thru the pinard Podcast
a conversational podcast with @Academic_Liz with midwives & other birth professionals about their studies/ research & how it's changing our practice globally - email thruthepinard@gmail.com
thru the pinard Podcast
Ep 102 Erin George on navigating birth settings and maternal health in Haiti and the US
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Ep 102 (http://ibit.ly/Re5V) Erin George on navigating birth settings and maternal health in Haiti and the US
@PhDMidwives #research #midwifery #education #birthsetting @uaznursing @acnmmidwives
research link - t.ly/bt1_-
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What happens when a college student's chance conversation with a midwife changes the trajectory of her entire career? Erin George's journey from aspiring emergency medicine doctor to certified nurse midwife, researcher, and advocate reveals the serendipitous and sometimes meandering paths that lead us to our true calling.
In this deeply personal conversation, Erin shares how her internship at Partners in Health and a fortuitous desk placement outside a midwife's office sparked her interest in a profession she knew little about. Her story weaves through nursing school, global health work in Haiti, hospital practice, and eventually to a freestanding birth center where her passion for expanding birth setting options took root. When that birth center closed during COVID-19, Erin channeled her frustration into PhD research examining how pregnant people choose birth settings and what barriers they face.
Most poignantly, Erin reveals how pursuing her doctoral studies became an unexpected anchor during her husband's cancer diagnosis and treatment. With raw honesty, she describes completing her dissertation while raising two young children during a pandemic and facing profound personal challenges. Rather than derailing her research, these circumstances focused her work on what truly matters in maternal care.
Now as a postdoctoral fellow at the University of Arizona, Erin is tackling critical research questions about birth setting transfers and postpartum hemorrhage prediction. Her work examines how we might better identify who's at risk for hemorrhage through genetic testing, placental biomarkers, and comprehensive health histories. The conversation highlights how midwifery research can bridge clinical practice with systems-level change to improve maternal outcomes.
Curious about the future of maternal health research or considering a career in midwifery? This episode offers invaluable insights into both the challenges and profound rewards of working to improve birth experiences and outcomes. Share your thoughts with us about how choice in birth settings has impacted your practice or personal experience.
Do you know someone who should tell their story?
email me - thruthepodcast@gmail.com
The aim is for this to be a fortnightly podcast with extra episodes thrown in
This podcast can be found on various socials as @thruthepinardd and our website -https://thruthepinardpodcast.buzzsprout.com/ or ibit.ly/Re5V
Thank you very much for joining me , as per usual . Can you introduce yourself , please ?
Speaker 2Yes , I'm Erin George . I'm a certified nurse midwife here in the United States , in Boston , massachusetts , and I'm a postdoctoral research fellow at the University of Arizona , working remotely with Dr Elise Erickson , who was recently on your podcast .
Speaker 1Yes , so okay .
Speaker 2Geography East Coast
Introduction to Erin George
Speaker 2so , okay , geography , uh , east coast . Yes , I'm on the east coast , and then I have a three hour time time difference with the university of arizona , which can sometimes be a little a little tricky , but usually it's , you know , it works out very nicely actually , and I've had the pleasure of getting to go out there several times now , um , which is really fun I think it's like we've got an hour and a half in winter time with western Australia and I think it's two hours of the eastern states and then daylight saving .
Speaker 1It changes . Yeah , it's trying to get that time difference . It's just working sometimes , isn't it ?
Speaker 2yeah , I still make mistakes , for sure time converters are magic , um .
Speaker 1Okay , let's go back to the beginning . How did you get into midwifery ?
Speaker 2because you've got a nursing qualification as well yes , which which is pretty common in the united states . Um , we have many different pathways to become a midwife , um , and typically , if you're working in a , if you're planning to , or you are working in a hospital setting , there's usually the bar of having a nursing degree prior to becoming a midwife . In my case , I never actually worked as a nurse . I did my nursing degree but then went straight
Pathway to Midwifery
Speaker 2into a midwifery program and then worked as a midwife thereafter . So I certainly very much appreciate the nursing background and really enjoyed my nursing program , but I never actually worked as a nurse , which is , you know , part of what's the interesting ways that we all become midwives here .
Speaker 1Oh , it's so many different pathways and so many reasons , so what makes you go into midwifery ?
Speaker 2You know I was always interested in healthcare in general , but I'm the oldest of four girls in my family , so I think women's health and sort of thinking a lot about women's experiences was just my natural background . But you know , I initially wanted to think about medical school . I was just really really interested in emergency medicine . Actually , my mom was a unit coordinator in an emergency department in Boston when I was growing up , and so I spent a lot of time visiting her at her work probably too much time . I don't know how they allowed us to sometimes just be loitering around in an emergency department . And then I volunteered there in high school and I just I really really enjoyed that work and thought that that maybe was where I would head . But I also was just interested in human rights and thinking about , you know , intersections of poverty and health , and I ended up doing an internship with an organization called Partners in Health in college . It's an American nonprofit that was founded by Dr Paul Farmer , who had spent his initial kind of formative years in medical school in Haiti , and that's where the organization started and it was just an incredible place to think about social justice , human rights , health care , all of it . Such an amazing experience . But my desk at this internship at the time , the Partners in Health office was in this maze of buildings by Harvard Medical School . So I felt like I was in this little cave and I had this little wooden desk right outside the office of a nurse midwife who happened to work in Haiti but , you know , would travel back to Boston periodically .
Speaker 2And so one day we just happened to strike up a conversation and she was just kind of asking so you're thinking about medical school ? Well , why ? And you know , what do you think you want to do ? And you know , and I was telling her that I was certainly really interested in women's health and I knew that surgery wasn't really , you know , of major interest to me , she was like so you're going to go to medical school and become an obstetrician and then not do surgery ? And I was like , yeah , that doesn't make sense . And she was like , why don't you become a midwife ? And I was kind of like , well , what is a midwife exactly ? I mean , you know , in the United States we have such a flip-flopped system where you know , so many people , you know , do not ever encounter midwives like in their pregnancy and birth experiences . And that was true for the women in my family . I mean , up until that point I don't think anyone had ever seen a midwife . You know , my mom had four cesarean sections . She , you know , it was just such a medical model of birth and experience so I really just had no exposure to it . But the more we got to talking , the more this midwife was like listen , you should just think about becoming a midwife . Like just , you know , she was like you need to do some more research and you know , kind of get it together . And she was a hugely formative person .
