From Hospital Halls to Homebirth: Bayla

Being a homebirth midwife is an all-encompassing, 24/7 career choice. Most homebirth services are offered by Certified Professional Midwives, but why don't more Certified Nurse Midwives offer homebirth services? 

In this episode, host Katie O'Brien sits down with her old colleague Bayla: CNM, serial entrepreneur, and one of a small group of nurse-midwives in the United States offering home birth services. What starts as a career retrospective quickly becomes a masterclass in everything nursing school doesn't teach you.

Bayla has done it all — cloth diaper store, bookkeeping firm, four-midwife practice, solo home birth CNM — and she's doing most of it simultaneously. She talks candidly about why she left the hospital (spoiler: she had her own baby and sprinted home), why she stays in home birth (the relationships, the autonomy, the lack of someone looking over her shoulder), and why she's finally starting to pull back (the board of nursing called — multiple times).

Along the way, the two dig into the state-by-state legal maze of home birth, the fraught reality of hospital transfers, the lost art of breech delivery, malpractice insurance that nearly hit $40K/year, and the gut-punch of going above and beyond for a patient who never speaks to you again.

Equal parts inspiring and sobering — this one's for every midwife who's ever asked "why do I keep doing this?" and then answered their own question at 2 a.m. on the way to a birth.

This episode pairs well with a chilled glass of moscato.

Transcript

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0:00

Hello, and welcome to my podcast, mindful Midwifery Presents the Labor Behind Labor. My name is Katie O'Brien and I have been a nurse midwife since 2007. Midwives have tremendous pressure to show up to their work every day as their best selves. We must show up despite bad weather, bad days, or bad situations. The goal of my podcast is to highlight this challenging world and give listeners and insider's view on what it feels like to be a midwife tasked with being your best self, both professionally and personally. For this episode, I'm excited to give you a glimpse into the life of a home birth midwife. My friend Bayla is a CNM that offers home birth services. Considering that very few CMS perform home births, it is amazing that she was willing to sit down with me and discuss the highs and lows of life as a home birth midwife. Further, she gives great insight on perhaps why the number of CNS offering home birth services is so low. Let's get started.

Katie 0:57

Well I wanna start out by saying I am really excited that you agreed to this because, well, so many reasons I think that there aren't that many CMS doing home birth. So that's kind of this niche thing you're doing, which is awesome. And I started my career with you, which is so

Bayla 1:18

been a long time. It's

Katie 1:19

a long time. It's been a long time. And it's interesting for me to think about where we started and where we ventured. And I think when you look at the practice that we were in together, it kind of makes sense where we both ventured because it was a practice that was kind of in the middle range of midwifery. You know, it wasn't, wasn't a home birth practice. And it wasn't ultra hospital medicalized, we were in the hospital, but we were doing all these great things like water birth, and, there's not many practices like that. So I, I think that a midwife that was attracted to that practice could end up in a lot of different places later. So

Bayla 2:00

Right. So definitely a unique practice. Yeah,

Katie 2:04

I miss it

Bayla 2:05

Yeah.

Katie 2:06

and I've tried to recreate it interestingly, and in some ways, like I started, doing prenatal care and realized after about nine months that even though I controlled that whole setup, I don't know that I'll ever, like the office the way I did at that practice. Like that was such a special time in my life, and also my midwife life and the office. In a lot of ways is notable because of the people that were involved at the time. Right.

Bayla 2:36

You need the right people for sure. Yeah.

Katie 2:38

And we were on this new grad like, journey together and then our,, we had this mentor that was so on the other side of, the longevity factor with midwifery. I think she was 60 when we, started something like that math wise and, these office, managers that had been there and knew what they were doing and it was like a family. And it's hard to recreate a family.

Bayla 3:03

Right. You should interview all of them.

Katie 3:06

Yeah. They, I say all the time that they, um, helped make me the midwife that I am

Bayla 3:10

today. Yeah.

Katie 3:11

You know, so we were in this practice that was, holistic but also capable of. Being medicalized if needed. Because we were in the hospital, people could get epidurals easily. They could get induced if they needed to. At the time I felt that we were really professionally handled when I was there, by the physicians and the attendings and everything. Which is hard to replicate in other places. So it was, a really great thing. And then I left there to move back, to Delaware, which at the time was not at all close to where Baltimore was as far as, what birth could look like in the hospital and what midwives were understood to do. Um. I was constantly having to explain what a midwife was, and that was a really new thing for me.

Bayla 4:04

what's the difference between a midwife and a doula? Right. Get that a lot. Right.

Katie 4:08

I had all kinds of crazy things said to me in the first couple of years that I was in Delaware, by patients, by families of patients, by it, whoever, And then about, we were doing so many of the verse that, and about three years later people weren't asking those questions, but, but that was a real transition for me and I went into more medicalized world just because that's what was there. Like I, I was moving home to be with family and that was what was there. And so that's kind of where my career journey went. Uh, by default, like I didn't really have an option in that. Meanwhile after I left you from that practice, you got progressively more out of hospital essentially. So take us on the journey of, kind of where I left you at that practice. And I think you were starting to think about home birth at the time and, you were kind of transitioning into that world. So why'd you make that decision and what it looked like for you?

Bayla 5:07

Well, you were there for the birth of both of my boys. Mm-hmm. 17 and 14 years ago. And then my daughter, she's nine and a half now, so I got pregnant with her and I could not find a provider that I wanted to go to in the Baltimore area, considering all the hospitals and all the, you know, connections that I had. There was really nobody that I was interested in, seeking care with, including the hospital that I was at. So I had some friends that had home births, so I decided to start looking into to home birth, and I hired home birth midwives. And at the same time I realized I didn't really wanna go back to work.

Katie 5:44

So

Bayla 5:46

I kind of did my own like experiment, my own like business expenses of having my own home birth to see what that was like. And meanwhile developing, my own practice. I mean, I've always been an entrepreneur.

Katie 5:58

Oh, definitely. I was about to just take this in a totally different direction. Talk about that

Bayla 6:02

I'm like, why would, why would I wanna work for someone when I can work for myself? And like I, I opened an office a couple years ago, like I bought a building to open an office. Like why would I wanna rent if I could, own a building? So I'd gotten to the point in my career where I'm like, I can do this. You know? So I started looking to opening my own practice and originally they had agreed, the hospital had agreed that I could continue keeping my hospital privileges there, while doing home birth simultaneously. Which lasted, I don't know, a few months. And, 'cause I had a lot of patients still that. Wanted me, but also wanted hospital birth. So we continued kind of like on that trajectory. I opened my practice, I gave birth to my baby. I was actually at work that night, or I guess the night before when I went into labor and I'm like, I've gotta get home. I don't wanna have my baby here in the hospital. And then after she was born, I left my like official job at the hospital and, and it takes time obviously to build up a practice, so there was still a lot of time involved before, like my practice really got off the ground. But I found that a lot of my, like I wasn't able to provide the type of care that I wanted in a hospital setting, like I could in a home birth setting. Like, it was obviously more autonomous that like, there weren't doctors looking over your shoulder and like telling you how to manage your patients. Um, so eventually I moved out of the hospital and then just doing home birth now. Mm-hmm.

Katie 7:29

I think if anybody's listening to this, they wouldn't realize without us taking a little side venture here that, um, you have done quite a few business things. Uh,

Bayla 7:40

so you're, I consider myself a serial entrepreneur. Absolutely. So

Katie 7:43

you're not the average midwife as far as your IQ in the business world. I mean, you started a company pretty early on into our midwife jobs you were selling. Um, it was like a boutique. Um, and you know, you were selling cloth diapers among other things, and that was somehow you were managing to do that while you were. Being a midwife in our practice and raising children. I mean, it was pretty impressive.

Bayla 8:10

Yeah, I really, I just like look for voids, I guess, and just fill them and there was There was no store locally that was selling cloth diapers, so I just got a wholesale account, started selling some diapers outta my house. And the demand was there. So it kind of just blossomed into a store

Katie 8:24

So I'm guessing that you took that information from, from the diaper business and you were able to, I'm guessing that it actually wasn't that intimidating to think about starting a practice. You had already done a lot of business things that I think, get really anxious about, because it's not something we learn anything about. Just even starting like an LLC, like the name, how do you get the name? How do you, you know, all those,

Bayla 8:53

places, right? Yeah. Starting the business isn't the big deal. It's just finding the clients. And this was just like the beginning of social media. I think it was like just starting to like, be a way people found business. Now I think it's much easier to like find clients 'cause you like find, you know, moms groups and things like that. But then it was a little bit more challenging to like develop like a client base.

