EBB 180 – Trauma-Informed Care and Consent with Feminist Midwife, Stephanie Tillman

Learn more about Stephanie Tillman and “Feminist Midwife” here (https://www.feministmidwife.com/). Read Stephanie’s article “Consent in Pelvic Care” here (https://onlinelibrary.wiley.com/doi/full/10.1111/jmwh.13189). Follow Stephanie on Facebook (https://www.facebook.com/FeministMidwife/), Twitter (https://twitter.com/feministmidwife), and Instagram (https://www.instagram.com/feministmidwife/). 

Learn more about the American College of Nurse-Midwives here (https://www.midwife.org/default.aspx). 

Learn more about Nurses for Sexual and Reproductive Health here (https://www.nsrh.org/). 

Learn more about the Midwest Access Project here (https://midwestaccessproject.org/). 

Learn more about the Queer and Transgender Midwives Association here (https://www.elephantcircle.net/qtma). 

Rebecca Dekker: Hi everyone, on today’s podcast we’re going to talk with Stephanie Tillman of the “Feminist Midwife” about trauma informed pelvic care. 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.  

Today, I’m super excited to welcome our honored guest, Stephanie Tillman. Stephanie Tillman pronouns, she/her is a midwife at the University of Illinois at Chicago. She completed her undergraduate degree in global health and medical anthropology at the University of Michigan and her graduate degree in midwifery at Yale University. Stephanie is on the Board of Directors of Nurses for Sexual and Reproductive Health and the Midwest Access Project is a member of the American College of Nurse-Midwives ethics committee and is an advisory committee member of the Queer and Transgender Midwives Association. 

Stephanie is a clinical medical ethics fellow at the University of Chicago, where she is focusing on consent and pelvic care. And this fall will begin a Ph.D. program in healthcare ethics at St. Louis University, also focusing on consent and pelvic care. Stephanie blogs under the name “Feminist Midwife”, and through that online platform, academic and public writing, and professional speaking engagements, seeks to interact with providers and consumers in conversations about consent in healthcare provision, ethics, queer care, sex positivity, anti-racism, nurses and advanced practice clinicians in abortion care and trauma-informed frameworks. Welcome, Stephanie to the Evidence Based Birth® Podcast.  

Stephanie Tillman: Thank you so much for having me. I’m really looking forward to talking.  

Rebecca Dekker: We are so excited to feature you and to pick your brain about all of these amazing topics related to trauma-informed care. I was wondering if you could start by sharing your personal story about how you got into this field to begin with.  

Stephanie Tillman: Sure. So I started out in undergrad thinking that I wanted to be a physician. I’m the first person in my family to go to college. And that’s sort of a go-to thing to say that you’re going to study and what you want to be. And quickly learned that based on other people who were studying the same, that those weren’t my people and I had met a sexual health educator on campus, thought she was the coolest person in the world, followed her around and realized public health was a field of study and of work and got really excited about public health, started taking a few different classes around public health and feminism. And the introduction to feminism class was taught by two midwives. And I had never heard of midwifery before, I had no idea what a midwife was and had just started into this path of public health.  

And my family was confused enough that I had switched a field of study. So I decided to stick with public health and ended up doing work in global health. And every country I went to midwives ran the show. They ran public health departments. They were heads of hospitals in many countries across Africa, in particular midwives with a penultimate nursing degree. And they are the experts of nursing, but also of care generally and largely because there aren’t a lot of physicians in many places, midwives and nurses really are the care providers in those communities in terms of how westernized medicine has taken over healthcare in those areas. So I did global health for a few years and after being inspired by so many midwives globally, I decided to come back and go back to school to be a midwife.

I honestly did not know very much about midwifery in the United States. I really became a midwife because of midwives of color across central America and across the African continent. And so learning the history of midwifery and not only it’s whitewashed roots, but also how it has been taken away from healers, Indigenous healers and Black midwives in the south to create this new midwifery that now exists and is in the process of hopefully being overturned and given back to its originators in this country, it’s been an interesting tenure. 

Rebecca Dekker: So did you know the history of midwifery in the United States when you started going into midwifery school and that path? So you learned about that later on?  

Stephanie Tillman: I did. Yeah, I learned about it after I started into school.  

Rebecca Dekker: And then you had to go through nursing school first then in order to become a nurse midwife?  

Stephanie Tillman: Correct. Yeah, I ended up doing an accelerated program. So as someone who didn’t have a nursing degree, it was a year and a half of nursing education. And then immediately went into the midwifery portion, having done global health work, also having a nursing foundation was important to me. I understood that there were other paths to midwifery that didn’t include nursing, but I believed I would be going back into global health work and wanted nursing as a foundation. So really I never worked as a nurse except for about a year in a planned parenthood recovery room. So even though I professionally identify as a nurse midwife, that’s my license, that’s how I practice, really midwifery is much more of my professional identity rather than nursing, because I never really worked as a nurse. 

Rebecca Dekker: So tell me a little bit then about your midwifery program. You mentioned that you learned about the history of midwifery in the United States and kind of the racists and also the whitewashed history. Is that something that you are taught in midwifery school or is that something you had to learn yourself?  

Stephanie Tillman: Definitely not taught in midwifery school. It ended up being more of a site education through my cohort and classmates, mainly classmates of color and more of an education once I started into practice and then started doing more with midwifery outside of clinical practice. So starting to do more leadership roles within the American College of Nurse Midwives, starting to write “Feminist Midwife” and really learning more and more about midwifery and socially, kind of the socio-cultural history of midwifery as I was writing and learning more about my profession beyond clinical practice. 

Rebecca Dekker: And when you graduated, how did you start off your career?  