Speaker 2That summer we just kept having conversations about midwifery and then that was just really where I got set on my path and fast forward . We ended up working as colleagues at the hospital where I most recently worked and she's you know , she's a dear friend and I love her so much and it's just really cool that we've remained connected all these years . So , yeah , that's what got it started . And then there happened to be a midwife in Boston who went to my college and so I just cold emailed her to be like hey , this is who I am , I'm interested in this whole midwife thing , and she's like come on in , and so sort of , once again , it was not official at all .
Speaker 2I just sort of walked into this hospital and got to shadow her , um , you know , on a , on a shift , and there happened to be a woman in labor who , unfortunately , was there totally unaccompanied , and so , you know , by this time I had started to , you know , do a little doula work and I was , you know , do a little doula work and I was , you know , I was , I was really sort of getting steeped in in all of it and I just ended up , you know , sitting with this woman for hours , um , as she was , you know , awaiting the birth of her baby , and you know , she
Midwifery Education and Settings
Speaker 2was just um , a really special person , to , to , to be , to , to have that experience with um , for a number of reasons , but , you know , saw my first birth and of course , that was that was it . I was like , obviously this is what I have to do with my life .
Speaker 1You get hooked after that first one , don't you ? Very easy , yeah .
Speaker 2But it's so funny when I , when I went to midwifery school , you know so many of my classmates had these like really profound you know birth experiences where you know they were there for their sibling birth or even some people had really amazing animal birth experiences , you know , like like lived on a farm and saw horses be born and like that you know that was their sort of interest in birth . And I felt like I came to it kind of later in the game where I didn't , you know , I didn't see my first birth until I was in my 20s and you know , and sort of had this more meandering path , I guess , to becoming a midwife , I meandering path , I guess , to becoming a midwife .
Speaker 1Um , I didn't knit either , which you know was also just . Yeah , I don't have that skill . I lost that along the female line , the rest of the females , my family all had that . It lost it with me but it was so funny .
Speaker 2You know , like in graduate school people would just be sitting in class knitting and I just I still can't knit .
Speaker 1It's one of the things I love at conferences is when you go to pre-conferences , there's always a couple of tables that end up being the magnet for all the knitters , and they're just knitting away watching what the presentations are going on . It's fabulous to see .
Speaker 2It is fabulous . It is fabulous , I mean , I'm pretty convinced that there are more knitters than not among midwives . Maybe someday I'll pick up the skill .
Speaker 1Michael O'Dent in one of his books , one of his early books , and he said that the ideal birth environment was a darkened room , the woman by herself and the midwife in a rocking chair knitting behind . So the woman's in the zone , she isn't getting that adrenaline spike with stimulation , but she knows that the midwife is there if she needs because of the sapphorific sound of the knitting and the rocking chair and that imagery has always . And then that's kind of like in that type of environment you have the natural birth ejection reflex and it was just that keeps him on , like every time . And he just , yes , the midwife just sitting there knitting . Yes , these days it's kind of like it's yeah , teaching yourself is impossible , um , so where did you do your midwifery then ?
Speaker 2so I I did a program at Yale University and in their , in their nursing program , um . So you know I did a . I did a nursing degree in Boston for people who already had an undergrad , um . So it was like you know , a 16 month accelerated program where you only did kind of all your nursing courses , um , and then got you know , got into the master's program and and did the two years at Yale .
Speaker 1What areas did you like working in the best ? Did you have a mix of community ? Is that community or was ?
Speaker 2yeah , um so it . So it was funny at the time at Yale there was a midwife who was doing she had a really robust home birth practice and so we all tried to to be there um for for a home birth and and some I I never actually had that experience , unfortunately . It was always , you know , never aligning with when I was available . You know , in part because a lot of our clinical rotations were , you know , sort of far flung around the around the you know campus . So , for example , one of my , you know , outpatient rotations was in you know a clinic that was almost two hours away from you know , from campus . So , you know , so there was .
Speaker 2So there were limited opportunities , unfortunately , and I think that's something that has really stuck with me now , having spent a lot of my career in a freestanding birth center , where you know I really am so passionate about the idea of students really getting much more experience in a variety of birth settings , because I think you know , seeing birth in , if you only ever see birth in hospital settings , it's just not you're never going to quite get the right frame of reference for when birth can happen elsewhere . I think that's true for doctors too . I think I really wish medical school in the United States , there , I mean and there are a few places I think that are know more that way , depending on where they , where they're located geographically here . But for the most part I mean you can , you can leave , you know , midwifery school and never have seen a birth outside of a hospital setting , which is just , you know , kind of astonishing and so many doctors never see a normal birth , or say normal , say physiological birth , because they'll only get called in .
Speaker 1So even as students they don't have the opportunity to see physiological birth happening . And it's how do we balance that ? How do we get them in ? So they've got to do a certain number and it's that balancing of the midwifery . Students need to do it and our induction numbers and rates are ridiculous and our induction numbers and rates are ridiculous and our c-section rates are ridiculous , and so they're struggling to get normal physiological birth . And if you then put medical students in which they need at the same time , it's a real struggle yeah , I also think I mean it .
Speaker 2just it would help so much with sort of demystifying why , why people may not want to choose a hospital setting as their first birth choice , or you know why birth can still happen even if you're not plugged into a million different machines and have a bunch of medication going into your body , and you know , this idea that you know we have to manage every single step of the way is really our default model , um , and it would be , I think . Just , I think I think the exposure to birth in different settings and in different ways as students would just set us on a different path altogether , for you know people's experiences and outcomes , you know , during pregnancy and birth , um , so someday , hopefully , hopefully .
Speaker 1We can keep working on a lot of the IPE . I've just been writing some stuff up on IPE activities that we've done and I think that's a way of getting in is having those joint activities while they're students , even if they're only there for a short period of time , because then you suddenly work out what each other's scope of practice is . Oh , wow , you can do that . Oh , I didn't realize you did that . And those conversations that are informal are really quite powerful and actually help guide those future relationships later on .
