I visited Monika Karaosman, an Independent midwife, at her home office on the St. Martin's River in Berlin, MD. We sat on her back deck as her daughter's played, watched the sun set and the boats motor by, and chatted all things birthy.
Our conversation covers Monika's unique journey into midwifery. Her experiences as a student midwife working in a Birth Center in the Philippines, alongside a traditional midwife in Mexico, and with local Amish communities.
I hope you enjoy!
Could you tell us a little bit about yourself and what you do?
Yes, I am Monika Karaosman and I am a CPM, or a certified professional midwife, licensed in both Maryland and Delaware. I have my own homebirth midwifery practice, Althea Midwifery, where I provide comprehensive, holistic care for pregnant women and then do their birth and postpartum care up until 6 weeks.
What led you into Birth work?
My story is different than other birth workers who knew that they wanted to work with babies and pregnant women for for a long time. When I decided to go into midwifery, I honestly was at a point in my life where I had so many different interests that I didn’t know which way I wanted to go. At the time I was running a fiber arts studio and teaching music and dance.
I am a dabbler in the fiber arts as well! My appreciation of the textile arts continually informs my work as a photographer-- I am always looking for those textural details!
I can see! You have little knitted looking earrings on!
So how did you get clarity on what you wanted to do with your life?
Well, I had grown up around birth. My mother was a labor and delivery nurse who had always wanted to be a midwife herself. And when my mother was pregnant with my youngest sibling, who is twenty years younger than I am, she was researching birth options. She had had a Caesarean with baby number 5, followed by two unassisted VBAC births at home, and she decided she didn’t really want to do it by herself again. During her research, a midwifery school came up in search results and she bought the information to me. That was when it felt like everything clicked. I had been interested in nutrition, health, art, music, and also teaching and education. With midwifery it felt like all those pieces fell into place. Which is hilarious to me!
Tell us about that midwifery school.
That midwifery school was based in the Philippines, and was run by Filipino midwives. It was a Birth Center for low cost birth. Many women went there because they knew they would receive more respectful, loving care than in the hospitals. I went there for two months as an intern to see what it would be like to be a midwife. At that point there wasn’t a great way to figure out how to be a midwife. It was hard to distinguish between the CPM from the CNM route, I wasn’t sure which way I wanted to go.
Could we pause a moment to explain the difference between a CPM and a CNM?
Yes, the biggest difference between a CNM and a CPM is the liscenes. The CNM is a Certified Nurse Midwife. The CNM goes for their Bachelors in nursing first, then goes on to get their Masters in Midwifery.
The CPM can have many different paths of education. Some with just a high school degree, myself included. Well, I am almost done my Associates Degree. But as CPM's we go straight into midwifery-- there is a lot that goes into that. The point is, I didn’t believe that I had to be a nurse to be a midwife- they are very different vocations. So that is one of the biggest reason I decided to be a CPM.
This is a little divergent, but I am really interested in your mother’s unassisted births. Where you present for those? Where do you fall in line with your siblings?
I am the oldest. I am the first one.
So, you are the oldest of eight! How many of your siblings do you remember being born?
So I am only two and a half years older than the next in line, I don’t remember his birth because we were so close in age. With the next sibling, the third child, I was a eight years old. I was not there for her birth, but one of the midwives that I went on to study with attended. After that we moved for a brief stint to North Carolina, my mother tried to have a home birth, but was super overdue. When her water broke it looked like she had had a bowel movement on the floor, there was so much meconium. That was how thick the meconium was! And the midwife was like "absolutely not", and got her in the car, but she was crowning in the car and barely made it to the hospital. She understands why the midwife did that but she also felt that she didn’t need any help because everything turned out ok.
In retrospect we can make that call.
With her fifth pregnancy she become involved in an unassisted birth movement. She was a labor and delivery nurse so she had extensive experience and knowledge of birth, but with that baby she ended up having a C-section. She felt in her gut that something was not right, so she went to the hospital. She had been in labor for a very long time and nothing was happening. I don’t recall if there was anything indicative. I think that when she was transferring in they were just like ”we are going to get him out”.
She says she never realized how hard C-sections were on women.
My mom, with her third, had a C-section. She always said that afterwards she felt like she had been hit by a Mac Truck. I can't imagine what the recovery must be like on top of caring for a newborn.
