EBB 135 – The Need for More Indigenous Birth Workers with Miranda Kelly

• Follow Miranda at her website and Instagram.
• Click here for information on the ekw’í7tl doula collective.
• Click here to learn about the Doulas for Aboriginal Families Grant Program, administered by the BC Association of Aboriginal
  Friendship Centres.
• Click here to see the Society for Maternal Fetal Medicine guidelines on evaluation and management of polyhydramnios.
• For the Evidence Based Birth® article, “What is the Evidence for Induction for Low Fluid at Term in a Healthy Pregnancy?” click here

Rebecca Dekker:

Hi, everyone. On today’s podcast, we’re going to talk with Miranda Kelly about her home birth story and the need for more Indigenous birth workers.

Welcome to the Evidence Based Birth podcast. My name is Rebecca Dekker and I’m a nurse with my PhD, and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

I am so excited today to welcome Miranda Kelly to the Evidence Based Birth® podcast. Miranda is a certified birth doula, postpartum doula, and childbirth educator who has worked for 10 years in Indigenous people’s health planning, policy, education, and research. Miranda holds a Bachelor of Science degree in Biology and Psychology, and a Master of Public Health degree. I had the privilege of meeting Miranda when we both spoke at an event in February 2020, hosted by the Doula Services Association of British Columbia. Miranda is passionate about Indigenous peoples reclaiming their authority as decision-makers in their own health and well-being. I’m thrilled that Miranda was willing to come on the podcast to let us know about the work that she and other community organizers are doing to support the Indigenous community. Welcome, Miranda, to the Evidence Based Birth podcast.

Miranda Kelly:
Hi. Thanks so much for having me. I’m really excited to be joining you today.

Rebecca Dekker:
I love that we get to talk again after we met in February. Can you tell our listeners a little bit about yourself and your ancestry?

Miranda Kelly:
Sure. I’m Miranda Kelly and my ancestral name is Tilyen, and I identify as Stό:lō and mixed settler ancestry. My grandparents on my father’s side come from Soowahlie, Sumas, Cowichan, and the Snuneymuxw First Nations. My ancestry on my mother’s side is Scottish, Russian, and Welsh. I grew up in my home village of Soowahlie First Nation, which is located near Chilliwack, BC. For the last 10 years, I’ve been living in Vancouver, BC which is the unceded ancestral territory of the Tsleil-Waututh, Musqueam, and Squamish First Nations.

Rebecca Dekker:
Yeah. Thank you for sharing that with us. Can you tell us what led you into birth work? Maybe go back to when you first had your children. I know you’re the mother of two children.

Miranda Kelly:
Yeah, that’s right. I’m a mom to two beautiful little girls. I think it’s hard to trace back exactly what brought me into birth work because I think there’s been little seeds throughout my life, but I can definitely trace it back to my own childbirth experiences. When I became pregnant with my first child, I just had this really beautiful, blissful pregnancy. I felt very strong and very empowered, and I immediately knew from the beginning that I wanted to receive midwifery care and that I wanted to plan for a home birth, and everything just went super smoothly. I had my beautiful home birth and I felt like the strongest I’d ever felt in my life. I felt like my partner and I were the strongest on our relationship than we’d ever been.

I just felt like because everything had gone so beautifully and smoothly, that the postpartum period would just come really easily, and then it didn’t. I really struggled. I feel like I had completely unrealistic expectations of what the postpartum period would be like, and I didn’t set myself up to have enough support in that time. I really struggled postpartum. I went undiagnosed but I believe that I had postpartum depression and anxiety. It took me really a few years to recover from that whole experience, and I definitely carry that forward with me in deciding to try to get pregnant again.

When my husband and I decided that we were ready and we wanted to try to get pregnant again, I was really thoughtful about how I would prepare for the postpartum period. I started seeing a counselor and really trying to take care of my holistic health, really being mindful of my mental health and my physical health, and trying to feel really strong again during my pregnancy. As far as planning for my prenatal care and my childbirth experience in my second pregnancy, I actually didn’t really give it a lot of thought. I just felt like, “Oh, the first time was so perfect and beautiful, I just want to do everything exactly the same.”

I went with the same group of midwives. I did try to hire the same doula that I had in my first birth but she actually wasn’t available. I went with a different doula who was actually my birth photographer at my first birth. I already knew her. She was going to be my birth doula and my birth photographer, again, for my second. I just thought like, “Oh, I’ll set up same birth team around me and everything will go smoothly,” and in retrospect, I wish that I had given that a bit more thought.

Rebecca Dekker:
Yeah. Tell us about that second pregnancy.

Miranda Kelly:
My second pregnancy started off pretty smoothly. I got pregnant fairly quickly without complication, and then I’d say it started becoming more challenging in my second trimester. Around 14 weeks, I had some bleeding. Just one night, I went to the bathroom and there was a bunch of bright red blood and I was really terrified. Thankfully, it just tapered off. My midwives told me if it becomes really heavy, let us know and you’ll have to go to the hospital but, thankfully, that didn’t happen. But it was definitely a big fright for me and something that really stayed with me for the rest of the pregnancy.

