I’ve been feeling pretty burned out lately. Just mentally and physically exhausted, and feeling very disenchanted with midwifery at the moment. My first year of midwifery school is over, and two things have happened. First, I can’t shake the terrible, in-my-gut feeling that I really don’t know much of anything yet, that everything I learned this past semester I need to re-learn again. And fine, I can do that. I can spend the summer playing catch up, because I really want to know this stuff, inside and out. My grades were good, but now, two weeks after the end of school, I am already forgetting whether megaloblastic anemia means hyperchromic and macrocytic, or hypochromic and microcytic. At one point this semester I knew the treatments for every STI under the sun, and in some cases the alternative CBC regimens as well, but these days I can only recall a fraction of it.
But even more than just the details, I have been growing more disenchanted with what I have discovered midwifery to be—at least, the midwifery I have experienced so far as a student. When you’re an idealistic, starry-eyed student who loves birth and has been longing to go to midwifery school for years, your expectations are naturally sky-high, and I guess it’s understandable that few programs or experiences will be able to live up to that. Which is not to say that my program is bad in any way, or is not giving me the information and training I need to become a good midwife someday, but it’s not exactly all I dreamed it to be. And the midwifery care I have experienced so far in my clinicals is not exactly all I dreamed it to be, either. The clinic I was working at was amazing in so many ways, and yet so inadequate in other ways. Time was the biggest barrier for me: I never seemed to have enough of it, even as a student when I was already taking too long on all of my visits. There always seemed to be too many patients to see, and a cookie-cutter approach to their care. And here I keep running into a conflict that I can’t quite resolve: I long to be able to give women competent, individualized care, care that has time to ask them about how their week has been, and work on diet and nutritional counselling, and go over their birth plans and thoughts and expectations for the birth, pain management, checklists for the new baby, etc. etc. …and there are certainly many midwives who practice like this, usually in private practice. But then, there are other midwives who will tell you that having too little time to give is just the nature of the game: that’s reality, kiddo, better suck up and learn how to deal. And the clinic I was working at was giving care to disadvantaged women who would otherwise have far inferior care through other methods, and even though aspects of their care were lacking, on the whole they were getting an amazing package, and midwives were really making a difference in their lives. So who am I to harp on cookie-cutter approaches and lack of time when these women were getting perfectly adequate care—nay, better than adequate care? And yet, that still isn’t the kind of care I want to give, and not how I thought midwifery would be.
I wonder, too, how much of this comes from my current job as a nurse in a hospital where women are just churned through the system, in and out—epidural, SROM, pitocin, push, okay, next—with no thought or attention paid to the miracle of birth. Most days, at work, I feel like a zombie. I do things I don’t believe in, uphold protocols I don’t agree with, help run women through the system like cattle, and all the while there’s a wall in place that’s keeping me from feeling any of it. I was reading a post by Navelgazing Midiwife where she discusses many of the cruel and horrific things which are done to women by their care providers during labor and birth, and I have seen so many of the things on that list done by health care providers in hospitals to women, and as a nurse, I have personally done some of those things on the list myself, such as holding womens’ legs while they’re pushing, or holding womens’ chins to their chests while they’re pushing, or encouraging them to push using a valsalva manuever. Often this is needed because these women have epidurals, and are unable to feel the contractions in the first place, but also it’s happening because that’s the only way doctors and nurses know how to push and deliver in the hospital, having never been exposed to any positions other than lithotomy.
I’ve been slowly growing more and more disgusted with the hospital system. For a long time now, I’ve been able to justify my work in the hospital as worthwhile and helpful because 1) women in hospitals are so disempowered in the first place that ANY act of love and kindness makes an enormous difference there and 2) the majority of women, for better or worse, labor and birth in hospitals, and it’s important to me to try to reach and help women who don’t even know they need or want help in the first place. I’ve always thought that the women who choose to birth in a birth center or have a homebirth have already taken bold steps to protect themselves, their bodies and their babies from unnecessary and maleficent (i.e. the opposite of beneficent) acts, and that in choosing such a thing, they have already educated and empowered themselves to a level that many women who choose hospital births never reach. So, I have justified my work in the hospital by reminding myself that I am able to reach the largest number of women possible, and help women who may not have had the chance (for whatever reason) to educate themselves, or are at a pre-contemplative stage, and haven’t been able to even think about other options; for quite awhile, now, I have been telling myself that just being there at births like this, as a pro-woman advocate who can try to minimize the interventions, or add a touch of humanity to an otherwise disempowering experience, is a worthwhile and meaningful endeavor.