Well, she decided after that birth to take the stance-- that I don’t recommend--that “she would rather die than go back to the hospital.” Personally, I think that is a testament to the early-2000’s state of hospital care. I was not in the room when the next one was born, but I was in the house. And the following one I wasn't in the room either because she had sent me to get the warm towels out of the dryer as she was pushing. And that one, at the time, I didn’t know anything about midwifery really. So the very last one, I was there for that birth, before I went to the Philippine's.
Was that the first birth you attended?
No I had done doula work before that, but it was the first unassisted birth I had attended. That was the first home birth I had attended.
I have always been interested in unassisted birth, mainly because my last three births have been very hands off. I had my first three at the birth center, number two and three arrived pretty quickly after getting there- my second was born 6 minutes after we arrived, and my third was born something like 40 minutes after. Karen Webster caught my youngest at home, and my sister had his head in her hands when she came through the door. I think Karen had said something like, “you are doing such a great job, would you like to continue?” to my sister who was like “nope, you're the professional!”
Yes, so that definitely isn’t the case for everybody in their births.
I am not saying my labors were quick or anything-- I just have chronic labor denial. Like with my fourth, my contractions started when I took my kids to the park after school, I came home, made dinner, put everybody to bed and I was like “I’m not in labor” I guess I’ll go to sleep myself, then I woke up at midnight and had a baby.
We love you guys. You make us smell the burning tires on our way there!
So I noticed this really awesome little painting on your wall. Could you tell us a little about it?
Sure, a Canadian artist, Amanda Graevette painted that for me. She does all kinds of birth paintings. My midwife did take a few pictures for me after my first birth, which I treasure, but when I had that painted it really helped me reframe that birth in my mind because it didn’t feel empowering at the time-- it was so exhausting. I had participated in many births, where women transformed before my eyes and I just didn’t feel that way from that birth. I really felt like I should’ve done this or I could've done that. I can remember when she came out and Karen, my midwife, put her on me I felt “who is this”? I think that is what is so powerful about birth photography.
I agree. Birth Photography (and Birth Paintings!) are a way we can revisit our birth experience objectively. It enables us to view ourselves as beautiful, powerful, and strong in a moment we may have internalized differently, are still processing, or can't remember at all.
Now you have spent time working abroad in the Philippines and in Mexico. What are some cultural practices that you observed within these birthing communities that are different for our own?
Ok, So I will say that the Philippines has been very westernized and we weren’t working in very rural areas so I didn’t observe many traditional Filipino cultural practices, but I definitely had some unique cultural experiences while I was studying there. For example, how the midwives would use their lips to communicate or the fact that you can’t do this {Monika pantomimes using a finger to call someone over} if you were trying to signal to the dad to come over, you have to do this {Monika pantomimes the Filipino way to call someone over with their finger}.
So you couldn’t point your finger up when beckoning someone to come over, you have to point it down, ok.
Yes, otherwise that gesture would be sexually suggestive.
Oh, no. That wouldn’t go over well in the delivery room. Could you clarify how the midwives communicated with their lips?
They would be like “it’s over there” {Monika demonstrates the Filipino practice of “nguso”, or lip-pointing}, or they would be “did you see that?” {Monika demonstrates “ngusto” again}... Or sometimes they would use their mouth to waive down a Tap Tap which is their taxi cab.
(I went down a ngusto rabbit hole. You can read more about it HERE)
That’s so cool! So you are learning ways to communicate with body language that are different from what we, as westerner's, are used to. So tell me more about your experiences at the school that you attended while in the Philippines.
Well it was a Christian based school. I know that there is a lot of the white savior complex that goes on, especially with mission work-- but this was not like that at all. We were working under Filipino midwives. Whatever they said was what went. We were practicing under their licenses and they had complete autonomy.
(Monika interned at the New Life International School of Midwifery. You can learn more about the program HERE).
I remember one time a woman came in, I had only been there a couple weeks, she was coming in for a check because she was 38 weeks. And the midwife checked her and asked her if she would mind if I could check her as well. She explained that she was sorry to ask her to be checked two times, but that it really helps with the student’s learning. And the mother was like that is no problem at all. She said that when she was in labor with her other baby, she had gone to the hospital and they didn’t even ask her and had ten men check her one right after the other.
