My midwife failed me: How homebirth transfer affects mothers

Homebirths account for just a small percentage of all births in the US: 0.59% of births happen at home. Interestingly, this number increased by 5% between 1990 and 2005, which we could call a surge in homebirths [1]!

Besides homebirths being more satisfying for women [7], one of the main reasons some women choose a planned homebirth over a hospital-based delivery is because both mothers and babies have better outcomes. The cesarean section rate in homebirths is around 4%, compared to over 30% nationwide [4]. Mothers have fewer interventions, including episiotomy (a surgical cut to open the vagina), and babies die less often [2].

There is no way to sugar-coat that. Babies born at home die less often -- because of the lack of unnecessary interventions. One meta-analysis found that the neonatal mortality rate tripled in planned homebirths versus hospital births, and attributed the better outcomes for babies to the decrease in interventions [2].

Not all mothers that plan to deliver at home end up doing so. For a variety of reasons, a transfer to a hospital may be necessary or preferable during or after childbirth. Sometimes the reason for transfer is maternal exhaustion -- labor takes a very long time and the mother is too tired to go on. Sometimes there are negative health signs with the baby -- heart rate decelerations, or meconium in the amniotic fluid. Rarely, the transfer is caused by something more grave. Usually, the decision to transfer from the home to the hospital rests on the midwife. In the US, the transfer rate is around 12.1% [4].

But how does a woman, who planned to deliver at home, who spent months preparing for her natural birth within the safety and comfort of her home, who anticipated an intimate experience, feel about a transfer to a hospital? Anecdotal evidence hints that something is missing from the birth experience. Does the mother blame herself for failing to deliver a baby at home? Does the blame later shift to her midwife, for letting her down? Is she grateful for being able to spend even part of her labor at home [6]?

We turn to science for an answer.

Is homebirth transfer traumatic?

Let's take a look at the Netherlands, where the homebirth rate is much higher than the US: In one study, over 38% of first-time moms and 67% of repeat mothers delivered at home (recall that the US average has risen to under 1%) [3]. For the first-time moms, 40% of the planned homebirths ended up transferring to the hospital at some point during birth or shortly thereafter; and 11% of repeat moms transferred to the hospital (compared to 12.1% of home-birthing mothers in the US, both first-time and otherwise). The Netherlands data is summarized in the table below.

	First-time mother	Repeat mother
Planned homebirth	38%	67%
Transfer to hospital	40%	11%

The women in this study rated their birth experience, their midwife, and their immediate postpartum days by marking agreement with specific adjectives on a five-point scale (where 1 is strongly agree and 5 is strongly disagree). The conclusion from this study?

Our research showed, contrary to expectations, that an unplanned transfer from a planned home birth to hospital has little influence on the experience of childbirth [3].

Let's look at Sweden.

In Sweden, homebirths are rare -- as rare as in the US -- that is, less than 0.1%.  In Lindgren, et al.'s study [5], the homebirth transfer rate was 25% for first-time mothers -- that is, one in four women that plan a homebirth end up in the hospital (much better than the 40% rate in the Netherlands). The most common reasons women transfer to the hospital are "lack of progress" and (this was surprising to me) the midwife being unavailable for the mother during labor.

The exciting conclusion in Sweden:

Being transferred during a planned home birth negatively affects the birth experience [5].

Looking elsewhere, we find agreement:

Women who are referred to the hospital while planning for a home birth are less satisfied than women who planned to give birth in hospital and did. A referral has a greater negative impact on satisfaction for Dutch women [than for Belgian women] [7].

In fact, the Swedish study found that women really hated and resented their homebirth transfer experiences, as visualized (by me, from Lindgren's data) by the graphs shown below in Figure 1 and Figure 2.  In these graphs, the blue line indicates a "very satisfied" response and the red line is anything less than "very satisfied." The thing to take away from these graphs is the area inside the red line. A large red area is bad. In the homebirth without transfer case, you can see that women were more likely to be "very satisfied" with all aspects of their birth (except for being in control -- but can you really control birth?).  In the homebirth transfer case, women were more likely to be less than satisfied with everything except partner support and the midwife making the partner involved.

Figure 1. Satisfaction among Swedish women regarding their homebirth experience [5].

Figure 2. Satisfaction among Swedish women that planned a homebirth but transferred to the hospital during or as a consequence of childbirth [5].

