Barbara Bechtel of has over three decades of experience caring for pregnant and laboring women. In the 1990s, at a time when there were almost no midwives in her home state of Indiana, she became a certified nurse midwife through the distance learning program at the Frontier School of Midwifery in Kentucky. She then went on to start a birthing center in Indiana. Six years ago, Barbara moved to New York City and has established her own private practice as a home birth midwife, Dahlia Midwifery. She is now one of twenty five home birth midwives practicing in New York City.
Barbara was my midwife when I gave birth to my son, pictured here, in my Lower East Side apartment last year. She and I got together for lunch recently to talk about her experience becoming a midwife at a time when, as she says, no one knew what a midwife was, and about her more recent experiences as a New York City home birth midwife. These are some of the highlights of our conversation.
How did you first become interested in midwifery and become a midwife?
I was very lucky, when I graduated from school and I was an RN, they told me I was going to be on a regular floor, surgical, and then the day before I was going in they called me and said no, you’re going to work in labor and delivery and I thought “oh that’s so exciting!” I was just lucky, one of the nurses was going on maternity leave. I loved it.
And then I became a nurse manager and then I started teaching at the university. I also was the coordinator of the prenatal classes. When I was teaching I’d always wanted to be a midwife because I was doing everything except delivering the babies. But it was impossible back then, we’d have to go to Chicago, that was the closest place. There was one midwife in Indiana back then and I talked to her and said, can I just see what you do? And she said you wouldn’t want to, all I do is lay out instruments for the doctor. For a while there it seemed impossible.
And then my friend said there’s this new program that’s distance learning, and that was, like, the early ’90s, and she said, there’s no reason why we can’t go to school. You go just a little bit then come back and practice in your community. They had the finest instructors in the United States, it was the oldest midwifery school in the United States.
What was the name of the school?
The Frontier School of Midwifery in Kentucky, in the foothills of Kentucky, that’s where it started. The midwives there rode horseback in 1925 and they started there as public health nurses and the way to get to the families was to deliver their babies, to earn their trust, cause they were in there hollers where people hadn’t come out for years, I mean, you couldn’t even get there, that’s why they rode horseback, and they were turning health around there with simple health teaching.
So my friend and I decided to go and I went, and then she called me the day before I was going for my orientation after I’d applied and was accepted, and she said we’ve sold our house and we’re moving to Florida, and I said ok! I thought, ok! She said, I don’t want to be a midwife, I don’t want to be up all night and never sleep, oh my gosh. I said, fine. She said, I think that the universe wanted me to guide you in there and give you that information. She became a teacher. I still love her and we stay in touch all the time.
And so I graduated! It just seemed to me like it was the only thing I wasn’t doing. I was teaching prenatal classes, you really form a bond with the families that way, and I would be there attending their deliveries as a nurse but not delivering the babies. So it seemed like it just went that way.
What were the major barriers at that time to becoming a midwife? The state laws?
Yeah, Indiana was pretty awful. It wasn’t so much the laws – you have to have a staffing doctor in the other 49 states, not in New York, we’re very great – but that wasn’t a problem for me, cause I grew up in a little town in Indiana (and so could find a staffing doctor), but it was the attitude, because people had never heard of them (midwives).
When I was in school online learning was very new, so my friends were saying, is what you’re doing legal? I go, yeah, yeah (laughs), no, I’m going away to school to do something illegal. But they didn’t know what midwives were. And one of the projects of the school was to go around, I just went around videoing people saying, what’s a midwife? People think they know what they are, you know. In Indiana when I graduated there were only 35 (midwives) and 5 of them were students, and some of them I think had been retired, Lord knows if they were just on respirators or what. We just didn’t have any. We were the lowest per capita in the United States. I think there was a lot of misunderstanding about midwives. So it was just, people saying awful things. And I grew up there, that was the only reason I could get staffing doctors. The doctors understood what midwives do. But the public didn’t.
And you eventually started a birthing center in Indiana?
I started a birth center because the local hospital thought it (midwifery) was a weird thing that they didn’t need, and they told me that. So I started my birth center, cause I wouldn’t have been able to practice (otherwise). And that was fine.