Stephanie Tillman: So I knew I wanted to take care of people who were uninsured or under-insured. I’m Spanish speaking, and so wanted to work with Spanish speaking communities. And my final rotation in midwifery school was with a free community clinic and community hospital in Chicago and I loved it. That’s where I wanted to be and felt very lucky that they hired me. So I was at that free clinic for three years and at a hospital on the south side of Chicago for three years, and then moved to University of Illinois six years ago. And I’m also in a free clinic system through University of Illinois, again on the south side of Chicago in a majority Spanish speaking clinic. 

Rebecca Dekker: And tell us thinking back over these years, after you graduated from midwifery school and you started practicing, what are some of your favorite memories from practicing as a midwife? Because I know you’re going on to kind of a new part of your life, you’re going into doctoral school. So I wanted to help you reminisce about what are your favorite parts of being a midwife?  

Stephanie Tillman: I’s so hard to kind of even focus it down to just a few favorites, especially as I’m going through this, closing this chapter and almost grieving leaving clinical practice, pretty consistently favorite memories come with students. I really loved being a preceptor and teaching midwives, teaching residents. It has been a true, true joy to see how people learn and how patients encourage people to learn and really take power over someone learning from them and sort of being the facilitator between students and patients in a way of how are we all learning from each other? Because I, as a midwife, I’m learning from patients all the time. 

So, I mean, I can remember so many very fast births in hallways and in emergency rooms, just thinking about students, really not understanding how quickly something was going to happen. It’s almost like a movie reel or a highlight reel in my head of remembering which students I said, don’t turn your back on a multiple, because they’re telling you they’re going to push and you don’t see anything right now, but in a half a second, you’re going to see something and students still turning around and getting gloves or preparing something and a baby’s out by the time they turn back around and how much fun that can be and particularly how fast and unexpected births can be, lovely. They don’t need to be emergencies. They don’t need to be stressful and how we can really bring a lot of joy to that.

I also have many memories of residents needing to have a supervising clinician with them in a birth or in a repair when their attending is not available. And both hospitals I’ve worked, all three hospitals I’ve worked in, the midwives come in whenever their attending physician is not available. And sort of addressing when residents perhaps are uncertain about something or feeling panicked about something and coming in and either through language or through presence, being able to impart like this is great. You’re doing a great job. This is normal, let’s take a pause, let’s take a breath. It’s okay that she’s bent over the side of the bed and she’s going to have a baby here. She doesn’t need to get into the bed. Everything is fine. 

And sort of really helping to change an energy in the room. And I mean, that both from the midwife feelgood sense, which I feel is very true to midwives, but also just from an experienced clinician sense of saying, whatever your gut is telling you right now is good because then you’re paying attention. But also how can we reframe that to say, okay, you’ve assessed everything, let’s take a breath and slow down. And I think it took me time as a new clinician to feel like I had enough confidence or enough experience to be able to tell people to do that. But it’s ended up being one of my favorite things is just teaching.  

Rebecca Dekker: So you love students basically learning about the midwifery model of care, because you worked with a lot of medical students and residents as well, who otherwise might not have been exposed to a different way of doing things.  

Stephanie Tillman: Yeah, absolutely. We call it inviting people in for midwife births, which is sort of a funny way to describe it because it’s not our birth, it’s the person’s birth, but we’re very good at making sure that that’s the focus, is the person’s birth, not our role in the birth, but really what that means to us is what positions can people be birthing in? What’s our stress level that we’re sort of giving off to people. Teaching has just been one of my favorite things, but also working with colleagues to think, why do we do what we do? How could we do it differently? How can we think about this being more queer focused? How can we think about our work being anti-racism focused? How can we reframe what the status quo is? 

I’m so over the status quo and really want to figure out why it is what it is and how to change it. That’s why I’m so geeked out right now over consent, because everyone’s so terrible at consent in healthcare. And it’s been going on for so long that even patients really don’t even know what to anticipate or what they can ask for anymore. So that’s sort of where I found my niche and where to disrupt the status quo. That’s where I’m going.

Rebecca Dekker: So I know it’s not easy to be somebody who disrupts the status quo, to be a change maker, a change agent. What are some of the biggest challenges you’ve faced in this role?  

Stephanie Tillman: Well, I think there have been waves throughout my career of feeling like I have the energy or I have the capacity both emotionally and logistically to be able to push the envelope on things and certain things, once you start to see a little bit of success, really make a difference, okay, something’s moving here. I’m going to keep going. I think what’s been particularly hard is thinking about being a midwife in a physician-dominated setting where physicians don’t particularly like midwives or feel threatened by midwives, or think that midwives really don’t know what they’re doing. And that’s been the case for all three hospitals where I’ve worked. And I could only do that for so long. So pushing certain topics, I feel like I’ve gotten certain things moving and I’ve had really great conversations with people. Where I’ve been struggling most recently is it seems like midwifery as an identity and as a professional expertise in the settings where I’ve worked, and this is not about me, it’s about the medical-industrial complex and how complicated power is in medicine.  

But really I haven’t seen much movement. If anything, I’ve seen it get worse for midwives where I am right now. And I’ve been reading a lot about moral injury and moral distress and burnout and secondary trauma and disenfranchised grief. And what I feel like are a lot of synonyms for what people are experiencing heightened during COVID, but has also been sort of a mainstay struggle throughout my career to figure out how to survive in settings where you’re not meant to survive. Whether that means as a midwife, really, you’re kind of always pushing a rock up a mountain, or if you’re a patient and someone always thinks that they have the final decision over you, or if you’re a student and you’re sort of at the whim of whatever someone’s willing to teach you, I feel like I’ve gotten to this place of, I refuse to use language that indicates that somehow I have failed, burnout and instead have started identifying, I feel morally injured by a system that is meant to keep me from thriving.  