Speaker 2Absolutely , and you can always tell , you know , when a physician has had a chance to work in sort of stronger midwifery cultures and it changes them .
Speaker 2It just undoubtedly changes them . And they all have some really interesting stories about moments like that where they had been taught just sort of this one way of doing something and then they have that kind of moment of being like oh , look at that , you know , and I think , and it goes both ways . I mean , when I was in my final rotation of midwifery school it was at , it happened to be at a hospital where there was a very integrated , you know kind of midwifery and medical model within our labor and delivery unit . And you know I I had I was still having a really hard time with , you know , my suture skills , probably because of my lack of knitting , and I had , I had a couple of really amazing , um , you know , ob residents who were so patient with me and taught me some tricks of the trade that I use to this day . And you know we're just incredible teachers and you know it was respectful and kind and it was really formative for how I would always hope any of our interactions are across disciplines .
Speaker 1Oh yeah . So how long did you stay ? When did you start at the free setting birth center then ?
Speaker 2Yeah . So I began my midwifery career actually doing not really working as a midwife I was . I went back to Partners in Health and I did a year , a year long fellowship .
Speaker 1Okay , so that happened right in the right early after qualification .
Speaker 2Yeah , so I happened to get this new fellowship that was being offered through Yale Law School . Actually it was a , you know , kind of a global justice and women's rights fellowship . So I was able to spend a year back with Partners in Health supporting their women's health programs in Haiti and in a few of their other sites , mostly in Haiti , and in a few of their other sites , mostly in Haiti , so helping to support some grant writing and then some rollout of different trainings , for IUDs , for example . And then also there was a new hospital being built and really thinking about how to supply the labor and delivery unit so that there were ways to support women in labor beyond just essentially nothing , sometimes depending on the hospital setting .
Speaker 2But I did get to do a little bit of birth with some Haitian midwives , which was really fun , including my first breech birth , which was really cool . I mean , of course , when a breech birth goes well , those babies just birth themselves . But another person was with me and they , um , but you know , another another person was with me and they were like , have you done that before ? And I was like nope . They were like , oh , I never . Would have known that . You just sort of seemed so at ease with it and I was like , well , we , we know how to do it . It just doesn't usually happen quite like that , um , so , anyway it was . It was a great experience .
Speaker 2And then I ended up actually at the hospital where I saw my first birth ever , with the same midwife who , you know , was the alumna from my college and we got to work together for a little while before she retired , which was pretty cool , but that was a very big midwifery practice at a huge tertiary care medical center . So you know lots of
Birth Center Work Experience
Speaker 2births and you know we had this sort of lovely midwifery practice that still kind of held on to some , you know , quiet , had this sort of lovely midwifery practice that still kind of held on to some , you know , quiet space for more physiologic birth . But it was a pretty . It was a pretty high intervention , high risk kind of place , and so I knew that at some point I wanted to try to , you know , see birth in a different way .
Speaker 2But actually it was when I had my baby , my first baby that you know , at a birth center , that really kind of started me on the path of thinking this is where I want to actually try to practice . It was an amazing experience and so different than you know , than being in a hospital . And so , about a year and a half after she was born , I ended up taking a job at the birth center and , yeah , I was there for six years before it . You know closed , closed at the start of COVID and , you know , remains closed to this day , unfortunately . Um , we'll hopefully get it back at some point , but it's hard on a little stuff with COVID .
Speaker 1One of the midwives at the last ICM in Bali was from Haiti and gave an amazingly powerful talk about the situation that was over there and the political situation and the danger that midwives were in to actually do their job , and really talked about the fact that some of them hadn't been paid for three and four months and there was kind of physical and some of their lives were threatened . How did you , did you find the similar over there , or is that just that the situation has changed since you were there ?
Speaker 2you know . So I , I was there , um , my time in Haiti sort of was maybe with the year before the 2010 earthquake , and then the end of that fellowship was the spring of 2013 . And it's it's it's very strange thing about it now , but I guess that was a relative period of calm in Haiti . I mean , it didn't . It didn't feel like it at the time in many respects , but I mean , I think , because of the earthquake and the initial humanitarian response and then the cholera epidemic that happened later in 2010 , I think there was so much attention and support and you know , resources , you know , kind of pouring into Haiti , not always well or effectively , but I think that , think that you know , I , there , there was , there was a lot of hope that there was maybe going to be some more sustainable changes happening in in the country , for , for you know , for its people and for you know , for all of the healthcare workers and really just everybody that there that there would just be more , you know , support and resources , um , to prevent what has now happened in Haiti or or at least , you know , slow it down .
Speaker 2But I mean , I think , yeah , I think that the story of Haiti is just it's so tragic , and , of course , the United States unfortunately has a lot , of , a lot of there's a lot of responsibility for how how it is unfolded .
Speaker 2But yeah , I mean , what's happening now is just , I think , unimaginable . You know , especially at that time of almost this hope that really a lot of us had that maybe things were really moving in a different direction for Haiti . So you know , now it's just , I mean people who you know had , I know who had been there for forever . You know , either either you know native Haitians or you know people who had been living in Haiti for decades , I mean , and through all the ups and downs , I mean so many of them are now out of Haiti , which , I mean , speaks to just the dire circumstances that have really taken hold , just the dire circumstances that have really taken hold and when you think about those types of circumstances and you think about the fact that women still need care , women still are getting pregnant , they're still giving birth and that there are still midwives .
Speaker 1And it was like talking , hearing Vera talk about what she did in the Ukraine when that that kind of conflict started in the first six weeks and the bombshell for what she kind of went through . Like there wasn't a dry eye kind of in the room when she spoke , and even when the Haitian midwife spoke , we're all just sitting there , kind of very thankful for our own countries , but sitting there going , you feel helpless . It's like how can you help ? Because it's another midwife , you know where their passion is coming from and why they're doing what they're doing , but you feel so helpless in this kind of global world but you just ignore the fact that they're still there . They're doing it because the women need them .
