When
Pregnancy
Goes SOUTH:
Keeping Birth Gentle
by: Robin Lim
M
others, father, grandparents,
midwives, nurses, doulas, doc-
tors and concerned citizens are
calling out for human rights in childbirth.
Yet, this worldwide push is relatively small
when we consider how many women, new-
born babies and families are affected by
human rights infractions in childbirth. The
bullying of mothers and their families, just
when they should be enjoying the miracle
of birth, is all too often, all over this world,
accepted as the norm, as though wom-
en should suffer in childbirth. I cannot
imagine that our divine Creator meant for
women to suffer. There is, in my experience
of birthing five times and receiving thou-
sands of babies into the world, a big differ-
ence between the challenging strength of
childbirth contractions/waves/rushes and
suffering. Suffering happens when mothers
are not supported, not well nourished, not
respected and not loved within the con-
text of pregnancy, birth and postpartum.
Please remember: Love is the nutrient that
14 Midwifery Today | midwiferytoday.com | Spring 2015
causes our cells to obtain the nutrition we
need when we eat, drink and live.
In 2012 I spoke at the Women Deliver
Conference in Kuala Lumpur, Malaysia.
I was saddened as I listened and came to
know that in a gathering of some 5000
birthkeepers, most were Ob/Gyns, few
were midwives and even fewer were doulas.
What I found there was that the reproduc-
tive health agenda being promoted world-
wide, as it relates to birth, is a global push
of childbirth into bigger, high-tech hos-
pitals and away from personal culturally
appropriate childbirth options, such as
homebirth and midwife-to-mother care. It
seems nearly no one in obstetrics is learn-
ing from the problems the United States is
having, as it becomes the country ranked
60 in maternal mortality, though it spends
more money on childbirth technology than
any other country in the world (Kassabaum
et al. 2013). Likewise for infants, birth in
the US is not always a safe journey. Babies
born in the US die at a rate of 24,000 per
Photograph | Randy Verlie—mozzaphotography.com
year, even though they are born in a coun-
try where there are more neonatal inten-
sive care units than the 25 countries that
have lower infant mortality rates (Haelle
2014; CDC 2014).
Suffering in childbirth need not be
the norm, for without drugs and without
medical interventions imposing iatrogenic
risks, healthy, well-supported women, car-
rying healthy babies, may make the pas-
sage of childbirth with dignity, surrounded
by people of their choice, with joy, grace
and even pleasure. The gentle birth move-
ment advocates for the basic human right
of women to labor and deliver their own
babies with respect from their health care
providers, with support for their choices
and privacy. Furthermore, families and
wise health care providers are advocating
for the rights of babies to be handled in a
way that does not impair their future health,
well-being, intelligence and longevity, i.e.,
delayed umbilical cord severance and skin-
to-skin uninterrupted contact with mother
following birth. Clearly, much of the trau-
ma experienced by mothers in childbirth
and babies at birth is preventable.
As a midwife, I find myself walking
the delicate line between completely advo-
cating and supporting every mother’s hu-
man right of choice in planning her baby’s
birth and needing to sometimes become
the “bad gal” when risks determine that a
particular motherbaby must be referred for
obstetrical care.
As a midwife, I do not often refer moth-
ers to obstetrical care, unless it really is
important to do so. Bumi Sehat Bali* has
about a 2% rate of referral for cesarean
among mothers who begin labor with us.
Sometimes transport is really needed; other
times it is caused because of the national
protocols we must adhere to in order to keep
our licenses. Other times, transport hap-
pens because of pressure from the extended
family, especially when labor is long. This
is cultural and cannot be avoided. We try
to support families to make wise decisions
by keeping them informed of the mother
and baby’s health status throughout labor.
Last night, our team of Bumi Sehat
midwives supported four birthing moth-
erbabies. One was a VBAC, who was told
by doctors on two islands not to attempt
a natural birth. Our back-up Ob/Gyn ad-
vised her to try a natural birth at Bumi
Sehat. Her birth was lovely, and her baby
girl was a good size—3.8 kg (about 8.4 lb).
Next we helped a first-time mother with
no apparent risk factors; she also did very
well and birthed her baby boy in a side-
lying position. Another was a first-time
mother, who was told she must have an
elective cesarean birth because her eyesight
is -7 (which is not really that bad, by the
way) and a natural spontaneous vaginal
childbirth would pose a risk of retinal de-
