This week I have been sharing some of the harder lessons I had to learn to become a midwife.  The value of humility is perhaps the hardest one I faced.

I thought I did approach birth with humility.  I believed I understood the process and knew that the best course of action was to let the labor take it’s course.  Yet, at the same time I failed to see how I approached birth with arrogance.

• When I would hear labor stories, I would decide for myself what doctors, midwives, doulas and mothers had done wrong despite not being present for the labor.
• I had answers for every problem a woman might face because natural birth was always possible.
• I assumed what I knew about birth was not only all there really was to know about birth, but also the most important things to know about birth.

I now approach birth with a different type of humility.

• I accept that there are things about the human body I do not know or understand.  I accept the ability of others to know and understand those things even if I currently do not.
• I accept that problems can arise in labor without anyone being at fault.  Babies and placentas can have problems despite the best health of the mother and care of the midwife.
• I accept that the hands and knees position and a doula cannot possibly be the answer to every problem.
• I accept that there are multiple ways to respond to a problem and most of them will give a good outcome most of the time.

I’ve been ignoring you…sort of.  I had to get through my final exams and the the last week of school.  Then I was visiting family out of state which, despite my best intentions on every trip, is NOT a place for me to accomplish any work.  Admittedly, I have been home and without classes for two weeks. But something unexpected happened to me…I had to transition to non-student life.

It wasn’t unexpected that I would need to transition, besides, I’ve done this a few times before.  The joke at our house is that I keep graduating because I’m good at it. What was unexpected, at least to me, was how I would balance all the things I had planned to do with all the things I had been putting off while in school.  What was unexpected was that the rhythm of life as a student, and the organizational tools I used as a student, would no longer be effective for me.

For example, each semester I made a list of all the assignments and projects for each class.  I then put them in order by due date because this was when they had to be completed.  But now, I don’t have ANY due dates except the ones I put on myself. These seem somewhat fluid to me, not because they are but because I haven’t put any dates on the calendar.  So for two weeks I tried to work on things without having my normal prioritization scheme – and really only made progress on one project (which actually had an outside deadline, go figure).

Another example, during the semester I have classes at scheduled times of the day.  This gave me natural built-in work times with “breaks” that I had to take.  But now I have lost the outside imposed stop times, and the urgency of getting my work done before class begins is gone.  This has made it very easy to slack off, and over the past two weeks I’ve noticed I waste more time than I actually work.

Added to all these structural changes is the uncertainty of my next step.  We haven’t decided yet if we will stay in Atlanta or if we will move.  We don’t know yet what type of “job” I will look for.  This has made it hard to want to prioritize the certification exams – a step which is priority number one for most graduating midwives. I need to decide which to take first, nurse practitioner or midwife.  And I need to balance this part of my work with updating the website — a task that has been on hold for four years!  And this needs to be balanced with publishing the results of my thesis — a task that is time sensitive due to the nature of research.

You see, I didn’t really plan well for my exit from graduate school. I couldn’t really give advice on how to do this better, some of it may just be the initial “shock” that all students experience during the move from student to worker. But I wanted to be honest about how much more complex this piece of the educational journey is, especially since I had not anticipated graduation would be difficult.

This week I completed my last final exam and submitted my last paper.  I have completed all requirements for both degrees and within a few days will be officially graduated.

What a strange feeling – to be done with school but not yet completed.  Before I can work, I need to pass the certifying examinations. At least to work clinically I need to pass the certifying examinations and then wait for the state to license me. I finished my last nursing class and took my final exam in May.  I’m not saying all the information is out of my head, but I am saying a review before the exam would do me well.  If I had only done one program, I would be ready to take boards tomorrow, or at least that is the theory.

So now starts a time of limbo – without a job and without the opportunity to apply until I get a license. It didn’t have to be this way.  Several of my classmates were offered positions at the practice that precept ed them. But I wanted different – I wanted to have as many different experiences as possible.  I think it was a good move – I am incredibly flexible in my skills.  I can work with very few resources and can adjust to different working styles and environments.  I’ve trained in a birth center, public hospital, a private hospital and in two public hospitals in low resource countries. I’m ready and capable.  It just means this first few months will have a shadow of uncertainty about my future.

My nursing school is hosting information about alternative breaks for student nurses thIs week. These are awesome opportunities for students with international aspirations to get their feet wet. The school organizes the trip, and the students often travel for a reduced rate and can use financial aid to pay the student portion.

At my school, both undergrad and graduate students are welcome. The roles send responsibilities are different, to match the growing skills. If you are in s university program, check to see if alternative breaks are offered.