Homebirth: Forbidden fruit


Could it be, then, that in places where homebirth is rare, women place undue emphasis on the location of birth? Could it be that birthing at home becomes kind of a holy grail that women strive for?  It is so rare in the US and Sweden that it is like a forbidden fruit. We hear and read so much about its beauty that we -- that is, those women that yearn for homebirth -- strive for it and are crushed when we do not get it.

Consider another birth outcome some women consider traumatic: the cesarean section. One thing that childbirth educators did to make the prevalence of the c-section more palatable and less scary is to demystify it. In childbirth education classes, c-section is presented as a possible birth outcome -- a real possibility. In a good prenatal education class, analgesia, surgical procedures, and postpartum recovery will be discussed in detail. When you think about it, this is a really good idea, because one in three people in the classroom will have this surgery, whether or not they planned for it.

It may be that one of the things that makes homebirth transfer an emotionally crushing outcome is that it is still an unknown evil. So why not demystify the homebirth transfer? Describe it in detail for women and their birth partners to take in: causes, procedures, outcomes. The Wiegers study made this interesting note:

It seems more important ... to reduce the fear of unplanned [homebirth to hospital] transfer, especially among nulliparas, than to advise women to choose a hospital birth in order to avoid such transfer [3].

Interesting because this is the only study that I found that did not result in negative emotions in the mothers resulting from homebirth transfer. Maybe in the Netherlands they drill the transfer as much as we (ought to) drill the c-section?

Lindgren had a different conclusion:

Treatments as well as organizational factors are considered to be obstacles for a positive birth experience when transfer is needed. Established links between the home birth setting and the hospital might enhance the opportunity for a positive birth experience irrespective of where the birth is completed [5].

In fact, in the Sweden study, one of the main reasons women were unhappy with the hospital setting was because everyone was so dang mean to them -- possibly for choosing a homebirth to begin with. They found that doctors -- obstetricians, general practice physicians -- simply do not understand what a midwife does in the home and why she should continue to be useful even after a transfer. Maybe the homebirth transfer education should start with the hospital.

Did my midwife fail me?

I do not know. But I do know that everywhere around the world where homebirth is rare, homebirth transfer to a hospital carries with it a negative weight. In the Sweden study, half of the women that underwent homebirth transfer were less than satisfied with their midwife's support, compared to over three-fourths (76%) of those that stayed home. Not surprising when you consider that the #2 reason for transfer is because the midwife simply could not come to the birth [5].

Conclusion

There are three ways to fix the problem of the negative affect of homebirth transfer.

1. Teach hospital staff about homebirth transfers. Drill it, demystify it. Emphasize that a transfer is not the mother's fault; it is not the midwife's fault. These things just happen.
2. Teach mothers that plan for homebirth about homebirth transfer. I mean, really drill it.  It is a real possibility and a mother should know the routine. Drill it, demystify it. Encourage that a transfer is not her fault.
3. Encourage homebirths. There is reason to believe that, when the overall percentage of women that plan for a homebirth is large, a transfer to the hospital is no big deal -- possibly because the hospital staff know what to expect from a woman and her support team, and how to best help.

Given our surge in national homebirth rates (still under 1%, but we do our best), you would think we would be quick to implement these items.


References


[1] United Press International (2010). US Homebirths Few, But on the Rise.  Retrieved 4/24/11.
[2] Wax JR, Lucas FL, Lamont M, et al. (2010) Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.e1-8.

[3] T. A. Wiegers, J. van der Zee, and M. J. N. C. Keirse (2001). Transfer from Home to Hospital: What Is Its Effect on the Experience of Childbirth? Birth, 25 (1).
[4] A. Haas (2008), Homebirth After Cesarean. Midwifery Today.

[5] H.E. Lindgren, I.J. Rådestad, and I. M. Hildingsson (2011). Transfer in planned home births in Sweden – effects on the experience of birth: A nationwide population-based study. Elsevier 2011.
[6] J. Davies, E. Hey, W. Reid, G. Young (1996).  Prospective regional study of planned home births. BMJ 1996.
[7] W. Christiaens, A. Gouwy and P. Bracke (2007). Does a referral from home to hospital affect satisfaction with childbirth? A cross-national comparison. BMC Health Services Research 2007.