Katie 9:14

Mm-hmm.

Bayla 9:16

But the actual business wasn't a big deal.

Katie 9:18

How long do you think it took you to develop a client base? One that was sustainable? Uh, financially,

Bayla 9:24

I think four to six months. Till you're like, kind of off the ground. But like you get them at the beginning of pregnancy, so then you're working with them for nine months. You're not really like making money at the beginning, they're making payments over time, but then until their baby's born is, a year out. So.

Katie 9:41

yeah. How did you, how did you get through that time financially? You had just had a baby so maybe, you were already in the mindset of, I'm not making the money that I was gonna be making before. But I think you were also taking shifts probably still the

Bayla 9:58

hospital. I wasn't.

Katie 9:59

So you just, you just dove in.

Bayla 10:01

Yeah. So as when I closed my store, my retail store, I started doing bookkeeping on the side because that's really what I had enjoyed about running a business, was like the backend. So I started taking bookkeeping clients. And at that point also I started working for like a outsource bookkeeping firm. So I was just increasing my bookkeeping, income until my midwifery really got off the ground. But working for a hospital practice, we actually weren't making that much money. So there was like a lag, obviously in income, but, it, it wasn't that long. And I was able to kind of make up for it and like my husband, was working or whatever. But yeah, working on my own is definitely a, more lucrative

Katie 10:43

In general. And so you started the journey towards home birth because you could relate to options, lack of options, and wanting to birth in a different way. What's kept you in home birth?

Bayla 11:00

I just love it. I love, first of all, I love the relationships that you develop with people. You know, working in a group practice, you're just not able to like get to know people as well. And also you don't have as much time to spend with them to get to know people. And being a solo provider, like you really develop really nice relationships. They come back for their future babies. So it's really nice to be able to follow them through their whole pregnancy, their birth, their postpartum, and then see them again for their next baby, which is really amazing. But also I can just provide the kind of care that I wanted to provide and that they, they can get what they want out of it as well. I just make sure that everything stays safe. They have the options to, choose or decline whatever. Extra things that they want. And you don't have that when you work for a system. There's protocols and rules and things that you have to follow if you work for a hospital or, a larger practice. And then also, usually if you work in a doctor's office or like a large office, you have 15 minutes for appointments, or 10 minutes for appointments,, now I can do whatever I want really.

Katie 12:02

Yeah. When I started prenatal care, that can be a blessing and a curse because you can do whatever you want. So suddenly you have all these options. And I've found, sifting through the options at times to be difficult. Like, what do I wanna do? And time management is really different too, when you start, something that is totally on your own time. I find that it's difficult sometimes to stay on track or to schedule people in a way that doesn't completely upend my whole day and then just make me have one hour segments across five days when,, when you're scheduling an usual office setting, you might be, putting all five in a row,

Bayla 12:43

right. I know some midwives, they like only schedule appointments on Tuesday and Thursday, they have specific days for appointments. I don't do that because some of my clients aren't available those days or those times or whatever. So I really try to just see them when they're available. But it is hard to have one here, one there, and I've tried to, I have students that work with me so they can't come like all the time. So I've tried to condense appointments more into like certain, blocks of time. But yeah, it's sometimes it's difficult to, to manage, i'm kind of just seeing people whenever

Katie 13:13

it's totally different way of

Bayla 13:15

Mm-hmm.

Katie 13:15

mm-hmm. And, one of the, CPMs that I work around, I should say collaborate with, however you wanna phrase it, the way she, like her work life is embedded into her. The rest of her life is just so different, than what I've been used to in, hospital-based

Bayla 13:33

practices. But then I hear of like, people that work in offices and they're working like eight to five, three or four or five days a week, you know, seeing patients every five minutes. And that's just insane. I could never Keep up with something like that. So even though my schedule is kind of all over the place, I really feel blessed that I'm able to like, take my time and enjoy the appointments and not feel totally stressed out by that type of schedule.

Katie 13:56

Yeah. Well, and you're not seeing them probably as frequently necessarily. Um, as, and I

Bayla 14:02

standard of care, so we do every month and then every week at the end. Mm-hmm. So, yeah, it's pretty standard.

Katie 14:09

Well, even, so the first practice we were in, which you're probably still following that kind of similar timeline, we definitely saw them a little bit more spacey than in, a very medicalized practice where you're seeing them without fail. I think it's like 14 visits, but like World Health Organization doesn't even endorse 14 visits. Right. We've just created that here. So I think, if you're. A midwife that is not used to working out of hospital. For me, it was easy to, to get kind of overwhelmed by this timeline of how many, how many appointments am I gonna have a week and how's that gonna look? But, but I think what I get from most of the people that are doing home birth is that, it kind of works itself out. It, it doesn't feel super overwhelming most weeks.

Bayla 14:56

Yeah. No, I really enjoy it. I really love when, patients come and we have time to talk about whatever they wanna talk about. Hmm.

Katie 15:03

Mm-hmm. Do you do any visits at their house beforehand or?

Bayla 15:08

I do a 36 week home visit, um, for new clients. Not usually repeat clients, um, just to see like where they live and where to park and where they wanna set up all their supplies and that kind of thing. But some of my clients are far, I mean far as relative I guess, but I don't go more than like 40 minutes to an hour. I try to stay in the Baltimore area. And because my schedule is tight, I really don't have time to be traveling, around to people's houses. So we do that one home visit at three, six weeks and then two postpartum home visits.

Katie 15:36

Maryland is an interesting state in that you are allowed to do VBACs here

Bayla 15:42

and only nurse midwives,

Katie 15:43

right? Sorry. Only nurse midwives. CPMs are not. And working in a state adjacent to Maryland, we do not have any ability for anybody to do VBACs at home. And it's really interesting to me right now, I have a prenatal patient that had, has a very good story for, a trial of labor this time and. She is just almost beside herself that she has to deliver in the hospital and there are no options for her. And so I find some of these things really thought provoking that,, in one state you can do something and in another state you can't. And how that really influences women and their thought processes about their body and their, decision making processes for her. She said to me recently, she's like, well, basically I'm being told I can't deliver any other way. So it is what it is. I have to be in the hospital. And I think a lot of women that have had VBACs, or I'm sorry, a lot of women that have had C-sections and want a vbac, there's trauma there as as to how their process went and how they're hoping their process goes this time and. So it was kind of the first time that I really processed the craziness that is in one state you can do something and in another state you can't. Uh, when it comes to home birth, I mean I've gone as far as to be like, well, could you possibly go to Maryland?

Bayla 17:18

Right. But the interesting, or Pennsylvania,

Katie 17:20

the birth centers won't take, you know, the birth centers in Delaware won't take VBACs. I don't know if the, are there any

Bayla 17:26

can't do home birth, a home birth, vbac

Katie 17:29

No, it's not, it's not legal in Delaware to do a home birth. VBAC and the birth center in Delaware won't, can't do them either.

Bayla 17:37

Yeah. I mean, I guess there's a lot of laws that are state by state

Katie 17:41

There are

Bayla 17:41

we, yeah. We have that issue for sure. With, I mean, in Pennsylvania, CPMs have a lot more autonomy than cns. Mm-hmm.

Katie 17:49

Mm-hmm.

Bayla 17:50

So, you know, it really depends on the state and the regulations.

Katie 17:54

Yeah. In Delaware, it's interesting. Being able to do home birth as a CNM is kind of implied. It's actually not outright written unless they've changed that recently. We, we had it on the table for them to change it, but to actually explicitly use those words. But it, it's not written out.

Bayla 18:13

Um, well, there's almost no regulations in Maryland for CMS besides your standard, advanced practice, regulations are, there's nothing specific what CMS are allowed to do in or out of hospital.

Katie 18:26

Mm-hmm. I, knew when I came out of school, that there were differences between, CMS and cms. Like I, I did that research before I went into school because I didn't actually wanna go through nursing. I would've ideally not gone through nursing to become a midwife, but. I did just even a baseline amount of research and realized that I was gonna be limited in what I'd be able to do as a CM compared to CN CNM, but I don't think I got how, how different all of this goes when you're talking about home birth, specifically across states until very recently. It is worth researching. If you were thinking about, home birth as an option, like even as a CNM, because, where are you gonna be able to practice? What does it look like? I mean, having the ability to do VBACs in a state when CPMs can't, like how did you even learn that was something you, I think sometimes it's even hard to figure out what the, the legal piece of it all is. I think it can be difficult to even figure out the rules.

