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Thursday
Oct132011

Interviewing a Homebirth Midwife (Part 5)

I'm continuing the line of questions as they come from the MothersOwnBirth.com site. I've found some questions are important and others useless. Here we go. 

"Do you keep statistics of your births and what happens at each one?"

As one wonderful LM I know said, one’s statistics do not really determine the safety of the midwife in question. Someone newer (like me) might transfer for something a more experienced midwife might feel comfortable keeping at home. Or, conversely, something an experienced midwife might transfer for, a greener midwife (not like me!) might not grasp the gravity of the situation and call for help. Therefore, a midwife’s statistics can be extremely misleading. If you are trying to see if you might be transferred for something, I would say there is zero way of knowing until after the birth. As much as any of us wishes it wasn’t so, birth can turn tragic (anywhere, not just at home) and help needed immediately. We certainly do all we can to eliminate risks, but there are simply unknowns that occur and, if I had to put a percentage on it, I would say almost all women (or babies) have the potential for needing help during or after the birth. This is why it’s so important to not go by something as variable and non-concrete as statistics. 

If, however, you want to know what she has transferred for, that’s an absolutely valid question. But, what do you do with the information? This is where the knowing what answers you are looking for comes into play again. Merely knowing why the midwife transferred/transported doesn’t answer how the situation came to be in the first place. For example, if she transported for fetal distress… was mom in labor for 25+ hours? Was she vomiting? Dehydrated? Starving? Wouldn’t change positions when asked to? Was there meconium? Was the baby post-dates? Early? Was there a nuchal cord or a compound presentation found afterwards? And we could go on and on. You see there isn’t just a cut and dry answer to many/most of the questions about transfers and transports. 

But, do you want to know the details? Are you prepared to sit and listen to case study after case study? Has the midwife’s sharing these details gotten approval from the mom? Is the midwife breaking her confidentiality agreement? This is an important part of her character, too. 

When you ask about transfers and transports, isn’t it true you are hiring the midwife to make these judgment calls? Your real question is, are you able to trust that this midwife will make the right decision for you if the situation calls for it… during your pregnancy, during labor and the birth, as well as postpartum. If you are unsure, keep looking. 

The same website above suggests you ask: 

"Are you a member of your state midwives organization?" 

Who cares? What does that have to do with anything? Many state organizations are a model of disarray and confusion. 

We all know the Better Business Bureau, right? How they are held up as a standard of how wonderful a business is if they are on their list? Did you know that to get on their list, all you do is pay a yearly fee? That’s it. Nothing more. When I owned my holistic healthcare center, I learned that everything from the Chamber of Commerce to getting articles in local papers was nothing more than paying for the privilege. Belonging to a midwifery organization is no different. One of the main reasons to join any group is to be on their referral lists. That’s it. No prestige at all in paying for your own advertising. 

"What is your hospital transfer rate (or, how many times have you had to go if it's low)?" 

We already went over this one above. 

"What happens if I go past 42 weeks?" 

As I mentioned in Part 2, you should already know what your community’s standard of care is on this issue. There is a lot more than comes before this question. 

“Do you suggest a vaginal exam when I get closer to term?” 

This lets you know she has a mindset that seeing what’s going on sooner than later can help know where the course of action might be headed. While I don’t think an exam should be done at 37-38 weeks like most OBs do, there is something to be said for one at 40-ish weeks. I’ve often said you can be 4 centimeters for four weeks and still hang out there for even longer or you could be long, closed and high and deliver by sunset, but the reality is those are the rare cases. The truth is that most women show early signs of “ripening” and these are helpful in determining what the midwife might start suggesting the mom do sooner than later. Some midwives suggest these “things to do” (Evening Primrose Oil [EPO] on the cervix, homeopathics if midwife and mom believes in them, encouraging a lot of sex and nipple stimulation, etc. starting at 37, 38, 39 weeks) for every woman either because they do not do vaginal exams frequently or because, in their experience, many moms benefit from these instructions. But, other midwives are of the mindset that the body will ripen in her own good time and these extras are superfluous for most women. These types of midwives still fall into two (or more!) categories; the never-do-an-exam-until-the-last-minute variety or the do-an-exam-and-let’s-see-what’s-happening-and-decide-with-the-information-what-to-do types. You get to pick who is a better fit for you and your baby. 

Have you had any women or their families dissatisfied with their care? Please explain. How did you handle this?

I’m not quite sure what the point of this would be except to possibly find out if the midwife gave money back to a dissatisfied client. A better question might be “If I’m dissatisfied with my care, how would we go about resolving the dispute?” The answers might be everything from taking it to Peer Review (where sister-midwives talk openly about cases and get advice from each other on what to do with complications or to process difficult births) to mediation. It is a rare… very rare… midwife who hasn’t had at least one person, for unexplained reasons, not be satisfied with her care. Each midwife handles it her own way and sometimes, the money is returned (or a portion of it), but not always. To me, as a midwife, if someone asks about disputes before care even begins, that’s a giant red flag against taking on that client, but not all midwives feel that way. And, as a pregnant woman, you certainly have the right to ask the question. 

A question not often asked is, “Do you have malpractice insurance?” The assumption is there isn’t liability insurance for homebirth midwives, but I recently learned that simply is not true. From the Midwifery Education Accreditation Council site:

“Do midwives carry professional liability insurance? 

“Most direct-entry midwives are not covered by professional liability insurance, unless it is required for practice in their state or for participation in healthcare plans. Some midwives cannot afford or choose not to purchase professional liability insurance, and at times it has been unavailable to purchase. Instead, most midwives rely on the personal relationships they have with their clients, conscientious practice, and the informed consent and shared responsibility with women and families that they encourage in their practices.”  

In other words, being friendly with clients is supposed to keep a midwife from being sued for negligence. I already mentioned how I feel about becoming friends with clients; it isn’t a surefire protection against losing a baby or a mother. Having malpractice insurance is not solely so clients can sue the midwife. It is also for times when a baby or mother have been damaged and need on-going care such as an NICU stay or a mother’s vaginal reconstructive surgery. Having liability insurance, to me, is the mark of a professional who takes her job and responsibility very seriously.

In my own state of California, I was led to believe no one offered malpractice insurance to Licensed &/or Certified Professional Midwives. Even the California Association of Midwives website makes no mention of liability insurance availability. If it weren’t for active consumers around the Internet dissatisfied with their homebirth midwifery care, I would still not know several companies offer insurance to homebirth midwives. Contemporary Insurance Services, Inc. is but one organization that sells insurance to midwives. While California’s midwifery law does not require malpractice insurance, it does require us to disclose whether we have it or not. I am currently not attending (as a midwife) homebirths, but I believe if I was, I would find getting insurance an important part of the professionalism of my practice.

Next: Skills Training for Midwives

References (1)

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    - Navelgazing Midwife Blog - Interviewing a Homebirth Midwife (Part 5)

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