Once I talked to people- I went to every place I could go to- they have rotary clubs, I went to those, I talked to old retired men about the birth center and I had my little slides and I talked to educate people and they’d say, Oh! Oh! You know, it was about the history of midwifery and what we do, and about out-of-hospital birth. And I had high school tours come through and junior high school tours, they teachers were always looking for learning experiences. It was fun.
How did you get the funding for the birthing center?
My friends. They said, that sounds alright. I said, well, I’m going to have to move (otherwise), and they said, well, we’ll help you out. So they did.
And you moved to New York a few years ago, is that right?
Six years ago.
And here you’re working as a home birth midwife. Were you doing home birth midwifery before you came to New York, or is that something you started here?
In Indiana there had been one home birth practice, with three midwives. And the staffing doctor quit staffing, I don’t remember why, but you had to have staffing doctors and they’re frightened of home births, they’ve never seen one and they think they’re going to get sued, so they usually won’t do it. Here you don’t need it.
Why doesn’t New York require staffing doctors, do you think?
The midwives here got together and lobbied for it. And it just makes sense.
I mean, I was fortunate cause I was a new graduate with really nobody else around me… I had grown up with these doctors and worked with them, and so… it was nice for them to review things and teach me more and give me their slant on things. So I would sit with them once a week, one was in Muncie and one was in Indianapolis, and they would review charts, anything I had questions about. They’d review all the ultrasounds and the labs and I learned so much. So that was fortunate for a new graduate. To be alone, you have to run to the textbooks. They were not kind, you know, I could not call them and say I don’t know what to do, you know, I had to research things too, and really be on the ball before I’d call them and say here’s what I think, what do you think? So that was lucky and I had a wealth of information. But you know, now, it would be ludicrous. After a while it kind of was. To sit there and sign off on all my ultrasounds and lab work. I know what I’m doing now.
How did your experience compare to people who are becoming midwives today in terms of the resources available and the process?
Well, Indiana started a Masters program in midwifery. And we’re doing more births all the time. I think when I started midwives did seven percent of the births and I think now we’re doing fifteen percent of births in the United States so we’re getting there. And there are more midwives, we have distance learning, and more schools open.
In New York, how many home birth midwives are there?
There’s 25 in New York City. But there’s a lot of them upstate, Hudson Valley, around Nyack, so I don’t know, but there’s more than in Indiana, I’ll tell you that!
Are there any barriers to home birth in New York City?
Yeah. There’s two doctors that are adamantly against it and they write articles and they quote research. But you need to look at a research article to understand it. When you have a small number of births and you have one bad outcome and you take a percentage it’s gigantic. Unless you get thousands it’s not very meaningful.
But we’ve been keeping statistics better. And we are getting more (home births). I had a really nice article in the Wall Street Journal, a newspaper reporter had researched how the home births in New York City are increasing, it was very nicely done, and she interviewed me, and that was helpful.
A lot of doctors… they haven’t come out as a professional organization sanctioning them (home births), but they’re coming closer. And they’re fine now with the birth centers, at first they were wary of those. Now they say oh, that’s ok. And the pediatricians, too, are becoming better. I think it was a year ago last April there was a research article that came out in the professional journal of obstetricians saying we only sanction birth center births or hospital births, but they said, but, if you’re gonna have a home birth, so it’s like, whoa, we almost got you to say go ahead and do it! Cause they said you need a certified nurse midwife or a certified midwife with a formal education, a birth assistant, emergency equipment, all the things we do. And that was a good article to me. I was happy to see it.
And I think it’s going to come around. And as we get more statistics… because we had small numbers, it showed that they were dangerous, but now that we have more and more home births, it’s showing that they are just as beautiful as birth center births and just as safe, better outcomes, and happier people that wanted them. As we get more midwives, professional midwives, it gets better and better. It used to be kind of hodgepodge, how they kept (records), we were just kind of out there. But now we have a program called benchmarking with the American College of Nurse Midwives.
You always work with both a birth assistant and a doula, right?
Yes, that’s the only safe way to do it. And they all have very separate roles.
People ask me a lot what the difference is between the role of the midwife and doula. Could you explain that?