Bayla 19:39

Well, like 15, 20 years ago, it was almost impossible to have a home birth in Maryland because CPMs were not legal. And CMS needed to have physician oversight, which. It's almost impossible to find a doctor who's willing to oversee a home birth midwife. So there were very few legal home birth midwives, at least at that point. CPMs, when my daughter was born nine and a half years ago, they had just passed the legislation, I believe. Um, but they weren't legal yet. So, I used illegal midwives, or illegal midwives, I guess. I think they were illegal at that point, for a home birth. So it was, it was a hard time to even find somebody who could, go to your birth. And for the midwives that were practicing illegally, I don't think I could have done that. I don't think I could have like chosen a profession knowing that it was an illegal profession. But that's, that's what the state of that was going on at that point. And there are still other states like that where, you can't practice the way you want to because the laws aren't in place.

Katie 20:44

I think it's easy when you're practicing in a hospital based practice to not see the face of that person that's out there that feels very strongly that they don't wanna deliver in a hospital, and that they feel like they don't have options.

Bayla 21:00

And well, when we worked in a hospital based practice, I thought home birth was crazy. Mm-hmm. You know, I would like, we'd have clients who would be like, I really want a home birth, but there's no midwives. And I'd be like, why would you want a home birth? You know? Yeah. What, you know, like, home birth is crazy. Why would you wanna do that? But, but now since Marilyn has become like, has gotten rid of the physician oversight, we have a lot more autonomy here than, like, I looked into Florida or Pennsylvania. You need physician oversight in those states. You can't work autonomously like you can here. So it's, it's really state by state.

Katie 21:31

Yeah. And, it's not easy in a lot of these places to, to turn the tides and,, I've always felt that you've fell kind of middle of the roader when it comes to home birth. There's providers that believe so strongly in your ability to choose where you deliver, that they would say that things that are questionably safe, they're gonna provide those services for, or let's say controversial. It is controversial in a lot of places to provide, breach deliveries at home, twin deliveries at home,

Bayla 22:07

breach deliveries at all, anywhere.

Katie 22:09

Well, that's true at all. You're right. And, so you have, a provider like A CPM saying, well, I think that this person should be able to choose, it's their body, it's their baby. If they know the risks, they should be able to choose what they wanna do. Versus, other providers that are like, but where's the line? How do you, how do you decide that something is just unsafe enough, uh, to not be worth doing? And I've always felt that you kind of fall in the middle of those groups to some extent. Luckily I think Maryland has the ability to offer a VBAC at home through CNM. So I think that's great because you've been able to practice legally with offering those services. And I think you have had quite a few vbac

Bayla 22:56

yeah, there's very few cn m's in this area really in Maryland, home birth, CNS in Maryland, maybe there's like a handful that serve the Baltimore and like greater Baltimore area. And I do toe the line sometimes and it's because I'm. Really the only one available to do some of these things. VBACs. I've done VBACs after three C-sections. I don't do those anymore just because it's not standard of care and I've gotten in trouble for that.

Katie 23:21

Mm-hmm.

Bayla 23:22

Um, but, somebody calls you, she's had really bad experiences in the hospital. The C-sections might have been for no reason for a c-section, might have been for no reason. And then she just had a repeats and she's like, I really wanna. First, maybe she wants more children and you can only have so many c-sections. And she just wants to experience birth. And when you get that kind of sob story, your heart goes out and you're like, well, why not? And the research does not show that it's that dangerous. Like the numbers are very, very minute. And you pull up the research, you can go through it with them and that's what they want and that's the choice that they're making. And you know, you decide to honor that. Um, I've done twins. I've done breach only with twin, like a second twin. I am trained in breach, So, but it's something that, should be available to people. Someone who just told me that she had a friend who got to like 10 centimeters and pushing and they realized the baby was breach and they rushed her back for a C-section. Oh, that. I mean, like, how's that fair? Like why is a c-section safer at that point? Mm-hmm. At any point, why is a C-section safer than a breach Ber, just because the doctor's more experienced and comfortable with that.

Katie 24:27

Mm-hmm.

Bayla 24:28

But a breached birth, I think is safer than major surgery, which can lead to a lot of complications and future complications for future births. Um, and there's, you know, breach Without Borders, they go around training hospitals and staff and you can have safe, safely trained breach providers. But a lot of, providers aren't willing to do that training. Mm-hmm.

Katie 24:50

Mm-hmm.

Bayla 24:50

And a lot of it's mal practice and liability, they don't liability, is high in OB and malpractice companies don't wanna back up these types of practices. So they put limits on what their doctors can do as well. So that's also an issue.

Katie 25:04

Yeah, I think the system definitely, continues that because your malpractice is high and then maybe they won't even assure you if you do said things. So then you don't learn said things. So then when you're teaching people, they don't learn said things and it just becomes this, this skill that's lost.

Bayla 25:24

Yeah. One of the hospitals we were working at, the doctor was teaching the students how to use forceps just so that you wouldn't lose that skill. Which who knows ethically that's even a good idea. But, um, there's a lot of skills that doctors are not teaching students. So students are, medical students and future doctors are losing those skills. And they don't know how to do breach anymore.

Katie 25:45

Yeah. I have, I've definitely had a few providers that are, that are still doing forceps deliveries and they're very, very good at them. But they were taught, and what's always been interesting to me is you go to these certain areas in the country where they have a lot of, internationally trained physicians, that came over. They were already, they were already doctors, full practicing attendings in their country, and then they came over to the United States. So they have a lot of years behind them and they're doing all those things. They're doing breach and forceps and all the things because they don't have that malpractice situation that they're learning under, in those countries. Um, so they're not practicing in the lens of, CYA and And what a gift that is actually to us. Still have some people that are able to do those things

Bayla 26:36

that have other skills. Yeah.

Katie 26:37

Yeah, but it, but it's hard for them too. I mean, I've seen a provider that train, is from a different country and was doing fundal pressure and the nurses were freaking out. But in his country that he learned in, that was, that was a, a, a normal, usual thing. That's, that's what they're doing. And, and the research on that is interesting. So, he was trying to get these babies out quicker 'cause they had bad heart tones towards the end. And so when, she's pushing, he's doing fundal pressure and everybody's freaking out, but, and but was it working? It was working,

Bayla 27:12

right.

Katie 27:13

But It's such a hot bed. So then, when you're talking about offering these things that other people aren't offering, it does take, it's gotta take some thick skin,

Bayla 27:25

but there's also like a limit to autonomy in a hospital setting. So like, I've had doctors say I would do this or I would do that, but the hospital won't let me.. Like, I'll be back after two, or, or breach or something like that. And they're limited on what they're able to do because of the system. So.

Katie 27:44

Yeah. If you want a breach delivery in general, that is really hard to come by, And so then I think it does come down to. Are providers willing to do it? And it's, it's a much messier question than people want. I think often it's so easy when you're in a medical establishment to, like you said, just be like, these are crazy people making

Bayla 28:06

these decisions

Katie 28:06

out there, these crazy people doing breach deliveries, doing twin birth, doing all these things. They're crazy, but they're not real to you. These aren't real people in front of you.

Bayla 28:17

And then when they call you sobbing, right? And you have to tell them, no, it's hard. I had somebody call me and she is like, I heard you do VBACs after three. I'm only gonna get pregnant if you'll, do my birth. And I'm like, do not depend on me to get pregnant. That's crazy. There's no way I can like, Commit to you. But she doesn't wanna have a baby otherwise.

Katie 28:38

Well, and I've seen people in the ho I had this one pa this patient who's mother. Died when she was young after a, a long illness. And so her association with hospitals was all wrapped up in her mother's So her anxiety was through the fricking roof. I don't think home birth was ever even a thought in her head, but that's like somebody that you can imagine if they could get into the idea of home birth, like they could just go there. That, and especially if they ever had a home birth, that the idea of going back into a hospital would be something they would absolutely not wanna do. You know, I think people bring some real trauma, to delivery, with these experiences that they have in the hospitals and, So it's, it's, it's so much messier than just, you

Bayla 29:29

and that's why a lot of people are like, I'm gonna have my first baby in the hospital, and then I'll come to you for home birth. I'm like, why would you wanna have a traumatic first birth? Just have a home birth. But

Katie 29:38

I, yeah, it's, it's not an easy, but I feel for, providers that, in their heart are feeling like they need to do this., I certainly think that as you, you need to do the things that you're doing because other people aren't. But it is kind of a heavy burden,

Bayla 29:54

you know? Yeah, for sure. It's a very stressful heart wrenching profession in many ways.