Then at my 20-week ultrasound, everything went fine, except that they noticed my placenta was low-lying. Also, they mentioned that I had a number of fibroids, which I knew actually that I had fibroids. I had some ultrasounds in between my pregnancy when I was having some weird spotting between periods and it was identified at that point that I had some fibroids, but it was brought up in this ultrasound. My midwives said like, “Okay, the fibroids, we’re not really sure what this means if it means anything at all and, for the placenta, we want to check in again later in the pregnancy and see if it’s moved.” They didn’t seem too concerned about the placenta. They said in most cases, it does just move as the uterus expands. I was booked in to have another ultrasound at 32 weeks.

Rebecca Dekker:
Oh, wow, so what happened next?

Miranda Kelly:
Things carried along in my pregnancy. This pregnancy, I just definitely wasn’t feeling as strong and glowing as before. I was definitely a lot more tired in this pregnancy. I just felt like I was lugging along with the pregnancy and more just looking forward to getting it over with, but I was still very much looking forward to the childbirth experience. I really loved giving birth the first time and I was really excited to do it again and excited to have another home birth. If anything, I felt just a little bit of fear that it wouldn’t go as perfectly as the first time, that somehow I just was lucky the first time and that I couldn’t count on having that luck again.

Miranda Kelly:
Anyways, moving forward into the 32-week ultrasound. The placenta had moved so that was no concern. For the fibroids, I had a consult with an OB, and the OB didn’t really think that the fibroids would be any concern, so that was fine. Now, I can’t remember at this point if she was breech or transverse, but she was not head down. I forgot to mention in my first pregnancy that my daughter had also been breech for a little bit. With her, I just tried everything that I could. I looked into all the different like spinning babies and acupuncture and Webster’s technique, chiropractics. I tried everything and she did actually end up turning on her own.

This time around when I heard that my baby was not head down, I was like, “Okay, well, this happened last time. I’m not really that surprised. I’ll just keep trying when I was trying before.” Then as things progressed in my pregnancy, they started to become concerned that I was measuring a little bit big. I had some follow-up ultrasounds where they ended up identifying that I had extra amniotic fluid, or polyhydramnios. I felt like I got conflicting information about what this meant or I guess what risks it posed.

The initial midwife that I talked to made it sound like I had a lot of extra amniotic fluid and that it was very serious. Then another midwife said, “Oh, not really, it’s just a little bit above the threshold of what we consider normal amount of amniotic fluid,” and I had a consult with the same OB who also said, “It’s just above the threshold so we don’t have to immediately rule out home birth or anything like that but we want to continue to monitor it.”

Rebecca Dekker:
What did they say you should do next?

Miranda Kelly:
They suggested that I have weekly ultrasounds and nonstress tests, and so I did. At this point, one of the midwives was really strongly recommending that I have a hospital birth. Some of the other midwives in the group seemed a little bit more open to still supporting a home birth. I felt like I wasn’t entirely getting a straight answer as to what the risks were or what my next steps should be. When I tried to look into polyhydramnios and what that meant, one of the potential risks is preterm labor. I knew in that case that I would go to the hospital if my water broke and I was in preterm labor, that I wouldn’t be eligible for home birth.

Beyond that, sometimes it’s associated with gestational diabetes. I’d had the gestational diabetes test earlier in the pregnancy and I did not test positive for gestational diabetes. Sometimes it’s also associated with anatomical issues with the fetus. If the baby isn’t swallowing and processing the amniotic fluid in the normal way, that may be associated with increased amniotic fluid. I’d had the 20-week ultrasound, the anatomical scan, and everything had looked really good with my baby. They repeated those measurements, a lot of the later ultrasounds that I had and, again, everything looked really good with my baby.

Then sometimes polyhydramnios is just associated with feeling really unwell in pregnancy and feeling like your belly is really, really tight and you feel really uncomfortable and sick, and I just didn’t feel that way. I felt like the way you normally do in your third trimester when you do feel like, “Ugh, I’m pregnant,” but I didn’t feel Like anything was wrong. My gut feeling of it was that this wasn’t really a big deal and that I didn’t think it was a reason to have to have a hospital birth, unless I went into preterm labor. I was scared that that would happen but, thankfully, it didn’t.

Rebecca Dekker:
Okay, so you’re still hoping for home birth at that point. What happened next?

Miranda Kelly:
As I carried on with the weekly ultrasounds and nonstress tests, everything was always good with baby and the measurements of my amniotic fluid fluctuated week to week. Some weeks, I was just below the cutoff so I was within the normal range. Other weeks, I was just above the cutoff but it was never extremely high amounts of amniotic fluid. I just felt, again, that my midwives were … especially one in the group was introducing her own fears into my birth plan and really strongly trying to get me to plan for a hospital birth and opening my mind to the idea of having a hospital birth.

It was the summer at that point and it was really hot and I was thinking like, “Well, maybe it’d be nice to be in the air conditioned hospital.” Our home is really warm in the summer. I just, again, had this gut feeling that I could do another home birth and it would be fine. I imagined myself, well, what if I did have a hospital birth and everything went fine. I would feel robbed of this experience of having another home birth. I also felt really comfortable with the idea of transferring to hospital if I was laboring at home and it seemed like things weren’t going well and I needed some additional support. I was totally on board for that.