These concepts have sustained me for almost three years now, but lately, I am really beginning to have second thoughts.
Case in point: the doctor orders pitocin because he doesn’t want to have to sit around all night waiting for the woman to give birth according to her own body clock. He’d rather be at home, sleeping in his bed; pitocin will speed up the arduous waiting process (and here I am, thinking the waiting process is a beautiful part of the mystery of birth—but clearly, I’m deranged) . The woman doesn’t need pit, and giving her pit is going to make her labor go more quickly, sure, but it’s also going to make her labor more intense, so that she’ll probably be begging for an epidural before too long (and epidurals cause an enormous cascade of interventions which irrevocably change the course of labor…and so many women come in asking for an epidural before they’ve even started active labor). Pitocin is also going to put her baby at increased risk for fetal distress as the little one is often exposed to enormous contractions that the woman’s body would otherwise have NEVER been able to generate on its own. Pitocin causes water retention and keeps the body from processing glucose as efficiently as it otherwise would…which is not so useful when a) the woman’s body is doing the equivalent of running a marathon, and needs to process glucose as efficiently as possible (forget the fact that most of the woman in the hospital aren’t allowed to eat during labor, and are trying to run a marathon on no glucose at all…we’ll go there later), and b) the near-mandatory IV in the hospital, and the fluid bolus that is necessary for an epidural, among other things, makes it almost unavoidable that the woman is overloaded with fluid, which the pitocin and its inevitable water retention, is just going to make worse . Pitocin more often causes more harm than good. I KNOW this, and yet…the doctor orders pit, and I dutifully go and get the pump, and begin the process.
I am complicit in making these womens’ labors longer and more difficult. What’s more…I have developed complex methods for accepting the rationale for the pitocin. I have caught myself agreeing with a doctor’s reasoning for why such and such woman needs pit. And this is just one small aspect of labor and birth in the hospital which I am complicit in! There are thousands of other acts as well. I am the one who hands the doctor the internal, invasive monitors. On occassion, I have even asked a doctor for an internal fetal scalp electrode, just so the woman who is on continuous monitoring but is wanting to avoid an epidural can actually move around, and dance, and squat, and not have to stay in bed the entire time in a position that allows the external FHM to pick up the fetal heart. I know that studies have shown that external fetal heart monitoring has a 60% false positive rate, or something outrageous like that, and that the monitors can show distress when in actuality the baby is fine. I know that studies that have found that intermittant monitoring with a doppler is just as effective as continuous monitoring, and that the continuous monitoring doesn’t improve outcomes at all, it just increases the cesarean rate. I KNOW this, and yet, I have had to enforce continuous monitoring on couples that didn’t want it. I have held women’s legs apart while the doctors cut episiotomies against their protests. I have tried to help these women accept such acts, and come to terms with them, and grieve and mourn for the labor they wanted but weren’t able to have…but is this really helping women at all?
I have had to explain and justify the hospital’s sick protocols to couples I should have been protecting. I’ve told starving women in the middle of 30 hour marathon labors that no, they can’t actually eat anything except ice chips, because the order says NPO (nothing per mouth), and as a nurse working in a hospital, I am legally bound to follow orders. I have tried for years to convince myself that I am trying to fight this terrible system, but in truth, I am beginning to see more and more that so long as I work FOR the hospital, I am just a cog in its soul-devouring wheel.
I am continually amazed and saddened by the sheer number of women who come to hospitals to give birth, some of them even knowing full well what they’re in for—such a small number of women find or even want anything else. I am astounded that women allow such things to be done to them in the hospital. I am saddened that so many women are willing to subject themselves to such treatment, and so few of them know to ask for anything else. Where are we going wrong when it comes to education and informed choice? How is this status quo perpetuated? I am discouraged (though no longer surprised) that when homebirth comes up in conversation, people will tell me that such acts are dangerous and selfish and uncivilized, and yet…they’ll allow providers to ignore their desires, talk over their protests, disregard their questions, disempower them, laugh at their birth plans, walk all over them, tell them what they need/want, physically hurt them and their babies, pursue courses of action which several studies have shown are harmful or dangerous, drag babies out with forceps, insist on unnecessary cesareans, cut episiotomies, push pitocin, urge induction, refuse to allow a VBAC…the list could go on and on. I have seen so many HORRIFIC things in the hospital, and much of it being performed on women who are more than happy to submissively let it happen.