And so that’s why a lot of people struggle with the word resilience because it’s this idea that you’re supposed to continue to thrive, despite all the odds, essentially. And again, thinking about disrupting the status quo, who made up these odds? This is the problem. The system is the problem, not the fact that we can’t work within it. And it’s taken a couple of years now to kind of get that reframing to think okay, this is where I can do best within the system. Perhaps it’s not as a full-time clinician anymore, but let’s think about for me anyway, how to kind of come at it. And so I think, sure there have been plenty of moments where I’ve gotten into actual screaming matches with physician colleagues over extreme ethical concern issues.

I’ve gotten into circumstances with fellow midwives where it just feels like each of us is so set in our ways. We really can’t find a way forward. And I don’t know, there’s something about me in this moment that I need to learn more and I need to understand more about the foundations of things to be able to come back and be a better negotiator, a better teacher, a better midwife. And so I think that’s where I really struggled is to identify where in the system certain things are so broken as I see them that they really aren’t moving or they’re actually getting worse and how I can continue to be a really good midwife within and outside of that setting.  

Rebecca Dekker: So it sounds like you saw some improvement on some things, but you also saw a decline in how midwives are being treated and viewed by medical colleagues.  

Stephanie Tillman: Yes, unfortunately. And absolutely I will celebrate the wins. So I will celebrate the fact that every nurse that I’ve worked with has understood how particular I am about consent and the length to which I will go to interrupt someone who is doing a traumatic exam or we’ll teach patients or students language and approaches to those exams. Because now, as I’m leaving, I’ve received messages from nurses saying, we interrupt residents now to tell them to stop doing exams if someone is non-verbally showing that they don’t consent for an exam to continue. Absolutely, those are huge wins. I feel such success with those things. It’s, I don’t know, nursing and midwifery, it’s really hard to be taken seriously and to be considered an expert in the medical model. And so it’s also why I’m getting my Ph.D. outside of nursing because I think that within nursing and midwifery, it’s just always this certain ceiling that you get to of how much someone will actually listen to you.  

So it’s really unfortunate. It was unexpected, particularly when I think full circle about what even brought me to this career, to think about the fact that nurses and midwives are experts everywhere else to then be here and say, never, ever, regardless of how educated or how experienced you are, will colleagues necessarily perceive you as an expert. It’s really unfortunate. And absolutely, I think that has a lot to do with some of the settings I’ve worked in, but now I’ve been in three different hospitals, two different free clinic systems, and it’s been the same. So I hear from midwives who work in really incredible empowering settings, I think that’s incredible and really lucky that those places exist. We need to figure out what that magic fountain water is and get everybody else to drink it.  

Rebecca Dekker: Yeah. And what you’re telling me sounds consistent with other people have told me about Chicago and the Chicago area. It seems to be in the hospitals there’s this culture that is not geared towards consent or midwifery care. So let’s talk a little bit about consent because you’ve mentioned that several times, is something that you’re passionate about and you’ve seen major ethics breaches. Can you talk about maybe why consent is important or where you see consent not happening in the medical system?  

Stephanie Tillman: Sure. So the framing that I tried to give around consent in pelvic care in particular, but consent in any type of intimate care, whether that be, if someone’s most intimate part of their body is their breast or chest or even an exam around their neck. Typically people will refer to pelvic care, is the most sensitive type of exam. The way that I think about it is whatever we would expect to happen in someone’s intimate, social setting, outside of healthcare. So interacting with a partner during sex, interacting just intimately with themselves, if something hurts or if someone decides they don’t want to continue with whatever’s going on, then it should stop. And if I had a loved one, for example, any of my nieces, if they came to me to say, Oh I was doing this thing with someone and I told them that it hurt and I asked them to stop and they didn’t stop. I think anyone would say, we need to talk about how that’s a problem here is what bodily autonomy is. Here is what consent is here is where you have power over your body, always and forever. 

There is something about healthcare that as soon as someone gets into a healthcare space, that all of that goes out the window, somehow the intimate nature of certain parts of people’s bodies or the degree to which we will hold people accountable for consent or accountable for paying attention to people’s pain or their requests, it’s just not the same. And I can’t understand why within a healthcare space, it’s okay to continuing an exam if someone’s telling you it hurts or to continue an exam if someone’s telling you to stop either verbally or by closing their legs or moving away from you, how we’ve rationalized to such a degree that we should just continue.  

And so that’s sort of the hardest examples to give because consent should be easy, right? Here’s the exam, here are the different parts of the exam, is this something that you’re comfortable doing? If the answer is yes, then we would move forward and then there’s active consent throughout. Like, okay, if I start and anything’s uncomfortable, please let me know so that I can stop or let me know if there’s something I can do differently. So then that active consent during the exam. And really making sure that people understand consent is both yes and no, we don’t just consent so someone says, yes. And in healthcare, that’s the default. It’s like, oh, I’m going to go consent to someone which is essentially making sure that they say yes to something. So really thinking about, okay, actually then you’ve started an exam and someone closes their legs or they start screaming or they start moving away from you. Or they’re telling you, stop, stop, stop, stop.

And then as a provider, you’re saying, oh, I’m almost done. Or I’m saving your life, or this is for you and your baby. And just continuing to force, which is how I would describe it, force healthcare on someone’s body when they’ve told you to stop, I consider that assault within the healthcare setting. And it’s been really hard over the past five years to try and teach people trauma-informed care, and really get down to sort of the basics of consent because many providers will say, well, if it’s a cord prolapse, I have to put my hand in there and my hand has to stay in there. There’s no other option. And so if I give a case and an example to say, okay, you do an exam, someone consented to you continuing to do a cervical exam, you do that cervical exam, you feel an umbilical cord. As you’re doing that, the person gets a contraction and tells you to take your handout. What do you do? And consistently providers say, you keep your hand in and that’s not the right answer, unfortunately.