The doula comes earlier in the labor, which is called “presencing” in nursing. Its very therapeutic, cause otherwise you’re alone in the dark having contractions and wondering, I hope everything’s alright, I hope the baby’s not coming out. They will come, it feels better just to have her enter the room, then she- different ones have different attributes depending on their experience, but she can help position the baby properly, she knows from the signs of where you’re getting pain or where you’re feeling things what to tell you to do position-wise, she gives a great amount of pain relief, gives you ideas of what to do, helps you not only physically but psychologically. And she cleans up afterwards- that’s great! And she feeds you. She can help you postpartum. She’s with you. And, we all work together as a team. I mean, there’s plenty for everybody to do.
Do you have any especially beautiful or interesting stories of home births in New York City?
I call them all boring and beautiful, you know. We don’t want the excitement. The transfers are another thing. Yours was… beautiful…I still talk about it. You know, there was a husband that put rose petals in the water, and they had the candles going. It was lovely, and you went so fast, and so healthy.
I didn’t know if I would be able to have a home birth at age 40.
Oh God no (laughs). You’re high risk! Why, I don’t know.
There is a big thing now about the age going up in the United States, being older having first babies, now the average age is 26 on a first baby which is phenomenal; in the ’70s it was in the teens. So the craziness with making women high risk at the age of 35 is senseless. And again, if you look at statistics back when they did the down syndrome statistics, it was in the ’60s. People didn’t have babies at age 35, they were done. So, you know, you’ve got again a tiny number with one bad outcome and I really think that’s flawed.
The only thing, I have many people inquiring and they’re 40, plus, and I’ll say yeah, you’re a little bit more at risk for gestational diabetes and then genetic testing starts to go up even though it’s less than a percent at age 35, so that’s the only difference. And the New York women are healthy. It’s a very healthy city. You walk, you eat excellent diets.
Speaking of the walking and healthy eating, are there other things like that that you’ve seen that have led people to have more comfortable pregnancies or easier births, in terms of lifestyle?
Yoga and exercise have been shown to greatly aid speeding up your labor and therefore making a better birth, a healthier birth. Pregnancy-wise, too, it just makes sense because of the good blood flow through your body and, you know, stress and fear will cause you to release adrenaline and that inhibits the birth of the baby and it’s harder on you and your body system. So yoga helps with that, meditation, any exercise, and people have healthier births.
And what about strategies for keeping stress low during pregnancy in New York City, which can be a stressful environment, are there strategies you’ve seen people use?
Besides that? (laughs)
Walking, don’t drive. I had trouble when I got here; I didn’t realize the rhythm and driving is extremely stressful, it’s terrifying. Well, even the subways, every time you’re traveling somewhere you never know if you’re getting there so that’s stressful plus the people, you know, hurrying, hurrying, trying to get ahead of you, it’s stressful. Walking for pleasure, too, in the park. You have many green spaces, thank God.
I did that a lot. Even just going to the East River Park to watch the sun come up or something like that when I was pregnant helped me stay really calm and relaxed.
The water is very soothing, if you can get to the water, or nature. You have that opportunity here. People don’t want to take the time, but you need that.
And then what about- I thought it was crazy to try to have a baby in a fourth floor walk-up tenement apartment, have you seen a lot of stuff like that in New York? Crazy spaces that people try to give birth in?
Yup, yup. And it always fits. That’s my job, to make things fit. And they always do. I hear that expressed many times, people saying, my apartment’s so little- it’s always bigger than a hospital room and people give birth in there!
Most people are in tiny spots. I think the tiniest one I ever had was a wonderful couple and they wanted to have the birth pool and it was the tiniest place I’d ever seen, in the East Village, and they would go out on the fire escape just to get a little room… it was like a long hallway and the kitchen had their shower in it, and it had a sink, and the bathroom was straight down the hall at the end and it was just a toilet, nothing else was in there because it couldn’t fit, so you had to come back out to the kitchen to wash your hands, and the bed was kind of built into the wall with drawers under it, there was storage everywhere… they were looking around and said, can we fit a birth pool? And I said, maybe the kitchen cause it’s got a little width here, I said that should fit.
So she went into labor, all they had in the kitchen was a little drop leaf table for the two of them and the sink and the oven and everything, there was a little cutout that the pool would fit into by the shower area, so in labor I come in and there’s the birth pool and there was maybe an inch around it… and I thought I was going to fall in (laughs) but I didn’t. So I got around to a chair and I’m looking and I said what did you do with the table? And he said, look! And he pointed up and there it was hanging from the ceiling by a hook! So it was fine and she had her water birth in there and it was lovely. We were laughing.