Speaker 2Of course , yeah , yeah , absolutely . I mean there's one group I mean , of course there's plenty of groups and government hospitals and everything that are still functioning and even under such dire circumstances , but one organization called Midwives for Haiti , which is a United States nonprofit that has really done a lot of work to try to train kind of like an auxiliary midwife workforce within the central plateau of Haiti and they actually , you know , essentially run the midwifery unit at one of the partners in health hospitals , that's , you know , within the kind of Ministry of Health for Haiti , and you know they're still boots on the ground and functioning . I mean , you know , I think it's still been extremely difficult and you know , certainly they've experienced a lot of threats and violence . You know , within that community even but you're right , I mean babies still are being born and the midwives are still . You're a midwife , you know the core of that other person .
Speaker 1You know what drives them to keep on working . Obviously , we all have different challenges , some more extreme than others , that keep us kind of like challenging , but ultimately every midwife kind of goes yeah , I know why you're being there for that woman . Right , ultimately , every midwife kind of goes yeah , I know why you're being there for that woman . I think that's a nice equalizer amongst everything . Is that compassion to be a supportive person for whoever's in that birthing situation ? Exactly , yeah , okay , so that was for six years , and so then , where did you go after that ? And then how did you kind of go into what was your exposure to research ?
Speaker 2so my exposure to research research came , you know , really , when I was in college , um , I did this , you know , urban studies degree with a concentration in public health . As you know , as you good , liberal arts college and um , I ended up getting a grant to go to Honolulu , of all places , which was really cool . But at the time Hawaii had a really interesting kind of like universal mandate for their state health insurance . It
PhD Journey During Personal Crisis
Speaker 2wasn't totally universal but I mean they really were trying to get , you know , everybody in their state insured Because , you know , again , in the United States we don't believe in health insurance as like a basic human , human right . So , you know , it becomes a patchwork of things . So Hawaii at the time was really a standout across our country for having a pretty high rate of insurance , having a pretty high rate of insurance and they were using a community health workers model within their , you know , insurance kind of network to try to really focus on people with , you know , certain chronic diseases , to really accompany them through , you know , the healthcare system and , really , you know , support them to get . You know , good , you know , go to appointments and get good care and make sure that they weren't falling through the cracks . You know , support them to get , you know good , you know , go to appointments and get good care and make sure that they weren't falling through the cracks . You know , because we know it's one thing to have actual health insurance that kind of can get you in the door but it's a whole other thing to navigate healthcare , especially when you're dealing with chronic illness and whatever else . So , and I was already really interested in kind of the community health workers model from Partners in Health , which was a really , you know huge backbone of what they had done all these years around , specifically around like HIV and tuberculosis in different parts of the world . So anyway , I got to go and spend time at this organization that was , you know , doing a lot of work with the health you know community health workers and that was like my , you know my thesis for my , for my college research , and you know it was I just really enjoyed it .
Speaker 2I really enjoyed , you know , thinking through you know kind of these broader questions about how to , how to actually not just not just get people access to , you know , to payment for health care , but how to actually think about you know what , what a person healthy , what gets them to that point of good health and you know I knew of course I still ended up becoming a clinician and doing sort of that like individual . You know , patient care piece , but always in the back of my mind , thinking about systems and about or lack thereof and some of these broader questions about you know , how do we really affect change . You know when , for example , we know certain things like you mentioned , inductions , which is a huge , huge topic of conversation . But you know , when you know that maybe certain ways of approaching labor induction can be more effective than others , like how do you prove that and how do more effective than others , like how do you , how do you prove that and how do you then roll it out and how do you show that it's effectiveness ? And so that was always sort of like whirling in the back of my mind .
Speaker 2And I did some research work before I became a midwife , like you know , in the years that I was taking courses to get into nursing school and that kind of thing , doing some work at a , at an organization that actually was very similar to you know what Partners in Health was doing . They were working with people living with HIV in Boston and had a community health workers model to try to support , you know , people to sort of sustain , you know good access to care and sort of good treatment , and then also did some work in women's health at the hospital . I first ended up having my midwifery job , so kind of kind of full circle moment . I started as a researcher there and then eventually became a midwife there but , you know , doing some really cool work on cardiovascular disease and diabetes in women . So , yeah , it was always , it was always there , you know , and then I just and then I was just a straight clinician for for quite a while did nothing else but catch , catch a lot of babies which is good and an important thing to do , so how did ?
Speaker 1you pick your PhD topic .
Speaker 2Yeah , so you know it , it kind of I actually went into my PhD program thinking that I was going to be working a lot more on breastfeeding , which is still a really interesting area for me , and that was , of course , coming from personal experience , having had a really rough start to breastfeeding my first baby and really thinking about how much it was such an alignment of all the stars that I ended up successfully breastfeeding her um and then realizing how easily my breastfeeding journey could have gone awry because of the initial problems that we were facing . So that was sort of the burning topic that I kind of entered um , entered with , but you know all . But you know this was also . I started my PhD , you know , in the fall of 2020 .
Speaker 1So you know , I think I got my acceptances right .
Speaker 2My acceptances , I think , came , I think my acceptance to Boston College , which was the PhD program I ended up doing , it came , I think , the week that everything shut down , you know . So of course I was like what am I doing , why am I , why am I getting a PhD in the midst of this , like global pandemic and you know all , all of those things . But eventually I still just made made the made the decision to start . And so you know , like I mentioned before , our , our birth center had closed very dramatically at the start of COVID , which was extremely controversial , remains very controversial to this day , but it brought up a ton of questions around birth setting choice , birth setting options . You know , in our state , like many others in the United States I mean , we had a big spike in people choosing home birth .
