and my son-in-law.
Esther Gallagher: [00:22:42] We talked about their first experience and how it really seemed to center on the baby but they didn’t feel that they needed someone to just take care of their baby. They were home together and could do that and didn’t understand any value in that. And so when I gave a deep description of how I would care for them they both were a little surprised that I would be interacting with them and I would actually be leaving baby care primarily to them which is not to say that I wouldn’t help with that but that my help would be in this form of guidance, question answering, addressing any concerns they might be having rather than swooping in, taking up the baby, telling them to go take a nap, and calling it a day.
That I would be guiding them day by day through the physiological changes that Mom would be going through, the physiological changes Dad might be going through and the social emotional shifts as the hormones came on. And that they also had an older child and that he would need somebody to interface with and in addition to Dad who was his primary care provider for those early weeks along with grandma and anybody else– Lucas has two grandmas who showed up for him in his postpartum period. But I also was one of the people Lucas could interact with during that period.
Timmi Pereira: [00:24:20] I just want to break in and share an anecdote from about day three postpartum with this second little one. And I showed up in the kitchen; it’s the first room you enter in their house. And here was Lucas up on a stool helping Esther make peanut butter balls that were going to be so delicious. Mom and baby were sequestered lying down either asleep or breastfeeding. And I think dad was just resting on the couch and Lucas burst in and told me how great these peanut butter balls were gonna be and he was so engaged in postpartum care.
Esther Gallagher: [00:25:07] Yes. Yeah. He was. I feel like there’s a real value in that. So often we think well, we just get rid of the kids when we get through this and then they can come home. I think there’s always a little sadness in that for me because I think there’s a real value in older children understanding that when a new baby arrives, much like when they did, that it’s a very special time and that it, in fact, is a time when mommy needs to heal and recover. And so she’s not just being her normal self.
And so often what I’m hearing from second time parents is well I just want to get back on my feet right away because I don’t want to neglect baby number one. You know I have to wonder what’s the message we’re sending to kids if it’s all about never having a day when you need to rest, recover, attend to a newborn that they need special care et cetera. Yeah. Lucas was really into helping mommy and helping grandma and dad. And playing chess with dad. I was so impressed with that.
Timmi Pereira: [00:26:17] Yeah. And I think that set a great foundation for all four of them, quite honestly, having that early care and the anticipation and the recruitment of my son-in-law who hadn’t experienced the pregnancy the first time because he was out of the country and really was a novice at newborn care because they had their first baby in the intensive care nursery and they all learned so much and their experience was so enriched by Esther’s care.
Esther Gallagher: [00:26:48] Well it makes me curious as to whether one of the things we need in this culture are classes for the people who say they want to take care of their family members when their family members have new babies. You know for those moms whose friends have friends that could show up and help them or maybe have parental units who might say they want to help but honestly don’t have a real grounding in what is helpful. Right. So often what new parents are experiencing, for instance working with the clients I’m working with now, they had the foresight to keep their parents away for a couple of weeks. And also the foresight to have their baby a little early.
Because what the mom could anticipate was that her mother would show up and tell her what to do. And that felt really invasive and uncomfortable for her in anticipation of her mother’s visit and not helpful. All right. So she knew she needed and wanted care. What she didn’t want was judgemental direction and in her case that was an either or proposition when it came to her own parents. So I sometimes wonder. Of course they had no economic barrier. But for those people who say well my daughter’s going to have a baby I’d really like to really help her out, great. Let’s help your daughter out but let’s know how to do that. Maybe that’s my next project.
Timmi Pereira: [00:28:40] Well I think postpartum care is such a particular kind of undertaking that we do need specialists and that in our current cultural milieu that is the Doula. I also think that grandparenting classes if you will would be a great idea. Personally I also suggest to expectant mothers that if they’re asking for gifts they might ask their parents to gift them with postpartum doula care and that it can be one of the best investments made in the family.
So I think there’s a lot of ways to approach that and I will say that often my Hispanic MediCal clients have extended family living in the home and they are experienced with nurturing the mother and feeding her and not making her get up to do that herself. So that is something that I think again we have a generation gap of about two generations in the mainstream.
Esther Gallagher: [00:29:45] Yeah there’s certainly cultural gaps. Clients I’ve worked for over the years have parents who come from whatever their old country was and experienced postpartum care within their cultural norms and so they’re concerned about their daughters, especially, that they’re not going to have that and want to import it somehow. Often that’s exactly what they’re doing. They’re actually hiring specialists from their own country of origin to come to America to do that care. Which is fascinating to me as an anthropologist. I think that’s really interesting.
Timmi Pereira: [00:30:23] That’s amazing.
Sarah Trott: [00:30:25] Timmi as a final question, what advice do you have for parents?
Timmi Pereira: [00:30:28] I think I start out initially even if I have an opportunity to speak to people before they conceive to think about what they’re wanting to create. And by that I mean what’s their family atmosphere, Who is going to be at home nurturing that child, Where do they rely on their support for the act of parenting, And if I’m meeting people for the first time newly pregnant, I offer them a choice and an option between midwifery care and physician care and the new centering program.
But I ask them to really contemplate what makes them feel most comfortable and if they want to have a physiologic birth, meaning an un-intervened birth, I suggest that they consider midwifery care. Because over and over again the outcomes are more towards lower surgeries and lower procedures. So having started with that and assuming that people have self selected into my care, they’re giving me some degree of trust. I do later talk to them about Janis’s book which I can’t recommend highly enough.
The first few chapters that talk about as a couple inquiring and investigating what sort of a family environment you want to consciously create. Is it about control? Is it about freedom? Is it about inquiry? Is it about observation and response? And then next encourage them to get some really fulsome concrete postpartum assistance that I tell them I can’t provide in my role. But you know here are the resources and I go grab a handful of cards.
Esther Gallagher: [00:32:23] Excellent.
Sarah Trott: [00:32:24] Thank you so much Timmi. Thank you so much again for being a guest on our program. We feel honored that you were able to join us today and hopefully we’ll be talking to you again soon.
Timmi Pereira: [00:32:33] Thanks a lot.
Esther Gallagher: [00:32:35] Thanks Timmi. Love you.
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