And I was worried too about the noise, with the neighbors.
I’ve never had a neighbor complain. Either they’re just smiling cause they know what’s going on or they don’t hear it. In transition, your senses are magnified so a lot of times it will seem like you’re screaming but you’re not. I mean, if you have wild sex it’s no louder than that, so the neighbors should be used to it. It sounds a lot like it too!
Speaking of the birth pool, it seems very intuitive in a way, to me, to give birth in water.
In the ’70s there was a popular custom that started going on because of a book that Frederick Leboyer wrote on Birth without Violence and he started the idea of giving the baby some water right after the birth, giving them a bath, which was the precursor to the water birth. It was a nice, it was the first time that people were thinking about the baby and how they feel. It was about ’75 I think when it came out and as time went on they started doing that so now, there’s the water birth, that’s better overall, but babies liked the bath, they thought that was kind of neat.
I have Leboyer’s book on baby massage, Loving Hands, on how to massage babies to release any tension they may be holding in their bodies. And the baby loves the massage!
I wish we had more baby massage classes and that it were more popular.
People ask me a lot about what kind of prenatal care you receive from a midwife if you’re planning on having a home birth. Could you speak a little bit about that?
If midwives are allowed to practice the way we’re taught the usual appointment takes an hour, if you’re busy maybe a half hour. But midwives are taught that birth is normal so you leave it alone unless you find something that’s wrong and believe in that, and just focus your attention on helping people to enjoy their pregnancies and recognize how normal it is. Our hallmark if we’re allowed to practice it, is to stay with the patient during her labor which takes a lot of hours so you can’t have tons of patients! The traditional role is to have very long prenatal appointments because we do all our teaching there too. We do anticipatory guidance to tell you what the normal is going to be because we have that time. And so we just tell people to enjoy their pregnancies, and they tend to be very normal, sometimes minor variations of normal, but still normal. If they’re high risk that’s a whole different situation. Luckily New York City is the best place in the world for high risk care.
You mentioned teaching people to enjoy the pregnancy and treating birth as normal. Are there other important values you hold?
I believe my patients are not children. I don’t tell them what to do. But I try to give them all the information so they can make an informed decision. So it’s very, it’s not structured, I mean it is, but you get certain tests, have certain preferences for the birth, you know, philosophies on how natural they are, that’s all very individual.
What would you say is your favorite thing about being a midwife?
I get to be part of those families at the best times of their lives, I see people at their very best in life. And it just makes you so happy for humanity. The pure joy on people’s faces.
Is there anything you want to add that I didn’t ask about?
You get yourself ready, prenatally, it seems to go fast and then at the end the last two or three weeks it seems to kind of go slower because you’re waiting and waiting and waiting and getting everything done. Then they have to just let go of things and just let the hormones flow. You have to trust in your caregiver, whether it’s a doctor or midwife, because ultimately you’re not going to control anything. And that’s scary for people but at some point you have to say, ok this is going to be out of my hands, all I can do is the best in my labor, and that’s what you need to go into labor with. And it really helps! You know, you do tend to tense up and think what can I do, what can I do? As a woman in labor, it’s another world, you have to just do your labor.
I wonder if that’s hard for New Yorkers, we’re so used to wanting to be in control (laughs).
Well think about it. They’ve been searching out their midwives, searching out their birth experiences, planning, getting ready, then to be told, ok there’s nothing more you can do. It’s like no, wait, wait!.
How do you see people making that adjustment in the moment?
Some don’t (laughs)! It’s a hard thing for anybody, to accept that you can’t do anything else. But the sooner you get to the point when you realize you have to surrender, the better you’re going to be. And whether you like it or not, at some point you’re gonna, cause that’s just part of labor.
I wonder if there’s lessons people take from that, from the experience of having to surrender.
The one thing I like women to come away with is: if I did that, I can do anything in my life. I think about that sometimes. When I feel like I’m being trampled on, I think, I’m a strong person! You’re never the same again. The minute of birth, you’re changed forever.