Speaker 2Oh yeah , and that has actually remained pretty significant and right free birthing as well , like people just wanting to avoid any sort of , you know , outside people you know , for a whole variety of reasons . So that was really what then brought me into the topic of thinking about . You know how people decide where to give birth . You know what factors influence that decision , what kind of barriers exist to any sort of choice , and obviously in the United States we have many , many barriers . But , yeah , so I , you know , I was able to work with an amazing women's health researcher , joyce Edmonds , who is my PhD advisor and was just , I mean , from the start . You know , it was just such a gift to be able to work with her and she was so supportive of the work that I was doing and really encouraged me to think about , you know , approaching the question from different angles . So , you know , like doing a literature review , of course , but then really thinking about , okay , what kind of data exists already to potentially look at this question , and then what new data need to come out to really think about it . So I was able to do kind of both , like a quantitative and qualitative project , um , to think about , you know , the that question . So so then , how did you , how did you kind of my second year of coursework . So he was diagnosed with a really aggressive form of kidney cancer the fall of my second year of coursework and so I had a really ambitious PhD project that I wanted to develop like a decision aid to think about , like how to support people to make decisions about birth settings and really kind of inform their choices and , if they didn't have access to a birth setting of their choice
Research on Birth Setting Choices
Speaker 2, how they can maybe , you know , garner more kind of like resources and support to make a secondary birth setting , maybe more like what they had initially hoped to have , or something like that . That was , that was my initial , you know big dream project .
Speaker 2And then , you know , when my husband got sick and I initially was thinking about leaving the program actually , I thought about leaving the program many times after that but , um , you know it , really , I had another really amazing you know faculty advisor who was like , listen , the best PhD is the finished one . So how do we , how do we , like you know , still take , take your interest in what you , what you want to research and what you're doing and really drill it down into a more manageable you know , a more manageable project ? Um , and so that's where you know , a more manageable project . And so that's where , you know , doing a secondary data analysis came in and then I did a small , you know , qualitative study , you know , interviewing people who had state health insurance in Massachusetts and how they chose a freestanding birth center and you know which was , which was really great because , of course , you know , a lot of birth centers don't accept state insurance , depending on where they are and and it's all all due to reimbursement and funding , unfortunately . So this birth center happened to , you know , accept any , any state health plan , which is pretty amazing .
Speaker 2And so , you know , that was just like one of those again stars aligning moments where I had an amazing midwife partner at that birth center who , you know , I think she lined up like 12 interviews for me in like two weeks . It was like the fastest recruitment ever . It was just like it just really was so amazing . So , yeah , I mean , I was able to kind of , you know , hone my topic on a couple of projects that weren't going to kind of , you know , hone , hone my topic on a couple of projects that weren't going to take , like you know , a decade to do , like like my initial project .
Speaker 1With so much going on then in your personal life , like talking major , major stresses in your personal life , you're doing this . How did you keep your sanity during that ? How did you keep your focus on ? Yeah , I mean .
Speaker 2I think that you know it's going to sound really crazy , but I think the PhD program was what kept me sane .
Speaker 1I was upset the same .
Speaker 2Yep . So you know I've always been an early riser and my husband and my kids have all generally not . So if I get up early , you know , I can have a couple of hours at least to myself in a quiet house before anybody else , you know , wakes up . And so I would just be up and I would just write a little bit , read you know , be focused , and then everyone would start to wake up and you know the day , because of COVID , all of my coursework ended up being remote , which was not how it was supposed to be . I was supposed to be on campus for my PhD but you know , those two years of coursework we were like the COVID cohort . So you know , I had kind of the best possible setup of really having such flexibility , with not having to do much commuting at all for classes . And then , you know , I mean , if I had been up , you know , for those hours which I normally would have been anyway , and I and I , if I didn't have , you know , articles to read or things to write , or you know , just the incredible support of , like , my mentor and my PhD classmates , you know , encouraging me like every step of the way , I mean I think I would have lost my mind . You know it was such a helpful distraction . So I mean , yeah , so people are kind of like , how did you do it ? And I'm like I think I would have been way worse if I didn't have , if I wasn't in the PhD program .
Speaker 2You know , if I wasn't in the PhD program , you know , um , which is a you know I , I'm sure if I hadn't had , you know , kind of the lightning bolts event of my husband getting sick happen , I'm sure I would have . I'm sure I'd have a very different response to it . I'm sure I'd be like , oh , that slog of the PhD and it was just so hard to finish . And you know , like the , I think it's just I don't know . It changes your perspective big time , that's for sure . But I think I needed it , I think it was . I was so grateful ultimately that I was in that program at that time and had something else to occupy my thoughts , like you know , sort of the sort of endlessly hopeless situation and my husband just getting sicker and sicker .
Speaker 1So serendipity , really . Sometimes you kind of the timing of things that occur . It's not until you like look at them after the years have gone by , you realize that that all happened at the right time when it was meant to be happening yeah , I mean it was .
Speaker 2It was crazy . I also think I mean , you know , we were my , so my husband was also a healthcare provider . He was a , he was a physician , and so you know , we both kind of went through that initial wildness of COVID starting and being frontline providers and no one knowing what was up or down in those early months , to say the least . And then you know things , things had of started to like get a little bit more normal by the fall of 2021 . Not actually normal , but I mean get it . You know , people were starting to like you know , not mask when they were like hiking up mountains and that kind of thing , you know . And then cancer , you know . So I think in some ways it was just that we were just in this race of just going from a global pandemic to then cancer . It was just , I don't know , there was a momentum . I guess that was probably not a healthy momentum , probably , but I don't know , it was sort of like , well , what do you do ? We keep going . We just keep moving on , we keep living somehow .
Speaker 1Persistence . Persistence and determination is what gets your PhD really as well . Um right , and how old were the kids at that stage when you were going through your PhD ?
Speaker 2yeah . So when I entered my program , let's see , they were two and four , um , yeah so . So I spent a lot of time under my desk because they were , of course , home , because it was COVID they would make these like elaborate blanket forts under my desk while I was like in class . And you know , it works , it works , it worked out somehow some way . You know , they probably have a lot of really random , you know , nursing philosophy and like data , you know , I don't know structures and things in their minds that that will come out someday later and they'll be like how do I know that ? Where did that come from ?
Speaker 1so I mean obviously your . Your brain and cognitive overload was at a high at that stage . What can you think about your PhD now ? That surprised you when you were doing it .