Living where I do here in British Columbia, midwives are integrated really well into our healthcare system. Our midwives have privileges in the hospitals and that transition to hospital would be very smooth. I wasn’t really concerned about anything there. Anyways, things trekked along and I finally get to 38 weeks. My midwives were still on the fence, not really saying whether or not they’d support me to have a home birth. I’ve been getting a lot of, “Well, let’s just wait and see.” My baby’s position had changed about weekly with these weekly ultrasounds. She’d been transverse, she’d been breech, she’d been head down, in every which way or direction.

I actually ended up, one week when she was in breech position, I was scheduled for an ECV, the external cephalic version. Then when I went in for that procedure, she had mostly turned. She was head pointing down into one of my hips. They really only needed to turn her 30 degrees to be head down and they went ahead and did that. It was super fast. I barely felt anything, and she was head down and I was like, “Great.”

Then the next week when I went in again for my weekly ultrasound, she flipped breech again. They were actually willing to schedule me for a second ECV, which I hear doesn’t happen that often. When I went in for that appointment a couple days later, she had turned on her own and was head … That was in my 38th week. At that point, I was just so done with all of these appointments, my weekly nonstress tests, my weekly ultrasounds, weekly midwifery appointments. I was having weekly consults with the OB. I just felt like there was too many cooks in the kitchen in planning for my birth.

Rebecca Dekker:
Wow, I can totally understand that.

Miranda Kelly:
I felt like I was really getting the runaround from my midwives. I asked my midwives to just give me a definitive answer. Are you going to support my home birth or not? They had a team meeting and one of the midwives calls me back and says, “Okay, our team discussed your case and half of us are comfortable with supporting your home birth and half of us aren’t. It just depends who’s on call when you go into labor.” I just felt completely that was not okay, that’s not acceptable, and that’s not my birth plan. I was really upset.

I spoke with my doula, who was really pivotal in encouraging me to make my own decision here and to go with what I felt most comfortable with. She’s an established doula locally and she did offer, “If you do want to try to talk to another healthcare provider and see if you could find a midwife who would support you for a home birth, I can help you try to set up some meetings.” I thought that makes a lot of sense. I think that it’s a hard decision at 38 weeks to change providers, especially when I had my first baby with this group of midwives that I’d been with and it had been a really positive experience.

But I felt like over the course of my pregnancy, the trust had really been whittled down. I was starting to feel like even if this group of midwives did support me to have a home birth, I felt like they were going to be introducing their own fears into my birth environment. I didn’t want anyone there who was just going to be looking for reasons to make me go to the hospital. I asked my doula to, “Yes, please, set up a meeting with another group of midwives,” and within a couple days, I met with that group of midwives. I felt very comfortable with them. I explained my whole situation and my understanding of the risks and my willingness to accept those risks.

They said, “We really support you in your autonomy to make this decision.” They were willing to take me on, thankfully. I switched providers at 38-and-a-half weeks. My baby was born just nine days later. It was a last minute thing. But I, thankfully, did have at least a couple prenatal visits with this new group of midwives so I had the chance to at least get to know them a little bit before I went into labor. I have to say once I reached that point of changing healthcare providers and just committing to that plan and that choice, I just felt this weight lift off my shoulders. Like, “Okay, finally I can relax. I have a provider who’s going to support my plan and, now, I can let go and give birth to my baby.”

Rebecca Dekker:
Yeah. That sounds like it would have been such a relief to know that you were with a team that was fully supporting your wishes.

Miranda Kelly:
At that same time, I decided I’m not going for any more meetings with the OB, I’m not going for any more ultrasounds or nonstress tests. The last ultrasound that I had, which is at that scheduled ECV appointment, she had been head down so I’m just going to trust her to be head down when the time comes. Basically, I spent those last few days just really trying to reclaim what I felt was stolen from me in this pregnancy, just feeling that excitement to be giving birth again. I just tried to go for long walks and relax. When it came time, I woke up on a Saturday morning and I was having some mildish contractions, they felt a bit strong but nothing too major, and I was like, “Okay, this could be it.” It feels like it could be it but who knows, we’ll see.

During that pregnancy, I had done a lot of swimming as a way to stay active and to relax. I went for a little swim and the contractions started to pick up while I was swimming. I was like, “Okay, I think this might be it.” I came back upstairs to get ready and I had a plan for my sister to come pick up my daughter and take care of her while I was in labor. I gave my sister a heads-up. Like, “I think this could be it, I’ve been having some contractions.” I gave my doula a heads-up as well. Then my sister planned to come out in a couple hours to pick up my daughter.

As I was getting ready for the day and showering and eating breakfast and getting my daughter ready, I felt just everything fizzle out, and I was like, “Oh no, I’m going to be pregnant for a bit longer.” My doula reassured me that this is actually really common for second time moms for things to fizzle out until your older child is taken care of and wherever they need to be. I was like, “Okay, maybe once my sister picks up my daughter, things will pick up again,” but it took a few more hours. She came and got my daughter, and then my husband and I had some free time together and nothing was happening.

