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Saturday
Oct222011

Interviewing a Homebirth Midwife: Skills Training

Too often, when the discussion of a homebirth complication comes up, the ineptness of the midwife’s actions comes into play. How would a potential client know if her chosen midwife is up-to-date and practiced with her skills? I’m going to propose something completely unique to anything I’ve ever heard before, an addition to the interview process that might actually have a hand in 1) helping women choose the most competent midwife 2) help midwives practice their skills until they are body memories and can be done in their sleep… or during an acute emergency. 

Ask to attend a skills training session with the midwives so you can see who is the most adept handling the fake emergencies. You don’t need to know how she is supposed to handle a shoulder dystocia or a surprise breech because they will be discussing that in the session. You’ll get an idea of who the “leaders” are as far as teaching the skills (usually the midwife with the most experience in that skill) and who has the least knowledge about a certain skill. I believe just asking to attend this type of session would give you an enormous amount of information about the level of transparency and disclosure the midwives in your area offer. If you’re refused entry, that speaks volumes. If you’re permitted in, that also speaks volumes. 

Skills that should be observed:

  • Starting an IV
  • Suturing
  • Neonatal resuscitation
  • Adult CPR
  • Shoulder Dystocia resolution
  • Surprise Breech
  • Surprise Twins
  • Cord Prolapse
  • Postpartum Hemorrhage
  • Calling 911

It's unlikely you'll be seeing all those in one session, but that a group of midwives even putting on a public session says great things about their willingness to display their knowledge and skill.

I do agree midwives deserve to have a safe space in which to learn and grow their skills, but if holding a public skills session forces the wary midwives to practice their heads off for the event, everyone wins… especially the mom and baby. 

I look forward to feedback from moms about how this request works in your community.

References (4)

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    Response: Saleh Stevens
    - Navelgazing Midwife Blog - Interviewing a Homebirth Midwife: Skills Training
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Reader Comments (22)

I agree that it sounds like a great idea, but how many midwives actually are in a position to show skill training in this way? Generally, apart from CNMs and some very conscientious CPMs, homebirth midwives do not engage in continuing education. Often, the midwifery school they attended is either out of business or in a place remote from where they practice [just as an example, At Your Cervix is based in Pennsylvania, but is doing her CNM through the Frontier Nursing School in Kentucky, and is doing most of the work so far via the internet. I rather think that the hospital where she is working would decline any request to observe her at work]

This is part of the reason I want a national governmental agency in charge of midwifery is because continuing education is important. For example, there have been major changes in adult CPR in the past year alone [the Israeli HMO I work for requires yearly refresher courses in CPR, among other things]. Only if a certain amount of CME is made a condition for license renewal, will midwives actually do it, and it needs to be a nationwide requirement for uniformity of practice.

I would take issue with a midwife being allowed to deliver either breech or twins at home. The "surprise" element should not exist. If the woman refuses any diagnostic test to discover either the presentation or presence of multiple pregnancy, she should be risked out of being a candidate for home birth; it's that simple. A competent midwife, doing antenatal care in the home or clinic, should be able to suspect malpresentation or multiple pregnancy, and the diagnosis should be confirmed prior to the onset of labor.

October 22, 2011 | Unregistered CommenterAntigonos

I would LOVE it if our skills & drills sessions we open to the public for observation. We have to attend a drill/skill yearly as a minimum & I find them invaluable.

October 22, 2011 | Unregistered CommenterLiz

Part of why I specify homebirth midwives, which are, almost exclusively, are non-nurse midwives, is because drills occur in the hospital all the time, practicing as well as real life experience. As you can see by what Liz said, they have a drills practice once a *year*. That is absolutely unacceptable, as far as I'm concerned. I believe drills and skills training should be at *least* monthly. ALL skills re-learned/re-rehearsed every two months... at *least*. This was absolutely NOT done when I was practicing homebirth midwifery. If I wanted to practice, it was on my own.