Katie 30:01

Yeah. And especially as a CNM, the grand majority of CMS do not do home birth, so,, you don't quite fit in with the CPMs. Exactly. Because. Like the way you, you even became, the way you trained, what you're bringing to the table, what you've seen. It's, it's a, it's different. But even among your own cms, like how many can deeply relate to what you're going through, because not many are doing home birth.

Bayla 30:27

right? An A CNM. Like, we're not who they're looking out for, our parent organization, we're a very small subset, so it's not really like on the, on their radar so much to like, protect our, your home birth midwives. Like there is like a home birth, I think there's a home birth committee or something like that, or, but, but I'm on the Maryland Affiliate Board for A CNM and that's become something that we've started working on was, increasing the smoothness of transfers from out of hospital to hospital births. Because as a home birth midwife, it's very stressful transferring a patient to. Potentially a hostile environment. And we're trying to smooth that out and they're trying to, introduce legislation and things like that. But for a hospital, CNM, that's not even like something that they're thinking about. So it's something that we're introducing now, bringing to the table to hopefully make it a smoother process. And also a less hostile, an easier way for the client, but also, for the midwife and for the receiving team.

Katie 31:32

That's what I think people also forget, is that you've got this patient in the middle of it, right? So even if you don't believe in home birth or you don't, believe in the services that home birth person is providing, you're still dealing with a patient, and receiving a patient. And, so to honor that patient, you need to make that process.

Bayla 31:57

easier. You would hope so. You

Katie 31:58

hope so. But that's not how it goes.

Bayla 32:00

A lot of the hospital providers are like, well, this patient made a wrong

Katie 32:03

choice. Mm-hmm.

Bayla 32:04

And they're, they're not being responsible. And yeah, it's not a great, experience to transfer a patient.

Katie 32:11

So in Dover, Delaware, where I'm practicing, we have a home birth midwife that is very well respected by the community. 'cause she's been doing home births in our Amish community for a really long time. And so her transfers go really smoothly, but it's in part because there is one hospital she's dealing with. There's only one, in, she's dealing in the greater Dover area, but the closest, there's only, one hospital in the, like major hospital in the whole county. And. People probably wouldn't be transferred even if it was more south, because there's not NICUs in those sections. So it's, it's almost like a monopoly, the, the hospital that they are getting transferred to. So it's a hell of a lot easier to make a transfer go. Well, when you're talking about one provider to one hospital, when you look at Baltimore, there's so many hospitals and so, and they, and my understanding has always been that they, the ambulance takes them to the closest hospital there is. If they're transferring, it's not, patient choice does not always matter in that scenario.

Bayla 33:21

right? I mean, if you're equidistance, like if you're in downtown Baltimore, there's like four hospitals to choose from, so sometimes they will let you choose. But yeah, like some hospitals know me and some hospitals are like, why, why was this baby born at home? Like, why are you transferring in a baby? Where, who's the doctor? And they don't even understand that home birth is an option. So you definitely run into like where you're trying to explain yourself. To a team in the middle of an emergency situation. And they're taken aback and they're like, we don't want her to send her to the hospital she's supposed to deliver at. And you're like, there is no hospital. She had her baby at home. Now the baby needs to be seen right now. But yeah, developing relationships is really important. But also as we're creating these like transfer policies, we're finding that different hospitals wanna do things different ways and then they expect us to do it their way. So we have to know how each hospital wants to do it. So like, one hospital wants you to call the midwife. One hospital wants you to call the hospitalist one hospital. You have to go through the nurses, and you call the wrong person. And like, why are you calling me? So trying to just, streamline things so that there isn't this lag. When care needs to happen is, is, has become an issue. Um, but yeah, there's no way that we can know what each hospital wants out of us.

Katie 34:34

No. And you look at other countries where home birth is more incorporated, and I don't think it's rocket science there, how this happens, But we're really trying to make it rocket science.

Bayla 34:45

I think it's ego, I think, the egos that get involved here, like, this is my hospital and this is my shift and this is my, and like it's not about, the client's needs at that point. But yeah, in other countries it's all part of one health system. And there's, they've made allowances for how to transfer patients from different places, but it's much harder when you, when they're, they're not connected at all.

Katie 35:10

I think malpractice has played into that too. I think

Bayla 35:12

they don't wanna be liable for this. Exactly. This person coming

Katie 35:14

Exactly. And I mean, there have been some lawsuits that have. Kind of justified their behavior. I mean, thank God, I think most are all have been overturned, but,

Bayla 35:23

most of these lawsuits are though, are because they weren't received and they weren't listened to, The way that the hospital receives and, treats a patient is really important and that's how, you know these things happen.

Katie 35:35

Yeah. I, I do believe that, if you're welcomed into a hospital, like truly welcomed, as a patient, even if you have a bad outcome, I have to believe that if you, I think people feel when they're truly welcome, that's, that's not a feeling that,

Bayla 35:54

right. Legally they have to accept them. Right. But when you start getting passive aggressive and start being mean to people or keeping them in pain on purpose, you know that you lose your credibility at that point.

Katie 36:06

Yeah. Well, good luck. I'm glad somebody's working on the transfer piece. I think that is hugely important in our country in general. And in places like Baltimore it's certainly trickier when you aren't just dealing, with one set entity, but potentially so many, options. I was startled to learn recently, that in Maryland, if you have a home birth and it is not a good outcome, that it can be considered a, a crime scene actually. And you look at some of these things that I think at the time are probably well intentioned or they fall under a gray area and then you start thinking about it from a patient experience and a provider experience. And it is mind blowing. And for the listeners, what I mean by that is in Maryland, if let's say you had a stillbirth, the paramedics team or, whoever's coming to to the birth, could decide to call the police and it can be labeled, a, a criminal investigation scene, in which case they don't let you clean up anything and they don't, um, It's not a normal process. And I think that can be really traumatizing to the family and the providers on top of an already really traumatizing event. And that certainly doesn't happen in the hospital. We certainly don't have police come to the hospital when we have bad outcomes.

Bayla 37:35

Right, for sure. In a hospital setting, like the hospital's responsible for, how the providers act, I guess, and then they handle the discipline and it usually doesn't go beyond that. But in an out of hospital setting, there is no, official. Bored or like, oversight, until you get to like the board of nursing or whoever's overseeing your license. So yeah, it is, there's nobody else to call except the police at that point. It's, yeah, it's a very, it's a terrible situation that, you'd have to go that route because obviously nobody wanted any of this to happen, but then they start looking for negligence.

Katie 38:14

Mm-hmm. Do you feel like, do you feel like there's a, a better way it could be handled? I mean, I'm sure there's a better way. Do you have ideas on a better way that it could be handled,

Bayla 38:26

that a loss at, at home?

Katie 38:27

Mm-hmm.

Bayla 38:29

I mean, the problem with bringing police into the situation is they know nothing about nothing about birth. They're not gonna know what happened, like what are they gonna do, take fingerprints or whatever, they can't. They're not in any way experts on the situation, so it doesn't really help to have police come and I don't know what they do, take photographs or whatever. I mean at that point you transfer to the hospital and then the hospital, people who actually know about birth should be able to weigh in, but I don't find in any way that it would be helpful to bring in police.

Katie 39:01

But yeah, it can, it can happen. And my guess is for the midwives and people that have experienced that, they were not prepared to experience that. And it probably is quite startling. Have you ever like, counseled your patients on the fact that police might show up?

Bayla 39:20

I'm

Katie 39:20

suggesting you should by the way.

Bayla 39:21

I mean, thank God that's never

Katie 39:22

The rarity, thank God, is, working in your favor. I

Bayla 39:26

like who called the police? To begin with. If you have to transfer, you're calling an ambulance.

Katie 39:30

So the ambulance can in Maryland is what I learned. They can decide to.

