May 26, 2015
Q&A with Suyai Steinhauer
IMUK member Suyai Steinhauer is currently caring for the Amish community in the USA, from where she took some rare time out to speak to us about her work and (with permission) her experiences caring for women there.
Thanks for your time Suyai, you must be busy. Firstly, where are you exactly and who do you care for?
It’s an absolute pleasure. I am in the United States, working as a midwife in a small practice, which mainly serves the Amish community. We do have some English clients – anyone not Amish is English, so the Amish always smile when I tell them that I am “real English”.
What attracted you to this position?
I really struggled philosophically with much of my training in the NHS. I found the practice/theory-gap really hard. I am very passionate about midwifery and birth and learning about being evidence-based and writing essays about being woman-centred and then seeing the complete opposite in practice was a real challenge. I knew from the beginning that I wanted to be an independent midwife, but I also felt that I needed more homebirth experience – I had only been at three during my training, including a fourth one with independent midwives. I felt like I wanted and needed to consolidate before going out on my own. I am fortunate in that I have American citizenship, so the US was an option for me in terms of preceptorship. The summer break before qualifying I came to the US looking for the right place to work and gain the experience I felt I was lacking. I visited a few different midwives across three different states, and the place I chose felt like a good fit.
“the more babies you have, the more of a history you build. Because the midwives here are used to working with women who have had many babies, they are more used to this idea of women having their own unique normality.”
Why are independent / external midwives sought by the Amish community?
Obviously the USA has a very different system to us in the UK. In the USA the mainstream medical system is still debating whether homebirth is even safe (!) so you can’t have a homebirth through the hospital system. The Amish prefer to have their babies at home as this fits more with their culture, it is obviously much more affordable (no NHS here, and they don’t have health insurance), and if you’re going to be having 8-12 children, avoiding a CS is especially important. Also the Amish tend to avoid mainstream medical care – they are more likely to see a naturopath or a chiropractor than an allopathic doctor. They all use herbs and supplements and rarely take medication, so it makes sense that they would seek care for pregnancy and birth outside of the medical model. I think it is also more comfortable for the community to work with midwives who are used to their community – trust has been built up, and we are careful to be sensitive in terms of dress (we all wear skirts) and language. For example, you would never use the word ‘sex’, but would ask about ‘coming together’ – that wouldn’t necessarily be the case within a hospital system or setting.
How long have you been there now and what is a typical day (if there is one) like for you?
I have been here three months now. The only thing set in stone is that we have our clinic days on Tuesday and Wednesday. Other than that, nothing is typical; births are happening all the time, so it’s just a question of being on call and being ready at all times for that call and attending births. Then there are the postnatal visits that come after the births.
We also sterilise all our instruments, which is my job now, and the general upkeep of the clinic and ensuring we have enough supplies – we sell herbs and supplements too, so there are always orders that need to be made, and boxes to unpack etc. In between I try to keep as rested as possible, as you never know when you might be at two or three births in a row.
In your Facebook diary ‘The Oxytocin Diaries’ you state that when it comes to pregnancy and birth, Amish women are “really listened to”, what does that mean?
Partly it’s got to do with parity – the more babies you have, the more of a history you build. Because the midwives here are used to working with women who have had many babies, they are more used to this idea of women having their own unique normality, and working with each individual to figure that out, rather than trying to fit women into statistical bell curves of what is supposed to be normal.
“The other factor here is continuity of care and the fact that this continuity is now extending to the next generation – that is pretty powerful.”
The other big difference is that the women here aren’t generally getting scans, whereas in the medical model and mainstream midwifery we rely a lot on scans – dating scans for due dates, anomaly scans for abnormalities and various other possible scans if women move out of ‘normal’ parameters. While scans can be helpful as part of the picture, in the medical model, once we have one, we tend to go on that information and completely disregard what women are feeling or telling us. Here we might suggest a scan if there is bleeding in late pregnancy (where is that placenta?), or if growth patterns indicate that there might be twins on board. Not having dating scans means we really have to listen to what women tell us about their last menstrual period (this can be tricky with women who may not have had a period between the last baby and getting pregnant again), the length of their cycle and when they usually ovulate or when they think they conceived. If measurements start to not correspond with dates, we will dialogue again about dates, review nutrition and look back at her previous charts if she has them. It is a real conversation that occurs, instead of automatically going to technology and relying on that. It feels like this is empowering for both the woman and the midwife. Obviously if there are concerns we recommend a scan, but not nearly as much as I was used to during my training. The other factor here is continuity of care and the fact that this continuity is now extending to the next generation – that is pretty powerful.