Speaker 2I think I think just the the breadth of you know people's experience coming into a PhD program particularly . I mean , you know I was in a nursing PhD program , so everyone in my cohort was coming in from you know , typically years of experience , as you know direct care providers . So I think that I think , and coming from so many different backgrounds , I actually I was lucky I happened to have another really really great midwife friend who was in my program with me . She's one of my best friends and we got to do our program together , which was pretty amazing . But in our full-time cohort we also had a mental health nurse practitioner , psychiatric nurse practitioner and a geriatric nurse practitioner , and then there were a bunch of part-time people who were also doing the program . But among the four of us it was really amazing how much commonality we ended up sharing from our really different clinical experiences and even though we all did such different projects and had such different , um you know , pathways in some ways through through the PhD program , um , I don't know really really being able to get where we , where each other were coming from , um and and just I don't know , wanting to see each
Current Research on Birth Transfers
Speaker 2other succeed , was just so amazing and I didn't .
Speaker 2Not that I expected a PhD program was going to be , I don't know like cutthroat or anything . I just I thought it was going to be a much more individual experience and it is in so many ways . I mean you know you're in charge of your own . You know destiny if you will , I mean no one's going to . You know like , if you don't show up to class , that's on you . You lost that time and you lost that . You know that potential . You know knowledge or opportunity to talk about something . But I think that the camaraderie and the just incredible learning that I received from my cohort was just so awesome and such a huge bonus that I did not expect it was really , really amazing .
Speaker 1And I think that common thread has come through with a lot of people too , that camaraderie to not only get in but to help with that , and it takes a village to kind of get to finish with that . What about the results from the interviews that you did ? What kind of still sticks in your brain now , these kind of like after all these years ?
Speaker 2yeah , I mean , I think so , you know again , because everyone I interviewed was um , you know , had state health insurance . Almost everyone universally thought that they wouldn't . They were surprised that they actually had access to the birth center and felt so grateful to have access . And sometimes it would make me mad , you know , like not mad at them , but just mad at this idea that you know that there's like this element of like deserving it or like maybe . I mean , no one I interviewed said that they didn't deserve to be there , but it was more the idea that oh , wow , I can be here , like this is an option where people , you know they expect they won't have choice or that they won't .
Speaker 2You know they just have to kind of like live with whatever they have and and it's , it's just so not right , obviously , on so many , on so many levels , but particularly when it comes to birth , I mean , you know , going back to what you were saying about , you know the idea of like a calm environment , right , or like an environment where people really feel , you know , less stress and you know , for some people , a hospital setting is where they're going to feel that way .
Speaker 2You know , I , one of my sisters , you know was was very articulate and always expressing that she would never feel comfortable not giving birth in a hospital because she felt like for her comfortable not giving birth in a hospital because she felt like for her . You know the the idea of of risk that could potentially happen when you're not in a hospital setting and not have the proximity to , you know , emergency services if you needed them . That that for her was really a comfort , you know , and so , and that's really important to consider , but but for , of course , many people um the ability to be in a more home-like environment or an environment where people are just , you know , going to respect the idea that . You know . Maybe you need and want silence , or maybe you need and want , you know , 50 people in the room with you .
Speaker 1Exactly and a place like a birth center .
Speaker 2It's like , fine , come Everyone , just come Everyone , bring all the food and all the music and all the things and just be here , just be around . You know that was certainly true for me . I mean , you know , I had , for my first birth , I had my sisters and my mom well , two of my sisters and my mom with me and then , but then downstairs , you know , my dad and my brother-in-law and my year and a half old niece , like they were all just like hanging out , you know , downstairs and around , and immediately came up after the baby was born and you know it was , it was , it was really wonderful and that was amazing . So , you know , I mean just just this idea that you know that you don't have access to , to the ideal environment that you would want , um is is just heartbreaking and and and so difficult . Um , and a lot of the people I interviewed about half of them had had babies before and all of which had been born in , you know , hospital settings , and not everyone had necessarily bad hospital experiences , but you know they just they wanted something different or they knew that they could have a different experience maybe , and now that they had their first kid , they wanted , you know , a different , or sometimes second or third kid . They wanted a different experience , maybe , and now that they had their first kid , they wanted a different , or sometimes second or third kid , they wanted a different way , and yeah , so I think that was something that has just really stuck with me .
Speaker 2And actually that study ended up being part of a conversation for our state insurance group to think about increasing facility fees for birth centers , which they ultimately did . I mean not to the point that it needs to be , but there was an increase which helps it certainly helps keep a birth center running to be able to get reimbursed at a more equitable rate . So you know , it was cool that that helped with this idea that , oh , okay , a freestanding birth center is going to be a different . That's not the same thing as a birth center that you know hospitals sometimes call themselves or you know just that this is a distinct option , you know , for people and we need to think about how we can serve our members in a different way . Think about how we can serve our members in a different way .
Speaker 1So with the state insurance , does that mean that there's no out of pocket for the family with the birth ?
Speaker 2It depends , and so this is what like . It's a little complicated Sometimes it depends on the tier of insurance , but typically that is true that there's , you know , very little to none . You know , out of pocket expense , but depending on where you live in the state , you may only have access to one place for care which you know may not even have midwives . It may not have anything that you want in terms of any sort of labor support . It may be a place that has a really high intervention rate . You know which gets challenging . You know , we know that not every place offers the same thing , and so what does that mean for people when it comes to you know , paying out of pocket or not for , you know , for care ?
Speaker 1And we won't go into the politics that's happening at the moment in Tennessee and antenatal care being refused by not being pregnant even though they've been together for 15 years . That's a whole different discussion , yeah there's a lot going on . It's quite horrendous to watch and sit there and go . It's living the handmaiden's tale . That's what you see in so many states at the moment . Yeah , yes , that's yeah in so many states at the moment .
Speaker 2Yeah , yes , we're certainly seeing , you know , I mean , we we sort of have a ? Um , somewhat of a protected bubble in our state for , you know , politically speaking , when it comes to the um , pregnancy and birth , but we are certainly seeing a lot of impact from people coming in from other other parts of the country . Um , and you know certainly tales from midwives across the country when it you know , if they're , if they're sort of a border state , if you will to places where women are being denied care , um , it's , it's really pretty horrific , um , but part of part of what you know is is also happening is that data is getting suppressed or are getting suppressed . And so , you know , I don't even think we really understand the full magnitude of the impact in certain places , because I mean we literally some states disbanded their maternal mortality boards you know , the boards that review cases of maternal deaths because they do not want to have any sort of implication that maybe some of their laws or some of their policies are causing more deaths , for example .