I was reminded of a great resource for the US today when one of the collaborators gave a lecture in my HIV in Public Health class – have I mentioned how much I love studying at Emory?

The resource is AIDSVu, an interactive US map that lets you investigate the spread of HIV by state or county.  Why is this a great resource?  Because you might be surprised at just how much of the US is affected by HIV, or by what parts are affected.

For those who want to be involved in working with the most vulnerable populations, you don’t need to work overseas. You can work with large numbers of HIV+ women right here in the US. Check it out.

My clinical time this semester has been at an HIV clinic.  I finished my last “official” day at the HIV clinic today.  I still have two optional days I plan to go, and I cannot believe how much I learned through this clinical.  I started thinking I just needed to get an understanding of what HIV care entailed.  But three months later, I have to admit I love it.  I love the complexity of the patient’s issues.  I love that visits are scheduled for half an hour to really allow time to deal with real problems.  I just don’t love how much I still feel I have to learn.

But learn I will.  An HIV specialist midwife has a great ring to it.

I’ve finally decided on a thesis topic, and it isn’t an “international” focus. But it is… let me explain.

I will be looking at he birth to practitioner ratio it the USA, to see if there is a level of busy-ness that increases certain outcomes.  In other words, how many births can a doctor attend a year before we see problems.  Seems like a simple question, but has never really been answered here in the US.  Actually, I can find very little about it anywhere.

I did a similar project while in my BSN program in New York.  There were counties where the birth to physician rate was over 250!  This has significant public health implications because it shows a lack of access to care if the providers are too busy for new patients.  I know looking by county is not “fair” because women may travel for prenatal care, but if they have to travel is that not an indicator of a lack of access to care?

This project has major implications for policy for the USA.  But it also can give some information globally about the minimum number of providers needed to give safe care and avoid problems.  I’m very excited to start.

This is my first semester in residence at the school of public health.  All that means they are receiving my tuition money, because I still have a full course-load of midwifery classes in addition to the public health stuff.  So far the semester has been manageable, but I haven’t begun my clinical hours yet. Ask me again in a few weeks.

My program director found a clinical site for me in an urban hospital with a large under served population. My family practice clinical site will be in a more rural area.  And if all goes as planned, I will do a few hours each week in an HIV clinic as well.  Very exciting stuff, but a lot to juggle with 20 credits. I’m trying to get all large projects out of the way now so once the clinical hours begin I won’t feel too stressed.

I was also able to secure a spot for my practicum for the public health school — in Honduras.  So in all things are falling into place.  I’m just ridiculously busy, but I’ve grown accustomed to that.

Classes begin today.  This is my first semester in residence at the public health school which means in addition to the nursing courses I need to take to finish, I am taking a full course-load of public health.  I am also preparing for my thesis and my practicum.  So much to think about, but some of it is already under way.

I have done some searching and really like an opportunity to work with a childbirth advocacy group in Honduras over the summer of 2012 for my practicum.  I’ll give more details if it all works out. I’ll ask for connections if it doesn’t.

As for my thesis, I have found a group that is working to improve maternal health for rural women in Kenya.  They are seeking someone to complete work on training modules for rural health workers.  The project is very me, so of course I have submitted a resume.

And just because I want to see all sides of global maternal health, I boldly asked an alum in the global AIDS division of the CDC if there would be an opportunity to observe or meet with a member of the team in maternal/child health. What luck, it was an alum who is very interested in helping the new students make connections.  So I sent him my resume an have my fingers crossed that within the next few weeks I will be able to visit and see what improving maternal health within a broader campaign looks like.

Exciting stuff ahead this semester, but not only in the experience opportunities. This is the semester I am taking my lactation class, and a health policy and management class about improving access to care.  I’m excited about both.  I decided this summer to read a few of the books on the public health school reading list.  One of them is about the Bottom Billion countries and what economic policies help (or don’t help) to improve living conditions and why.  It is a different way for me to look and think about what a country needs.  While I am not nieve enough to believe everything the author says must be right, I am wise enough to understand that having grasp of the economic complexities of improving the living conditions in a country will only make me better prepared to do what I do.

And the final bit of excitement as I head out the door to class…I have permission to participate in the Sexual and Reproductive health issues class through the global health department.  I needed permission because part of the class is during one of my nursing classes–but both teachers are fine with the plan we have worked out.  The class will teach me not only what the different markers of health are, but how to find the data and analyze it.  In fact, I will be assigned a country, and my work throughout the semester will be finding the necessary data sets for that country, and doing the math myself.  I cannot wait!