Preserving Normalcy: An Interview with Dr. Bootstaylor
By Cindy Morrow
#seebaby #DrBootstaylor #BringBirthBackI remember the first time I saw a midwife walk into a non-emergent transfer where she had a working relationship with the physician. She walked in, head held high. She was greeted by staff who reflected the professionalism with which they had observed their boss treat midwives.
As we waited alone in the room while the mom had what turned out to be a needed surgical birth, I said, “Wow, you were treated almost like a peer.”
“I know,” she said as she raised one eyebrow ironically. “It feels good.”
Every Midwife I know is grateful for access to skilled OBs, peri- and neonatologists and emergency services when there is the need. I have yet to hear of a midwife who prefers working in the shadows during a transfer and posing as the woman’s doula or photographer.
I asked Amy Romano, acclaimed researcher and co-author with Henci Goer of Optimal Care in Childbirth, to comment on the importance of a seamless, respectful transfer when needed:
Critics of homebirth point to the possibility of bad outcomes when there is a complication that requires timely intervention. It’s true, of course: any delay in the face of urgent complications can harm women and babies. This is the biggest patient safety problem in hospitals, too, which is why there is a massive enterprise of hospital safety programs that emphasize teamwork, communication and patient-centered care.
The logical response for planned homebirths requiring transport should be no different: The midwife and the woman herself should be seen as core members of the team and value for the critical information and perspective they bring. Instead, homebirth transports still frequently involve lack of respect for the midwives’ role in providing continuity and disregard for the woman’s needs for respectful care. These attitudes are a direct threat to the safety of the woman and her baby.
Not only does a respectful, professional transfer feel good to the midwife, but it is good for motherbaby. In my area, metro Atlanta, Georgia, homebirth midwives are quietly ecstatic with a fairly recent development — they all have access to not just medical back up in an emergency, but back up prenatally. They have access to backup that doesn’t just tolerate homebirth midwives, but actually loves them! And it is all because of an evidence-based trained, evidence-based, evidence-practicing, former Special Forces, Green Beret and perinatologist. Meet Atlanta’s Dr. Brad Bootstaylor.
Dr. Bootstaylor is board-certified in obstetrics and gynecology and maternal-fetal medicine by the American Board of Obstetrics and Gynecology. A practicing perinatologist since 1994, Dr. Bootstaylor worked on referrals from OBs in maternal-fetal medicine for over 15 years and has had his own practice since 2010.
Dr. Bootstaylor doesn’t necessarily advocate for one particular kind of birth over another. Quite the opposite; he has built his practice on a basis of helping mothers become informed and empowered about their pregnancy and birthing options. He has even referred patients to homebirth midwives and works cooperatively with midwives and other care providers to give women and babies the most well-developed, comprehensive team to help support them to a healthy, safe, positive birth.
One of the colleagues he works closely with is Anjli Aurora Hinman, CNM, at Intown Midwifery, in Atlanta. She commented with great enthusiasm on working with Dr. Bootstaylor:
Countless times I think to myself how grateful I am to work with an individual with Dr. Bootstaylor’s expertise, skill, temperament and unwavering dedication to the greater good of humankind. Families, midwives, students and birth professionals know him in our community as a warrior in bringing birth back to women. He faces many challenges in birth culture, clinical cases and peer dynamics with impressive reason, action and heart. Birth is changing for the better in Atlanta because of this man@ We are in awe of what he gives up in order to provide his service to women, midwives and our birth community.
Dr. Bootstaylor was kind enough to submit to an interview. The highlights are below.
#seebaby #DrBootstaylor #BringBirthBackCM: How do you see your practice differing from standard OB practice in the US?
BT: Well first off, I am a perinatologist in addition to being an OB. As for the OB part, I work with midwives and I support the homebirth community.
Please describe your family-friendly cesarean — it is very similar to the one described by the Jentle Childbirth Foundation?
It is very similar with the exception that I don’t require a planned cesarean. If a mom is laboring and baby is not coming down or for whatever reason we end up with a cesarean, we have the lights low, the midwife is at the head of the table, baby goes right to the chest skin-to-skin with mom, baby nurses right away. There is no separation.
Have you always done evidence-based practice or was there a light-bulb moment why diverged from the mainstream US medical model practice?
Well, I started as a perinatologist — and that is just how we are trained — practice was based on evidence. If an OB sent a woman to me, I made a recommendation. I am used to giving evidence-based recommendations, that’s just what I do. But the OB could follow my recommendation or not — it was their call. The epiphany was when I realized the OBs weren’t practicing evidence-based care. I wasn’t dot the obstetrics at first, but the consulting. So when I incorporated the OB practice, I was unscathed. I’m doing what I was trained to do in the 1980s. We were trained to do evidence-based care.
You are a perinatologist. Your norm is high-risk or potential high-risk. How did you get to see physiological birth as safe and normal when you see so many high-risk pregnancies?