Surprise birth during a doula interview!

Hey! I thought when I received the friend request on Facebook. I haven't heard from Mia in years! I wonder what she's up to.

I scrolled over to her photos and found she was very, very pregnant.  How lovely! I posted on her wall. Almost immediately she replied: Did I read that you are a birth doula?

We chatted over Skype a few days later.  "Do you really want me at your birth?" I asked.  She grinned into the webcam and gave the double thumbs up.  We decided we would have our first prenatal visit on that Saturday, just five days later, when she would be at 38 1/2 weeks pregnant with her baby girl.  We would discuss her preferences for the birth, I would meet her partner, Henry, and the three of us would read over my contract.

Saturday rolled around and I hopped on a train in the morning to go into the city to their central apartment, leaving my son in the care of my mother and my husband.  I brought nothing with me but my positive attitude and a can of iced coffee.  I looked out the window and thought about how exciting it was to be reconnecting with an old friend, and going to a doula interview.

My phone buzzed with a text message from Mia: "These contractions are different," she wrote -- not like the Braxton-Hicks contractions she had been feeling for the last several days.  Different how? I texted back.  She described them as achy, spreading from her belly into her back and hips.  "Like menstrual cramps," she wrote.

Huh, I thought, How curious.  I considered how she messaged me two nights ago saying she was filling her freezer with food, and later that she spent all morning cleaning and rearranging her apartment.

I arrived at the train station, where Mia was waiting beside her dusty, grey car, wearing a stretchy dress.  She was just as I last saw her: very tall and very skinny, with curly dark hair and cute, small glasses, but with a basketball tucked in her sweater.  I ran up and hugged her, scolding jovially: "Are you in labor?"

"Maybe!" she exclaimed.

This could last all night

We hopped in the car and tried to catch up while I drove.  She rattled off directions.  It was hard for both of us to conceal our excitement.  Then she hesitated.

"Ah, a contraction," she said.  "I'm going to try to talk through it, just to show that I can." And she continued her story about how she and Henry went to the movies the night before.

No problem, I thought.  Early labor.  This could last all night.  

"So did you know?" I asked. "That you'd go into labor today?"

"Oh yeah," she said, "I knew. Henry didn't, but I knew."

In Henry's one-bedroom apartment that they shared, we got ready to go to breakfast.  During contractions Mia would roll her eyes, take a long breath, and pace the living room.  I texted my family: Mia in early labor. Maybe tonight, maybe tomorrow night. Staying here.

The three of us took a slow stroll to a nearby restaurant, on top of a beautiful, tall building with flowers and trees growing on the roof.  Eastern drum-beats played over the speakers and I thought of belly-dancers with bells around their ankles.  We were seated in low armchairs surrounded with pillows in front of a copper table.  Mia, sitting on a towel just in case, ordered a hearty breakfast.  By this time, during contractions, she would stop what she was doing and concentrate inwardly, breathing deeply with eyes shut loosely.

The waiter approached us with our food and looked concerned.  After a contraction, he smiled and said, with a light Persian accent, "You aren't going to have the baby right here, are you?"

"No, no," Mia replied, smiling. "It will be a while."

With this public acknowledgement, suddenly, I became energized.  Everything was tingly, exciting, colorful, happy.  We were going to have a baby!  Other patrons of the restaurant turned to us and smiled encouragingly; I beamed back.  Henry beamed, touching Mia tenderly on the knee.  We were supposed to discuss business, but it never happened: we were too excited that this was all happening!

We ate our breakfasts gaily.  Every few minutes Mia would put her plate down, lean back in her low chair, and exhale.  After the contraction, she would bring her plate back up to her belly and use it as a shelf.

On our walk back to the apartment, Mia sat during contractions on the benches we passed, but noted that walking felt better.  However, as we approached home, she mentioned she would rather not be around other people.  Aha! A clue about our labor progress: in active labor, women prefer to be in a safe place with fewer distractions and no strangers.  There is a hormone released that can actually slow down or stop labor when women feel threatened.  It is part of the fight-or-flight response.

Meanwhile, my husband was coming up by train to drop off my doula bag with some overnight necessities.  With Mia and Henry's blessing, I parted ways for about 15 minutes as I ran to meet my husband half-way between the apartment and the train station.  

