EBB 363 – A Remarkable Journey from “Babies Are Not Pizzas” Student to Critical Care Nurse to Nurse Midwife with Liz Carr, CNM

Dr. Rebecca Dekker – 00:00:00:

Hi everyone. On today’s podcast, we’re going to talk with Liz Carr, a former nursing student of mine, about her journey from nursing student to critical care nurse to certified nurse midwife. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone, and welcome to today’s episode of the Evidence Based Birth® Podcast. Before we get started, I wanted to ask you – would you like to join me in a summer educational series? Starting this coming Tuesday, July 8, we’re kicking off a six part live lecture series called how to help families get evidence based care, inside the EBB Pro membership. This series is designed to help you build your knowledge, stay grounded in the latest research, and feel more confident as you support families. So, what’s the summer lecture series all about? Well this July and August I’ll be presenting on topics like models of care, the research on birth settings, labor support, and childbirth education, and we will also be talking about human rights and informed consent and refusal in birth. The very first session is titled, “What is Evidence Based Care?” and it starts on Tuesday, July 8th at 1pm. In this first session we’ll break down what evidence based care really means, how it’s different from routine care and why it matters for the work you do as a birth worker or healthcare professional. This series continues through Tuesday, August 26th and if you complete all six sessions you’ll have the opportunity to earn contact hours for nurses, nurse midwives, and physicians. And, if you miss a session or can’t make it live, the recordings will be available inside the pro membership so you can catch up anytime. Now, this summer lecture series is available exclusively through the EBB pro membership but we wanted to make it available to as many people as possible who wanted to attend. So right now you can join the EBB pro membership for just $19 for your first 30 days. This gets you access to the upcoming sessions and the summer lecture series during your membership plus access to our continuing education library, monthly live events, and a collection of printable handouts for your clients. If you decide to keep your membership after the first month you’ll also lock in a discount on your membership rate going forward. And, you can choose from a monthly, quarterly or annual plan. To see the full schedule of classes I’m teaching and all the details just head to ebbirth.com/summer. Everything in the series is outlined for you there and you can reserve your spot right away. So I hope I get to see you at this summer’s learning experience starting Tuesday, July 8. And now, let’s get into today’s episode. As a content note in part of our guest’s interview we will be talking about non-consented episiotomy, as well as abortion care both pre- and post- the Dobb’s decision. 

With that I’m so excited to introduce you to our featured expert Liz Carr. Liz Carr is a certified nurse midwife with a background in critical care nursing. Liz attended the University of Kentucky for her undergraduate nursing degree, where she was a student of mine, twice. She attended both my pathopharmacology and my honors course, Babies Are Not Pizzas. Liz went on to work at the bedside as a cardiovascular cardiothoracic intensive care unit nurse for more than five years at the University of Kentucky. She was trained as a doula in 2020 before beginning her graduate program in nurse midwifery later that year. Liz supplemented her midwifery education with a training in abortion care residency through Nurses for Sexual and Reproductive Health, where she had the opportunity to provide care for patients seeking abortion care both before and after the overturning of Roe v. Wade and she did that at CHOICES Center for Reproductive Health in Memphis, Tennessee. Liz went on to receive her master’s degree from Frontier nursing University in 2022. Since passing her midwifery board certification, she spent two years working at a small community hospital in North Carolina and recently transitioned to a new position as a nurse midwife in a major academic medical center. Her new role represents an opportunity to bring midwifery care to birthing patients at all levels of risk, as well as participate in the education of resident physicians. If you know Liz you will know she is passionate about reproductive justice and relationship-based care. Liz, welcome to the Evidence Based Birth® Podcast.

Liz Carr – 00:02:09:

Honored to be here with you.

Dr. Rebecca Dekker – 00:02:11:

I’m so excited to see your face again and to get to talk with you. I know we’ve connected a few times on and off throughout the years, and I would love for you to share your story with our listeners and maybe start off with what first inspired you to nursing as a career.

Liz Carr – 00:02:26:

So when I was 14 years old, I completed my required high school community service internship at Brady Memorial Hospital, which is the big public hospital in Atlanta. And I was in the neurology unit there and watching the interaction that the nurses got to have with patients. It was a no-brainer to me that if I ever worked in healthcare, I wanted to be a nurse. Just the connection and the care that they got to provide for patients is totally different from what physicians get to do for patients. And I really love to watch the ways that they could invest in and get to know their patients. And I knew that that was what I wanted to do if I ever worked at health.

Dr. Rebecca Dekker – 00:03:14:

So did you grow up in the Atlanta area?

Liz Carr – 00:03:16:

Yeah, I was born and raised.

Dr. Rebecca Dekker – 00:03:18:

And what drew you to Lexington and the University of Kentucky?

Liz Carr – 00:03:21:

So I came for college and stayed-

Dr. Rebecca Dekker – 00:03:27:

For a while yeah

Liz Carr – 00:03:28:

Yeah. I wanted; I lived there for 10 years. Um, so, I did not think I would live there for 10 years, but just got, a really wonderful job, when I graduated from nursing school, and had a really supportive supervisor, when I was in midwifery school, which is…key.

Dr. Rebecca Dekker – 00:03:48:

Yeah. So going back a little bit to nursing school, tell us what your experience was like. You know, you took the Babies Are Not Pizzas honors seminar. It’s like an elective class with me while you were still a nursing student. And what were your thoughts and feelings going on in you as you were navigating nursing school and learning about midwifery and all of these things?