There is no such thing as high risk! What I do is put risk into context. For example, I got a call from a mom who was pushing and the baby was having decels. I walk in, Mom has on an oxygen mask — she looks like a patient. I go over and take off the mask. The OB and the nurses said, “Wow. You took the O2 off.”
Now, when I took the board exams — as did this OB, too — we had learned it does not increase the O2 to the baby to have a mask on mom. But now that you are a practicing doctor, you don’t adhere to the facts. Why is that? Is it because you feel you need to do something? Anything? Is it a case of “if you a hammer, everything is a nail?”
What bothers me is it seems there are two generations. There’s my era — I am 55 and my training was in the 1980s — we were trained to sit on our hands a lot. We did vaginal breech, we did vaginal twins and we did VBAC. The there is this new crop of OBs and they’ve never seen normal. Most have never seen a normal, unmessed-wth birth. They don’t know what it looks like; they have no reference point.
It reminds me of when friends share that they are struggling in their marriage. Nine times out of ten when I ask if they’ve ever seen a healthy, happy marriage — the answer is, “No.” It’s difficult to catch a vision for something you’ve never seen.
Yes, great analogy — and that worries me. That’s why I say my greatest hope for normal birth is homebirth midwives!
Who was most influential in your training?
Amos Grunenbaum. He is a perinatologist originally from Germany. As an Ob/Gyn resident, I knew if I didn’t do a VBAC, I had to defend a cesarean. Amos ran a midwife-based practice and presumably supported homebirth. When you have that kind of a mentor, you just always ask, “What would Amos do?”
Every midwife I know is grateful for access to skilled OBs, peri- and neonatologists when there is a need. It seems the medical model, not only in the US but worldwide, is threatened by the midwifery model of care. What would you say to your fellow doctors as they are faced with the increased demand for midwifery care?
They need to listen to the patients! Don’t try to challenge the trend, but be more open to dialogue. What I tell my colleagues is, “Ask yourself why is that trend there. Why would a mother want to have a homebirth? What is it about a hospital birth that would make her want to spend her own money and take what 99% of her peers see as a risk and have a homebirth? Something must be going on, guys! Ask those questions — and ask them without being cynical or disparaging or condescending.”
What has been your biggest challenge professionally?
Dealing with being an outcast among colleagues. I consulted for OBs for 15 years; I went to their kids’ graduations. I gave their kids summer jobs in the office licking stamps. To be ostracized because I’m supporting midwives, and especially homebirth…[For some reason, this answer moved me. I had expected his answer to be something like, “The crazy schedule” or “Being on call 24/7” or “Balancing family and work.” I felt profoundly sad for him. It sounded very lonely. ]
Can I ask what being ostracized looks like?
I’ll tell you what it looks like — what it looks like is not having a vacation for three years, and having to go to Portland, Oregon — Portland! — to find a backup doctor so I could go on vacation.
Who has been your biggest support?
The midwives! And the patients! I still do what I do — OBs still send referrals to me as a perinatologist — but the piece that keeps me going is the patients who come to me for a second opinion, who were told their only options was a section, and I say, “No, no, no. You can have a normal, vaginal birth.” They are so grateful, so thankful. And the midwives…[He trails off. This surprises and warms me.]
Let me give an example: Just last week a mom planning a homebirth started throwing up. She went to the ER, very sick. They diagnosed her with HELLP syndrome and told her she needed a cesarean. This mom had her midwife call me and we talked. I then talked to the OB. We both know HELLP syndrome is a clotting disorder and cesarean poses a great risk. I tell the OB that the best course for these patients is to induce and let her labor down and have the baby. She couldn’t do it! She couldn’t get out of her cesarean mentality. So mom left the hospital, came to me for a consult. We induced and had a lovely, vaginal birth. They were so grateful. Those kinds of patients — and midwives — keep me going![Dr. Bootstaylor relayed another time, a few months prior to this interview, when he stood firm for normal birth for a mama-baby against a room full of opposition, and prevailed.]
That took incredible courage. Where did you get the confidence to stand up to so many of your colleagues?
It really helped being Special Forces. You are trained and put in situation where you have to stand firm in the face of tremendous opposition — when others do not understand or agree with what you are doing. I guess the training paid off in many ways.
You have affectionately been referred to as a midwife in doctor’s clothing. How do you see the midwifery model of care now in the US? What is your version for it to become?
I’d love to see more homebirth support, but I don’t see that happening. Birth centers and the cost differentials make sense, not to mention the humanity. So, I hope to see more birth centers.[He sounds like someone dreaming.]
Yeah, but I’d love to see more support of homebirth.
Here’s where my hope and inspiration lie: the homebirth midwives. Forget the OBs. I know there are little pockets across the country, a few here and there, who are trying to maintain normalcy. But there is a steep rise in first-time moms choosing homebirth. That gives me hope. But my real hope is in the homebirth midwives. Hope for normalcy to be preserved.