I mean, I’ll go through a two-hour presentation on consent and trauma, and I’ll give this case example and everyone will say, you keep your hand in. And it’s like, where am I going wrong here? What’s happened. And it’s not like I don’t know how to manage a cord prolapse. I absolutely do. And I understand the risk to the parent and the baby. That being said, you have a second, that cord didn’t just get there. It’s been there for a minute and we can hear the baby’s heartbeat. And there are other things we’re doing too, like flipping them over. And have you ever had someone’s entire hand in your body while you’re turning over from one side to another? Maybe take your hand out for a second. It could be okay. And so again, trying to think about the status quo of, Oh, sure. I hear what you’re saying about consent. No, yeah. That’s a good point. If someone closes their legs, maybe they’ve told me to stop, but then you put it into kind of these exceptionalized circumstances of emergencies and everything goes out the window, but then it’s disrupting the status quo of well, was that an emergency or are we crafted to believe everything’s emergency? And everything has to be handled to that degree.

Rebecca Dekker: And the more we claim things aren’t emergency the more we can take power away from the person’s body and say we know what we’re doing, we’re in charge.

Stephanie Tillman: Exactly. And the less we involve them in the emergency, the more power we have as their provider.  

Rebecca Dekker: Okay. So what are some situations people find themselves in when they need to have a pelvic exam? I think one of the reasons this topic is so hard is like you said, it’s very intimate, but it’s also the cervix facing and dilating is an integral part of the process. And clinicians seem to think that they need to have this kind of continual idea of what’s happening in your cervix. So can you talk about the different scenarios where in the healthcare systems you’ve worked people are told they need an exam.  

Stephanie Tillman: Sure. So if I think about the clinic setting, so not in the hospital, pretty much any exams someone would need in an outpatient setting, not an emergency and also probably not needed. But what I’ll hear people say are needed exams would be for example, a bimanual examination after a pap smear, meaning that we are inserting two fingers into the vagina, pressing upward to help aid the uterus, pressing down on the belly, to palpate the uterus from that direction. There are many providers who still believe we need to do that. And the evidence against that has been debunked for a while. And I know I’m preaching to the choir in terms of evidence related to these things, but it’s very hard to convince people to stop doing bimanual exams. There are still many providers who say that someone needs to have a pelvic exam to receive contraception even if that’s the pill, the patch, the ring, the shot, or the implant, which has nothing to do with the uterus.

So it’s very hard to tell people we don’t need to touch people’s uteruses to be able to do that. Other times that people are told they need an exam would be at the initial OB visit. Many providers believe they need to do pelvimetry or do an exam to palpate how large the uterus is to try and correlate that with gestational age. Pelvimetry is this idea that we’re measuring people’s pelvis to see how likely they may be to successfully have a vaginal birth, pelvimetry is bogus and really not helpful in any kind of indication as to whether or not a birth will occur. But also it’s rare that we base any medical decisions off of a palpated gestational size and uterus. 

Very often we’re doing dating ultrasounds or the testing that we would do, for example, for genetics is so dependent on accurate dating that we don’t go off of if I’m palpating a 10-week uterus or I’m palpating a 12-week uterus. So in the outpatient setting, I really challenge people to think why we’re doing these exams, if it actually is getting any information that’s helpful. And to think about the invasiveness of those exams as an important component of why or why not to do them and people don’t love to talk about those exams being invasive, because they want to normalize it in healthcare. But in actuality, those are very invasive exams.  

Rebecca Dekker: It’s normal for the clinician because they’re doing it day in and day out. But for the person who’s on the table, it’s not normal at all.  

Stephanie Tillman: Absolutely. And I talk about exceptionalized care and that’s something I’ll be focusing on in my Ph.D. too. But there are certain circumstances, particularly in the outpatient setting where clinicians do exceptionalize how we provide care. So meaning we make it extra special or extra different if we know certain things. So for example, if we know that it’s someone’s first exam ever, we’re very different during that exam. If we know someone has had sexual assault, we’re very different during those exams. If we know it’s a queer, trans, or non-binary person, we’re different during those exams. And I wrote in my article, “Consent in Pelvic Care,” and I’ll write about it more that particularly for trans, queer, and non-binary people, very often in those people’s personal lives, they are not engaging in penetrative intercourse to the same rate as their sister hetero counterparts, if at all.  

And so the invasiveness of an exam is really important to consider if you actually have someone in front of you who says, yes, they’re sexually active, but you don’t actually know that that means it doesn’t involve any kind of penetration. So then if we’re doing an exam, really the invasiveness is kind of pushed to that degree in that circumstance. So part of what I want to kind of get to from a scholarly perspective is why are we okay exceptionalizing care for certain circumstances, but we can’t just do that for everyone. Why is it so hard to normalize the exception? 

Rebecca Dekker: So is the principle of trauma-informed care then that you treat everyone as if they’ve experienced a prior trauma? 

Stephanie Tillman: Yes, exactly. 

Rebecca Dekker: Instead of only treating certain people that way.  

Stephanie Tillman: Yes. And right now I’m writing a piece about how much I dislike ACOG’s committee opinion about trauma-informed care, because that’s really where they got it wrong. They are talking about trauma-informed care for known survivors and really trauma-informed care should just be applied across the board. 

Rebecca Dekker: Why is that? 

Stephanie Tillman: Well, because very often people will not come out as a survivor. They may already be nervous or uncomfortable during an exam. And so there’s been research to show that survivors are less likely to tell a provider who’s going to do a pelvic exam because they feel like that provider will treat them differently or they feel like their assault will be the focus of the exam rather than the healthcare itself. But also because trauma is not just about sexual assault, it’s about police violence and brutality. It’s about immigration. It’s about mass incarceration. It’s about racism. It’s about homophobia and transphobia. It’s about misogyny. And really anyone who would be in our care likely has experienced some form of trauma, whether they identify that for themselves or not. 