Liz Carr – 00:04:12:

I loved that class. It totally reinforced for me all of the reasons that I was interested in midwifery. Just, all the ways that, birth and pregnancy and prenatal care are really powerful. They’re really, it’s an important moment in the life of a family. I was so inspired to learn about all of the ways in which we maybe are not utilizing evidence that’s available to us in obstetric care and the ways that we can evaluate the evidence that’s out there and utilize it to hopefully provide better care and better outcomes to patients.

Dr. Rebecca Dekker – 00:04:54:

And I do have vivid memories of you sitting in class. I think it was knitting or was it crocheting?

Liz Carr – 00:04:59:

Oh, yeah.

Dr. Rebecca Dekker – 00:05:00:

Knitting.

Liz Carr – 00:05:00:

Yep. I’ve always been a knitter. All I make now are baby blankets. That’s the only thing that I ever knit because it’s just a big square. But I love to knit. And so that’s what I would sit in class and do because it helps me to have something to do with my hands while I just absorb the information.

Dr. Rebecca Dekker – 00:05:18:

Exactly, my kids are the same way. And it’s interesting because it’s something that midwives do a lot. And doulas, they do the fiber arts and because we’re sitting, but we’re being present. And it’s like a way to keep your hands busy. And so, yeah, it was really easy to kind of look at Liz and be like. I feel like there’s a midwife hidden in there.

Liz Carr – 00:05:40:

I’ve definitely had an OB or two that I wanted to teach to knit so that they could just maybe just, you know, we don’t really do anything. You know, we can just we can just be here and just and just not do anything.

Dr. Rebecca Dekker – 00:05:52:

Yeah. After you graduated from nursing school, what led you to critical care nursing? And was there anything to do, you know, your interest in obstetrics and midwifery? Like, how did you balance that?

Liz Carr – 00:06:02:

One of the influencing factors of me not working in labor and delivery was you. We talked about it. And I said, can I be a midwife if I don’t work in labor and delivery? And you were like, yes, absolutely you can. I think you were the one who told me it was about 50-50 in terms of folks who have worked in labor and delivery and those who haven’t. And you know that one of the formative experiences that made that decision for me was my obstetrics rotation in nursing school.

Dr. Rebecca Dekker – 00:06:32:

Yeah. So tell us about that. What happened?

Liz Carr – 00:06:34:

Yeah. So the first vaginal delivery that I ever got to see in person I watched the physician do an un-consented episiotomy.

Dr. Rebecca Dekker – 00:06:44:

Oh my gosh.

Liz Carr – 00:06:46:

And I… I mean, that moment I still remember viscerally.

Dr. Rebecca Dekker – 00:06:52:

I remember that. I remember which hospital, because you came and told me, and it was at St. Joe’s, right? Yeah. I remember you telling me this story, where it happened, and how shocked you were. And I remember being surprised as well, because it was probably, of the three hospitals in the town, one of the ones that tended to have better care at the time.

Liz Carr – 00:07:11:

Yeah. Was interesting.

Dr. Rebecca Dekker – 00:07:14:

And what were your thoughts is that you were witnessing this as a brand-new nursing student, basically?

Liz Carr – 00:07:22:

Yeah. I mean, I felt powerless because I was aware of the fact that I didn’t have a lot of knowledge. And so, part of you wants to believe maybe there’s something going on here that I’m not aware of. Maybe there’s some concern that I don’t know about. But that doesn’t erase the fact that it was done without the patient’s consent, without even informing the patient that it was happening. And so there’s not a scenario I can think of.

Dr. Rebecca Dekker – 00:07:49:

And you told me afterwards, I remember you were relaying the story to me and you said she was stretching beautifully. Like there was no need for it at all.

Liz Carr – 00:07:56:

Yep. I think the next contraction, she probably would have birthed her baby. And it just was an impatience issue. I just thought I cannot witness this every day in my nursing career because it will break me to watch this happen to people. I just didn’t really want to bear witness and participate in care that is not evidence-based and violent, non-consensual. I have no interest in doing that as a nurse. And, I didn’t want to learn a medical model of care, knowing that midwifery is a different model of care. Some of what you learn as a labor and delivery nurse, you then have to unlearn as a midwife because it’s a different model of care.

Dr. Rebecca Dekker – 00:08:46:

Yeah. And you were anxious about like, will I be able to get into midwifery school? Will I, somebody want to precept me? Because I think there were a few preceptors at the time who would only take people who had labor and delivery nursing. Yeah.

Liz Carr – 00:08:58:

Yeah. And that’s definitely something that I have encountered throughout my education is there are definitely people who think that midwives have to have labor and delivery experience. And that is their opinion, and they are entitled to it. And I don’t agree. I think that diversity of experience matters. It makes us better. It helps us to provide better care to patients, it’s kind of a small-minded way to think, in my opinion, that only one type of experience is valuable.

Dr. Rebecca Dekker – 00:09:34:

You’re right. Probably the diversity of experiences, especially on a team of midwives, might make for better care for patients because you all bring different perspectives. So tell us about the perspective of a critical care nurse. Like, you know, how did that experience shape how you eventually approached midwifery?