tachment. Fortunately, this young mother
did her research and found no reason for
her to elect cesarean to preserve her eyes**.
This young mother’s birth was glorious as
she squatted in the water tub, singing. The
next mother to birth was a second-time
mom, who was quite malnourished, but
showed good lab results. She did have a
mild shoulder dystocia, which was resolved
by the Gaskin (hands-and-knees) maneu-
ver. She lost 450 cc of blood, which is not
unusual given the normal Indonesian diet
of white rice and GMO soy tempeh.
One would think that all mothers are
willing to give up their plans for child-
birth without interventions should medical
procedures become necessary for the baby
and/or mother’s safety and well-being. This
does not mean the birth cannot be gentle
and respectful. I have witnessed many nec-
essary, gentle, miraculous cesarean births.
I wish for all cesarean mothers to know
that birth is a miracle no matter how it
happens. Cesarean mothers have faced
the furthest reaches of modern science to
bring their baby Earth-side. Sometimes
a cesarean birth is not necessary, but is
imposed upon the mother. How can we
dare to judge unless we were there and
know all the facts? We cannot know for
sure from afar whether the cesarean birth
was necessary or not. Clearly, too many
are done. But darn it—we need to support
our cesarean moms so they do not feel like
failures. I have sung Gayatri Mantra and
Amazing Grace with the surgeon, anes-
thesiologist, nurses and the mother during
cesarean births. I have assisted many times
as a doula at cesarean lotus births. There is
normally no reason to immediately clamp
and cut the baby’s umbilical cord, even if
the birth is by cesarean. Sadly, the hands
of many caring, well-informed doctors
are tied to archaic or non-evidence-based
protocols by the hospitals they work in.
A Pregnancy That Went South
Three years ago, a tragedy unfolded that I
will never forget. A pregnant tourist came
to Bumi Sehat to say, “My baby is not mov-
ing.” We midwives were able to comfort her
by giving her the joy of hearing the baby’s
normal heartbeat. The amniotic fluid was
low and this mother’s blood pressure was
140/90, which she said was normal for her.
As we had never seen her before this visit
at 30 weeks’ gestation, we could not know
what normal was for this mother. My heart
felt heavy and I sat with this second-time
mother and her mom. They had come on
a mother-daughter vacation to get to know
one another, as they had been separated for
most of their lives. I became very alarmed
when this raven-haired beauty shared with
me that her first baby was born by emergen-
cy cesarean three years earlier due to fetal
distress—a situation similar to what she was
feeling now with less and less frequent baby
movements! She had been diagnosed with
Spring 2015 | midwiferytoday.com | Midwifery Today
Antiphospholipid syndrome (APS, also
known as sticky blood syndrome). Her first
child, a daughter, had survived prematurity,
spending six days in neonatal intensive care
and several weeks in a hospital nursery. This
mother had also suffered three miscarriag-
es. It was shocking to me that this mother
would still choose to travel in a developing
country when pregnant and in a high-risk
situation. She was not on anti-coagulant
medication and her Ob/Gyn in Australia
had strongly recommended she not travel.
I gently but firmly advised this mother
to go home to Australia immediately, where
she had access to excellent free First World
care—a luxury most Indonesian families
do not have. She had noticed reduced baby
movements. Her blood pressure was quite
high, and she did not glow as pregnant
women usually do. Her mother said they
were leaving in five days’ time, and the flight
home to her part of Australia was only 3.5
hours. I advised them to leave that very day
and go directly to the hospital from the
airport. The mother’s mother proclaimed
they could not afford to change their tick-
ets. To facilitate the return of this mother
to her homeland, where very good medi-
cal care is available on the National Health
System, I had a travel agent friend change
their departure, so they could fly out that
evening without charge, on medical advice.
Four days later, this mother arrived at
dawn at my home in tears. “My baby did
not move all night,” she sobbed. I bit my lip
so I would not shout, “What are you still
doing here in Bali?!” Instead I hugged her.
The baby was indeed dead—the mother’s
blood pressure was now 189/120! I went
with her to the hospital in our ambulance.
I stayed for hours while they stabilized her
BP. I helped her use my phone to call her
husband in Australia. I stayed and held
her through the cesarean birth/death. Our
Bumi Sehat team arranged the cremation
and made the proper traditional Balinese
offerings for baby James. Because they did
not have enough money, I paid their hos-