Speaker 1So we are literally flying blind in some places and that data is lost , we'll never get that back , we'll never have a joint standing and whatever happens in the future , even when it is reinstated , these could quite literally be the dark years , because data is not going to be traceable again . We might get some of it back , but we won't get a lot of it back . Let's go to something a little bit happier . How did you celebrate your PhD when you finally did finish it ?
Speaker 2Yeah , I mean , so , my . So , first of all , my , my , my , my dissertation defense felt really quite festive . I mean , I had I had a bunch of my , you know , midwife sisters who were there and one of them came with champagne . I was like this is a little premature . She was like no , it's not like we're ready , we're ready to um , but it was , and you know I had my family was there , um , including , you know , one of my aunts , who's um , who's a nurse and was , and actually is an alumna from my college , like the , the , you know , the college where I did my PhD program . So it was just , it was really , really amazing to have their support . And you know , my husband wasn't able to be there in person , but he was able to .
Speaker 2You know , see my defense , you know , over Zoom , which was really amazing . I mean part of weird silver linings of COVID , right , that we just , you know , increased our ability to have remote , you know , I don't know capacity , if you will , I don't know that anyone ever got to do Zoom in any way , but like pre-COVID for a dissertation defense or have you know , have that as an access point . So it was really great . And then , you know , just had a big , you know Italian dinner at home , like this , you know handmade pasta and like lots of bread and just was . It was a celebration of carbs and it was wonderful , excellent yes , that's the way it should be .
Speaker 1Now , one of the places that you've now subsequently worked after your phd is now . I'm gonna get it wrong in in , mum is that right ?
Speaker 2oh yeah , so that's , um . That's dr erickson's lab . It's the mechanisms underpinning maternal health . That's right , um . And that's her lab at the university of arizona , which is um . You know just , it's such an amazing experience to be a part of , and so when research when we talked about her stuff .
Speaker 1The research that is happening there is just so cool and groovy .
Speaker 2It is so cool , I mean , and I wish that my brain could gel with all of it , because I mean , you know at least we'll talk about you know Dr Erickson will talk about you know something related to like DNA methylation and all of a sudden I'm like why aren't I in a lab pipetting DNA ? She's so inspiring with her research and you know it's been such a gift to be able to be a part of it at all , even on the fringes of the work that they're doing . And I mean arguably , obviously , you know , in my bias , I mean I think that you know part of the mechanisms underpinning maternal health . Beyond , you know all of the . You know cellular work that is happening in a lot of Elise's research and , of course , the wearable data , and you know the idea that we can really , we really need to be probably testing a lot in a lot of different ways to actually understand . You know why things like postpartum hemorrhage occur and who's at more risk for that , and you know all of those things .
Speaker 2But you know , thinking about the access piece and the data piece , I mean , if we're not , you know considering systems or lack thereof and sort of how those systems are working to help . You know , people not only access care , but access the right care at the right time . And then and then really considering , you know , how we're protecting data , using data , making sure data doesn't disappear . I mean those are all part of it , parts of it . So I mean it's , it's really . I mean she's created this really amazing umbrella for considering all of these different angles that we need to really employ to think about . How do we , how do we understand some of the you know , components of pregnancy and birth that we still don't understand or we still don't have a great understanding of ? But then , how do we also improve people's experiences and outcomes when it comes to , you know , pregnancy and birth ?
Speaker 1so what area are you playing in at the moment , then ?
Speaker 2so at the moment I've I've been really I mean again inform , inform from my work in a birth center and then also thinking about all of these data pieces I'm really interested in you know kind of points of transfer from one birth setting to the next . And part of what drives me in that interest is that we have such little data to really look at that , look at those transitions of care . So you know , even though we have a lot of electronic health record access in the United States , it is it's really difficult for you know records to integrate if they don't have the same platform . So , and it's so easy if somebody is coming in from you know one hospital to another , for example , if they don't have the same electronic health record system , you know you're only ever going to get the data most robustly from the place that they actually give birth and you won't really know what was happening in the hospital that they transferred from , for example . And then certainly it's a whole different story when people are coming in from a home setting or a birth center setting and need to then go into a hospital for care . You know , we know , for example , that a lot of people end up waiting a long time to actually be seen , Not usually from the you know , like midwives and obstetricians , that they're ultimately seeing in a hospital setting , but maybe they're sitting down in registration for like an hour before they get , you know , get up to care . Maybe they're sitting down in registration for like an hour before they get , you know , get up to care . Or maybe they're getting seen in the emergency department first and it's in a different building than where labor and delivery is or what have you . And we know there are just so many points of delay that could potentially be impacting people's ultimate outcomes and certainly their experiences of care .
Speaker 2Um , so , yeah , so just trying to think about , you know , places that are starting to have been starting to really look at this issue a little bit more and and try to kind of create more of an integration across settings .
Speaker 2Um , so , in the united states , for example , washington state um has been doing a really exceptional job trying to create a universal kind of like data platform across their many of their hospitals and then also integrating that with community birth , and so you know they're starting to really be able to kind of evaluate almost like a 360 look at what is happening from , like , the start of labor to birth and everything that is going into you know all of it , especially if there's a transfer that's happened and then being able to really study the transfer event . Going into you know all of it , especially if there's a transfer that's happened and then being able to really study the transfer event to understand , you know , is there anything else that could have happened that could have optimized this transfer ? Or , like you know what was good about this transfer that we can try to replicate in other ways ? Or , if something did go wrong during a transfer , what can we really learn from this ? So it's definitely an area that is driving a lot of what I'm doing right now .
Speaker 1Purely from a quantitative big data point of view , or are you also looking to incorporate qualitative interviews and experiences in that , so you get that holistic viewpoint as well ?
Speaker 2Yeah , so I'm interested in doing both . So I mean , my focus at the moment has been Arizona , just because of where I am for my postdoc , and so the American Association of Birth Centers , for example , has a perinatal data registry that collects data from mostly from birth center settings , but also some home and hospital data as well . But any minute now I should be receiving the data set for birth centers in Arizona .
Speaker 1Oh nice .