Liz Carr – 00:09:53:

Well, I chose cardiovascular ICU very specifically. I knew that if I didn’t work labor and delivery, I wanted to choose a background that was still going to serve me really well. I knew that cardiovascular complications are the biggest contributor to morbidity and mortality in the perinatal period. And so I felt like having that cardiovascular background was going to serve me well. So I chose to work in this wild ICU. And it is a very different, obviously fueled, but I learned so many things that translate so well. I learned about the provider that I want to be when there’s an emergency. How to look at my patient and assess really quickly how sick I think they are. And to trust my gut, even if I can’t put my finger on why I think something is not right. I learned to trust that, that’s usually, there’s something to that and it should be investigated when something just doesn’t feel quite right. You learn how to cope and exist in high-pressure situations, which are very common in obstetrics.

Dr. Rebecca Dekker – 00:11:12:

I was also thinking about your communication skills because a lot of times your patient might not be conscious. Like awake, but you’re having to communicate with families and healthcare professionals and advocate for the patient. Can you talk a little bit about that?

Liz Carr – 00:11:27:

Yeah. I mean, I was always a believer that even if you really think your patient can’t hear you, you should still tell them what they’re doing. And I think that’s a great practice in just autonomy and, you know. Informing patients of what’s happening and what’s going on in their care. And that translates beautifully to, you know, maternity care as well. But yes, you get used to being able to translate for folks. In a high-pressure situation, just here is the gist of what is happening. And, this is the concise version of what I can tell you and why we’re doing what we’re doing. And the rest we are going to debrief and talk about later. And I think that that’s a very valuable and translatable skill because there are a lot of times in obstetrics where you do want to move really quickly. But that should not negate. Telling patients and families, here is what is happening. Here is why we are doing the things that we are doing.

Dr. Rebecca Dekker – 00:12:31:

What about interventions in the ICU? Because, I mean, the whole point of being in the ICU is so you have an intensive level of interventions. And I know in America in particular, we have a problem with, with extending people’s lives when they probably should have been in hospice care. And that is, I’m sure, a lot of what you saw in the ICU. Can you talk a little bit about like, how the interventions environment is different maybe in ICU versus obstetrics.

Liz Carr – 00:13:03:

I think, I mean, it is different. It’s very different. But I think in a lot of ways there are so many similarities. Just because we can do an intervention does not mean that we shouldn’t. That is universally true. And the other thing is that you have to become comfortable with the fact that my opinion of what intervention is best or whether or not something should be done. Is in many cases irrelevant. It’s about what does the patient want? What does the family want? And is the intervention something that is evidence-based and that is likely to work or is worth trying from the standpoint of the patient and the family. And that is very true in obstetrics. And it’s also very, very true in the ICU.

Dr. Rebecca Dekker – 00:14:06:

Interesting lessons you learned. I know it’s been a while, but for a lot of people, that first year after graduating from nursing school is really challenging. I imagine even more so in the ICU. So after you kind of got past that first year, how did you start transitioning to birth work and incorporating that into your career?

Liz Carr – 00:14:30:

The big thing that I did was I did doula training. And that was such an amazing opportunity to put tools in my toolbox. I knew that I didn’t have the same experience of watching labor and knowing about just how to support people through labor that a labor and delivery nurse has, right? Because I have not been present for laborers as much as they have. And so that was one of the ways. And also just reading books, you know, reading books and hearing birth stories and watching birth videos helped me to stay connected to why I wanted to do this.

Dr. Rebecca Dekker – 00:15:13:

Were you the college student who told me you put birth books on your Christmas list while you were still nursing?

Liz Carr – 00:15:19:

Absolutely.

Dr. Rebecca Dekker – 00:15:19:

I might have had a few people told me that. And then their family is like, uh, is there something we should know?

Liz Carr – 00:15:25:

But see, my family, they were like, they knew, right? I told them when I was 13, I wanted to be a midwife. So they were like, that’s fine. We know that. We know that stuff.

Dr. Rebecca Dekker – 00:15:35:

And. What was your doula training like? Like, how did you leave that experience?

Liz Carr – 00:15:42:

So it was a great experience. Just all of these tools and all of these, again, just questions to ask yourself about how we provide care for people. One of the most important things that I took away from it was our, our trainer talking about how we should ask for consent every single time we touch people. And that, in some ways, as an ICU nurse, kind of rocked me. Because I realized, wow. I have not been doing that. Right. And. It made me reflect a lot about what are the ways that I can hand power and autonomy back to people? And one of those ways is, you know, when people are in an ICU room. Their world is this big. It’s so small. It’s that tiny room. It’s their chair, if they can get to it, and it’s their bed. And so often what we’ll do as nurses and providers is we’ll go in the room and we’ll maybe sit on the bed and talk with them. And so one of the ways that I started to try and just integrate choice into my care more was I would ask permission to sit on the bed. Because I would recognize that that is part of a very limited space that belongs to the patient. And just the act of asking, I’ve never had a patient say no, right? But just for them to know that it is their choice and that I want to be invited into their space, not bust into it.

Dr. Rebecca Dekker – 00:17:25:

Beautiful. And you had mentioned that earlier about asking patients everything. So that was something that kind of was partly inspired by your doula training?

Liz Carr – 00:17:33:

Definitely.

Dr. Rebecca Dekker – 00:17:34:

Okay.

Liz Carr – 00:17:34:

Definitely. I always tried to explain to patients and families what I was doing, but it is a different mindset to ask permission.