I was sitting on the birth ball and trying to distract myself by playing board games and going for a walk and nothing was happening yet. I was getting really pouty and disappointed. Then my doula reassured me, “Often things will pick up in the evening once things start to wind down and it gets dark.” Sure enough, around dinnertime, like 5:00 p.m., I started to feel a few contractions coming again. I was like, “Okay, yes, this is it. I’m so excited.” My husband went to go make some dinner and I was just resting in our bedroom and watching some Netflix.

For about an hour, I was just relaxing and feeling things like starting to get more intense. But I was timing my contractions and they weren’t really regular. It was every 9 minutes, and then 11 minutes, and then 5 minutes, and 2 minutes, and 7 minutes. It wasn’t really following a pattern. I was keeping my doula posted and she’s like, “Okay, well, let me know if you’re starting to have a lot more intense or they’re getting more like five minutes apart.” It got to a point where I could no longer concentrate on the show I was watching. I shut it off and I started to feel really grumpy, like what’s taking my husband so long to make dinner and I just wish that he was here beside me. I should have recognized that that’s a good sign that things are progressing. My contractions still weren’t really following a pattern, but they were definitely starting to get more intense.

Around 7:00 p.m., my doula’s like, “Are you focalizing through them,” and I’m like, “Yeah, definitely.” She’s like, “Are they generally coming under 10 minutes apart?” I’m like, “Yeah.” She’s like, “Okay, I’m just going to head over. I’ll just start getting ready and head over and let me know if things get more intense.” I’m like, “Okay, will do.” Thankfully, she was really fast getting here. It only took her about half an hour or so to get here. She walks in the door and, at this point, my contractions are every two minutes apart and super intense.

Rebecca Dekker:
Wow.

Miranda Kelly:
Yeah, and it had ramped up really quickly. I was still not thinking that it was happening this fast. I was just like, “Oh, these are intense. I need to get ahold of myself and pace myself because I’ve still got hours and hours to go.” Shortly after my doula arrived, I decided to get into the shower. The water had really helped me in my first labor and I was really looking forward to using the water again. My doula was setting up a birth pool for me and I couldn’t wait to get in. I was in the shower and my doula had called my midwife for me. My midwife arrived around eight and checked on me while I was in the shower, just let me know that she was there.

As soon as the doula said, “The birth pool has enough water for you to get in,” I just climbed in, couldn’t wait to be in there. It was still filling up as I was in, but even just the amount of water that was in there up to my hips or so felt really, really nice. The doula was holding the hose to my lower back, so warm water was on my lower back and that felt so nice. My doula was asking me, “Do you feel that urge to poop,” and I was like, “Why is she asking me this? It’s way too early for that.” But I didn’t feel it yet. I felt it very shortly after that, and I finally came to realize like, “Oh, this is actually happening much faster than I thought.” I’d gotten into the birth pool at about 8:30, and it was only 20 minutes later that I started feeling that pressure and urge to push.

In my first labor, I had tried really hard to not just bear down and push. I wanted to just try to really create space and allow the baby to come down. I was meditating on that as I was breathing, to just open space and let baby come down. It was only right as the baby was crowning that I really gave in to that urge to really push hard. I think I pushed probably too quickly and I’d had a bit of tearing in the first, so I thought, “Okay, this time I want to try to prevent tearing if possible,” so I want to try to really slow it down as the baby’s coming out.

Rebecca Dekker:
You were trying to avoid some of the tears that you experienced the first time around, it sounds like.

Miranda Kelly:
In my first birth, my doula at the time had said, “You can reach down and feel your baby if you want to,” but I just felt frozen in the position that I was in. Every time I moved, I’d have another really strong contraction so I just felt like I couldn’t move. Again, going into this one, I was like, “Okay, this time, I want to try to reach down and feel my baby.” This point, I reached down and I feel this really soft bulge and I was like, “Oh, my gosh, what part of my baby is coming out? I thought she was going to be head down and now, I don’t … What is this coming out?”

I asked that out loud, “What is this,” and my midwife said, “Oh, that’s the bag of water. It hasn’t broken yet.” It finally dawned on me like, “Oh, this is why everything is feeling so much different than the first time. The water hasn’t broken yet.” It definitely didn’t feel like the same intensity and pressure that it had the first time. I didn’t have that burning sensation of stretching. It actually just felt like pushing a water balloon out. It actually felt, honestly, pretty easy. It was only about six minutes of pushing. Her head was born with the water intact.

My midwife had asked if she could break the water and I didn’t understand why she was asking me that, and I just couldn’t answer so I just didn’t say anything. She actually went ahead and broke the water after the head had been born, and I’m not entirely sure why at that point it was necessary to do that or relevant. But I couldn’t say anything at that point. Then just with the next contraction, baby came right out and my husband helped catch her and then hand her through my legs and I grabbed her. It was nine o’clock that she was born, so four hours total, and I was just in complete surprise that it went that fast, but also really grateful that everything went very well, very smoothly.