But the healthcare system and the medical-industrial complex is such an embodiment of every power dynamic in society. Whether that’s white supremacy or paternalism, patriarchy, capitalism, classism, you get into a healthcare system where really all of these default settings are turned up as high as they can go if anyone comes in, who doesn’t identify with this idea of a majority, meaning a cis white man educated coming in for care there’s a very high likelihood that people will be traumatized within healthcare, retraumatized whether from a prior healthcare experience or from a social one, or experience assault within the setting. So trauma-informed care is just supposed to be the standard. It’s not supposed to be exceptionalized.

And so I’m writing a piece essentially saying, “Hey ACOG, I’ve taught trauma-informed care for many years now, here’s everything that you’re getting wrong.” So if I think about, when you need a pelvic exam in the hospital setting, really that comes to labor. And I feel like kind of that’s where you’re getting to also is, okay, if we’re admitting someone, how do we know that they’re in labor before we admit them? And people being told you have to have an exam so that we can know how open is your cervix? How ready is your cervix? What are we going to use to get your labor started?

Rebecca Dekker: It’s presented as a requirement for admission, right? It’s not optional.  

Stephanie Tillman: Correct. And actually that was then written into policy in the UK during COVID that people were required to have an exam before admission, because there was concern about admitting people and then having long labor stays or long inductions with “unfavorable” services, and they didn’t want that during COVID. And I hadn’t actually seen that written as a policy or advertised as a policy so blatantly, usually it’s an assumed conversation. 

Rebecca Dekker: It’s usually not necessarily written down, it’s an unwritten policy. That’s our policy, you must have an exam in order to be admitted.  

Stephanie Tillman: Yeah. Well, and same thing for certain people’s understandings about which medicines or which approaches we use for labor, whether that’s labor support or labor augmentation, or induction, this idea that you have to have an exam to do certain things again, who made that rule? It doesn’t say that on the medicine, it doesn’t say it on the packaging. It doesn’t say it on the labor ball. It doesn’t say it on the labor tub that you have to have an exam before using this. So really trying to kind of push that for people, both for patients and for providers to say, well, do you? Why would we need to do that? And again, thinking about exceptionalized circumstances in the setting of someone’s bag of water being broken, all of a sudden we go into this place of, okay, we shouldn’t do as many exams. And absolutely that’s within this understanding of increased exams increases someone’s risk of an infection moving into their body.

However, really we’re talking about invasiveness and we’re talking about how we’re structuring those conversations for people. If for someone whose bag of water is broken, if they don’t need regular exams, but somehow we’re still able to support or and if there’s a circumstance where we’re “managing” their labor, why all of a sudden don’t we need an exam anymore? So it’s interesting to kind of throw those points back to people who are like, well, she’s due for an exam, it’s been four hours, or they’re due for an exam. It’s every two hours to say, well, where are you coming from with that? Because really that’s not based in anything. That’s based on your need to control what’s happening or your feeling of concern, perhaps for their own understanding of how long labor is taking or what the next steps are. And why wouldn’t you just talk then to the patient about what you’re thinking or where the labor is.  

Rebecca Dekker: So let’s talk about inductions then because it’s my understanding that the Chicago area is really big on 39-week inductions. And they’re applying the results of the ARRIVE trial and the ARRIVE trial did not say everybody should be induced at 39 weeks, but they’re misapplying the results. And basically telling everyone they should be induced at 39 weeks. Most hospitals in the Chicago area are doing that. So with inductions, like you mentioned, there’s usually an exam to determine how ripe the cervix is, whether or not you need cervical ripening. And then there’s a lot of procedures during an induction that require a lot of invasive exams in order to help ripen the cervix because most people at 39 weeks don’t have a ripen cervix. So can you talk about, what is the number of exams that might happen to someone having a 39 week induction in your part of the country? 

Stephanie Tillman: It has been fascinating to be a clinician in Chicago post-ARRIVE trial because it was at Northwestern, the primary researcher was at Northwestern. And I went to the initial presentation with OB colleagues to hear about the results and had already prepared to stand up and be very angry and very vocal. And the head researchers very casually would say, in no way are we saying to induce everyone at 39 weeks, but really that’s the smart thing to do. And so quickly, Chicago.

Rebecca Dekker: Even though that’s not what they posted in the paper publishing the results, but they would tell their colleagues that’s what you should do.

Stephanie Tillman: Well, they would say, this is not explicitly what we’re saying. I think everyone’s going to interpret this how they’d like to, mind you, Northwestern induces people at 39 weeks. I mean, Rebecca, I’m so grateful for everything you put out after the ARRIVE trial, because really I printed out your website and your words right after that happened to be able to walk into meetings and walk into settings to say, here’s everything that’s wrong. And one of my favorite things to point out to people is here’s the research on doulas as an intervention. And actually, doulas being present in the room dramatically decreases need for C-section or long labors, or I’m not going to quote you perfectly in this moment, but I was ready to say doulas improved by this percent. And that’s better than the ARRIVE trial showed and hydrotherapy this percent. And that’s better than the ARRIVE trial. Nobody wants to hear those things because it isn’t focused on medicine and physician power. 

Rebecca Dekker: This is really fascinating to hear that there is a background story because I didn’t really understand why Chicago was so insistent about inducing people at 39 weeks. And I mean, this is such a big problem that some of our EBB instructors in Chicago say that their clients are told, literally told, if we don’t induce you at 39 weeks, your baby will die. They are getting the dead baby card constantly in the Chicago areas. This is really fascinating. So keep going.  