Dr. Rebecca Dekker – 00:17:46:

Yeah. What happened next then? So how long did you work in ICU before you start, you know, applied to midwifery school and started that?

Liz Carr – 00:17:55:

So I had been in ICU for about two years. When I applied and got in, And It made sense for me to stay in my job because my boss was very supportive of me going to midwifery school. He was like, I don’t understand why you want to do that, but more power to you. Great.

Dr. Rebecca Dekker – 00:18:21:

So he didn’t mind that you were going to be like maybe cutting back hours or having to go to class at certain times.

Liz Carr – 00:18:28:

No. One thing about working in a CVICU at a major academic medical center is that there are not very many people who work there for a really long time. For most people, they go there because they want to go on to be an acute care nurse practitioner or a CRNA. So wanting to go on to midwifery school was maybe a little bit unusual, but the fact of people going to school and needing to kind of alter their work around that was pretty common.

Dr. Rebecca Dekker – 00:18:54:

Okay, so it was accepted on your unit.

Liz Carr – 00:18:57:

Yeah, so I think that that’s when you choose nurses who are really passionate about like learning and working at the highest level. You’re also you’re choosing nurses who probably do want to work at that advanced practice level. And so that’s a known thing, I think, in most, particularly in cardiovascular ICU.

Dr. Rebecca Dekker – 00:19:19:

So what was your training like then as a midwife?

Liz Carr – 00:19:24:

So I went to Frontier’s program and the first portion of the program is didactic. So, mostly online lectures and classes and coursework. And then you attend an in-person kind of clinical orientation on campus before you transition into your actual clinical work. So the didactics for me I loved I mean I was learning about all the things that I had been spending my free time reading about for the last however long so I really enjoyed getting to learn all about pregnancy birth and I’m a nerd and I like learning about pathophysiology and the way things work. And it all kind of makes sense when you break it down. And so it’s nice to learn about all of those things in depth. So. I enjoyed my didactic classes, but I was really, really looking forward to that clinical portion. And also nervous as somebody who hadn’t had experience in obstetrics. It was very scary to think about being completely new at something again. I worked in the ICU for long enough that I got pretty comfortable there and I knew how to take care of any patient on that unit. And so it was a whole new experience to be new at something.

Dr. Rebecca Dekker – 00:20:56:

And then what about when you get to the clinical part? I’ve heard from a lot of nurse midwifery students in the United States that one of the most challenging parts of their program is finding a precept or finding a clinical site because often you are, as the student, are the one who has to do that. So was that easy for you? Did you have classmates who struggled with that? And how did your clinical experience go?

Liz Carr – 00:21:20:

It was very challenging to find clinical sites.

Dr. Rebecca Dekker – 00:21:23:

Okay.

Liz Carr – 00:21:23:

Very challenging. So you start looking for clinical sites when you start your program, which for many people is, a couple of years before they actually begin their clinical work. So I had a couple of clinical sites that were available in my area. I definitely had some sites that either never responded to me. Maybe that had to do with me not having labor and delivery experience. It was also COVID. So it was a very challenging time to be reaching out to places because often the answer was, we have no idea. If students are going to be able to come back or when they’re going to be able to come back. So it was a challenging time to look for clinical sites. Even though looking for clinical sites in the best of times is still tough. So I did several different sites. And as I was nearing probably the last third of my clinical work. I actually lost the clinical site because of staffing challenges at one of the sites. So they had three midwives. They had two midwives leave within the space of a few weeks, just different life circumstances. And so they really couldn’t, they couldn’t take a student at that point. So here I am, I have essentially no clinical site and I panic. I’m like, I don’t know what’s going to happen. But I will say that Frontier was incredible and helped me find a site. I wound up going to Gary, Indiana for seven weeks. Not something that I ever anticipated I would do in my life. But I stayed there for seven weeks to finish up my clinicals. And it was an incredible experience. It was what I needed to feel really ready and prepared. And my preceptor there was incredible. So it was a great experience. But it was hard. It was hard to find sites. And tough to coordinate between having all of these different sites. It is not easy.

Dr. Rebecca Dekker – 00:23:31:

And you also trained at CHOICES in Memphis. Did you do that while you were still in school or after you graduated?

Liz Carr – 00:23:39:

I did. So I had hoped that as part of my midwifery program, we would be trained more than we were in abortion care. To me, that is part of providing whole person care. And so. By the time I reached the end of my didactic work at Frontier and realized that that knowledge was never going to be coming from my didactics. I decided that I wanted to seek that out myself. And so I found the training in abortion care residency and applied and was accepted. And had a really interesting experience. So this was in 2022. And so I was in my clinical portion of my midwifery program. And part of the training in abortion care residency is going and doing clinical hours somewhere. And so initially, the plan was for me to go to a site in Louisville because that was the closest place where I could provide abortion care to patients. And then sort of restrictions kept rolling in. And so then it was Indiana, which is four hours. And so I knew there was another resident who was at CHOICES in Memphis. And CHOICES is the only place in the country that has a birth center and also provides abortion care in the same facility. So I had known about CHOICES for a long time. And. Said, if I’m going to go a few hours away for clinical, I want it to be a choice. So I want to go and I want to learn from…

Dr. Rebecca Dekker – 00:25:25:

And that’s more than a few hours away from Lexington.