And there’s the rub, isn’t it? Because for a lot of women, a hospital birth is exactly the kind of birth they want. And if they’re happy with this, then who am I to try to intervene and impose my own sense of what makes a good birth on them? I may tell myself that I am working to help protect women who may not have received all of the information necessary to make an informed decision about the type of birth they wanted, but if they HAD received enough information, perhaps they would have chosen a different kind of birth…and sure, there are plenty of women out there who fall into this category. But then, there are plenty of women out there who DID receive all the information they needed to make an informed decision, and having done so, chose to have a hospital birth.
And that is their choice, certainly. But these women don’t need advocacy from a nurse like me. My passions and ideas, all of the energy and love and support I want to offer to laboring women—all of it is wasted in a hospital. I am beginning to think, more and more, that me, personally…who I am, given what I believe about birth…that I won’t be able to work within the hospital system for much longer. I want to go outside the system and promote a vision of labor and birth in this country that has absolutely nothing to do with hospitals and their sick protocols, or active management, or pitocin drips, or continuous monitors. Lately, whenever I go to work, I find myself thinking: how in the world could people ever really want to have their babies here? Just the rooms alone…so sterile and inhospitable, despite the hospital’s attempt to make them more palateable with wood panelling or whatever. You’re still giving birth in a fishbowl, full of icky equiptment, in lithotomy position nine times out of ten, with your feet in stirrups or held by the nurse (me) and your partner, flat on your back, in the glare of bright lights, while someone gowned head to toe in sterile blue, with a mask on, and gloves, “delivers” your baby for you then hands it off to a pediatrician to suction to kingdom come.
Yes, I know this post is taking quite a departure from my normal lines of thought, and may even be pushing me so far out on the “radical fringe” that many of you, my loyal readers, won’t even be able to understand where I’m coming from any more…and yes, I usually have a much more positive and chipper spin on birth and midwifery, and am ready to fight the good fight. But lately, I’ve been feeling too disenheartened to fight much. And I guess in my attempt to chronicle my journey towards midwifery, it’s as important to capture the downs as much as the ups. There are choices and options available to women which exist outside the hospital, and I want to be able to offer these to women as a midwife, but from where I’m standing as a student, I have no idea how to even get there. I’ll graduate and get a job wherever I can find a job (IF I can even find a job as a midwife) and this will most likely be in a hospital, since the majority of jobs for midwives in this city are in hospitals, and very few midwives fresh out of school with no experience are ready or able to move into private practice directly. So, hospital midwife, hi ho, hi ho. I know I have to start somewhere and gain experience somewhere, and I guess it’s better to know the system inside out before you move beyond the system, but my heart is sick atm, and I find myself enjoying my shifts on postpartum so much more than labor and delivery lately, because at least in postpartum the trauma is done, and all you have to focus on is healing, and the joy of the baby.
I’m really hoping that my Birthing From Within childbirth education classes at the end of the month are as rejuvenating as I think they’ll be, because I really need some rejuvenation.
16 Comments
Wow, reading this I’m half thinking, at least things are different in Canada, but also I feel the same way lot of the time. I suspect that feeling this way is inevitable when you work within a system that is so oppositional to your own philosophy. I wish I had a solution for you but how do you as an individual midwife work against a pervasive culture of medicalized birth? My best advice is to keep being political, and keep doing the best you can for your clients. It is possible to change the system (I think Canada is a good example of that). And go try out some homebirths already!
I had hoped against hope that you were off enjoying life outside of study… alas, you are bogged down in the whole “fight” as many seem to be these days.
I can only say thank you for sharing. It seems to be my night for midwifery mayhem on the blogs I know and love =)
I love reading the good, the bad and the ugly…
I’m glad you shared this.
k
Thank you so much for writing this post. I haven’t made the decision on how I want to pursue my studies to become a midwife, and this is exactly what I worry about when I think about becoming a nurse.