When I returned, red suitcase in hand, to the apartment, Mia was on the phone, calling friends are relatives and checking in with her doctor, to let the hospital know we would be coming within the day.  "Henry and I are in labor," she would say.  Then: "I need to call you back." She would hang up the phone, breathe through a contraction, and call again. "It is hard to talk through those," she explained to the person on the other end.

I thought it would be a good time to talk about drugs in labor, because we never did that.

"Do you want to pick a safe-word?" I suggested.  A safe-word is a secret word that we choose in advance that means I really want medical pain relief.  "Sometimes, women may say they want drugs, but what they mean is that they want more support," I said.  "Sometimes women want more support when they're scared, and they ask for drugs."

"No safe-word," Mia said.  "I'm not scared.  I just don't want to be in pain."

"There is a line between pain and suffering.  Pain is expected, and it is good.  But we don't want you to suffer."

Mia took a long shower.  Then, Mia said she was tired.  Still thinking there was plenty of time and that this was fairly early in the labor, I suggested she take a nap and mentioned -- you know, by the way -- that intercourse was likely to speed things along.  Henry looked at me like I was crazy.  Mia disappeared with Henry into the bedroom and I waited in the living room, listening for sounds of difficult labor and hearing none.

Undressed

About an hour later, Mia re-emerged, naked.  I thought: The apartment is very hot. That is why she is naked.  One midwife once said that you can tell how far along in labor a mother is by where the sheets are.  If the sheets are pulled up to her chin, she is in early labor. If the sheets are at her waist, she is in active labor.  If the sheets are missing, she is in the second (pushing) stage.  We were certainly nowhere near the pushing stage, but the lack of clothing was a sure sign.

From here on, Mia's bowels moved every half hour and contractions were about five minutes apart, but some lasted only 30 seconds and some were longer.  Playing it down, I said, "Your uterus is finding a nice pattern, and you are likely entering active labor."  Turning to Henry, after a particularly long contraction (about a minute and a quarter) that required a lot more concentration, I added: "That is what active labor contractions look like. We want them to look like that."  Mia leaned forward over the bathroom sink and danced slowly from foot to foot while I counted in rhythm with her dance.

Mia came out of the bathroom saying,  "I am certainly in an altered state now."  An altered perception of time is common in active labor.

I grinned, proud of our accomplishment. "Do you know what time it is?"

Mia thought.  "Maybe five?"

Henry looked at his phone.  "Six," he said.

In our postpartum meeting, Mia pointed out that it was not just an altered perception of time, but an altered state of consciousness that she felt at this point.  "In one of our classes," she said, "we were told about early labor task. We were told about a woman (an author, I think) who monitored her state of consciousness for change between early and active labor by baking cakes. Making a cake requires one to read a recipe and measure amounts carefully. In active labor, it is not possible to do anything accurately. The will and perhaps even the ability to focus on a multi-step task just goes away."

What about massage, stroking, and other physical comfort measures in labor?  Twice, Henry tried to stroke her on the shoulder, or would touch her curly hair in a loving gesture.  Mia's response was unilateral: "No touching."

Smiling, I turned to concerned Henry and said, when Mia was out of earshot: "Totally normal."

A few hours passed in this way: We counted through contractions: ten counts up, nine counts down.  Mia changed positions from the toilet to slow-dancing with Henry to leaning over a chair to leaning back on the coffee table from an ottoman.  She looked so beautiful -- her round belly illuminated by the sunlight filtering through the closed shades, as she rocked back and forth or danced from foot to foot. Her head rolled on loose shoulders.  She visualized waves breaking over her body.

With each contraction, Mia announced: "Start!"  Henry dutifully pressed the start button on his contraction logger app on his mobile phone.  Then, she would breathe and roll her eyes and dance, exhaling the contraction.  "Stop," she would announce.  Henry would mark the end of the contraction. In my opinion, the contraction app was a blessing: it kept Henry busy and made him feel like he was performing an important role in labor.  During contractions, his focus was on Mia, but between, he could mentally calculate averages and cross-reference them with his knowledge of labor.