Liz Carr – 00:25:28:

Yeah. It’s a good six, seven hours.

Dr. Rebecca Dekker – 00:25:30:

Yeah. Eight with traffic, you know.

Liz Carr – 00:25:32:

Yeah. So it was a hike. But it was important to me to learn. And. So I got to go and I spent a week there in June. Which was we knew that the Dobbs decision was coming. But it was not final yet. And so they were still providing both medication as well as surgical abortion when I was there in June. And then to finish my hours, I returned in August, which was after the Dobbs decision, the overturning of Roe v. Wade. It was a very different experience to be there in August. So starkly different from what I had experienced in June. It was really interesting.

Dr. Rebecca Dekker – 00:26:23:

Did you see people turned away then for care that they needed?

Liz Carr – 00:26:28:

Yes. So when I went in June, I believe that I cared for patients from five different states. That were there seeking some form of abortion care. And when I returned in August, there were still people coming from out of state to seek care. But at that point, there was essentially a six-week ban. So there was, if there was any cardiac activity visible on ultrasound. We could not provide abortion services to patients. In Tennessee, there is a, I believe it’s a 48-hour waiting period. So patients would have to come in and their first day they have an ultrasound. So if they have cardiac activity on that ultrasound on the first day, they’re already not eligible to receive any kind of abortion services. They have to come back in 48 hours and have another ultrasound. And so if they have cardiac activity visible on the ultrasound the second time they come, they’re also not eligible. That is a very finite period of time in a pregnancy. Often, it’s very difficult to actually confirm that a pregnancy is intrauterine. Before there’s cardiac activity. It’s just such a short period of time. And so it’s a very challenging thing to safely provide care when the parameters are so strict. And You know, these are patients who are seeking this care. They’re coming from often a very long way away to seek this care. Because they need it. It’s devastating to have to turn people away. You know that you’re causing people to face a lot of challenges and a lot of risks, right? We know in obstetrics that there are risks to pregnancy, there are risks to birth. And I think that part of being a midwife is, I believe, in people’s autonomy to make choices about how and when they birth their babies. I cannot profess to believe that and not extend it into whether they continue pregnancies. And that’s, that’s just not, it doesn’t make any sense to me to say, oh, I think that I should have. The choice about whether people continue their pregnancies, but how they give birth is their choice. I think that we have to believe people that they know their lives, they know their limitations, and they know their capacity to parent. And so it’s really, it’s morally injuring to have to turn away patients who are telling you, I need this care. And we know that it’s safe for them to receive this care, but we can’t because of political barriers.

Dr. Rebecca Dekker – 00:29:32:

And so if they leave and choose, for example, to try and terminate on their own, they’re kind of on their own from that point.

Liz Carr – 00:29:39:

In some ways and you know the truth of the matter is that for a lot of patients They simply will not go on to attempt to terminate their pregnancy if they’re turned away. For an abortion, they’ll continue their pregnancy. And so, we know from the Turnaway Study that there are real, you know, there are harms associated with forcing people to continue pregnancies that they do not desire to continue. And so I. Was very aware of that. And so turning those people away is really tough.

Dr. Rebecca Dekker – 00:30:13:

Literally the name of the study you’re referencing, which we’ll make sure to link to in the show notes, we’ll also link to CHOICES. And we’re excited to have one of their team members on the podcast soon. So stay tuned. We’ll be talking more about the work that they’re doing at CHOICES. So then you finished midwifery school and started your role as a nurse midwife. What were the biggest challenges and rewards in the first couple of years of practice for you?

Liz Carr – 00:30:46:

All of the societal and systemic things that I have no control over. And that patients are still existing. And combating. I think about a patient who, was having a tough time postpartum. I saw her in the hospital and it was her first baby. She didn’t have really any social support. She was a recent immigrant. And I remember her looking at me and asking, What do I do when I need to take a shower? Like, who’s going to watch the baby? And just thinking, I wish that I could just like put you in my pocket and take you home with me because It just feels terrible to send people home and know that they feel so helpless. So unsupported. And that’s a reality for a lot of the patients that I was caring for. That’s really hard because even if I’m giving them the best care possible. I can’t address the very real issues that they are facing in their life.

Dr. Rebecca Dekker – 00:31:58:

And I guess it also depends kind of on the clinics you’re working in. Like if they’re offering wraparound services like postpartum doula care and nutrition provision and things like that, like there are some up and coming birth clinics. Like in Kansas City that we’ll link to in the show notes that we’ve had their founder on the podcast to talk about, but most practices are not set up to provide those wraparound services.

Liz Carr – 00:32:26:

And I think even wraparound services, it doesn’t address that social and emotional support. There are things like centering pregnancy can in some ways create an environment where maybe people do have an opportunity to form some social bonds and have some more social support. But that is something that you can’t really. Create for people. Unfortunately. And often that is the greatest need.

Dr. Rebecca Dekker – 00:32:57:

Is the social support and community.

Liz Carr – 00:32:59:

Yeah, it’s just that social support of somebody to, to listen to them, to maybe give them a 30-minute break so they can take a shower or go to the grocery store with other kids or whatever it is. Just that little bit of extra support is often what I think people are really hungry for and something that we just can’t create for them, unfortunately.

Dr. Rebecca Dekker – 00:33:28:

What about the rewards? Do you have any memories of like some of the first births you attended as a new graduate?