Bayla 39:35

So EMTs and ambulance, personnel also need more training. I did a training, I guess it was during COVID because it ended up being probably in 2020 with an, with a fire company or whatever that we told them what we did and. What our qualifications are and what supplies we carry and what, what we're able to do in a home setting because they don't know that. Like if you look at the EMT handbook, one of the first things it says is cut the cord. You should never cut a cord if you don't know what you're doing, ever, ever, ever. And that's not a priority in any situation. Um, so I think the training for the EMTs and for ambulance personnel is, is really important for sure, especially of that type of situation. Um, that they know that we're more trained than they are in neonatal resuscitation and postpartum hemorrhage and things like that. And all the EMTs I've worked with have always been very respectful. And they're there to kind of step in and help us make this transition, but not to push us out of the way because they don't wanna be resuscitating a baby in an ambulance if they don't know what they're doing. Mm-hmm.

Katie 40:41

Have you had to call an EMT, for a delivery to be present at a delivery? If so, and you've had to resuscitate, how has that gone? How has that experience gone for you?

Bayla 40:50

So, yeah, thank God I haven't really had like, that emergent transfers. We've transferred, like babies for trouble with breathing or like postpartum hemorrhages. And they usually go very smoothly. I had a patient call me that, she was basically giving birth while I was on the way and the baby was breach and I'm like, call an ambulance. And I get there and they're like outside her door waiting for someone to open the door. Which obviously wasn't very helpful, but I haven't had really any issues with transferring,

Katie 41:21

from an EMT standpoint. Right. How has it been on the receiving end of the hospital?

Bayla 41:27

It really depends on the hospital. I mean, personally, I don't go to the hospitals anymore with transfers. I find it too traumatic, personally, and they don't need us. Like I call them ahead and I send over records. But when we get there, we either wait in the waiting room while they're triaged or we're like pushed into the corner of a room. We don't have a place anymore once we get to the hospital, if a client really wants me to come, I will come with them. But also, usually there's a limit to how many people can be in the room. So if they have, their husband and their mother and their doula, I can't even come with them at that point anyway. But it really depends. So usually I'm only speaking to the hospital staff over the phone, not in person. And I give report and a lot of times they're like, why are you sending her here? Isn't there another hospital you can send her to? Like they don't wanna be the ones responsible. But, and then they're, they start questioning your judgment, like, why did you do this? And why did you wait for that? And and it's much easier, obviously, to question something in hindsight than it is like in the moment. So,, you do the best you can, you send over the records and then they, they take over from there.

Katie 42:33

Yeah., I, I think we're cn msms would. Do home birth if some of these issues weren't there? I, I was not against the idea of home birth from a, clinical perspective. For me it was always, I didn't want the lifestyle of, I mean your lifestyle. I never wanted the just to be called whenever, you

Bayla 42:58

mean, when I worked in the hospital, I was working part-time. I feel like I spent more time like on call. with a patient than I do now, even though I'm on call 24 7, the amount of time that I'm actually called in is much lower than I was when I worked part-time in a hospital.

Katie 43:13

I think midwives, the majority of midwives I've met in my life either are call people or they're not meaning. They can either handle. Okay. The idea that at any point they could be called by a patient or they can't, and I don't know that it actually is like a time of life. Like I have actually never been good at that. I do better with knowing exactly when I'm gonna work and exactly when I'm done working. Sure. And it could be 10 to 30% more hours than you're working and I'd still choose it, because

Bayla 43:44

I mean, it's true. I can't leave town like I have to stay, but like, I'm not going anywhere anyway. And you have to be comfortable having your phone on twenty four seven and getting woken up in the middle of the night by people texting you at one in the morning for no reason. But yeah, that is definitely a lifestyle. And sometimes it is like. Very anxiety provoking when you know, somebody's like warming up and they can call you any minute and you're like, should I go to sleep? Should I wait up? And then you go to sleep and they call you like an hour later. Um, and you have to go to sleep early a lot of the time because they might call you tonight.

Katie 44:14

Yeah. Logistically. Schedule wise, that has always seemed like something I couldn't do. But clinically, clinically and philosophically, I would say I fall more in line with, home birth than I do ultra medicalized birth. Even though I'm playing the game. If

Bayla 44:31

which is why maybe a birth center would be a better

Katie 44:33

option. They still have the same Well, and they still, I always felt like a birth center was in between those worlds in a way that I also didn't think was enough. Like you still, especially if you have first call, second call, if they have hospital privileges, to me that's still too much like unknown call time. But yes, it, philosophically and clinically a birth center would be great if I had one down the street. I don't, uh, so it's not

Bayla 44:59

there are no birth centers in Maryland and I've never seen the benefit of a birth center. You're not in a hospital and you're not at home. So I bother,

Katie 45:08

I think birth center birth can be so beautiful. The thing that as a patient I always would've struggled with is getting kicked out of there in four hours. That never sounded super appealing to me. Right. Um, not, you

Bayla 45:18

to go there in labor. Yeah. You still have to leave with a brand new baby. And if you have to transfer, you still have to go to the hospital. Yeah. I mean, it's definitely more convenient for the provider because you have all your supplies in one place and you're not traveling around the state. But I don't know why patients think it's a safer option.

Katie 45:34

I don't, I think a lot of times I don't know that it's about safety. Well, so in Delaware we have a very good, wonderful, thriving, birth center. We do not have the home birth presence actually, and certainly not. Uh, well, I guess VBACs can't do. Any kind of

Bayla 45:51

outside the hospital

Katie 45:52

delivery. Um, but I think for a lot of them, it's actually not about safety. I don't know that I've ever had a patient choose the birth center from a safety perspective. Over home birth. It's usually more logistics like they don't want to deliver in their house, maybe they don't like the mess or maybe their husband's anxious about delivering in the house. So the birth center, the birth center, in Delaware is, it has a very, very well established relationship with the hospital. So I do think that's one benefit. Like the transfers are really easy. Um, they accept them nicely, and for those kind of anxious family members, I think they can get on board with it quicker.

Bayla 46:30

Yeah. I've looked into opening a birth center. It's just, it's a lot logistically.

Katie 46:34

Oh, definitely. Lot

Bayla 46:35

of red tape. Yes. You have to find a hospital, you have to find, like, you have to find midwives to staff this birth center, which is very difficult 'cause of long hours. I mean, I'm sure if, if I opened a birth center I would, be inundated with people and I don't want more clients, Yeah. And you need to find staff to, to be available for that.

Katie 46:56

There is a lot of red tape. We've, um, I, I've looked into this a little bit with the, midwife that does home birth for the Amish community, and we've talked a lot about what does it look like to open and birth center for, for that group. And, there's a lot more red tape than when you're doing home birth. Because when you're doing home birth, I guess the thought is that you're going to their house. You're not bringing It's the, the pieces of like, what are you doing with the waste? Right? What are you doing with the medical supplies? What are you doing? With the, like there's just so much that they put on the birth centers that is not present for the home birth piece

Bayla 47:36

right. But to, to open up our center in Maryland, you have to be accredited by A A, B, C.

Katie 47:40

Right. So same

Bayla 47:42

a lot of

Katie 47:42

Exactly. There's a lot of, there's a lot of, rules. Rules, yep. Mm-hmm. And then I also think that the state, is taking responsibility for it is also interesting. So in Delaware, our CPMs, are not handled by the board of nursing. They're handled by their own like board. Whereas here now the CPMs are handled by the Board of Nursing in Maryland. So, I think who the person is that actually. Agrees to the birth center is also part of the problem sometimes in a state. Like who's the person beyond just, the, birth center accreditation piece. Like, you still have to have the state involved on some level and sometimes that's difficult too,

Bayla 48:26

right? You need that regulation for sure.

Katie 48:28

I think we need more birth centers in general. Sometimes people, choose them because it's also just easier to find, than the home birth midwife. So yeah, that'd be a great thing for you to do though, Bailey, you're very, talking to birth center. Yeah. You're very, business capable.

Bayla 48:45

Yeah, it's, it's a lot. I even had somebody who would fund the birth center. But you need, you need the staff. Like you can get the clients. That's not a problem. You need midwives who are willing to staff it, and we just don't have that

Katie 48:59

here. Well, and reimbursement I think is rough. So then you'd have to,

Bayla 49:02

reimbursement is rough.