You totally wrote down the way I would expect to feel, and the best of it is that you ARE a nurse and you have had this hope that you could help out the laboring women in the hospital. This is helping me realize that even with the best intentions, if you do something that doesn’t necessarily agree with the way you feel about it, doing it everyday of your life is hard. It’ll eventually catch up to you.
I wish you the best of luck.
I can’t tell you how grateful I am. I am going to have to put a link of this post on my blog.
Thanks,
Bebu
Well, I’m relieved to hear that this post is helpful in some way, even as nothing more than a cautionary tale. I do feel as if I’m in the trenches, and sadly, I need the money at the moment, so just up and quitting is not really an option right now….until it is, I guess I just have to keep reminding myself that I won’t have to work in a hospital forever, and that there ARE women giving birth out there in a supported, loving environment, where they are respected by their providers and not forced or pressured in any way (and yes, these kinds of births can and DO occur in hospitals, and not just homes….but I feel like they’re fewer and farther between in hospitals)….but in any case, now I just have to find my way to more births like this. Seems a bit overwhelming, but yeah, it’s definitely time to find some homebirths. Wish homebirth midwives weren’t so few and far between…
And, you guys rock! Thank you so much for all of the support.
I read the vaginal breech story (and linked to it) before I read this…but I feel your “pain” and exhaustion…
Hh
I feel your pain, too.
Don’t lose hope. This temporary place is serving you well by helping to shape the *wonderful* midwife you’ll be one day.
I think midwifery is a great and noble profession. However, I do so wish you didn’t mourn hospital births the way you come across in your blog. You write that you’re “saddened” by the numbers of women who come to hospitals to give birth. I get the impression that you think that if women were just more educated about the wonderful world of homebirths and birth centers, and about the evil world of hospital births, that they would naturally choose not to have medicated hospital births. As someone who chose a hospital birth, I feel somewhat condescended to in many of your posts. I had a wonderful, loving birth experience (epidural, stirrups and all!!) that I wouldn’t have changed for the world. You write that hospital rooms are “sterile and inhospitable.” I beg to differ. My hospital room had drab decor, I’ll grant you that, but sterile and inhospitable it wasn’t. It was filled to the brim with the love of my husband and I for each other and for our child. The decor didn’t matter a whit to us.
You want to avoid burnout? Make peace with the fact that hospital births happen every day. Learn that there are those of us who willingly and enthusiastically embrace hospital births. There was no “trauma” for me in my interventions, I went in fully informed about every aspect of my child’s birth. I don’t intend to knock your ambition to attend homebirths, but I do hope that you are open to experiencing the miracle that is every birth, no matter where it happens. Promote your vision all you want, but understand that your vision of birth is not right for every mother. You’re right when you say that “for a lot of women, a hospital birth is exactly the kind of birth they want.” And not because we don’t know any better – give me some credit, please! I’m an organic-eating, baby-wearing feminist who rejoiced in my hospital birth. My birth experience was no less valid or beautiful because I was hooked up to “icky equipment.”
Respectfully,
R
Good points, R, and thank you for making them. I’m glad you had such a joyful and wonderful hospital experience. You’re right: I *have* attended many loving and very beautiful births in the hospital, and just b/c they are in the hospital in no way detracts from the love. I can see how you would find parts of my rant condescending, and I apologize for that. There is nothing wrong with having an epidural, or hospital birth, or pitocin drip or anything like that, if you know all of the benefits and risks, and that’s what you have chosen. Many women actually feel safer and happier in the hospital, and if that’s the case, they should absolutely be birthing in the hospital. What I’m saddened by is the number of women who have no idea that there is another way, and have not made informed decisions…or even wanted to make informed decisions, or be proactive in their care. I’m saddened when I see providers disrepecting women, and the women just letting it happen, and not knowing that they could ask for and demand better care.
I worked at a different hospital 2 years ago, and I never felt as burned out there as I do at my current job, despite the fact the number of epidurals, c-sections and pitocin drips were probably about the same. I think a lot of it has to do with the attitude of many of the providers at my current hospital, which is much more aggressive and seems much more disempowering than at my former hospital. Or maybe it’s just b/c I’ve been doing this for longer now, and it’s finally starting to get to me. Each unit has its own culture. I think the burn out is also coming from the fact that is IS hard to work in an environement where your own personal philosophy differs so greatly from the dominant philosophy, on a daily basis. This post was delving (wallowing?) in that friction.