Liz Carr – 00:33:36:

Oh gosh, every birth is so special. Birth is magic every time. And. There have been so many incredibly special births throughout my time catching babies. Some of the ones that come to mind actually are, I’ve now had the opportunity to do a couple of sibling births. So I caught their first baby and then they asked me to catch their second baby. Those were really, really special. What an honor to have someone say, hey, I loved having a baby with you and I want to have another baby with you.

Dr. Rebecca Dekker – 00:34:13:

In a different way, like not as your partner, but as.

Liz Carr – 00:34:15:

Oh, yeah. Yeah. Sorry. Well, you catch my second baby because the first birth was such a good experience. So those were really, really special. And a couple of patients that I cared for when they were having miscarriages. That then I got to hand them a baby. That was really, really special. To just know How old? Deeply desired these babies were and get to get to hand them to their parents is very special.

Dr. Rebecca Dekker – 00:34:44:

That is special. That’s what your dream was.

Liz Carr – 00:34:47:

Yeah. Yeah. So it’s I pinch myself off and I think about the fact that these really are the days that I dreamed of. I can’t believe that I get to do this every day.

Dr. Rebecca Dekker – 00:34:59:

So you recently transitioned from a role at a smaller community-based hospital to a major academic medical center as a nurse midwife. So what are you most excited about for this new environment that you’re going to be in?

Liz Carr – 00:35:13:

I’m really excited to be in a place that values the evidence and values implementing the evidence. And I’m also really excited for the opportunity to invest in the education of residents. I think it’s an incredible opportunity to invest in the future of maternity care, to get to help train obstetrics residents in labor. Birth is an incredible and sort of unique opportunity that not a lot of midwives get to have. So I’m really excited about that.

Dr. Rebecca Dekker – 00:35:47:

Yeah. So when you’re talking about being involved with medical residents, people who are our future obstetricians, like what are some of the things you like to show them and explain to them? Or role model, I guess I should say.

Liz Carr – 00:36:02:

Consent is a big one. So I have my little spiel before I do any cervical exam on a patient. I say, This is your body. You are in charge of it inside and outside of this room. If at any point during the exam, you need me to stop so you can catch your breath, check in with your body, check in with me, get through a contraction. You tell me to stop, I’m going to stop. If at any point during the exam, you need me to take my hand out and be done. If you say out, I’m going to take my hand out. The exam is done. No questions asked. And I think that it just, again, opportunities to hand people’s autonomy back to them.

Dr. Rebecca Dekker – 00:36:42:

And I’m assuming you asked permission to do the exam in the first place. How would you phrase that? Because this is about like the act of the exam. But how do you?

Liz Carr – 00:36:50:

Yeah. So. I will often just go in and just check on a patient. How are you doing? How are you feeling? Would it be okay for us to do a cervical exam? How would you feel about that? The reality is that this is a very medical model of care where I am. So most patients are pretty agreeable to doing a cervical check. A lot of them are being induced for one reason or another. And so it’s sort of an expected part of the process for them. But sometimes patients will say, I was really hoping to get an epidural. Great, let’s wait. Let’s wait until you are really comfy before we do a cervical exam.

Dr. Rebecca Dekker – 00:37:34:

Yeah, because there’s no need to really, if you can.

Liz Carr – 00:37:36:

Yeah, it’s not going to change.

Dr. Rebecca Dekker – 00:37:37:

Yeah.

Liz Carr – 00:37:38:

Let’s wait and let’s do it when you’re really comfortable. Can I have pain medicine before the cervical exam? Absolutely. Like, let’s ask her what you need and let’s give it to you. So those are important ways that I think sometimes get missed right in the busyness of training in a medical model of care is just Patients still have CHOICES. We can give patients choices and we should give patients choices about things. I think that’s so important.

Dr. Rebecca Dekker – 00:38:11:

Well, Liz, I’m really excited for all of the, you know, students, future nursing students who won’t be witnessing any unconsented episiotomies when they’re at a birth year attending. And, you know, the future residents who get to learn from your presence, you have a very healing. And positive presence whenever you’re in the room. So families are lucky to have you. Your coworkers are lucky to have you. And our listeners are lucky to be able to listen to your story. So do you have any words of wisdom or advice, maybe for nurses or doulas who are considering a path specifically into the nurse midwifery path that you chose? Any thoughts you want to share?

Liz Carr – 00:38:54:

I think that You should choose midwifery for a reason. And most people do. Most people are not becoming midwives because they think that they’re going to make tons of money and work great hours because that’s not the reality of being a midwife. So you should choose this work really consciously because you know that it’s exactly what you want to do. I think having yourself firmly rooted in that reason why you want to provide this care will help keep you going in the moments when it is really hard. When you lose your clinical site and you have no idea how you’re going to be able to finish your clinicals. It’s really important to remember why did you start doing this in the first place? The other thing is I think you should make your choices consciously. I made a really conscious choice not to work labor and delivery. And I’ve definitely met plenty of people along the way who question that choice or don’t agree with it. And that’s totally fine. But because I made that choice really consciously, really thoughtfully, it means that I can answer any question people throw at me about it. Because I didn’t just stumble into this. I made choices all along the way with a lot of thought. And I think if you do that, it allows you to stand firmly in those choices because you know that you made them for a reason.