I got out of the birth pool pretty quickly. As I was standing up to get out, the placenta just plopped right out and that was really easy. I waddled over to the bed and the midwives were watching pretty closely for my level of bleeding, just as that being a possible risk factor of having extra amniotic fluid and my fibroids that just there may be some extra bleeding. There was no drops of blood between where my birth pool had been to my bed, and I had hardly any bleeding at all, so that was really great as well. No concerns or complications there.

My second birth was just beautiful and I also had a much, much easier time postpartum. I had hired a postpartum doula. It had been very important to me to find an Indigenous doula. I did find a local Indigenous doula who is really fantastic and a great support. I just had this peace of mind knowing that she was going to be coming and she’d be there to help me hold the baby so I could go to the bathroom and not have to rush and I could shower and get a cup of tea. I also noticed having more confidence the second time around. I had less questioning of myself whether or not I was doing things correctly. I think mentally, I had prepared myself a bit better for the expectations of having a baby and what it would feel like. I had much more realistic expectations of breastfeeding and then demands of breastfeeding.

Also, I just have to say that my second baby just had a much easier temperament. She was much easier to settle down and made my heart ache a little bit for my former self and having my first baby and just thinking like, “Why can’t I soothe this baby?” Like, “I’m just not meant to be a mom. This poor baby deserves a better mom than me.” It made me think back and just feel like, “Gosh, I wish I could go back and tell her that you’re doing everything right and it’s just some babies are really difficult to soothe and it doesn’t mean you’re doing anything wrong.” I felt a lot stronger postpartum and the whole recovery just felt a lot smoother.

Actually, so much so that just a few months after my baby was born, I started to feel like I really wanted to explore more learning around supporting families in this transition period of pregnancy and childbirth and postpartum. Just being able to compare and contrast my first postpartum experience when I struggled so much and my second postpartum experience when it was so much easier, I felt like parents are really missing critical information in preparing for the postpartum period and also really a lot of times missing critical support.

Rebecca Dekker:
That is so true. What steps did you take next?

Miranda Kelly:
I found some training being offered through a local organization, the Pacific Postpartum Support Society, and it was training for their telephone volunteer support line. I completed that training when my baby was five months old. That was a really big step for me in healing my previous postpartum experience and learning more about how to support families in that transition period.

Following that, I started to look into doula training, and I thought that by just taking postpartum doula training, I could learn more about how to support families in that period. I wasn’t quite sure that it would lead to me working as a doula, but I thought it would just be really interesting information to have, and that maybe somehow I could figure out how to incorporate supporting parents into the work that I’ve been doing in public health. I started to pursue doula training and I did postpartum doula training first. Then a couple months later, I also did birth doula training.

As I have started doing more of the training and the reading towards certification, I started to reflect more on the experience I’d had in my second pregnancy. Just without question, just going with the same group of midwives and just assuming that everything would go smoothly and fine and then coming to the place where I changed providers at 38 weeks and thinking that not everyone would feel comfortable making that decision or even has the choice to make that decision if they live in a small community where there aren’t a lot of providers to choose from, and I felt really fortunate that I had a doula who could support me to make that decision and make that change.

But I also was just reflecting on how there was nothing really overt that I could point to and really pinpoint that my midwives had done wrong, like anything that I could say, “This is absolutely unacceptable and I have to change healthcare providers.” It was more of the slow whittling down of the trust relationship and this slowly growing feeling in my gut that this wasn’t the right fit and that it wasn’t going to work for me. It just took me a long time to reach that breaking point. I wish that I had considered it earlier.

But I also just felt like people need to know that they can make this choice for themselves, that they can change healthcare providers, even if it feels like it’s last minute. If there aren’t that many healthcare providers in their area to choose from, then I think it’s really important to be thoughtful from the beginning about the relationship that you have with your care provider. In my case, I wish that I had still interviewed a few different midwifery groups instead of just automatically going with the one that I had been with last time. Because even though that worked for me in my first pregnancy, people change, midwifery practices change, and I changed. I think it would have been helpful to just still go in to my second pregnancy with the mindset that I’m still actively making choices along the way, I don’t have to just go with what happened last time.

Rebecca Dekker:
I was going to ask you, Miranda, is it an option to have an Indigenous midwife near where you live or are there not any available?

Miranda Kelly:
Here in Vancouver, we have one that’s currently practicing. I get to work with her a lot as a doula. I have to say I think it makes an incredible difference for families to be able to access their care from an Indigenous midwife. Unfortunately, we just don’t have many practicing Indigenous midwives locally or even in our province of BC. I do think it would make a huge difference if we had greater accessibility to Indigenous midwifery care.

Rebecca Dekker:
Talk to us about as you became a doula and started getting more involved in working in your community, what are some of the struggles your community is facing? You mentioned a little bit about your experience about almost feeling like your pregnancy was taken away from you in a way and not having control over the experience.

Miranda Kelly:
Yeah, I did feel that way, for sure. It felt like it took some effort on my part to reclaim that. I did start to feel like there’s definitely a lot of work to be done for our Indigenous communities to reclaim birth in general. There has been a number of policies and practices over the years that have taken birth out of our communities. One policy that impacts our communities a lot is an evacuation policy, which basically requires pregnant people in remote and rural communities to leave their community weeks before the due date, sometimes like 37, 38 weeks, to go to a larger city or town where there’s a hospital that can support maternity care and-

Rebecca Dekker:
There’s a lack of access in rural and remote areas, and they make you travel to a metropolitan area, leaving your family behind usually?