pital bill and funeral expenses—a consid-
erable amount—which they promised to
pay back, and never did.
The bereaved father yelled at me over
the phone saying I should have forced his
wife to go home earlier so they could be
together through this ordeal. I was kind;
I was firm. My advice was not received
15
 or followed. This family actually believes
that I failed them. Three years later, I ad-
mit, I am still doing the mental/emotional
postmortem.
We hear stories in social media about
mothers being forced to have a cesarean
birth. We shudder to imagine how hard
this must be for any mother and her fam-
ily. We are beginning to understand the
unseen risks of cesarean. Films like Micro-
Birth are helping disperse this information.
However, I know I will make no friends by
asking this question: “What if the mother’s
choices really do endanger herself and/or
her baby? What happens in the context of
human rights in childbirth then?” When
a mother brags to me that she is 17 weeks
pregnant and has just completed her sec-
ond ten-day water fast! How should I re-
act? Who speaks for the baby? Do I, as a
midwife, have any right to protest? How
do I handle the fact that this mother has
every intention of delivering her baby at
our free-standing birth center? And how
do I sleep at night when accused of being
a “bully” because she will not adhere to a
reasonable diet in pregnancy, and as her
health and the baby’s health deteriorate,
I want to risk her out? The nine Balinese
midwives who work with me worry that
if something goes wrong, we will all lose
our ijin praktek (license to practice).
My question as a birthkeeper is: “How
do I balance prenatal care with prenatal
scare, when pregnancy goes south and be-
comes high risk?”
A Pregnancy Well Saved
Tomorrow at dawn I will be arriving at the
hospital to support a gentle, necessary ce-
sarean birth. The mother planned well her
home delivery. However, at 37 weeks ges-
tation, she lost her amniotic fluid; in fact,
there were zero pockets of fluid to cushion
the footling breech baby with a double, tight
nuchal cord. This motherbaby’s amniotic
fluid had not released; it had just disap-
peared. When this mother came to me for
an external version, I put my hands on her
belly and shuddered. The baby seemed to
shout: “Be careful!” As much as I don’t like
the misuse and overuse of ultrasound, in this
case I wisely applied science to give us clear
guidance. In this case, it was the midwife
calling the Ob/Gyn to say, “We have some
risks here; we need to pay special attention
to this motherbaby.” Our first attempt to
solve the zero amniotic fluid issue was to
encourage hydration via drinking plus acu-
puncture, herbs, homeopathy and improved
nutrition. We began immediately with the
help of the expert practitioners of holistic
medicine that share our work at Bumi Se-
hat. Everything helped for a day, but the
next day the baby was again without fluid.
We closely monitored and found the baby’s
movements were deteriorating and the heart
rate was slowing. The next intervention was
hospitalization and IV fluids. Things began
to look brighter when fluid pockets were ac-
tually found in the womb with baby. How-
ever, the next day there was less fluid, and
the following day nearly no fluid was found.
Given the stress the mother was under, it
was not a surprise that the mother’s blood
pressure was climbing. Her platelets were
climbing high above normal. Hospital food
in Indonesia is far from healthy, but her hus-
band and friends were bringing her healthy
food, so diet alone could not explain why
+2 protein was found in her urine with high
levels of leukocytes.
Imagine how shattered this mother was
as her dream of a completely gentle, hands-
off homebirth slid away. As a birthkeeper,
midwife and doula, I was frustrated for
this mom who had done everything “right.”
Having a breech baby was not the reason
that she ended up in the hospital facing a
cesarean birth. Heaven knows that the di-
sasters I attend as a midwife have me han-
dling breech birth a lot, because when the
world goes topsy-turvy, so do the babies. I
don’t love breech birth, but I do it as long as
I feel I am not endangering the baby. Some-
times I do it because the mother arrives at
our disaster relief camp in the Philippines
with a foot protruding from her vagina, and
I have no choice but to be calm and gentle
and employ the skills I have learned about
receiving the breech.
Wayanik’s situation, as described above,
became a beautiful dance of risk reduction
made possible because the mother listened
to my advice and followed it. It was also
possible due to my trusting and respectful
relationship with Dr. Hariyasa and other
Ob/Gyns in Bali. These quality professional
and egalitarian relationships between mid-
wives, the guardians of normal birth, and
Ob/Gyns, the angels of intervention, can