Katie 49:03

You'd have to figure,

Bayla 49:05

but I feel like even if we had like a self-pay center where everybody was paying out of pocket, I don't think we'd be able to find enough midwives to staff it. I mean, maybe eventually, we'd pull from hospitals and stuff, but we don't have that ready to go.

Katie 49:18

A lot of midwives talk about, what if I opened a birth center, but the actual ability to do it gets

Bayla 49:25

the one we had here, like midwives, were working 12 hour shifts. They were just really burnt out. It was just like office days, 12 hour office days in order to keep up with the demand. And it was a lot like they just, they had really high turnover.

Katie 49:39

Mm-hmm. I don't know a birth center that doesn't,, even frankly, our practice that we started out in, we weren't a birth center, but we labor sat and, spend a lot of time with patients and that does not reimburse well because they're not paying you for your time. So even that is gonna have turnover because of just, you just get burnout from the combo of giving so much time and then feeling like you can't afford what you need to afford. Yeah. You just

Bayla 50:09

don't make the money that you need

Katie 50:11

Yeah. So right now you are in a place where you are considering stepping back a little bit from, doing midwifery. To the capacity that you have,, for some time now, like you have been, doing home births at a pretty high volume, I would say, from my perspective.

Bayla 50:32

Mm-hmm.

Katie 50:33

And, you're thinking about what to do and what's next, and, tell me what's influencing you on those decisions.

Bayla 50:41

Yeah, so they say like every 10 years the board of nursing wakes up and then they start, looking into us and saying, what's going on with all these things? I don't know what's true about any of that and why it would be like that. But because we have no, like hospital oversight, they are our oversight. So any. Complaints that anybody has, like patients, family members, EMTs, hospital staff, anybody. It all goes to the board of nursing. And the board of nursing has to investigate everything, every complaint that they receive. So you might've had a beautiful birth and their patient's happy, but maybe the grandmother wasn't, something like that. Or you transfer to a hospital and the doctor thinks you're crazy, so she reports you. So I've had a bunch of investigations in the past year, two years maybe, dating back, like dating back four or five, six years. And eventually most of 'em got thrown out because they were so old or they didn't really have any weight to them. But that's extremely stressful to have to go and open up your old charts and defend yourself. Things that, maybe you're not even practicing that way anymore. Like, I used to do VBACs after three and I'm not doing this anymore. But just dealing. Yeah, with defending yourself for the type of care that you're trying to provide for your clients, is really, is heart wrenching. And you're like, why am I doing this? Why am I putting myself out for people who aren't appreciating it or, aren't taking care of, aren't doing their part of the deal. And it's like, why am I doing this? Why am I like putting myself through this? And, luckily most of 'em get thrown out, but what if they don't get thrown out? What, if you have to defend yourself in court or whatever, like, why is it, why is it worth it? So yes, I've been trying to step back, but people keep calling. I have a lot of repeat clients right now, which I love. But I'm really not taking new clients, because I don't, I don't trust them really. Like, I don't trust that they will look out for me if it comes down to it.

Katie 52:36

That is really, that's really hard in this country right now. And in midwifery and obstetrics, I don't think it's just midwifery, but I think. As midwives, we are already trying to straddle the system. No matter where you fall on the midwife spectrum, you're already trying to navigate this system that maybe philosophically you believe one thing, and then everybody's telling you you need to practice a different way. And so you hope at the end of the day that patients are going to understand that you went there for them, that you gave them what they were asking for, and that you supported them in their decisions. And for the longest time, I think as a, as, as midwives, we stood by the fact that we wouldn't get sued or we wouldn't get reported as long as the patient was in agreement with the plan of care. But I think. During, personally, I think COVID actually was a, a huge factor, and I think there is a lot more mistrust now, and I think that we can't stand by that statement as much now. We can't stand by the, the, it doesn't give us relief because we've seen examples where we, people get what they wanted actually, but maybe the outcome wasn't good or they weren't happy with whatever, and they're not standing by you. And that, that cuts so deep.

Bayla 54:06

Yeah. I had a client who moved here very late in pregnancy. She'd had two C-sections and wanted a vbac, and I took her on knowing that nobody else would. I. Like she wouldn't be able to have a V back in the hospital. There's no other midwives available. She was very late to care, which a lot of practices won't take. I gave her a really delayed payment plan. She never finished paying me. Like I checked all these boxes that nobody else would. And then when it came down to it in labor, her labor stalled. They got really unhappy. They ended up going to the hospital by themselves and they never spoke to me again. And I really, and I did evening appointments for her. Like I really, really went outta my way for them. And I feel like I got stabbed in the back., Like I didn't do anything wrong and they just didn't like the way things turned out. I mean, everything was fine in the end. She did end up having her be back in the hospital because she refused a C-section. But without my care, that never would've happened. Like she would've had to have a C-section if she just got care anywhere else. And that it feels terrible to go outta your way for somebody and for them not to appreciate it.

Katie 55:16

Yeah. And this is something people don't wanna talk about. I mean, we wanna talk about it. Midwives wanna talk about it. But I think, depending upon. The audience that you're with. It's, it's hard to talk about. But it happens and it happens quite a bit more often now, I think. And and I think that is part of what leads to our burnout. I think that's part of what drives midwives out of the field. Because if, at the end of the day you feel like you maybe even put your life on the, like, you not on the line, but you, you, you like paused your life, you went out of your way in ways that took you away from your family or that you weren't able to sleep at night easily because, you know, decisions that you made together that maybe are a little bit more, difficult for you to make, say, they wanted care that is a little bit outta standard of care, but you've, you understood why they wanted it and you agreed to their plan and. You were on the same page, but maybe that still sits with you a little bit. Maybe, you don't just walk away from that visit as easily, all that adds up and it weighs on you. And then in the end if you feel like, wow, on top of it, they're angry at me, or they don't believe that I did all these things that I did, I think that really, really hurts.

Bayla 56:36

Yeah.

Katie 56:37

And I think more of us have had that happen than we sometimes get to talk to.

Bayla 56:42

I mean, in the American medical system, all patients are just numbers. They see so many patients all day long. Nobody remembers anyone. But it's not that way in home birth. Like I really put myself out for each person. Some obviously more than others that need more than others. But each person just makes a huge impact on my life. And again, the decisions I make and the work I put into their care and things like that, that for something, to happen, for 'em to think, oh, she's not gonna even notice, or she won't think about me again. It's not true. I remember almost, I think about a lot of my clients regularly, like from years ago.

Katie 57:17

Yeah. We certainly don't go into this to make somebody's day worse, especially their life force. I mean, 'cause sometimes, the outcomes are the very life altering. That is, I don't think anybody goes into midwifery for that, But we are often the byproducts of experiences that may have been predestined, on some level.

Bayla 57:42

And it's terrifying to know that you hold someone's, li lives in your hand, like the mother and the baby. You know that if something goes wrong, you're responsible for their life. And like, why would I wanna do this? But like, I feel like this is my calling and this is what I was sent to do and I have to do it and I'm not supported, like to not have that support and like also support just from the community. Like in a hospital you might have a practice or people that you work with. I work by myself, I have students that rotate. I have some midwives that I call once in a while, for things. But, you're, it's very isolating.

Katie 58:16

Yeah. And it's interesting to think about, In Maryland, like you were saying, the way you're practicing the board of nursing is your answering party. And I can see how scary that would be. I went through a lawsuit. Lawsuit worked out in our favor, but, The, The woman's put things to the board of nursing on everybody pretty much that touched the chart. And just that process of knowing that somebody complained about your care is, is really difficult to handle. Even just the idea of it, forget what the process looks like, just the idea of that happening is, upsetting. And I think that that could look really differently depending upon how the state's handling it. And if your only way of talking through something is with the state and what looks very similar to a, like a criminal or a lawsuit case. That's what's been so surprising to me that I think a lot of midwives are not aware of, is if you have complaints to the board of nursing, it can look very, very similar to a lawsuit. Like you get what looks like a deposition. I don't. Think they call it that. But you, you have to go over all of the events. You can end up in what is pretty much court and that can be, it's a really scary process. And, it can happen with so much less actually than what happens in a lawsuit. Meaning in a lawsuit, some, a lawyer has to decide that this is even worth taking the case, right? Like, if they come with something bogus, they're gonna be like,, that is not worth anybody's time that, that I'm not doing that. But when it comes to, if you're only, like governing board is the board of nursing, well they're gonna take every complaint seriously. They're not just going to immediately, be like, this is completely bogus without even informing you. Like if somebody goes to a lawyer and and is looking to sue you, you don't necessarily know that unless it comes to you. But you hear from the board of nursing that somebody made a complaint, even if it is the craziest complaint that could possibly happen. And, and ultimately they're gonna be like, this person is crazy. You're still gonna have to go through the anxiety of knowing about that and waiting for an answer and all the follow up. Yeah. Um,

Bayla 1:00:37

and nobody like prepares you for something like that. Like if you. A summons to court, you get a lawyer, right? If you get a call from the nurse investigator, the board of nursing, you're like, okay, I'm gonna go talk to the nurse investigator. Like, you don't really take it seriously. You don't think you need a lawyer for that type of thing, especially if you have a few of them and then later on you're like, oh my gosh, I really should have gotten a lawyer first. And like at that point it might be too late because you've already said some things that maybe you shouldn't have said.