Miranda Kelly:
Yeah. Yeah, exactly. Having the medical system really take over and claim birth away from local community midwives has also contributed to that. We don’t have many Indigenous communities that have local midwives that can support them to birth at home. As far as challenges go, I’d say systemically, racism is there and strong and a big factor. I’d say our communities, I think, face challenges in capacity. We don’t have many Indigenous midwives or Indigenous doulas, and that’s definitely been a challenge for me in my own work as a doula.

I mentioned that I’d had a postpartum doula who was Indigenous herself, and she helped me connect to a collective of Indigenous doulas here in Vancouver. It’s a small collective and a number of our members are inactive right now as doulas because they’re in midwifery school. We have three of our collective members currently in midwifery school, which is great that we’re going to have some future midwives supporting our communities.

But there’s certainly a really high demand. There’s a lot of Indigenous families out in our communities that want support from Indigenous doulas and aren’t always able to find an Indigenous doula in their community or, in our case, our capacity as a collective, we’ve had to turn people away because we simply don’t have the time and enough doulas actively taking on births right now to be able to support everybody that contacts us. It feels really hard to say no, but it’s also essential that we hold our own boundaries and recognize our own capacity, myself as a mom and our other collective members being in midwifery school or one of our collective members as a PhD student and a single mom.

There’s limits to what we can do in our doula practices. This has triggered one of our members and myself, her and I have worked together to develop curriculum for Indigenous doula training. We’ve now offered that training twice since last fall. Our idea is to build up more capacity and have more Indigenous doulas in our communities so that more people can take on this work and so that we’re not having to turn people away and that everybody who wants a doula can find a doula.

Rebecca Dekker:
I love that solution. It sounds like you’re basically growing your own team of doulas because there aren’t any, so you’ve got to grow them up.

Miranda Kelly:
Yeah, for sure. It’s incredible, heartwarming, and spirit-lifting work to sit in a room together with other Indigenous people who are passionate about this work and have felt the call to take that training. Many of them have so much experience and have already supported their own family members in birth and could probably be teaching that class alongside of us. Sometimes I think it’s just a matter of giving ourselves permission to do this work and recognizing that we are experts already.

Rebecca Dekker:
Yeah, you’re totally qualified to teach your own people.

Miranda Kelly:
Yeah, exactly. But another challenge of it is we’re training people to go about into their communities and do this work but, often, it’s really hard to sustain yourself and to support yourself and your family in doing this work. A lot of the families that we support can’t afford to pay out of pocket for doula services, and so, it requires a lot of advocacy and working with partner organizations to try to find sustainable ways to pay doulas for the work that they’re doing and supporting indigenous families.

We’re lucky here in BC that we do have a grant program that’s funded partially by our Ministry of Health and partially by the First Nations Health Authority and administered through our BC Association of Aboriginal Friendship Centres. It’s $1,000 grant that a family can apply for to put towards birth or postpartum doula support. Many of my clients are accessing my doula support through that grant program, which means that I get paid through the grant, the family doesn’t have to pay me and then go reimbursed or anything like that. I just get paid directly through the grant program. They have the choice of choosing whichever doula they want to support. The doula just needs to go through an enrollment process to be approved to be paid through the grant. But this grant has existed for a number of years now.

There have been some barriers, Indigenous doulas being able to enroll for the program, which has meant we’ve seen non-indigenous doulas getting paid through the grant program and not very many Indigenous doulas getting enrolled and being paid through the grant program. In part of our advocacy and work around training doulas, we’ve also been working with those funding organizations and administration of the grant to try to lower barriers for Indigenous doulas to be able to access the grant, and to really try to encourage more training and more supports for Indigenous doulas to make this sustainable so that they don’t burn out after going to a few births because it’s just too hard to maintain.

Rebecca Dekker:
Right. If you’re not being paid a living wage, it would definitely be something that would be not sustainable in the long run.

Miranda Kelly:
Yeah. Certainly for myself, I found as I was getting started on my doula journey that I really drew on the support of the Ekw’í7tl Doula Collective, and that friendship and sisterhood that I found within the collective helped me through some of the challenges of becoming a doula. That’s our goal, too, is to build more of a community of support and to make sure that doulas don’t feel like they’re really isolated in this work and that they can reach out to us and find friendship and mentorship as they’re getting started, because it can be really hard, especially for doulas who are working in isolated or remote communities where they might be the only doula and they might be supporting families within a very large geographic region around them.

It could be very hard for them to find a backup doula. They face a number of challenges that we don’t living in Metro Vancouver area, where our hospital’s only 15 minutes away and there’s plenty of transportation options and we don’t quite deal with the same weather challenges and no flood season or snow season that some of our Indigenous relatives and remote communities may deal with.

Rebecca Dekker:
Can you tell us, are there any success stories or strategies you’ve seen that have worked really well that other people can learn from?