Antigonos: I haven't ever met a homebirth midwife who was not up-to-date with NR(P) or CPR. And this was one skill the midwives I've ever talked to practice on the way to each birth, as well as several times inbetween. However, as we know from listening to moms who've lived through emergencies, even NR can be a deficient skill when the baby most needs it, so practicing this skill more than on the way to the birth... and in tandem... could help save a life. Arguing about HOW to do NR while a baby dies is, in the most understated way, vile.

Re: emergency breeches and twins, I agree it shouldn't be a surprise, but until ALL skills are up to par, surprises are going to happen.

I trusted a new mw when she said the baby was vertex, believing she knew what she was talking about, not checking afterwards when she palpated. Stupidest thing I ever did. When the baby was breeching, I called 911 and she had a crash c/s for her breech baby. I play and replay that experience over and over... kicking myself for not checking after the woman, not doing a vaginal exam myself during labor, wondering if I should have encouraged her to continue pushing, delivering the (primip) breech baby. I learned a LOT LOT LOT from that birth... and know I would never just trust another mw again, no matter how experienced I thought she was. If she was using my license, it was my responsibility to find the truth.

And, remember that not all homebirth women have u/s, especially near the end of pregnancy. And if a student/apprentice hasn't EVER felt/heard a breech baby, detecting one can be nigh on impossible if it happens with a real life client in labor. Sad, but true.

October 22, 2011 | Registered CommenterNavelgazing Midwife

homebirth midwives, which are, almost exclusively, are non-nurse midwives

What are the stats, if you don't mind my asking? I never cared much because in my area, all HB MWs are CNMs or they're underground (and I've only heard of a couple of those). Is this something that's more true in California? I could see "the majority" (in states that don't require a CNM-- and there are many of those), but "almost exclusively?"

October 22, 2011 | Unregistered CommenterDreamy

I like this idea of skill drills being open to observation. As a student midwife on the CPM pathway, I practice these skills as I learn them, and then monthly with other students and midwives. I also have practiced many of them with my preceptors, rehearsing how we would work together at a birth.

Just a couple of things in reply to the comments:

Continuing Education: CPMs are required to do continuing education AND stay current in CPR and NRP to maintain certification. Midwives who are not licensed obviously don't have these same requirements, though I think the majority of midwives enjoy continuing their education, and so do it. That last bit is a guess, based on the midwives I know personally, so it may or may not actually pan out to be true.

On surprise breeches: Babies have been known to turn in labor, I know of a few documented cases. So EVERY birth provider should be prepared for a surprise breech. Some breech babies who are planned cesareans end up being born vaginally, due to precipitous births, which is why hospital based providers also need to be prepared for a vaginal breech.
On the topic of diagnosing breech with U/S, I truly believe it should be a woman's right to decline an U/S. I may be more comfortable with an U/S to confirm or rule out any number of conditions, but it is not my body or my baby. I respect that.

And surprise twins: My stance on respecting the right to decline ultrasound stands. Surprise twins can also happen in hospitals, if a woman receives no prenatal care, so again, EVERY provider should be prepared for a surprise twin delivery. It would be hard to imagine missing twins, if a client had routine prenatal care, though. And taking on a homebirth client who didn't get prenatal care at all is not a low risk situation, so should not be done.

On requiring ultrasounds: However, as a midwife, if I suspected a breech baby or twins (or placenta previa/low-lying placenta, poly- or oligohydramnios, IUGR, etc, etc,), I plan to make an U/S a requirement to continue with a planned homebirth. Just because women have a right to choose does not mean I have an obligation to stumble forward without critical information that may affect the health of the mom and baby.

October 22, 2011 | Unregistered CommenterJD

Antigonos: atyourcervix is doing the _didactic_ portion of her courses online. Her clinicals are indeed not going to take place in one centralized location, but with a preceptor in a care center, just like a medical resident's. Her evaluations will be sent in to her program directors. This is no different than a non-distance MSN program. Frontier is an accredited nurse-midwifery program, with a good reputation, too. AYC will be a CNM and will have to earn CEUs to maintain her certification and her state licensure. I'm not a frontier grad myself but have met many excellent cnms from there, including several who are now professors in other programs.