Oh, That's terrible. That gives me goosebumps. I would feel so violated.
That was just the kind of care that they were so used to in the hospital there. So when they would come to us, they knew that they would receive respectful care. They would have people who would name their kids after some of the midwives. We celebrated each birth with them. We saw all kinds of births, some really, really hard births that ended in transport, and some easy births with partner's crying. But because it was a birth center, culturally it wasn’t all that different. Mexico was another story.
Tell us about Mexico!
In Mexico, the midwife that I worked with was named Angelina Martinez. She was a third generation midwife. So her grandmother was attending births, and her mother attended births. Angelina attended her first birth when she was twelve and her first solo birth (like completely on her own) when she was fourteen. I just loved her so much. And she loved her clients, they became family to her. There was a language barrier, I didn’t speak much Spanish, and she didn’t speak fluent English although she was much better at English than I was at Spanish. I learned a lot while I was there. I didn’t necessarily learn things that I could put into practice in the United States, but I learned lot of traditional medicine from her. There are different laws in Mexico obviously and the leniency as far as what you could do and what you could not do is vastly different.
One of the things that she did was a closing ceremony. I have a picture of me, another student, and Angelina doing this. The closing ceremonies I’ve seen recently here, they bind you with a rebozo and that’s that. The way she taught me, you bind each part of the body separately, starting at your foot and as you are doing it you say a prayer or a blessing and then you move it up, say a prayer or a blessing and move it up. All the way up to your shoulders and then to your head. And in the end we would cover the woman with our bodies. So this picture is of all three of us curled up around this woman in a loving embrace to close up her body after pregnancy and childbirth. I would love to find a way to bring this into my own practice.
She also did a lot of yoni steamings, which was always very interesting. And she would often stop on the side of the road and grab herbs that we would take with us to births. I don’t even remember what half of them were because they don’t grow here. She had a stock tank that she would strap to the top of her tiny car that we would take to take to births, that would be the birth tub, and we would clean it out, sterilize it, put it back on top of the car and off we would go again.
One of the births I attended in Mexico. There are some areas in Mexico where they have a lot of obsidian, a volcanic rock which is extremely sharp on the edges. They had it around their outside shower as landscaping and they took a piece of obsidian and wiped it down with alcohol and used it to cut the cord and which is so cool and the family saved that rock. I remember that birth as a turning point for me as a student midwife. I attended that birth on my moms' birthday while I was there.
(I found this interview with Angelina Martinez for those that are interested. In it she describes attending that first birth at 14. You can read it HERE)
Did you observe any traditional practices regarding how the placenta was handled when you were a student midwife in Mexico?
Oh, yes. Angelina always made it a point that people would consume their placenta. Actually, I can’t recall anyone who did not consume their placenta, in some way, while I was there. I remember that one way that she did it for a particular couple, was to just cut it up, cook it, then serve it like a taco. Literally she just put it in a tortilla and it was eaten like a taco. And the husband even tasted it…and then she tasted… which I still can’t even…ha! She also used the same blender to blend up people’s placentas after she dried them that we used in our daily kitchen!
We also did a lot of placenta prints with just the blood. I don’t see many midwives around here who do that. You usually see it done with paints, where you paint the placenta, then press it onto the paper to print it. But in Mexico we did it with just the blood. Her clients really loved and appreciated it.
It was also interesting working with her because she did a lot of teaching everywhere that she went and it was really great to see her teach. At one point we went to Oaxaca where she taught a circle of girls there that were student midwives. It was so beautiful when they were practicing. Because they don’t have all the things that we have. They were doing the heart beat and the palpitations with just a baby doll and a blanket, trying to figure out positioning, one women came in and let her use her belly and they did a blessing circle before she left.
I remember one particular remedy Angelina prescribed was to boil a gold ring and a bit of a particular herb in water, then the mother would drink that tea.
That sounds like alchemy!
Right, And that was supposed to fix this or that. Some of what I learned was sooo traditional, but because of the laws changing Angelina was starting to incorporate more modern methods of care into her practice, she carried Pitocin and IV’s with her.