On the toilet, mucus and water came out.  "I think this is my mucus plug?" Mia said, examining the toilet paper.  "Sure," I nodded.  But we were far past the mucus plug, even though when I checked Henry's meticulous log, I saw that contractions were 4 minutes apart but rarely over a minute long.  In fact, most were between 40 and 60 seconds long.  When we talked about this discrepancy postpartum, Mia explained: she did not announce the beginning of the contraction, but when the real discomfort began; similarly, she announced when the discomfort stopped, not when the tightness eased.  Henry and I should have mentally added 10 to 20 seconds to each measurement! 

Surprise at the hospital

Henry called the hospital.  During the phone call, I took the phone from Henry during a contraction and talked to the nurse.

"First contraction happened at eleven this morning," I said.

"Has she been keeping hydrated? Is she resting?" the nurse asked.

"Yes," I replied, "a sip of water after every contraction. She had a good breakfast and a nap in early labor.  We've been in active labor for, hmm, maybe an hour?"  Even as those words escaped my lips I knew it had been longer than an hour.  But I did not offer a correction.

There was a pause. Then: "OK, you'd better come in."

"We may be a while," I said as I looked at Mia, totally naked, draped over Henry.

"That's OK," the nurse replied.  "We will have a room for you."

And so we started getting things together.  The car was already packed; we just needed last-minute things: camera, charger, phone, charger, Mia's earrings that she removed earlier -- oh, and clothes for Mia.  Because she was still naked.

"I'll wear my grey stretchy dress," she said.  "It is really stretchy."

She waited patiently in the bathroom while Henry rifled through her drawers, bringing grey things that weren't dresses or dresses that weren't grey, until finally, he found the right dress.  Mia started pulling it on.  I tried to smooth a wrinkle.  "No touching!"

She put on panties with a maxi-pad, green slippers, and waddled to the door.  We went downstairs to the parking garage and waited by the car for a contraction to pass.

"Henry, sit behind me; Mia in the front; I drive," I said.  "Go! Go! Go!"

Mia spoke directions in the same voice as this morning, but a little more distant.  Outside, the sun was setting over the city in a beautiful red, pink, and purple sunset.  A contraction started.

"It's OK to pull over," Mia said.  "Just double park."  I did that and counted.  Up to ten, down to one.  We continued, pulling over twice more.

Mia said: "I will want an epidural when we get there.  I have been enduring this long enough."

"Let's see where we're at in the labor," I suggested.  "After they check you, we'll see. OK?"

Arriving, I helped Mia out of the car, and let Henry take her inside while I parked in the garage.  We had considered parking all together and walking in ("the walk would be good for you," I said) but it did not seem possible anymore.  How far along were we?  I had no idea.  I gathered our things (three bags) and ran to the main hospital entrance where I dropped off Henry and Mia.  To my chagrin, it was closed -- that entrance closes at 8 o'clock, and it was exactly that.  A pizza guy was standing outside the main entrance as well, looking confused.  I greeted him, turned, and ran up the hill to the emergency entrance.  Her last contraction, Mia puffed at the peak and then mentioned some pressure.  Pressure means pushing.  Could we really be that far along?  I imagined her and Henry walking toward the entrance, stopping for a contraction, and the baby suddenly being born, right there on the sidewalk.

I signed in to the visitor log, with the pizza guy right behind me.  The emergency waiting room perked up with the smell.  I ran down the hall, waited hours for the elevator, and finally arrived at Labor and Delivery, where I had to sign in again.  I saw that Mia and Henry signed in just five minutes before me -- good sign, it means the baby was not born on the sidewalk or in the corridor as I feared.

Mia was in the tiny triage room with Henry and a nurse, on the bed, still pregnant, with the fetal monitor strapped to her belly as the nurse tried to find the heart beat.  For a while, there was nothing.  I held my breath.  Where was the baby?  Was she OK?  Then, she found her: low.  She breathed through another contraction as I counted.  At each contraction, the nurse paused what she was doing and waited.  How nice, I thought. A nurse that knows how to let a woman labor.

"Have your waters broken?" asked the nurse between contractions.

"I think so," said Mia.  "There was a trickle."

The nurse explained that there does not have to be a gush: sometimes when the waters break on top, there can be a trickle as they leak around the amniotic sac and out the cervix.  When they break on the bottom, you get a gush; then, the baby's head presses against the cervix and stops the flow.

The nurse said, "I'll let the doctor check you once we get you a room, since your waters may have broken.  I don't want to increase the chance of infection."