Anyway, paying attention to the miracle of birth, no matter what the setting, has always been a goal of mine, and maybe I’ve been slipping away from that lately. In any case, thank you for the reminder. You’re right: this isn’t about me, this is about the woman who’s giving birth. If she’s not traumatized by her experience in any way, I shouldn’t be traumatized on her behalf. However, I’m really glad that I’m going to start to teach childbirth education, because that’s the best way to actually prepare and reach women *prior* to giving birth, so that they really, truly can know all of their options, and actually make choices about what they want.
Speaking of joyful, beautiful hospital births, would you like to share your birth story with us? Most of the birth stories so far have been skewed to homebirth…not b/c I’m choosing to focus on homebirth only, but just b/c those are the stories people have sent to me! I’d love to hear about your birth, and have a more representative selection of birth stories, because after all, almost all of the births in this country DO happen in hospitals; homebirth is a distinct minority, as I am very aware.
Student,
I’m sitting here thinking, “Be careful what you apologise for!”
Your strong sense of empathy for birthing women is very much alive in your posts. I hear you advocating for nothing more radical than basic humane care for women and their babies in our hospital system. I hear you longing for the recognition of women’s diverse emotional – as well as physical – needs and respect for the mother-baby bond. I hear you advocating for something as simple as dignity. (And, when we get down to it, lying exposed on your back with your feet in stirrups and someone fiddling between your legs compromises most women’s concept of dignity.) Please don’t apologise for this.
We all know, that no matter what the topic there is a good chance someone will take offence, it’s an inevitable and unavoidable part of human interaction. Each and every one of us has trigger topics and issues in various stages of resolution. But I think it is important to recognise the line between your culpability – deliberate or clumsy offence – and the other party’s issues/’stuff’. Own that blame by all means, with humility, when you are at fault, but hand it back when you are not.
Your passion has lent you an intuitive understanding of birth and the issues surrounding it. Please don’t fall into the trap of apologising for your core truths each time someone is offended. That will wear you down just as effectively as the system. Own your truth proudly…but gently.
It never feels good to realise you have offended someone. As women it is our natural (or conditioned) inclination is to fix things and make the other person feel right again. That’s an admirable trait but keep in mind you don’t do anyone a favour by taking his or her issues on board. It may ultimately be kinder to respectfully offer them back again.
Perhaps, in situations such as this, it might be more appropriate to offer a simple and genuine acknowledgement of the person’s feelings, “I’m sorry you’ve taken offence.” That way you invite the person to own his or truth, (and perhaps even connect with their feelings) without it diluting yours. I can’t stress how vital that is – for your own preservation, if nothing else – when you find yourself in a minority speaking out against a well-accepted system.
As someone once said to me, “Don’t be so quick to apologise for the things you hold close to your heart, as you are apologising for your very being.”
Penny
I’m used to posting about controversy, but this is the first time one of my posts has caused controversy. It’s kinda neat! I’ll always welcome everyone’s diverse opinions, both on what I write here, and on the subject at hand. It was my intention to apologize for causing offense, rather than for holding these opinions. It’s a hard line to walk. That’s an amazing quote, Penny—one I’ll definitely remember. You’ve given me much to think about.
I will also say this: RR, having read your birth story now (which I am going to post as soon as I finish this) I can absolutely see why you gave birth in a hospital—after a prior stillbirth, of course the extra monitoring and reassurance is comforting and welcome (and for good reason! If I had had a prior stillbirth, I’d want to be in a hospital too). And again, I am *so* glad your birth went so well, that you were satisfied with the experience, respected by your providers, and able to birth your baby into the world surrounded by love. But I will also say that not every woman is so lucky, and I have seen many births in the hospital where the couple is longing for that exact same experience, and sadly do not get it, for so many of the myriad reasons I’ve described above. I was trying to speak from experience, rather than generalize.
Thank you for posting this – know that there are other student midwives out there feeling the exact same way…
I’m a bit afraid for you, that even a career at a birthing center or doing homebirths may not measure up, either. Probably moms who choose a homebirth would most closely share your ideals. However, I’d bet that even their enthusiasm won’t compare to yours. After all, unlike you, they aren’t really involved in the process because they believe in the power of their own bodies; no, they got involved because they want a baby. You are making a lifelong commitment to midwifery; they are making a nine-month commitment. Presumably, their true passions lie elsewhere.