Why does ‘really listening’ to women happen less in mainstream culture? Is it the medicalization of birth or perhaps fewer pregnancies to inform caregivers?
I think both of these are partly the answer to that, and it is also an attitude and the culture. The midwives here are used to listening and working with women, so even a woman having her first baby is really listened to, since the definitions of normal are much more fluid and flexible here and based on this idea of each woman having her own normal. Also as I said earlier, not having/depending on scans for answers. This means that we are really talking with women for the answers to questions, rather than relying on technology, that often gives us the wrong answers anyway. This approach certainly makes the whole question of due-dates much more relaxed. This has really made me think and reflect a great deal on our use and even dependence on scans. I have always felt that we over-use scans, and that this over-use can undermine women’s inner knowing… instead of supporting/encouraging women to tune in to their bodies and their babies, we are relying on technology to tell us and them that everything is ok. I think that dating scans are an over-use, as there is no medical indication for this scan, other than being pregnant, and pregnancy is not a medical event.
Are procedures / protocols different in any other major way?
It’s hard to compare, we are not talking apples to apples here because there is no NHS, there is not really any standardised care – even between hospitals things are done very differently. Also, there is no Nursing and Midwifery Council. Each state has very different laws and in some states midwives can legally work without a license. This means that as a midwifery practice, they are able to work within their own framework; no protocols, guidelines or policies.
In your experience, what is the Amish attitude towards pregnancy and childbirth and do you think the (presumable) lack of media stereotypes and depictions of birth is central to this?
Strangely I hadn’t actually thought about that but yes I think you’re right; the Amish women have no exposure to media or the internet at all so they have no media depictions of birth. And no, I have not come across or heard of any tokophobia here.
“We had a first time mum who had a five hour active pushing second stage, and never once did she say she couldn’t do it; this woman had never once doubted her body’s ability to birth her baby – I don’t think it is even a consideration.”
There is definitely a lack of fear around birth within this community, and they seem to take pregnancy and birth very much within their stride as a normal life event. I think this is partly to do with their faith in God – having faith and trusting in a power bigger yourself takes a lot of stress out of daily life and then there is the expectation that they will have a big family. The women grow up in large families, knowing and expecting to have their own large families one day and that only happens by giving birth every couple of years, so it is all much more matter of fact, and everyone is doing the same. This also extends to how childbirth is approached – I have never once heard an Amish woman say, “I can’t do this” during labour, even during a really hard labour. We had a first time mum who had a five hour active pushing second stage, and never once did she say she couldn’t do it; this was incredible to me, and it only dawned on me after the birth that this woman had never once doubted her body’s ability to birth her baby – I don’t think it is even a consideration. Probably growing up on farms around animals that give birth helps too. It is all just matter of fact and there is no expectation either way – positive or negative about the birth experience – it is just something that happens, something that you do.
At home, women are well served by a variety of antenatal and birth preparation class options. Is there any culture of that in your community?
We offer free antenatal classes for our clients, and most first time couples do come. Otherwise there are not any other classes on offer for the Amish population and I’m not sure they would go to them anyway – partly because of the money and certainly because of time. The Amish work very hard, and prefer not to take time out, and we often have to persuade our couples to come to these classes. The classes have been condensed to include all material in either two evening sessions or a 6-hour Saturday session, because if the classes run over more sessions they are reluctant to come. The last Saturday class we had, several of the couples were disappointed that the weather was so good and they had missed a day’s work on their farms – rain would have justified them missing half a day of work!
“We have a lending library of books, and can’t have any with nudity – even anatomical pictures. Books that have a naked woman on the front, even just a pregnant belly have to have clothes drawn on top!”
Given that they have no access to the internet or mainstream information, often the only information they get is what we give them. They are actually woefully unprepared for their sexual lives as married women and childbirth… you would think that with all the women having babies, the young women would be prepared, but they are very sheltered. In the Amish culture, childbirth is actually very hidden, and especially from children. Birth happens secretly and quietly, and the older children will not be introduced to their latest sibling till the baby is dressed, everything is clean and in order and we have left. At times we have had to sneak in or out of the house so the children don’t get suspicious.