Stephanie Tillman: Yeah. In our hospital setting, I haven’t even seen, for induction sometimes we’ll write EIOL. So elective induction of labor, meaning that the patient has requested it or it’s for a social indication, a family member is only present during this time or whatever. I don’t even see that anymore. It just says 39 weeks IOL. So it’s not like someone is inducing electively at 39 weeks. It’s just 39 weeks IOL. If we can pause for a second, I guess I want to go back and say during that presentation, I didn’t hear him explicitly say, this is really what we want you to do. It’s more like everyone has distilled it down to the point of the basic points of the research are induced at 39 weeks. If you don’t babies will have mec aspiration or they’ll be admitted to the NICU or risk of C-section increases. So people have distilled it down to such a point of, well, of course, 39 weeks, induce. 

Rebecca: And I want to point out that if you look at the actual data from the ARRIVE trial, there was no difference between groups in admission to the NICU or meconium aspiration, and they also found that inducing labor at 39 weeks did not improve the primary outcome of death or serious complications for babies. But I hear about care providers, particularly physicians, misquoting the studies all the time, saying that it improves outcomes for babies, so we need to induce you at 39 weeks.

 Stephanie Tillman: And it’s an unfortunate confluence then of also this social requesting for induction because people’s bodies get so uncomfortable. They can’t work anymore. They don’t have good support at home.

So particularly thinking about Black and Brown communities in Chicago where people are like, actually I work in a social logistical framework that it would be really helpful to me if you could induce me at 39 weeks so that my FMLA can start, because right now they won’t give me FMLA until I go into labor or I’ve had to stop working because I can’t stand for long periods anymore. Can you induce me? Because then I can get back to in six weeks and I’m not losing two to three weeks of work. And so there are these really unfortunate circumstances of people who are under socioeconomic constraints to say, I have good reason for induction, for my livelihood, for my family safety, for us to be able to pay rent, et cetera, that then you end up in this circumstance, particularly as a provider on the South Side or in a free clinic community where people are saying, “How can we work the system in our favor to be able to safely have a baby, but also to kind of work against my body essentially to make this happen.“ 

So then the ARRIVE trial starts and it’s like, oh, okay. Particularly for community hospitals, which Northwestern is not, it’s such a difference to say, okay, so Northwestern came out with this study of here is a lot of complex research around decision-making, around whether or not to induce at 39 weeks for their population at Northwestern who’s largely white, insured and incredibly educated. If those providers are in a room with patients saying, so we recently have this study, I’d like to talk it through with you to see what your conclusions would be about whether or not a 39-week induction makes sense for you. That’s an incredibly different situation than a community hospital where you’re balancing people who are under socioeconomic constraints to try and have their pregnancy be done. And providers saying, “Well, we have this study that says, maybe it’s a good idea anyway,” and then the induction makes sense for everybody. 

So it’s really unfortunate because then it’s not like I take care of people who can easily understand the nuances of research. If I say there is a study that shows perhaps there is a difference in induction at 39 weeks, but also by the way, inductions at 39 weeks can take a very long time. There are a lot of procedures and exams, which I know was your original question. It’s a higher likelihood of more pain, which I feel like we don’t talk about very much, an induction against someone’s body causes more pain than someone’s natural contractions would. So I let people know there’s potential for more pain because Pitocin gives you different contractions than you would be feeling. So then your need for perhaps management of the stronger pain could be different. So then you get to a point where you need an epidural or you need to be supported in different ways.  

And then it’s like, okay, you’ve hit day three of an induction, which in the ARRIVE trial they supposedly control it to such a degree of how much time they give people. That’s not a freaking realistic induction. There aren’t physicians, in particular, sitting around being fine with three-day inductions and fine with minimal exam. That’s not reality. So then you hit day three of an induction and a hospital that I worked at, it was a very common phrase to say, you only let the sun set twice on an induction. 

So when you get to day three and it’s like, okay, we’re at day three. Where are we at? And then it’s a C-section. It’s incredibly uncommon to go past three days. But if you have somebody whose cervix is closed thick high, and you’re starting an induction, especially for a primip or someone pregnant for the first time you’re doomed. So this idea that, oh, it’s going to decrease C-section rates. I mean, that’s the most ridiculous gas-lit rewording of research that I’ve ever heard. Let us control your labor dear first-time pregnant person at 39 weeks when your body is not anywhere near ready and we will do everything we can to prevent a C-section, it’s a wild gas-lit rewriting of physiology.  

Rebecca Dekker: Well, we know that circumstances in randomized controlled trials can be quite different than the real world where in the randomized controlled trial, they’re very motivated to avoid cesareans and the real world when they’re implementing this study, it might not turn out that way. But to going back to my original point, there’s a lot of exams during an induction, a lot of procedures that involve the pelvis.  

Stephanie Tillman: Yeah. So let’s say someone’s cervix is very closed or unripe or unfavorable. So many words we may use, there will be an initial exam to decide exactly how favorable their cervix is. Then there may be the offer of a medicine, every four hours to help with their cervix. That means every four hours, your cervix will be checked to see if it’s progressing and if a different kind of medicine is necessary or to continue with that same one, or there would be a balloon or a different kind of medicine, that’s every 12 hours. So then if you think about using either the balloon or Dinoprostone every 12 hours that perhaps already puts you at 24 hours on day one, if you need a balloon or Dinoprostone twice, so then you’re already in to day two of your induction. 

Very often people will integrate breaking the bag of water into an induction method. So at a certain point, if your cervix is open enough, baby’s kind of low enough, breaking the bag of water is one of those next steps to helping labor progress. And the physiology of the bag of water is out the window because it’s just a checklist box of something to do. And then babies don’t always love all these medicines and approaches that we do. So you’re on monitors the whole time. If your baby becomes stressed or doesn’t like any of the methods, those monitors will be hyper-focused on those. If we feel we’re not getting enough reading from those monitors, then monitors are often placed inside of the uterus to be able to listen to the baby or to be able to measure the contractions better. It’s a lot, it’s not physiological.