Miranda Kelly:
I think just the fact that this doula collective existed when I started my doula journey, that really meant a lot to me. Basically, it was this grassroots movement of just a few individuals in the community that were passionate about indigenous birth that came together and decided to form this collective, but that groundwork that they laid really helped me find my footing and find my confidence. Also, it helps our partners find us. Partner organizations can find our website. If you google indigenous doula Vancouver, our website is one of the first that comes up.

I’m really grateful that they laid that foundation for us so people are aware of us and families can find us when they’re trying to find an Indigenous doula. I think there’s success there in coming together and forming a collective. Even if it’s just one other person, having that one person can really make the work more fulfilling and help you through some of the challenges, because it is hard. It can be hard to try to change systems. When we have partner organizations approaching us and wanting to partner with us and get our feedback on their projects, it’s exciting to be seen and that people want to hear us, but we’re also still working within their systems.

I find that it’s pretty common for us to be invited to, say, an engagement session or a working group session. People want to have voices from the Indigenous community at their table, but they often don’t approach us and offer to really compensate us for our time or recognize our expertise is just as valid as anybody else sitting at the table. I’ve been at tables where there are physicians receiving $500 for half a day of consulting and I’m offered $100 an honorarium.

Often, it involves me having to really actually ask for it. They don’t just offer to compensate me for my time, and I have to remind them that to be there, I am having to have my own costs of childcare and transportation and this is a day that I’m not seeing a client, because I’m coming here to this session. Just trying to really fight for that recognition within the system, that if you want Indigenous voices at your table, you have to recognize that we are experts, and experts cost money. You can’t just expect us to do that work for free.

Rebecca Dekker:
Yeah, that sounds really compelling. I can totally see that. This is Rebecca circling back after this interview was recorded to let you know that I was really thankful for Miranda for bringing up the important point, that it’s a lot of labor for People of Color, for Indigenous people, Black people, Latinx people to talk about these issues, and that for too long, they’ve been expected to do so for free. I appreciate Miranda bringing up this point, although I know she wasn’t talking about coming on this podcast. Her words started me on a month-long journey of thinking about this topic, and also listening to other birth workers, talking about how it’s a form of racism for white people to expect them to educate white people about racism for free.

I made the decision that although the podcast model typically expects guests to come on for free, we are now giving an honorarium to People of Color who take the time to come on the Evidence Based Birth podcast to educate others about these topics. I want to thank Miranda for her honesty and for the other birth workers of color who have spoken up on social media about this topic, and to me personally. I’d like to be part of the change by offering financial compensation for Black, Indigenous, and People of Color who come on the Evidence Based Birth podcast.

Miranda, thank you so much for sharing about the work that you’re doing. Do you have any questions for me? How can I help you?

Miranda Kelly:
Yeah. I did want to ask a question related to my second pregnancy and the experience of having multiple ultrasounds and measuring the amniotic fluid level. I’m wondering if you are aware of just the research evidence around measuring amniotic fluid level. My understanding is there’s a couple different methods to use. There’s like amniotic fluid index, and I think like a deepest pocket, something like that. Also just, I guess, the accuracy and also just the validity of this, who determined and how, what is a normal level of amniotic fluid? Because I was continuously walking that line of just below or just above what they were telling me the threshold was for normal, but how do we even know what normal is?

Rebecca Dekker:
Now, this is great. You’re the second person this month to reach out to me about high fluid levels, borderline high fluid levels. This just sounds like what you had. There are two resources I could point you to. One, I’m happy to send it to you, is the Society for Maternal-Fetal Medicine in the United States has a guidelines paper all about evaluation and management of polyhydramnios. That’s what I said to somebody recently who had polyhydramnios who contacted me. The other resource is, if you google Evidence Based Birth amniotic fluid, there is an article I wrote a while ago for Lamaze Blog, Sciences and Sensibility. It was written a while ago, about eight years ago, but I recently redid the literature search, and really, the research hasn’t changed. The findings haven’t changed. Those are two resources for our listeners.

But we have amniotic fluid, which surrounds the baby inside the amniotic membranes. During the second half of pregnancy, amniotic fluid is made up of your baby’s urine and lung secretions. Now, that liquid originally came from you as the parent who’s pregnant. That liquid comes through the placenta to the baby and then off to the baby’s bladder and lungs, and then the baby swallows it, it gets reabsorbed. There’s this constant shifting of the mother’s fluids are the original source of amniotic fluid, so changes in your fluid status can change the baby’s fluid status.

There are also factors related to the baby that could affect levels of amniotic fluid, such as issues with the urinary tract or kidneys, or like you said, maybe if the baby has trouble swallowing, they’re not able to swallow the fluid so it builds up. There are a variety of factors that can influence amniotic fluid, and there’s two main ways to measure it. As you mentioned, one is called the amniotic fluid index and the other is single deepest pocket.

Amniotic fluid index is often abbreviated AFI. To calculate the AFI, the ultrasound technician divides the uterus into four areas or quadrants. The largest fluid pocket in each area is measured, and then those four numbers are added up to make the AFI. Then there’s different cutoff values for what they consider low fluid or oligohydramnios, or high fluid which they call, which is too much fluid, polyhydramnios. But you got to understand the amniotic fluid levels exist on a continuum. There’s no agreement among researchers about cutoff points that predict poor outcomes.