October 22, 2011 | Unregistered CommenterKatie

ALL CPMs are required to have continuing education:

http://narm.org/accountability/ceu-information/

October 22, 2011 | Unregistered CommenterBirthkeeper

Birthkeeper: I'll tackle the CEU issue eventually, but for now, I'll just say the CEU requirements leave a LOT to be desired.

Re: Frontier Nursing Program, it is one of the most wonderful CNM programs in the country. I've known at least a dozen CNMs that came through Frontier and are some of the best midwives I've ever worked with. Katie is right, the book-learning/class portion is online, but the hands-on training is done in birth centers and hospitals around the country, usually close to where the midwife lives, although I have known students to travel to their preceptor's site for 6-9 months at a time. I loved learning the average age of a Frontier student was 35 years old!

Dreamy: I'm trying to find the number... and must be searching wrong, but if I recall correctly, only 3% of homebirth midwives are CNMs. The main reason for that is that CNMs are required to have OB back-up and we all know how hard it is to attain that, right? The CNMs I know that do homebirth, do *not* have OB back-up and are operating out of the scope of their CNM practice regulations. I imagine getting insurance is the same as for CPMs, though.

Great discussions!

October 22, 2011 | Registered CommenterNavelgazing Midwife

But not all states require CPM licensing to attend births. And in OR there is a HUGE political push to protect unlicensed midwives and continue allowing them to practice without having to conform to the requirements of licensure.

October 22, 2011 | Unregistered CommenterRebecca

Rebecca... not sure I understand why you were saying that. True, not all states use CPM as their licensing, but most who license, use CPM. And yes, on the OR front about the unlicensed mws. An-noy-ing.

October 22, 2011 | Registered CommenterNavelgazing Midwife

I think there should be skills trainings available to the public and privately as well. I could imagine feeling very loathe to ask questions in front of a potential client if I saw something I didn't understand or with which I didn't agree, because I wouldn't want to be seen as displaying my ignorance.

A good solution there might be to have FREE public sessions for midwives that everyone can attend, including homebirth clients, and then have the usual paid CEU skills sessions remain closed so that midwives can really ask questions and delve deep into improving their skills.

As for CEUs, I think as with most things a midwife will get out what she puts in. I am a really intense student and I hope that as a midwife I will continue to be that way. I can't imagine doing only the minimum for licensure - I've never done the bare minimum for anything in my life. The CEUs might be lacking (I don't know, I've not attended one yet), but I expect I'll get a lot more out of them than the kinds of CPMs you talk about in this blog. ;)

October 22, 2011 | Unregistered CommenterEmily D.

I did say that, Emily, that having public skills training would most certainly cause a LOT of *private* training/learning so they didn't look inept in the public displays. And that would be a fantastic side effect of the public skills demonstrations... safer moms and babies because the trainings were so often.

October 22, 2011 | Registered CommenterNavelgazing Midwife

Agreed. More training is unequivocally a good thing. I just can't imagine that any midwife who actually wants to serve women would disagree with that.

October 22, 2011 | Unregistered CommenterEmily D.

Emily: But you *are* seeing the numbers of women who *are* against it, right?

October 23, 2011 | Registered CommenterNavelgazing Midwife

Not really. The midwives I apprentice under are all about training, and my classmates and I share the attitude that you can never have enough practice. I believe that there are midwives out there who don't have that attitude, but I can't say I've ever met any.

October 23, 2011 | Unregistered CommenterEmily D.

Rebecca writes: But not all states require CPM licensing to attend births. And in OR there is a HUGE political push to protect unlicensed midwives and continue allowing them to practice without having to conform to the requirements of licensure.