What were your biggest takeaways from your experience working with traditional midwives in Mexico and how have you applied it to your own practice?
Angelina always took time with her clients. The time that we spend together and spend connecting is so important. She had such a caring spirit. She also taught me a lot about the rebozo. The rebozo is something I bought into my practice
For those that don’t know, What is a rebozo and how might you use it at birth?
A rebozo is a traditional Mexican scarf. In the birthing world, it is used as a positioning tool we use it to help with pelvic floor relaxation.
The rebozo and her care with clients where the biggest takeaways, also her complete cheek! I still share this with my clients to this day because she cracked me up so much. So, whenever anybody would present with a yeast infection, Angelina would always be like: “You know warm tortillas? You just cooked them and then you put them in a plastic bag and you put them in a cabinet and then you bring them out a couple days later and they are all moldy? Well that is what it is like down there… and so if you could just sun it!” and I would think, “There are so many buildings here-- absolutely nowhere private to be sunning your tortillas anywhere in this area!” So Angelina would say "you would just get in front of a window and do this {Monika demonstrates “sunning” her tortillas in front of a window}". So, to my client’s with yeast infections, I’m always like “if you really want to, that is a suggestion!”
I had a childhood friend’s mom who would always recommend sleeping without undies.
Yeah that would probably help. I think the Bradley Method is very similar-- going about your day without any underwear on to air out those tissues.
So, you have also have had plenty of experience working with the Amish. Could you share about what this experience was like and any lessons you may have learned from them about birth and family?
I have worked with the Amish a lot and I will say that the Amish bring a dimension of safety to the birth. They want very minimal interventions. They just want birth to take its natural course. They trust their bodies and they trust birth. They also have the instinctive belief that whatever happens is the way that God wanted it to happen. And that is beautiful!
Amish women also have the support of their community-- their moms, sisters, and neighbors are always there postpartum, they have help for weeks-- 24 hour help!-- for weeks after having a baby. Just imagine having that kind of support! That is very different from most women who give birth. Personally, my mom lived across the country from me, none of my sisters lived close by, so it was me, my grandmom, and my husband after I had my girls.
When I worked with Karen Webster, who works a lot with the Amish, an Amish woman was my first catch as a student midwife. And I got to go back and attend her second birth with Karen, which was so meaningful.
I also worked at an Amish birth center which was run by Diane Goslin where they do high volume birth. There are at least two or three midwives on staff, then there were students. I worked there for almost two months. As an example of how busy we were, we had 44 women due to give birth in a single month. I attended three Sarah’s for their births in a 24 hour period, all on the day before I was supposed to leave! It was insane the number of births that I attended there as both an assistant and primary midwife.
The other thing is that the spring is wedding season so all the Amish first-time parents would be due in the fall.
Out of curiosity, how do the Amish inform you that labor has begun?
It depends on the Amish, but often they will have what looks like an outhouse out in the field but is really a phone booth. A lot of time’s the father calls and he has no idea about what’s going on other than his wife is in labor and can’t answer any of our questions. I remember working with Karen to redo our “when to call the midwife” packet to add that before you call the midwife these are things you should know. Like “before you call the midwife make sure you know when it started” or “how frequently is it occurring?” whether that is bleeding or contractions. We had to put these prompts in there because the Amish dads would be like “I don't know” “I don’t know” to all our questions and we would have to ask them “Well could you go find out and call us back?” And the dads would have to run back up to the house, ask their wives for all those pertinent details, then run back down to the phone booth in the field to call us back.
Diane Golsin did told me this story about an Amish dad, and I share it all the time because I think it is so hilarious. So, she said that she was conducting a childbirth education class for expecting Amish parents and she had informed them that active labor is when you are about five centimeters dilated. She went on to explain that active labor was when she would come to the house and stay so that they could have their baby. She said this father called her and was like “yup, it’s time to come”, and she was like “oh, ok, how do you know?” and he replied, “Because she is five centimeters” and sometimes there are Amish dad's who are very interested in the birthing process so she asked ”did you check her?” and the dad responded, “No, that is how much I can see of baby's head” And she was like "OH My God!” She has always clarified at every childbirth class afterwards that it is not five centimeters of babies head, but five internal centimeters of your cervix that you cannot see, but you can feel.