In His Hands
be lifesaving. I encourage all birthkeepers
to work in harmony together.
Wayanik’s baby boy was born by neces-
sary cesarean. Dr. Hariyasa did not clamp
or cut the umbilical cord. The reluctant but
openhearted pediatrician allowed me to
keep the cord intact for 20 minutes follow-
We provide birth supplies to Midwives, Birth Centers, Doulas ing the cesarean. A nurse tried to scrape the
abundant vernix off of the slightly prema-
& Expectant Parents across the United States. We strive to
ture baby’s skin while the pediatrician was
have the lowest prices and a high level of customer service. worrying about hypothermia. I stopped the
Please visit our website to shop our wide array of nurse from scraping baby Putu and he was
midwifery supplies or contact us to set up your own put skin-to-skin with his mother in recov-
ery. I used a sterile gauze pad to swab the
custom birth kit. We look forward to serving you! mother’s vagina and placed that in baby’s
mouth to insure that even though he was
Follow us! cesarean born, he would have all the mi-
crobes if his mother’s vagina.

16 Midwifery Today | midwiferytoday.com | Spring 2015

 I have said this many times, but it de-
serves to be said again. We birthkeepers
must stand on three strong feet to avoid
falling down: Respect for Mother Nature
and Father Time, good science employed
only when necessary and Adat, which is the
Balinese word for “spirit/tradition/faith” so
that we may be wise.
*To donate to the Bumi Sehat Foun-
dation, please visit bumisehatfoundation
.org. The organization is always in need of
funding, and with the incredible need they
face in their country, it is vital that readers
of Midwifery Today and others around the
globe give financially to keep the organi-
zation afloat.
**We concluded that prenatal treatment
of asymptomatic retinal pathology is not in-
dicated and that spontaneous vaginal deliv-
ery may be allowed to take place in women
with high-risk retinal pathology. (ncbi.nlm
.nih.gov/pubmed/8543212)

References:
Kassebaum, NJ, et al. 2014. “Global, Regional, and Na-
tional Levels and Causes of Maternal Mortality dur-
ing 1990–2013: A Systematic Analysis for the Global
Burden of Disease Study 2013.” Lancet 9947 (384):
980–1004.
Haelle, Tara. 2014. “US Infant Mortality Rate Worse
Than Other Countries.” CBSNews.com. Accessed
January 20, 2015. http://www.cbsnews.com/news/
u-s-infant-mortality-rate-worse-than-other-countries/.
CDC. 2014. “Infant Mortality.” Centers for Disease Control
and Prevention. Accessed January 20, 2015. cdc.gov/
reproductivehealth/MaternalInfantHealth/Infant
Mortality.htm.

Robin Lim was born in 1956 when

a Filipino-Chinese woman married
a German-Irish-Native American man. They
built a bridge of love across cultures at a
time when the world was not nearly ready
to accept the changes that love would
bring. Robin now lives in Indonesia where
she is called “Ibu Robin” (Mother Robin). Lim
is a certified professional midwife with the
North American Registry of Midwives and
Ikatan Bidan Indonesia. She devotes her
life to Yayasan Bumi Sehat, a not-for-profit
organization with clinics in Bali and Aceh. New data published in The Lancet (thelancet.com/journals/lancet/article/
In 2006 Ibu Robin received the Alexander PIIS0140-6736%2814%2960696-6/abstract) shows the US now ranks at #60
Langer Peace Award in Italy. In 2011 Lim in terms of maternal mortality, falling from our previous ranking of #50. The
was named CNN Hero of the Year for her rate of maternal deaths in the US is rising and more women are dying from
work in maternal and child health in Indo- pregnancy and childbirth-related causes now than they were in 2003. That in-
nesia and disaster zones. Currently Lim and
crease contrasts sharply with most other countries, including those in East Asia
the Bumi/Wadah Foundation have adopted
full responsibility for the Medical Relief and
and Latin America.
Childbirth Camp in Dulag, the heart of the The US is one of only eight countries where maternal deaths are rising
Philippine Disaster zone, where an average (everymothercounts.org/u-s-maternal-death-rate-is-rising/).
of 40 to 60 patients are seen per day and 2
to 7 babies are born in the tent each night.

Photograph | Randy Verlie—mozzaphotography.com Spring 2015 | midwiferytoday.com | Midwifery Today 17

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permission.