As I understand it, currently 11 states do not permit midwives with ANY sort of qualification whatsoever to practice, and another 16 allow direct entry midwives with qualifications like CPM, LM, CM, etc. to practice as well as CNMs, while there are still a few states which simply define a midwife as "anyone" who attends a birth. Further, there are no restrictions on obtaining licensure in state X and practicing in state Y, whereas all registered nurses know that no hospital will hire an RN without a current license in the state where the hospital is located. I haven't worked in the US since the early 70s, but back then, the situation was that only NY and California licenses received reciprocity throughout the other states of the Union; licenses from many states were not honored, for instance, my DC license was not accepted in NY: and had I wanted to work as an RN in NY, I would have had to repeat my State Board exams [one of the reasons I trained in NY].

Because, unless they are on hospital staffs, midwives are essentially self-employed, there isn't any real way to control them. This actually is to the detriment of the profession. If women knew what they were getting, it would improve the standing of the profession.

October 23, 2011 | Unregistered CommenterAntigonos

I know of the Frontier Nursing School's reputation; in fact, it was the first American institution which trained professional midwives back in the days when degree programs in nursing weren't yet even a twinkle in anyone's eye. [I even thought of going there, but in the end went to Cambridge in the UK].

My point is that in some of the less-than-adequate programs, where one can do one's practical work in a place like Africa, rather than being well supervised in the US, the opportunity for cheating is greater. [I will be fascinated when AYC begins her clinical work; I wonder how she will be able to manage with her current job]

October 24, 2011 | Unregistered CommenterAntigonos

Barb, I am new to the San Diego area from Texas and i am due in the spring. I would really love a homebirth, but i have read previous post of yours stating there is only a very select few good HB midwives in this area. I am doing some research and and it seems that SD has A LOT of HB midwives. I am feeling very overwhelmed. Is there any way for you to recommend a few to me? Are their any CNM's doing homebirth or are they all LM's. Thanks in advance.

October 26, 2011 | Unregistered CommenterLonghorns

As I do on my midwifery page, I recommend Marla Hicks and Vickii Gervais. Both of them have extensive training and experience. There are a couple of others, but through interviewing varying midwives, you will be able to see who has the most experience. There are also a couple of CNMs here, so feel free to interview them as well. Hope this helps!

October 27, 2011 | Registered CommenterNavelgazing Midwife

"Ask to attend a skills training session with the midwives so you can see who is the most adept handling the fake emergencies. You don’t need to know how she is supposed to handle a shoulder dystocia or a surprise breech because they will be discussing that in the session."

Skills being open to observation by lay people is totally useless. Might as well ask the electrician to show me how he wires something. Beats me, I don't know if he's doing it right.

Why mess, when you can just go hire obstetricians who I know already have the necessary skills, attained by going to real universities, real medical schools and real residencies? I know that their skills were observed many times over -- by professionals who are qualified to critique, show them how to do it better, and so forth. Over 4 years and hundreds if not thousands of births.

Honestly, it's like there is a world of professional higher education and rigorous training that the midwifery community has no clue exists.

October 28, 2011 | Unregistered CommenterTired of Birth Junkies

Tired: laughing!
You are absolutely right about a lay person watching the skills training. My thoughts were women would be able to watch the midwives and see which ones were competent, which women were the teachers and which were the followers... that the teachers were the ones to choose from.

But, you are totally right that it's absurd that I even have to write a series like this because there are providers that offer women what they're looking for in a safe and educated way.

But, because all women are not going to choose OBs or CNMs, I wanted to offer a mechanism for women to have so they can try and separate the wheat from the chaff.

You did make me laugh, though.

October 28, 2011 | Registered CommenterNavelgazing Midwife

This is an interesting idea. I feel that any mother, especially a first-time mother, is going to be incredibly anxious about the whole experience. Feeling absolutely comfortable with their choice of midwife will be extremely important. Obviously the lay-person won’t know exactly what is going on in a training session, but observing how a person simply deals with each scenario could potentially influence a woman’s decision. Having another way to feel absolutely comfortable with the process and decision could be a great thing. Just the option to attend a public session would make me feel more comfortable.

January 10, 2012 | Unregistered CommenterKristi

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