Speaker 2Included in that data set are mandatory fields about transfers of care , yep . So even just being able to describe you know kind of the burden of transfer and sort of how often it happens and at what period of time it's happening will be , you know , great . I mean , as far as I know anyway , no one has looked at that from a state level in this data set . So it'll be really interesting to kind of have that view . And then I'm also working at the moment at least I promise I'm getting it in any day now but my IRB application to do kind of a mixed methods survey of community birth midwives in Arizona and their experiences transferring into hospital settings , and that has actually been informed by the kind of perinatal quality board in Arizona .
Speaker 2It's an organization called the Arizona Perinatal Trust but they're really interested in thinking about transfers of care . About 25% of all of all you know kind of like labor experiences in Arizona have some sort of transfer of care . That occurs , you know , in part because there's just a lot of kind of like more remote rural places in the state for example . Um , but also there's , you know , a decently you know high number of people who are birthing in in community settings . So of course that also , you know , is going to come with a certain rate of transfer as well .
Speaker 1I think the thing to remember that transfer is not a negative thing all the time . Transfer actually is not a failed home birth or a failed . It's actually appropriate in the setting if the situation changes . But it's like , oh , it's a failed home birth because you had to be transferred , like , no , that's not the truth .
Speaker 2Well , that's , I mean , that's ultimately what really my hope would be to to think about , you know , putting more kind of like data on the whole transfer issue . It's , it's not a failure if somebody has to transfer . It's , you know , thank goodness we have the ability to transfer , you know , not only in the cases of , you know , emergencies , but also if somebody , if something happens that people are like you know what I feel like I need to go into a hospital setting , I feel like I am interested in an epidural . I feel , you know , I mean , for all the reasons , that things can change during somebody's experience .
Speaker 2You know , being able to have , have those connections is is critical , and I think you know this has certainly been true , for , for in my experience , especially in that the hospital where you were sort of like the transfer site , you know , for pretty much everybody in the New England area anyway , you know if it was really busy already and then somebody was coming in as a transfer , that initial sort of like , oh , what is this ? Like what's happening , like what's going on , you know , like not , sort of like , oh , we're here to help , we're here . You know our first instinct isn't always the best one , and I think you know , really kind of thinking more critically about the continuity of care and the right care at the right time piece and really frankly celebrating the fact that we have the ability to not always , but hopefully I'll , you know , often have the ability to get people to the right place at the right time .
Speaker 1So that's a really cool thing . Is there anything else that you're excited that you might be able to do in the future ?
Speaker 2Well , of course , because of because of Elise's enthusiasm and mentorship . You know , one thing that I've
Future Research on Postpartum Hemorrhage
Speaker 2I've really been able to get into is thinking about . You know how we assess people for postpartum hemorrhage risk and how poor of a job we actually do in predicting who is going to have a postpartum hemorrhage , and so I've gotten to do some really exciting work with both Elise and then another one of our colleagues at the University of Arizona , dr Julianne Rutherford . Thinking about , you know the implication of placental analytes and whether screening for certain analytes earlier on in pregnancy can actually show a potential increase in risk for people who may eventually hemorrhage down the road . And then also thinking about other factors that may come up . For example , things that we don't typically put into a postpartum hemorrhage risk assessment is whether somebody's had a cervical surgery before , like a leap procedure , or there's certainly been some interesting associations with . You know , the there's certainly been some interesting associations with um . You know antidepressant and anti-anxiety medication use and increase in hemorrhage , and we're not totally sure what that's all about Um and if it's the medication driving it or if there's something out . You know something else going on .
Speaker 2But you know , just thinking about different , different um , both you know kind of like clinical history pieces , but then also actual . You know both . You know kind of like clinical history pieces , but then also actual . You know changes that are happening in somebody's body that may , you know , give us better information about who may actually be more at risk for hemorrhage .
Speaker 2A paper that we just submitted recently was actually looking at the OXTR gene and how certain you know genotypes of that gene seem to be putting people at more or less risk for postpartum blood transfusion . So you know kind of like higher order morbidity from postpartum hemorrhage , and so you know , should we be thinking ? I mean , you know we have our typical panel of prenatal labs , right , but maybe it's actually that we also need to be screening , you know , for people's genotype , or maybe we need to be checking placental analytes at certain times in pregnancy , or maybe we need to be considering more about somebody's health history to then really think about how do we prepare people better for the potential for postpartum hemorrhage and then how do we respond better and then maybe even prevent it someday .
Speaker 1And then how do we respond better ? Yeah , and then maybe even prevent it someday , especially when you think about in so many countries anemia is such a critical issue in the antenatal care that if and therefore they're at much more risk if they do bleed of more kind of catastrophic outcomes than if there is a test that eventually isn't prohibitive in cost but can be done easily , that could kind of help bring that up . Then that's potentially many , many lives that are saved .
Speaker 2Yeah , especially because I mean , you know so many people hemorrhage who have no risk factors or are considered low risk for hemorrhage . So I mean , you know , you're of course like something , something like anemia , I think , you know , is putting people a little bit more at like , oh okay , this person we know is probably at more risk for potentially bleeding . But then the hemorrhages that seem to come out of nowhere and you're sort of , and of course , like I mean we're all prepared for hemorrhage , right , like you're prepared for a hemorrhage at every birth and you have all your things , or ideally you do , um , but you know , I think it's a very different situation when you're , you know , expecting a hemorrhage , versus you know you have this like lovely water birth and then all of a sudden you're like , oh god , get out of the tub , let's get out . So anyway , I think , basically , if the funding is there .
Speaker 1You've got lots to keep you going for the rest of your life .
Speaker 2I , yes , I hope so . Right , if the funding is there , and even if it's not , I mean hopefully I'll always just be , you know , at least dabbling . And I mean I've told Elise I'm like please just keep me forever , because I , I just want to , I just want to be , I want to be your postdoc forever . Can't I do that ?
Speaker 1and she's like no , but there's no need to move on . There's other ways that you can go . That still kind of like , keep the linkage up . Um , yes , which is exciting . Thank you very much for your time yes , thank you so much , liz .
Speaker 2it was so . It's such a pleasure to talk with you and you know huge fan of the work , work that you do . I think midwife stories and experiences are just so needed . We need more of them , and you know your work is awesome , thank you .