Dr. Rebecca Dekker – 00:40:26:

One more kind of random question I just thought of, but, you know, one big challenge is clinical sites, but another is the cost of nursemen with free school. Were you working as a nurse at a facility that offered some tuition reimbursement or not?

Liz Carr – 00:40:43:

Yes. So I had some assistance with my tuition for the first portion of my program. The caveat with that was that they altered the program while I was in school to be, you owed time after graduation. For each. Course that they paid for. I knew, that they might not have a midwifery position for me after I graduated. And so I kind of calculated at the cost of, okay. How much is getting paid for in my tuition versus how much income would I potentially be turning down to continue working as a nurse if they don’t have a midwifery job for me? And so I did ultimately have to. Opt to do some loans for the latter portion of my program just because I did not want to owe time to a place that didn’t have a midwifery job for me.

Dr. Rebecca Dekker – 00:41:47:

Oh, that’s so funny because I remember making the exact same mathematical calculations when I went to graduate school because I was at the time working before I started grad school. I was a nurse in Michigan and they did offer tuition reimbursement and I could have gotten, you know, my master’s paid for, but then I did the math and I was like, wait a second, I’m going to owe them this many years and like I could be making this much elsewhere. So yeah, hard decisions for sure.

Liz Carr – 00:42:14:

Yeah, very hard decisions. And decisions that feel really overwhelming, you know, when you’re starting school, you’re like, I can’t think about when I graduate and where do I want to live and what setting do I want to work in? I don’t know yet. But I’m glad that I chose the path that I did because it, I think, has served me well. And I wouldn’t change particularly where I worked as a new graduate. It was like it was a good choice for me. It was a very supportive place.

Dr. Rebecca Dekker – 00:42:47:

What would you suggest people look for when they’re looking for their first midwifery job? Like any tips on you know, green flags, red flags, anything that is a good sign or a bad sign.

Liz Carr – 00:43:01:

So. Every single place that I interviewed said a couple of the same things. This place is like a family. Which is so loaded to me. I’m like, there are functional and dysfunctional families. So that’s, they’re using it as a selling point. And I’m like-

Dr. Rebecca Dekker – 00:43:20:

Well, it also can be a bit repelative. Like, we’re your family, so you have to prioritize.

Liz Carr – 00:43:23:

Very much so. Very much so.

Dr. Rebecca Dekker – 00:43:25:

That was common everywhere.

Liz Carr – 00:43:28:

I can’t think of a place I have ever interviewed that has not said that. They all say that. And then the other thing is that everyone will say, we really value like physiologic birth and midwives. And when I realized that every single place said that, What I did was I started looking up their C-section rates on Leapfrog. If you really value physiologic birth and midwifery care, let’s see. And that’s how I wound up in North Carolina, because I searched this little tiny community hospital and they had the lowest C-section rate I’d ever seen. And I said, that doesn’t happen by accident. And it doesn’t. The reason that the C-section rate was what it was is because the physicians who were here when I started really valued. They valued vaginal birth and they…

Dr. Rebecca Dekker – 00:44:30:

The priorities showed.

Liz Carr – 00:44:31:

Yeah.

Dr. Rebecca Dekker – 00:44:32:

In their actions-

Liz Carr – 00:44:33:

And also, interestingly, there’s a facility that does not offer VBAC. And I actually think that that influences how quick people are to do a Cesarean section. Because we know if we are taking a first-time birth giver and we are doing a C-section, if that person returns to us for care in a future pregnancy, we are saying that either they have to have a repeat C-section or they have to go and attempt to have a vaginal birth somewhere else. And so I think that that weighs into the decision when you know that you are, you’re sentencing people either to a repeat C-section or to never be able to deliver in your facility again.

Dr. Rebecca Dekker – 00:45:18:

In your own community.

Liz Carr – 00:45:19:

Yeah. And so a lot of the patients, some of them were born in this hospital, like they really want to receive their care there. And so it matters to them whether they can give birth there.

Dr. Rebecca Dekker – 00:45:33:

Interesting. I think, yeah, I mean, that’s so funny. I never really thought about how, you know, like in the EBB Childbirth Class, we teach people how to go look up the statistics of their hospitals. But yeah, if you’re looking for a labor and delivery nursing job, if you’re looking for a nurse midwifery job. It’s important to know for yourself what you’re getting into. So you’re not shocked or, you know, kind of traumatized by having these high expectations that they built up. And then you get there and realize you kind of. Not been told the full truth.

Liz Carr – 00:46:04:

Yeah. And I think that there are so many interesting things that go into this. Like, you know, one thing that I’ve heard a lot of midwives say is, oh, you should look for a facility that offers VBAC and TOLAC. And. I would have missed out on a really great place to be a new midwife if I had paid attention to that. And I think, there are some really interesting things I had never considered that go into some of those, some of the factors about patients who get C-sections and C-section rates. There were factors that I never really thought about before I worked in a community hospital. When you don’t have an anesthesia team that’s there 24-7 and it takes 30 minutes for your OR team to arrive. What that means is that sometimes things get better. I had a really interesting conversation with one of the OBs at my newer facility who said, oh my gosh, that is just so scary to like not have your OR team right there, ready to do a C-section right when you need it. And I absolutely understand that perspective. Because, all of the patients that she thinks need a C-section quickly get one really quickly. And so there’s never an opportunity for things to get better, right? The baby’s out. So you’re not going to see an improvement in your strip or you’re not going to see anything get better because the baby’s out. But for me, like sometimes I would call people in and be like, I don’t think that this is going well. I think we need to call in the OR team and be ready to do a C-section. And sometimes they deliver before then or sometimes things get better. And we say, actually, I think that we can wait. And so it’s really interesting having that perspective of being in this smaller community hospital where, yes, you cannot do a C-section quickly. And also, sometimes that means that you avoid a C-section that perhaps was not necessary.