I think you will place too great a burden on your patients, if they sense that in order for you to help them best, they must agree with your philosophies and then – yikes! – perform a certain way during labor. I doubt you want your patients to be afraid of disappointing you or losing your approval. The pain of childbirth will go away – but guilt over failure can haunt someone forever. (And it won’t win you too many referrals, either.)
Heather, I appreciate your concern, and perhaps you are right: perhaps I wont find many women who want the kind of birth which I, having seen a fair few in my relatively short time, happen to want to advocate. I do think you have this somewhat backwards though – I’m not looking for my future patients to create the kind of births I want to participate in, rather I am looking to help facilitate this kind of birth for those who choose it. I’m not asking others to share my ideals – I am presenting myself as someone who shares the ideals of a (currently rather poorly represented) group of women. I’m not asking for patients to perform in the way I want – I am saying my goal is to perform in the way this type of woman would want. Granted, I am also saying that I wish more women chose this, and I am even saying that I wish more women knew that this kind of birth is an option. As we all know, a hospital birth is available to pretty much anyone that wants one, but I am confident that you will find more guilt in the “you’re not progressing fast enough, not pushing hard enough, not being compliant enough” approach which is so often utlized in our hospitals, as opposed to a “you’re not connecting with the moment enough” approach from me. Every single day that I go to work as a nurse I try to provide the very best care and support to every patient I see, and frankly I am a little offended that you would suggest I might behave otherwise. You know me: do you really think I’d be like that to the women I’m taking care of? What I had hoped would ring out of this post is that I am disappointed with a system which often treats laboring women like slabs of meat, and not that I am in any position to judge whether women *should* want to get anything out of their births besides a baby.
Needed to say something here…. I read, reread and thought long and hard about Heathers post. Not an easy thing in my world =).
I figure I need to make a slightly tangetical (is that a word?)point.
In a hospital with a doctor a woman who has had a c/s (for whatever reason, I could go on forever on this topic!) she is “Allowed a trial of labour”. With a midwife it is just labour. Not once was I told “we’ll let you try”. The only thing that peeved me was being told that I’d be having a “first labour” … as if those 15 hours (including transition) with my c/s child did not count!
I know that if I’d been in the hospital, I’d have been labeled a failure to progress and sectioned again! Instead I had my son at home, without the fear of how many cm’s how fast. It took 7 hours to get from 3 to 4, then 90 minutes later I had a baby. At the hospital, I’d have been on the operating table at that point.
I “think” the student was mostly voicing the concern of what is held as a view of normal in mainstream hospital settings. If a woman varies from what is normal to the doctor… it is time to “help her out”. In midwifery, these things happen too… but not as often. Midwifery gives a different approach to “helping out”. I know it isn’t perfect and uniform in care (even here in Canada), but I personally see midwifery as an ounce of prevention in the vbac struggle going on…
just my biased view.
k
Well, you have stated it all perfectly. I also worked ten years in a hospital, and I am still amazed that so many women birth their babies in an institution! It is time efficient and has an air of religiosity to it all, with the high priests of medicine, the special medical terminology, and now the sacred rituals of tecnology. There are always ups and downs in midwifery whether it be home birth or hospital, or birth center. Home birth also has the problem of not being ‘accepted’ by all powers that be, nor encouraged. When the tragic outcomes that all of us nurses have seen IN hospital occur, often due to iatrogenic causes or negligence, no news gets out to the community about the babies we’ve seen with scalpel cuts from mom’s cesearean, or the botched circumcisions, or the hsv virus the baby caught because the mom had asymptomatic hsv and the doctor insisted on an internal scalp electrode for a ‘better’ tracing. Yet should there be any problem with a home birth gone south, all the usa knows about it, and the ole’ fear of home birth gets reved up. OB’s the specialists in surgery and pathology get assigned the ‘normal’ births and the nurses do most of the ‘work’ and try to time it all so the dr. is at the birth, for god help us should a nurse have to ‘deliver’ the baby. The whole system is wrong. It’s like having everyone with a tension headache go to a neurosurgeon!
Anyway, you have spoken succinctly and stated the issues we RNs face in hospital. That is why I earn 20K a year as a home birth cnm, and not 80K as I would if I ‘sold my soul’ and worked as an in hospital cnm at Kaiser.