One thing too about the Amish is that they don’t always let you know that they are pregnant until they are very pregnant. This is an extreme example, but while I was working at the Amish birth center, one of the women came in for an intake appointment, and she turned out to be 34 weeks. It was her first prenatal visit ever and she was 34 weeks pregnant! I think we told her, “So we got to do your initial and we could possibly do your birth before we leave. That’s a new one!” They just really, honestly believe that whatever happens is supposed to happen.
Is there a way you can encourage that kind of confidence in our own bodies and to have the faith that everything is going as it should? For me, it came with time and it took actually giving birth to feel fully confident in my birthing ability.
Having done it once helps.
Or having done it twice-- or three times too-- the more times I gave birth, the more confidence was there.
I saw a lot of really difficult births, some with 36 hours of really excruciating back pain. Obviously these were first labors, and my own was not far behind them-- I was in labor with my first for 24 hours.
My first was long and hard too.
I attended a birth as an assistant with a baby that was not compatible with life. That was really hard. That was devastating. We had no idea because there weren’t any ultrasounds during the pregnancy. They aren’t routine for the Amish and we won’t order one unless we are specifically seeing a reason for it. Often times with a baby that is not compatible with life, they are just fine in utero.
There was one women who I attended when I was assisting. The primary midwife was like "just make sure if her water breaks, you catch the baby!" and her water broke and I was like "should I lift up her skirt?" and the midwife was like "lift it up now!" And she caught the baby. That was apparently how all the woman's other children had been born.
I think it is ingrained in the Amish that birthing babies is what their bodies are meant to do. That it is their purpose. I think that is what makes them keep going.
Something that I’ve heard other women say that is that they knew that when they were in labor, hundreds of thousands of other women around the world were in labor with them and and they were all going through it together. I think that is a beautiful sentiment to hold onto throughout your birth. It will help you and give you the strength to get through it, it won’t make the birth any easier.
I think there is also power in knowing who you are. My trauma showed up a lot during my first birth and that postpartum. If I had been willing to face that before hand, it would have helped.
Like in "Birthing From Within". Where she talks about birth tigers. And the things that you are afraid of.
I love "Birthing from Within" and all the practical tools Pam England gives you in that book-- especially the art therapy prompts and the exercise that uses the ice cubes to test your pain threshold-- she calls them “pain cubes”. (you can read more about pain cubes HERE)
So the birth tigers is a metaphor that is basically preparing for your birth by thinking of it as your birth safari and there are going to be tigers-- which are your fears for this birth-- and in my experience, whatever your fears are will generally be the ones that will pop up, By identifying those fears in pregnancy, you learn to recognize whether they are tigers that need to be put in cages, tigers that need to be faced, or tigers that you realize aren't actually tigers but are more…
Like imagined shadows moving through the trees?
Yes, I think that is important to name your tigers and accept that there are some fears that aren't really there, that there are some fears that you are not going to be able to face, get through, and get over before the birth, and there’s some that will come up just because of the birth. Like with my daughter, my past came up a lot with the thought that “I’m not going to be able to do this”. This didn’t have to do with the birth itself, but it had to do with a belief that I couldn't get through labor and that was the tiger that I couldn’t face until I actually gave birth myself.
You have had so many amazing and varied experiences during your study to become a midwife. What advice would you give to a young person interested in pursuing birth work?
I think you should check your motivation for why you are going into it. I think that midwifery can often seem-- well, I don’t want to say glamorous-- by it can be romanticized. People will say something like “oh, you are a midwife-- helping moms and catching babies, attending birth” there is something magical about this profession, but it is so much more involved-- there is so much paper work! So much to file- birth certificates and metabolic screens-- most of my job is paperwork. Yes it is absolutely magical at times, but there are also many not-so-magical moments.
My other advice is to attend as many births as you can and to view each birth as a learning opportunity because you never stop learning. I have yet to come across a birth where I have not learned something new. My clients and their babies will be my teachers all throughout the rest of my life. They are incredible. I have met some amazing families.