Rebecca Dekker: So there’s a lot of opportunities or reasons for exams during inductions. Then also what about right before pushing is that a scenario where people are told they have to have an exam before they can start pushing the baby out?

Stephanie Tillman: I’ve been doing midwifery for so long, I kind of forget that that’s the case, but if someone has an epidural and they aren’t quite sure if their spontaneous urge to push is what they feel that it is then yes, very often we will do an exam like, okay, you’re nine centimeters, or you have an anterior lip here is kind of the next step. Either we wait another hour or some people will reduce an anterior lip, or if the person’s a multip and it’s very stretchy nine centimeters. If you feel like pushing, you can push, let’s see if your cervix moves out of the way. I have seen a lot of my resident and physician colleagues be very adamant about exams before pushing, but also during pushing.

So someone will be pushing and the provider will put their hand in to feel around the baby’s head or to push down on the perineum and people don’t always consider those exams, but very often that’s our whole hand inside of someone’s body going inward as someone’s pushing outward, which has never made sense to me. So that’s not necessarily based on induction, that’s just based on how people are during a second stage or pushing.

Rebecca Dekker: Yeah. So in other words, there’s 100 different reasons why somebody might have a pelvic exam or cervical exam during labor. Do you feel like most clinicians are equipped to provide trauma-informed exams in those situations?  

Stephanie Tillman: I think every provider has the potential to be trauma-informed in those circumstances. I think that medical teaching and concern about emergencies or medical ego, override all of that. And so that’s the biggest trick is telling people in an emergency, how can you be trauma-informed or it is very common for someone to scream or push you away during an exam, how are you handling that when that happens? Because that’s someone telling you that they have rescinded consent and even framing it in that way is shocking to providers like, oh, well, some of this is going to hurt. And of course that hurt because there was a lot going on and they didn’t have an epidural. And it’s very hard for people to realize, and that’s sort of where I tread very carefully and teaching providers, because then it’s me essentially telling them you’ve assaulted someone or you traumatized someone and that is not normal. That’s not that shouldn’t be normal for us as providers. It’s definitely not normal for the person we took care of. 

So let’s now make a space for the fact that, you’re recognizing you assaulted somebody. And I think that moment really does a lot for providers to understand that, because then it’s like, okay, if they can realize that, if they have the capacity to understand the degree to which their “care” was actually assault in that setting, then there’s an incredible opportunity to turn it around because no healthcare provider wants to assault someone unless in the case of Larry Nassar and a number of people who have done awful, awful things, supposedly in the name of healthcare, but healthcare providers who are trying to provide good care or even in the circumstance where they’re like, we’re trying to save a parent or a baby. Sure, fine. But you can’t assault someone while you’re doing it. So how do we reframe that? 

And so I think people do have the capacity, but it really takes driving home some points of we are now at the point, where do no harm has no meaning anymore because we’re assaulting people. And so it does take that revision and sort of a calm approach of all of us have probably caused trauma to people, some more than others. How do we all do better? And I think that’s, for myself as a sexual assault survivor, who’s now a provider in circumstances where I’m watching someone inflict trauma against someone’s body. For me, I’ve had to sort of create my own emotional boundaries around witnessing that and then around teaching people that, but then also selectively letting people know, I need you to know if this was you taking care of me, this is how I would be telling you what happened. And not everyone even knows that that’s the framing they can use. Not everyone understands assault can happen anywhere, including in healthcare. And so it does take just some of that reteaching.  

Rebecca Dekker: You mentioned that the nurses learned from you in how to interrupt these kinds of exams when the patient or client is basically saying no and the providers not stopping. For anybody who’s listening, who’s a nurse or doula partner, what wording do you recommend using when you’re witnessing this?  

Stephanie Tillman: That’s a great question. So typically if I’m watching another provider do an exam, and during that exam, I either witness or hear someone say, stop or physically start moving away or close their legs or start shaking, or one of the most common things that happens, particularly for people with known trauma, PTSD is they’ll dissociate. So if someone’s actively talking with you, is actively engaged in an exam, they will mentally leave their body. And they’re no longer talking with you and no longer engaging. So dissociation and someone tapping out is also, they are no longer able to consent once they’ve dissociated. What I will do is say, Hey, let’s take a pause or it seems like we need to take a minute here or let’s take a break. So I think sort of the, we have a second approach is a good one, because then it just resets the conversation because providers are likely in a momentum of oh, this person’s uncomfortable. I should hurry up and finish rather than let me actually stop and find a different way to do this. 

So I think it sometimes is important to point out that someone’s in pain because not every provider sees it like, “Oh, I’m seeing her grimace I think we should stop or let’s check in on pain. How are you doing? Do we need to do this exam differently?” So I think lots of different questions, I’ve been meaning to put together a scripting for that, for people to interject. But generally, let’s take a second is sort of the right way to approach.

Rebecca Dekker: So just asking for a pause is perceived both as non-threatening, but it also interrupts what’s going on. And then what do you see if they refuse to stop or what do you recommend saying if somebody is refusing to stop?

Stephanie Tillman: Stop. And I think that’s the hardest thing, the patient has the least power of anybody in the room. The next least power is the student. The next least power is the nurse. And so I think, well, and I would put doula just above patient, just under student in the settings I’ve worked at.

Rebecca Dekker: What about partner?

Stephanie Tillman: I think partner and patient are kind of parallel. The one caveat to that is if it’s a cis male partner, it changes the dynamics.

Rebecca Dekker: A cis white male partner.