Also, there are factors that can make it difficult to measure the fluid levels. As they get lower, the results from the ultrasound are less accurate. The technician can also play a role. If your technician is less experienced, that can affect the results, as well as the amount of pressure that the technician is putting on the ultrasound probe. The position of the baby can affect the accuracy of the results. I can imagine in your situation, there might have been two possible things going on. One, the extra amount of fluid or slightly extra amount was what was allowing your baby to maneuver around a little bit more, or because your baby was in a different position, it affected the results of the measurement.

In order to get a true measurement of a fluid, it’s actually really difficult. It involves injecting a dye into the inside of the amniotic sac, and then withdrawing fluid to measure the dilution, which obviously that’s incredibly invasive. We’re not going to just be poking needles into people and doing that. Instead, that’s why they developed these ultrasound measurements. Unfortunately, the ultrasound measurements are just never going to be as accurate as actually going in and figuring out how much fluid is in there, so they’re estimates.

With the single deepest pocket, with that one, the technician looks for the largest pocket of amniotic fluid in the uterus, and then measures that largest pocket. There is some research that when they’re looking at low fluids, that it’s safer to use the deepest. Single deepest pocket method has less side effects in terms of leading to unnecessary interventions. With the Society for Maternal-Fetal Medicine guidelines, it’s really interesting to look and see at how they categorize polyhydramnios, which is what you had. For example, they can categorize it as mild, moderate, or severe. If you have an AFI of 24 to 29.9, that would be mild. If it’s 30 to 34.9, that would be moderate. If it’s 35 or greater, that would be considered severe. Do you remember all what your numbers ranged around?

Miranda Kelly:
No. I feel like they might have given me the number for the AFI maybe in one of the first or second ultrasounds. I think after that, they were giving me the deepest pockets.

Rebecca Dekker:
Okay. Yeah. When it’s mild, which it sounds like it was for you because they were just monitoring you and they weren’t suggesting interventions, usually with mild, it’s idiopathic, which means we don’t know the cause. If there is a cause identified, it’s usually because of maternal diabetes or fetal anomaly, like you said. But most cases of mild polyhydramnios where the fetus seems to be normal and there’s no other complications, they just don’t know the cause. You can look and see at the Society for Maternal-Fetal Medicine guidelines, they would call that an isolated polyhydramnios. Isolated meaning there’s no other complications going along with it. It’s just on its own. They’ve noticed this.

They actually suggest that you don’t need to do frequent fetal testing for mild, idiopathic polyhydramnios. They say that’s Grade 2C evidence. They also say that there is no data to suggest that induction of labor or delivering the baby preterm would improve outcomes, and they call that Grade 1C evidence. Grade 2C is a weak recommendation, low-quality evidence. But the recommendation that labor should be allowed to occur spontaneously is a 1C, strong recommendation, low-quality evidence.

Hopefully, that’s helpful for you to see that professional guidelines do break it down into mild, moderate, and severe. It sounds like what you had was mild, and that extra fetal testing might not have been necessary to have you go in every week, and that, as you said, you still had good outcomes. There was no underlying complication associated with it.

Miranda Kelly:
Yeah.

Rebecca Dekker:
Is that helpful?

Miranda Kelly:
Yeah, thank you.

Rebecca Dekker:
Yeah. Miranda, can you tell us the best way for our listeners to follow the work that you’re doing?

Miranda Kelly:
Sure. My own personal website is mirandakelly.com, and on Facebook and Instagram, I’m @mirandadoula. Then the work that I do with the indigenous doula collective, our name is Ekw’í7tl Doula Collective. Ekw’í7tl is not intuitive to know how to spell. It’s a Squamish word that means family. That’s E-K-W-I-7-T-L, Ekw’í7tl. On Facebook, we’re Ekw’í7tl Doula Collective. On Instagram, we’re @ekwi7tlcollective.

Rebecca Dekker:
Great. We’ll link to those in the show notes to make it easy for people to find. Thank you, Miranda, so much for coming on the podcast and sharing your story with us and encourage our listeners to follow you and support the work that you’re doing.

Miranda Kelly:
Thanks so much for having me.

Rebecca Dekker:
This podcast episode was brought to you by the Evidence Based Birth® Childbirth Class. This is Rebecca speaking. When I walked into the hospital to have my first baby, I had no idea what I was getting myself into. Since then, I’ve met countless parents who felt that they, too, were unprepared for the birth process and for dealing with a broken healthcare system. The next time I had a baby, I learned that in order to have the most empowering birth possible, I needed to learn the evidence on childbirth practices, find out how to stay comfortable during labor, and my partner needed to learn how to speak up for me.

I’m excited to announce that we are now offering the Evidence Based Birth® Childbirth Class in about 50 communities in the United States and around the world. In your class, you will work online with an Evidence Based Birth instructor who will skillfully mentor you and your partner in evidence based care, comfort, measures, and advocacy so that you can both embrace your birth and parenting experiences with courage and competence. Get empowered with a childbirth class you and your partner will love. Visit evidencebasedbirth.com/childbirthclass to find your class now.