Dr. Rebecca Dekker – 00:48:19:

Interesting. Yeah, it reminds me of my sister, Dr. Shannon, talking about learning from an elderly family physician in Eastern Kentucky in the mountains. And he showed her, you know, he taught her how he delivers while he never touches the baby as it comes out, you know, and she didn’t realize that that was even possible. And so it’s sometimes I think it’s true. You know, we get in these bubbles in different cities and we don’t know that there have been people who’ve been practicing for decades, even with very good outcomes who do things a little differently. So I always think it’s interesting to learn from people who are in different settings.

Liz Carr – 00:49:00:

Yeah. And I think one of the most important gifts that you gave me as a teacher was to ask about the evidence and to really dig into not only is there evidence about things, but also what’s the quality of it, right? And it made me realize there are so many things in obstetrics that you just, you can’t randomize and you can’t really know. It’s very difficult to know what is superior, hands-on or hands-off.

Dr. Rebecca Dekker – 00:49:27:

Yeah. The scientific method is difficult to use with birth.

Liz Carr – 00:49:31:

It’s very difficult. And so I think that awareness of not only evidence, but also what are the things that you’re never going to be able to get a randomized control trial on because you can’t randomize them and you can’t blind people to them. I think that awareness is really important because yes, you want to know what the evidence is, but you also want to know what evidence are you just not going to be able to get.

Dr. Rebecca Dekker – 00:49:58:

There’s a whole balance between you know, the science and the art of both nursing and midwifery and even medicine. You know, there are things that you use your intuition for and your, the wisdom that’s been passed down by countless generations of midwives. And then there’s things that we can study and figure out better paths that are less harmful.

Liz Carr – 00:50:21:

Because evidence-based practice isn’t just evidence, right? It’s the evidence. It’s the clinician’s experience. And it’s the patient’s preferences and desires.

Dr. Rebecca Dekker – 00:50:30:

And you were paying attention in Babies Are Not Pizzas.

Liz Carr – 00:50:32:

I was. I got a lot out of Babies Are Not Pizzas.

Dr. Rebecca Dekker – 00:50:38:

That’s awesome. I love how you can just like spout it off from, you know, internalized.

Liz Carr – 00:50:42:

It’s really, I think it’s really important. And it’s something that I bring up often, right? Is like, yes, the evidence is a piece of it, but it is not all of it.

Dr. Rebecca Dekker – 00:50:49:

Yeah. You don’t want it to be like a bad dictator.

Liz Carr – 00:50:53:

Yeah, exactly. Evidence is not a baseball bat.

Dr. Rebecca Dekker – 00:50:58:

I love it, Liz. Well, thank you so much for coming on the podcast and sharing your story. We really appreciate you. And we wish you the best in your next year of your career.

Liz Carr – 00:51:08:

Yeah. Thank you for being a formative person who helped me choose a path that was right for me.

Dr. Rebecca Dekker – 00:51:13:

Well, I think you chose your own path. You just, you know, got a little, some the right signs and people that came into your life at the right time.

Liz Carr – 00:51:22:

Yes. But I don’t know if you remember us once having a conversation where I said, I don’t know, maybe I want to be a nurse practitioner or maybe I want to. And you just looked at me and you said, Liz, you’re going to be a midwife.

Dr. Rebecca Dekker – 00:51:36:

Oh, no.

Liz Carr – 00:51:38:

No are you kidding that that memory like, I, I thanked it, and in the moments where I doubted myself, I said, Liz, you’re gonna be-

Dr. Rebecca Dekker – 00:51:49:

I love that because it’s like, yeah, sometimes I say things and I don’t, I don’t realize people take them deeply.

Liz Carr – 00:51:55:

No, you were completely right. You were completely right. So.

Dr. Rebecca Dekker – 00:52:01:

And you were like 19. I was like, no, or 20. I was like, no, Liz. Yeah, I mean, I can see it in you. It’s just you were already like a midwife in the classroom. You just hadn’t. Had the training.

Liz Carr – 00:52:16:

I know one of the best compliments people ever give me is, oh, you’re such midwife energy. I’m like…

Dr. Rebecca Dekker – 00:52:21:

Thank you.

Liz Carr – 00:52:22:

Great compliment.

Dr. Rebecca Dekker – 00:52:24:

Well, Liz, we see you and we appreciate you. Thank you again. This podcast episode was brought to you by the book, Babies Are Not Pizzas: They’re Born, Not Delivered. Babies Are Not Pizzas is a memoir that tells the story of how I navigated a broken healthcare system and uncovered how I could still receive evidence-based care. In this book, you’ll learn about the history of childbirth and midwifery, the evidence on a variety of birth topics, and how we can prevent preventable trauma in childbirth. Babies Are Not Pizzas is available on Amazon as a Kindle, paperback, hardcover, and Audible book. Get your copy today and make sure to email me after you read it to let me know your thoughts.