And my other piece of advice is that whoever you decide to use as a preceptor, realize that you are learning to be the kind of midwife that they are-- and that doesn’t always work when you are out on your own because you have to learn to be the midwife that you are. I would make sure the midwife they are is the midwife that you would like to emulate because there are lots of different types of midwives out there. I am lucky to have worked with some amazing midwives, but I have heard a lot of stories from others. And never settle if the area that you live in doesn’t have a lot of midwives or doesn't have the one for you.
Make sure about your path of education and the route that you are taking
because it can be difficult to figure out which way you want to go and the way that you want to pursue midwifery. No matter which way you choose, the time will pass and at some point, the money will be spent. So make sure you do it the way you really want to do it.
You should also make sure you learn to set boundaries now, as a student, because it is very easy not to have boundaries as a solo practice of a home birth midwife. Learn to set them now to protect your physical health, mental health, family and relationships in general.
What is your advice for expectant parents on how to find a midwife that is aligned with the kind of care you want to receive?
I think that you should ask questions! Read their bio and, if you have a chance, have a consultation or in-person meeting to see if you align. I would ask how they handle their births, what a birth looks like for them. And if you are someone who wants to be left alone ask “how hands off are you?” or would they want to be in the room the whole time your labor? There are midwives that will step in the room, let your partner get heart tones and they will listen, and then they step out. How involved do you want them to be? Figure out the things that are most important to you. Is it that you want them to really connect with you? do you want a really great friend, partner, or person in your life--
A Karen Webster?
(By now, you may have realized that Monika and I have a truly amazing midwife in common. You can learn more about this incredible woman HERE)
Oh yes, someone who becomes your the second mom! Or do you want someone who is very professional-- that gives you the space you would like from them.
What kind of a midwife are you?
I do follow very similarly to Karen. Some of my really good friends started out as clients. I have one person who is having her third baby with me and there is nothing more complementary. It is the best feeling to know that they trust you enough to keep coming back to you. All of my prenatals are an hour, there are few that are not a full hour. We learn about each other and each other’s lives. We use the time to connect.
Another piece of advice for people considering homebirth is knowing that home birth might not be the right choice for you and being able to see that. I have had some people contact me and they almost want me to convince them to have a homebirth. I'm not going to do that . I think that there is a reason for hospitals and I have no problem sending you to a hospital if that is where you and your baby are going to be safest. There are also women who, because of past trauma and their past experiences, are going to feel safer at the hospital and there will be some who feel safer at home. I want birthing parents to have all the options. I'm not going to convince somebody that homebirth is best-- they have to want that for themselves.
You have shared so much with us already, but do you have any closing wisdom?
Yes, trust yourself and trust your instincts. It is your body and your baby! One of my favorite things, especially with first time moms, is to make sure that women have everything they need and a good support group during their postpartum. I still feel it so deeply-- it has not been that long for me. So a lot of my time with first time moms is spent encouraging moms to set up that support group! You don’t know what you are going to need until you need it, but if you set yourself up to succeed now- for example every Tuesday you know your mom is coming and maybe if you don’t want her to hold the baby, then she can go do dishes instead. I had such a hard postpartum so I always tell them "here are the things that I wish I had done". They might not need the same things that I did, but as long they are aware of what they might need and the support is in place at home, I feel good.
Making sure that they have that support and have things scheduled that they know they can count on is important because it is so hard to ask for help when you don’t know you you need it! Oftentimes, we don't know what we needed until we receive the help. Like when someone is holding that baby for you and you are in the shower-- or you are holding that baby and the dishes are being done by someone else.
I also love to encourage parents when they are in the throes of making decisions about erythromycin and vitamin k or circumcision and all that-- that this is the first step to being a parent. You will be making decisions for your child for a very long time and all you can do is educate yourself with the information that is out there the best you can, and then make your best decision. If you start now with that practice, it won’t be so hard to make those choices about whether or not you are going to give them Ibuprofen or Tylenol, or let them use a pacifier-- whatever that decision is for you-- cloth diapering or not. Know that you are going to be making those decisions forever and it can feel very overwhelming just trusting yourself to make decisions at first, but you should feel good about taking that autonomy back for your family.
How can people connect with you?
If you have any questions please reach out!
443-373-3115
You can also find me on:
instagram- @altheamidwifery
Facebook- /althemidwifery
If you enjoyed this interview, check out these other articles featuring birth and baby workers and creative momprenuers!