“Supporting an Amish woman through labour and birth in her home and feeling deeply connected, despite our very obvious lifestyle and life experience differences reminds me of the universality of the birth experience and human connection.”
Even pregnancy is hidden and not spoken about, and it is very taboo to mention due dates. If a curious child asks too many questions, they are told not to question, and they behave. Amish children are very obedient, I think this secrecy is to do with innocence – if you start talking about pregnancy and birth, you will end up talking about how babies are made, and this is a very private/repressed culture in that respect. We have a lending library of books, and can’t have any with nudity – even anatomical pictures. Books that have a naked woman on the front, even just a pregnant belly have to have clothes drawn on top! I think some of our English (non-Amish) first time couples sometimes get other childbirth classes in addition to what we offer. I love the mix of the Amish and English couples at our classes but we have to be very conservative and sensitive about what material we use – no videos or films, no nude pictures, or body parts.
Most Amish groups forgo using power from the national grid. Has this meant any modifications or innovations to your practice or care at all?
Not as much as one would think other than ensuring you have a good torch with you. This is vital for entering the house, which is dark, except for the room where the woman is labouring, and also for going to the toilet while you are there. Also when the room is cold, the propane gaslight can really heat up a room, so we sometimes have to move the big propane light to the bedroom so that it can be warmed up, if she has been labouring in another room (I have never seen an Amish woman birth in a room other than the bedroom unless she has her baby in the bath).
“The Amish have some pretty powerful torches that use reusable batteries… hmmm… I’m not sure how they recharge them come to think of it!”
I’m not sure how this is going to work in the summer when it is hot and we have a propane light throwing out tons of heat, I guess we will rely on flashlights instead. The Amish have some pretty powerful torches that use reusable batteries… hmmm… I’m not sure how they recharge them come to think of it! The other interesting thing is that because they don’t have mobiles or even landlines, the husbands walk out to the nearest phone shanty, so you are never talking to a labouring woman about her experience and what is going on with her body when the birth call comes in, this makes for some quite interesting lost in translation moments, as not all husbands are great at communicating what is going on for their wives – especially first time dads.
Though generally, when the call comes form a dad who has several children already, you know that it’s for real and you had better get a move on!
Home or hospital, birthplace is a hot topic in the UK. Where does birth take place in the community you serve?
Our births happen at home, the women who come to us would not do so if they wanted a hospital birth. Homebirth very much fits in with Amish culture, and given the high rates of caesarean section in the States, is a good idea, since these women go on to have a lot of babies, and with that kind of childbearing career it is better to avoid abdominal surgery where possible.
What is the most rewarding aspect of your role with the Amish community?
At the end of the day being a midwife is incredibly rewarding… especially if you are working within a continuity of care model, and have the time and space (= freedom) to build relationships with your clients. I do get an extra kick out of really connecting with women from such a different culture. Supporting an Amish woman through labour and birth in her home and feeling deeply connected, despite our very obvious lifestyle and life experience differences reminds me of the universality of the birth experience and human connection and makes me feel connected to the ancient art and tradition of midwifery and being with-woman.
What are you going to remember about this experience, what really stands out?
Hard to answer this question at this stage, as I am really just at the beginning of the journey here, and there are still so many experiences to come. So much stands out; arriving at houses in the dark…attending births with the glow of a gaslight… the very particular smell of the barnyard… the way the women carefully undo the strings of their bonnets under their chins, but leave them pinned at the top when they lie down for an abdominal palpation in clinic…the way that many of them say “baby dear” to their babies when they’re born. I write a weekly blog on facebook that captures what has stood out for me that week, so that is a good place to go to and see what experiences I am having. You can check it out here.
Fascinating stuff, thank you Suyai! P
Please keep in touch and ‘like’ the IMUK Facebook page here.
IMUK member Suyai Steinhauer is currently caring for the Amish community in the USA, from where she took some rare time out to speak to us about her work and (with permission) her experiences caring for women there. Thanks for your time Suyai, you must be busy. Firstly, where are you exactly and who do […]