Stephanie Tillman: Exactly. But I think, whenever I hear doulas or whenever I hear nurses say, I’m not sure I have power in the room. If I say something, I’m not sure I have power. I point out that in healthcare, anyone has more power than the patient. So if the patient is they’re saying, “Stop, that hurts. I don’t want you touching me,” whatever, and no one’s hearing them. And the exam is continuing or moving their body is continuing, you’re the next person to have power. And perhaps someone else will hear you. And if you say, “Hey, we need to take a second.” or “Let’s take a pause. Something’s not right.” If the provider continues, then there’s already been a slight interruption in the momentum. Very likely then the student will say, now we’ve heard twice that someone should stop and no one’s stopping, or the nurse will hear that. Or ideally everyone’s hearing it. Ideally we’re all sharing power on the same place hearing each other, but that’s not the reality. So this powerless that I’ve given, that’s not how I view things, but that’s how I’ve witnessed sort of the listing of power go. 

And so I think if someone’s saying stop, no one hears the patient. If we say, let’s take a pause in this gentle, non-aggressive way, which is a feminist I really struggle with, but it’s also people want to stay safe in their care. And I think the worry is you push too much and then your providers will become aggressive towards you, which is also a huge problem and speaks to how important trauma-informed care is. But if then you’ve said, let’s take a pause and nobody hears anyone with power in the room needs to say stop, and you need to say it loud and you need to say it hard and things need to stop.  

Rebecca Dekker: Okay. Yeah. It seems so simple, but often people find themselves not knowing what to say, but that seems really helpful to just know the word stop is what you need to say. Do you have any other tips we’ve talked about from kind of the perspective of other people in the room? What about for any clinicians who might be listening such as, I don’t know, a lot of nurses do a lot of pelvic exams during labor and we have a lot of nurses and midwifery listeners, midwives. Do you have any advice for them or where can they go to learn more perhaps about giving trauma-informed exams?  

Stephanie Tillman: I have learned so much about trauma-informed care from a white supremacy lens, for example, by following midwives and doulas of color. And so I inundate my own feeds with my colleague experts of color to really understand as much as I think I know as a queer person, as a sexual assault survivor, as a midwife, as someone who has studied and taught these things for a long time, following doulas and midwives of color has really taught me so much. And I’m so grateful for all of the content that they put out. So I would say if your feed is not dominated by birth workers of color, you’re really missing out on so much information, particularly if you’re a white person, even if you are actively engaged in your own anti-racism personally or professionally, we really need to be looking. We should have been looking all along, but there’s no question now we need to be looking toward birth workers of color.

Secondly, there is a chapter in Gynecologic Health Care on history and physical examination that myself and Frances Likis wrote that talks about how to do an intake questionnaire and how to do an exam from a trauma-informed care standpoint. I wrote similarly for an article in the journal of midwifery and women’s health about consent in pelvic care and includes a bunch of different scripting that people can practice. Because the suggestions that I make for scripting may not work for everyone. We all need to find the language that’s going to make sense and feel true to us. So those options are there for you to practice and edit and play around with. I write a newsletter once a week that includes a new script every week for both. And I write always from a place of patients and providers. So telling patients what language they could use to interrupt scenarios or what questions they can be asking or how to be thinking differently about is this a safe provider or not.

And if you ask for something and a provider scoffs, or kind of brushes it off or tells you, no, probably you shouldn’t do any kind of exam with that provider, but also really thinks through, for anyone who is providing care, touching people’s bodies, asking questions, catching babies, any of those things, there’s so much that we could be doing differently. And I am humbled before this work that I’ve been doing now for almost 10 years, both writing and practicing as a midwife, because there’s so much that I’m still drafting. And when I put ideas out there, really I’m like, what do you guys think? What’s everybody else saying? What language are you using? And I feel really grateful that both online on social media, but also through the newsletter, people are really engaged to say, here’s the language I use here are the thoughts that I’ve had. And it’s been such a lovely community through feminist midway for people to be really actively having those conversations with each other. So we’d love to have folks joining us.  

Rebecca Dekker: Yeah. And I have to say I’ve been a subscriber to the newsletter for, I think a year now you’ve been doing it for about a year, correct?

Stephanie Tillman: Mm-hmm (affirmative)-.

Rebecca Dekker: And I’ve really enjoyed getting the emails every Sunday night. I read them on Monday mornings and I learn a lot from you, Stephanie. So I appreciate your work. And where can people go to become a subscriber to your newsletter?  

Stephanie Tillman: So either through my website, feministmidwife.com, the newsletter link is there. That’s also where people can book me if you want me to present for your group on trauma-informed pelvic care. I do private trainings for people on that too. But then on Instagram, I have a link in my profile on Instagram for people to sign up or to reach out. And I’m a one-person show. If you reach out, I’m the only person who’s going to respond. So feel free. If you email me, I’m the person you’ll hear back from. I love to be connected with people. Feel free to reach out.  

Rebecca Dekker: Thank you so much, Stephanie, is there anything else you want to share before you go?

Stephanie Tillman: Rebecca, I have to say I have loved watching Evidence Based Birth® grow to be the powerhouse that it is. It’s so lovely to see everything that you’ve done. I reference your work all the time. The ARRIVE trial is my best example. I mean, I came with pages to hand out to colleagues from what you had written on Facebook after the ARRIVE trial to say, this is what Rebecca Dekker’s saying, we need to be saying this. And particularly over the past year in the movement for Black lives, knowing that you’re a fellow sort of white leader on platform to see all of the anti-racism work that you’re doing is really inspiring. And I’m so grateful to you to be doing that.  

Rebecca Dekker: Thank you so much. There’s definitely always a need for more people to do the work. So we’re in this together. 

Stephanie Tillman: Yeah.

Rebecca Dekker: All right, everybody. Thank you so much for joining in and listening to our interview with Stephanie Tillman, all about trauma-informed care. And please, please follow Stephanie on Instagram or Facebook @feministmidwife. Thanks everyone. 

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 navigating the 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. We are now offering the Evidence Based Birth® childbirth class totally online. In your class you will work with an 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 an interactive online child birth class, you and your partner will love. Visit evidencebasedbirth.com/childbirthclass to find your class now.