Katie 1:01:05

Mm-hmm. Yeah. I think this is one of my hopes for, the podcast is to bring some of the not well-known parts of our field that people get kind of hit by surprise with, to light. And so people can know, if you have a complaint to the board of nursing and if it is anything that you think is gonna go anywhere, You can use a lawyer and malpractice, your malpractice insurance will usually cover that. Actually,

Bayla 1:01:34

the problem is if you. Call your malpractice insurance too many times they're gonna drop you. Well

Katie 1:01:39

that, I mean, that's a whole nother argument, but,

Bayla 1:01:41

so you have to choose, what you want them to know., And like usually you just tell them what things you think are going to be escalated, but you don't really know that at the beginning. So you might have already had your initial in, interview or whatever you wanna call it with the nurse investigator. And you didn't call, I didn't call my mom practice insurance company until, I got a hearing and then I needed a lawyer. Mm-hmm.

Katie 1:02:04

Mm-hmm.

Bayla 1:02:05

I didn't even know that I could do that. At first, I was calling lawyers and they said, well, have you called your malpractice insurance company? I'm like, oh, I didn't know that he'd do that.

Katie 1:02:12

Yeah. Luckily, in our case, the midwives that are going through this with me, currently because the lawsuit had already happened, we knew that the lawyers would deal with this too. And that was, that, that gave me great, piece to, to know, that, but it's, but I, I, I just wanna come back to this idea that, it's a shame that. nurse midwives that are doing home birth in Maryland. I, I'm, and I say Maryland just 'cause we're here, but I'm sure there's many other states that qualify, uh, or that use, um, this same channel. And your CPMs who are doing home birth, their first face is the board of nursing for this. And I That's scary. It would be nice if it wa if it didn't have to feel so, I, I don't know, scary is a reductive word, but,

Bayla 1:03:08

well, there is a, and there's an organization for out of hospital midwives, aim, the Association of Independent Midwives of Maryland, and they have a grievance pro. Policy or process. But it's not like legally official. It's just if, if you wanna complain about a midwife, but you don't wanna like escalate it, you can go through us. So that's, it's not like an official way to do it.

Katie 1:03:29

Well, and I think that's gonna come up, much further down the line on a Google search, frankly, than your board of nursing. Right? When you put type in, like how to complain against. And, part of some of the states, legal process to legally be offering, care is informing that, the patient of where they can complain. And part of that is the board of nursing. I think there's gonna be, it's, they're gonna find them, they're gonna find their way to the board of nursing, And it, it would be nice if, the process looked a, a little bit more like a, like a hospital process in the, in the scariness factor. Because, yeah, like if you have a complaint at the hospital level, you're going to go to risk management. Risk management's gonna have a meeting, but it's not like immediately threats are being dropped usually, it's usually a like a case review. And I Did it feel like that when the board of nursing reached out to you? Did it feel casual or did it feel threatening?

Bayla 1:04:28

It really did feel casual at the beginning. Like she was very friendly and, but they're taping you, like it, they're developing evidence against you, but you don't real, or maybe for

Katie 1:04:40

you, you would hope,

Bayla 1:04:42

you would hope, but that's not why they're calling you in. But you don't realize that, because that's not like the situation. I mean, especially if you've never done this before, how are you supposed to know,, what to say or how to defend yourself. But yeah, she seems very friendly, but like she's a prosecutor. Her job is like, to get like the facts.

Katie 1:05:00

So your initial interview was with a prosecutor.

Bayla 1:05:04

She's a nurse investigator, but technically she's a prosecutor.

Katie 1:05:09

Mm-hmm. Yeah. That sounds like a lawyer. I mean, like, you'd want a lawyer, right? When you phrase it that way, yeah. And Then so when you go to, when you have a lawsuit and you do the deposition, which is essentially very similar to that process of a interviewed conversation with the nurse investigator. I think it feels very similar. You have your lawyer there, and you've you might have been heavily, heavily, heavily prepped by the lawyer, before the deposition on, what the possible questions could be, how you could possibly answer them. It's not just. Oh, okay. I am just showing up and, and having this nice conversation with you. And part of the reason they handle that with the deposition so strongly, is that, the lawyers are gonna use that deposition later in court. And they might even use exact words that you said in front of, the juror or the judge or whatever. And, try to say, you said this in deposition, you said this right? And so,, you could be quoted. So you go into it knowing that every word that you're saying could carry weight. But I don't know that people go into the, conversation with the nurse investigator with that same thought process. But maybe we should. Maybe we all should.

Bayla 1:06:23

Yeah. I was too naive, And who tells you these things? Who tells you that? Like in nursing school, they're gonna tell you one day you might get called into the board of nursing. Like that just doesn't happen. Maybe they does. Maybe like at some point in nursing school we went through like. You know, chart of accountability or something, but nobody's ready for that.

Katie 1:06:42

No, I, I didn't fully understand the whole process. I've ended up working in capacities where I've learned a lot about this process. But it's been later in my career, it was, I, I was practicing, I think for well over a decade before I, well, over a decade before I started understanding a lot of this. That's not okay. I've had several jobs over that, timeframe that I had no clue. No clue. And so I hope that we can change that, that narrative because it's, it's gonna drive providers out. And it's gonna continue our shortages because when you have really experienced people having this happen to them and they're blindsided by it, and they've already kind of been in the field long enough to, so they've gained all this skill, they've gained lots of skills because they've been in the field long enough, but they've also gained, they've also become jaded. 'cause everybody's gonna become some degree of jaded over time. I don't know how anybody could not. But then you're losing people at their highest skill level because mentally they're like done with it. So anyway, you've had this experience of dealing with, the board of nursing recently, and, it does sound like you're getting close to. At least an answer on what's gonna proceed forward. Because that takes a while too, right? To even get to a place of like, knowing where everything's

Bayla 1:08:14

headed. It takes them years to even bring up a case. They'll be like, four years ago this happened and now we're talking to you about it. And then everything just takes so much time. And, but then if they want an answer, they give you a deadline. It's, you just don't know anything could come out of the woodwork at any time.

Katie 1:08:30

But you're headed closer to an understanding and so in your head right now, piecing together everything, you are looking at some options on how to proceed forward and, one of them is, is going, back to bookkeeping, which you've never really left, I don't think. It sounds like since

Bayla 1:08:52

you started

Katie 1:08:53

with the store.

Bayla 1:08:53

Yeah. I am building my bookkeeping business so I can cut back on midwifery and really just. I really just wanna take repeat clients at this point. And give my family a break. Also, my kids have grown up with a mother on call, like every, like, all the time. Like, sorry, I gotta go to a birth. I'll be back later. Now they're almost outta the house, but, yeah, it'd be nice to have like, maybe a normal life.

Katie 1:09:17

Do you feel, and I think this is a great question for you because I do feel on the scale of midwives, you, understand the financial aspects of some of this, better than most. Do you feel like there's a number of clients that you can take? A month or a year that you can justify continuing to have these things like EMR, where you're paying for, for whatever you're paying for, right? Your overhead costs on a business. How part-time can you get with it? Because I know for me, that has been a factor with offering, prenatal care, like through my own practice. It's like how many patients I have to see? Is it worth it for the overhead cost to keep it going? And for me, that's been a really hard line actually. So how do you look at it as far as pulling back and, and how you make the decision on how many people you can keep justify even having a practice to, to begin with?