After the next contraction (she puffed at the peak again, quick in-out-in-out breaths), she turned to me and Henry and said, "Pressure again."

I looked at the nurse, who did not seem to hear.  "Mia says there was some pressure," I said, emphasizing the word.  "Pressure."

"Perhaps I had better check you now," she said.  All eyes turned to her as her hand disappeared between Mia's legs and the blanket.  Her eyes widened.

Grinning, she said: "You're not going to believe this.  Guess!  Guess how far you are!"

Mentally, I guessed as from under the sheets escaped the smell of transition.  It is a peculiar, memorable smell.

Getting no reply, the nurse continued: "You're a nine.  Nine and a half!  There's just a little lip.  Zero station, meaning the baby's head is right up against your public bone."  Holy crap!  Henry's eyes widened.  I had no idea.  Mia's contractions were short, she had never vocalized, and she looked so natural and calm!

"Can I have an epidural now?" Mia asked, not amused.

"Honey, there's no need," said the nurse.  "Look at you! You are doing so well! By the time we get the doctor in here, and the epidural to take full effect," she gestured a circle with her arm, "the baby will be born!"

I suggested, "The contractions aren't going to get any worse."

The nurse continued: "That's right, and it will feel so good to push against all that pressure."

One more contraction.  Breathing, puffing, as the nurse struggled to find an empty room for us.  We were not even in the computer.  Nurses started coming in and out, introducing themselves to Mia in loud, even voices.  One nurse started a hep-lock (IV with nothing going into it).  One checked again: Mia was complete.

But the orders were to puff, not push.

Eventually, we were all transported into the operating room because, unbelievably, that was the only room available where we could deliver a baby.  Henry and I dressed in white paper jump-suits and white fluffy shower-caps and shoe-covers, and Mia was instructed to hop (hop?!) from the triage room bed to the operating room birthing bed.  A tall order for a lady pushing out a baby, but she did it with grace.

Birth

As soon as we arrived in the operating room -- large, round lights overhead and little carts of equipment everywhere -- I asked: "Can we push now?"  The nurses beamed and nodded.  "You sure can!" I turned to Mia.

Without instruction, without anyone yelling at her to push, without anyone coaching her to make a C with her spine and pull her knees to her chest and hold her breath and count to ten and wait for a contraction, Mia pushed in a raised position on the hospital bed, hands on her thighs.  And those were some mighty pushes.

Her water finally broke in earnest, spraying eight feet down the bed and narrowly missing the nurse.  We laughed; a lock of the baby's hair was seen.

To Henry, I said: "Want to see?"  He shook his head, but after a little more coaxing, he glanced, white knuckles hanging on with all their might to the side of the hospital bed.  He looked pale, and stroked the pillow above Mia's head with his thumb, looking gently at her forehead.

"She has curly black hair, just like you," I said to Mia.  "And it's long.  Reach down and touch her." With long, slender fingers, Mia stroked the top of her baby's head gently, until another contraction came.  The head was at the perineum.

"You have to get past this," I said as Mia squirmed her hips side to side.  "You have to go through it."  I hope I sounded brave.  I really wanted to sound brave.  It is hard to tell a woman to do something clearly painful, something contrary to what the body says: to push into the pain and the burning on the perineum.  Henry clung to the bed; a nurse poured mineral oil on the baby's head to lubricate the exit.

In two more contractions, just an hour and a half after our arrival at the hospital, baby Cathy was born in the operating room, in what was one of two natural births in the hospital that day (usually they have one every other day or so).  Cathy cried on Mia's chest as nurses rubbed her pink body; pale, Henry cut the cord, signifying the entrance into the world of his baby girl.  Against Mia's skin, baby Cathy was visibly calmer, though still bewildered.  Mia shielded Cathy's eyes from the harsh operating room lights and cooed: "I know, baby, I know -- it's so bright in here."

Postpartum

In the recovery room (which was actually a labor room -- all of the recovery rooms were still busy for the next hour or so), Mia breastfed her newborn for an uninterrupted two hours.  The nurses waited until Cathy was full to do the usual weights and measurements.

While breastfeeding, Mia turned to Henry and me with glistening, happy, tired eyes and said, with her mouth watering: "Oh, man -- we should order a pizza. A deep dish pizza. Doesn't that sound so good?"

Conclusion

That was the best doula interview I had ever had.