Bayla 1:10:12

Well, my overhead costs now are very minimal. Four years ago I had a four midwife practice. I was the owner and I was paying salaries and we had an office rent and supplies and we had to have a minimum number of patients in order just to pay, payroll. But I've moved my office back home. I'm a solo provider. Besides like my supplies, which, you know, every couple times a year I, have to buy more like medications and things like that. So my overhead is really very limited. I think my most expensive cost right now is malpractice insurance, which most home birth midwives don't even carry. Um, really the main reason I care malpractice insurance is so that I can accept Medicaid. You can't take Medicaid if you don't have malpractice insurance. And most of my clients, I don't know, most probably half of my clients are on Medicaid. The rest are self pay. Medicaid is the only insurance that I'm in network with. So my self-pay clients, are getting less and less, which in which decreases, my income. 'Cause my, my Medicaid pay clients, obviously it's a much lower reimbursement than self-pay. But yeah, so I have to kinda like figure out how many self-pay and how many Medicaid clients I can take in order to like. I pay my bills, basically. But right now we're just talking about like my personal bills,, my mortgage and my kids' tuition and things like that. My actual practice has very little overhead.

Katie 1:11:30

How can you share how much your malpractice has been?

Bayla 1:11:32

So that one through a huge change. I think when I first started, and it, it increases every year because your liability increases the more like client history you have behind you. I don't know if it's Maryland or in the, probably right? But clients have 21 years to sue, so the more clients, the more experience you have, the more patients you've seen, the higher your liability is. So yeah, my mile prior just started at like, I don't know, seven, and then it went up to like 15 and then it went up to $40,000 a year. And I couldn't do that. And at one point the malpractice company started asking me like, how many shoulder dystocias have you had? How many postpartum hemorrhages have you had? How many, infant resuscitations have you had? And like, these are all standard things that everybody has. it doesn't reflect on how I, provide care. It's just somebody has a shoulder to shut. You have to, make it happen. And postpartum hemorrhage, you know how to deal with it. They're not asking like, how many transfers have I had? They're asking how many things happened in your care. So I got risked out because I have a high, I mean, relatively high, volume. So yeah, I have shoulders social and I have hemorrhages and I have neonatal resuscitations. So they weren't even willing to provide coverage anymore. So I switched to a new company and the number of malpractice companies that will. Cover home birth midwives or like two, maybe a couple more, but like, there aren't that many options. So I switched to this other company and then dropped my rate because it was a new policy, so I didn't have any history behind me. But then it started creeping up again. And so last year I, again, I canceled my policy and I opened a new policy. So I think I'm at like 15,000 right now. But just having, like dealing with the board of nursing, like malpractice is paying for my lawyer. So it's like critical at this point, right? Besides being able to take Medicaid, but that's very prohibitive. And most home birth midwives don't care malpractice insurance because they don't need it. Like people don't sue home birth midwives. But the board of nursing is a whole nother story. When I started accepting Medicaid, I met with another lawyer to find like, what the regulations are because if you're accused of Medicaid fraud, you're in big trouble. So you wanna make sure you know what you're doing, in terms of Medicaid. And then these things change. I really do need to meet with a lawyer again, just to make sure any updates or whatever.

Katie 1:13:59

How'd you find a lawyer that was able to answer these questions? That can be frustrating. For me, with the starting the business, there are a lot of questions I had that I have a lot of lawyers in my life, but they were never in that type of law. So it was like difficult to even find

Bayla 1:14:15

I don't remember. But I guess you just ask around and then, finally you get pointed in the right direction of somebody who's like a healthcare attorney or something like that. I know I reached out to a lawyer that I had worked with previously, but like he's working for a hospital system now, so he couldn't help me. I guess you could start on LinkedIn and look for healthcare, healthcare attorney. But yeah, it is important to make sure that you, you know what you're doing.

Katie 1:14:37

Yeah. It's easy to get overwhelmed by the. Upfront costs of opening a business and to do short change things that you don't have to do. Like you don't have to hire a lawyer. You should like, absolutely, you should, but you don't, in your mind, you don't have to, So I think it's important to,

Bayla 1:15:00

yeah, you have to get like your name trademarked and like your website and like you have to, set up a tax account with the state and, get a EIN with the IRS. There's a lot of little details, which I mean, I did them myself. Most of these things you can figure out yourself, but you have to know what you need to do.

Katie 1:15:16

Mm-hmm. So there are mentors out there. With businesses, business consultants. Maybe that's something you should consider doing. Actually,

Bayla 1:15:24

I don't know that much.

Katie 1:15:26

eh, I think you know more than you

Bayla 1:15:27

you realize.

Katie 1:15:28

In fact, you probably just listed a bunch of things that people in this podcast are like, I have no idea what any of that just was, and I think going in in that direction can be helpful for some people that are overwhelmed too.

Bayla 1:15:39

Yeah.

Katie 1:15:40

How did you fund your first business? Going back to the, even the

Bayla 1:15:45

my diaper store. Yeah. I told my husband a thousand dollars, that's all I need, just to buy some diapers I'm gonna sell. And it just blossomed, obviously. I mean, we really went into debt for the store. Retail does not make money, especially something that's, specialized. The companies tell you what you can sell them for, and then they're competing with you on their websites. So you really, until I started moving into like car suits and strollers, which have a higher, price points, we were not, we never made money. We lost money and we were paying back debt even after the store closed, but. It was fun. It was a hobby. you start doing your research, you just start like looking up things and obviously nowadays it's much easier than it was, 15, 20 years ago to like Google different companies and, And then you just try to stay in budget and pun it.

Katie 1:16:32

I think you did a good job of growing slowly.

Bayla 1:16:37

That was for my husband. Yeah. I would've grown much faster, but he's like, no. It was a little crazy, but yeah, it was fun. I would do it again. But then really the reason I closed was because Amazon really took over the world and you just can't compete with Amazon.

Katie 1:16:51

That is true. That was before Amazon. But. Uh, the, the joy of a brick and mortar, especially in Baltimore. It was, it was nice.

Bayla 1:17:00

shame.

Katie 1:17:00

Yeah. Do you feel like it's coming back a little bit in Baltimore?

Bayla 1:17:04

mean, I have some friends who still have their cloth diaper stores. They sell more things now. You need more things for your margins. But, yeah, 15 years later they're still running their store in other states, I don't know about Baltimore. Retail is very hard. And like I look at like clothing stores, like at the end of the season, they have to just discount all their merchandise. Mm-hmm. Like how do they survive? But yeah. And the hours are long.

Katie 1:17:29

Well, it's an interesting thought. When as midwives, I think we all have this, what we would do instead of midwifery. Right. You've, you've actually done a couple of things instead of midwifery. Yeah. Why you've still been a midwife.

Bayla 1:17:42

Um, well, I just registered in college to get an accounting degree.

Katie 1:17:45

Yeah. But there is this idea that, oh, life would be easier if I did X, Y, Z. But as you've, right. As you experience with retail, it's like, okay, well maybe yes, maybe no. You know, depending upon the angle you're looking at.

Bayla 1:17:58

right? So no, nothing's easy. You have to choose what you're strong enough to handle.

Katie 1:18:05

Hmm. That's a good way to put it, isn't it? We each have our own breaking points Yeah. In, in different areas. I could talk to you a million hours longer and Will, I'm sure. But we have friends coming, so, we're gonna get off, and go hang out with our mentor and our office staff from our very first practice

Bayla 1:18:29

15 years ago.

Katie 1:18:30

I know. We started even longer

Bayla 1:18:32

than

Katie 1:18:33

but, but it's wonderful talking to you and I'm sure I'll have you on again and, you might be doing even more different things then, so, 'cause every couple of years for you is a whole different story.

Bayla 1:18:45

Always something new in my life. I can't sit still very long.

Katie 1:18:48

Yeah. It's a good thing. Well, thank you Bayla.

Bayla 1:18:50

Yeah. Thank you.

1:18:52

I hope you have enjoyed this episode of Mindful Midwifery Presents, the Labor Behind Labor with my guest Bayla. I am so grateful for her sharing such a vulnerable account of her experiences as a home birth midwife. I hope that as cn m's, we can work harder to make our colleagues feel more included and valued when they venture out to offering home birth services. In two weeks time, I'll be sharing Beverly's episode with you. Bev became a midwife later in her nursing career and has since gone back to postpartum bedside nursing. She's close to retirement, and her episode provides a great example of life work balance in the final years of your career. I look forward to sharing her episode with you in two weeks.