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Sunday
Oct092011

Interviewing a Homebirth Midwife (Part 4)

Beginning the Questions 

So, now you’re sitting in front of the midwife. Be sure to never ask questions that can be answered in the affirmative or negative: 

  • “Do you attend twin births?”
  • “Are you a hands-off midwife?”
  • “Have you ever transported a woman during labor?” 

The biggest un-question of all is “Do you trust birth?” Asking this is opening the door to a dogmatic, cult-like belief in the minimization of all care, including care that is used in an emergency.

Open-ended questions are much better ways to learn about the midwife and her practice. 

From GentleBirth.org:

  • What is your general philosophy about pregnancy and birth? 

This question is really broad and should not be answered with a rehearsed statement. It was one of the most ambiguous questions I was ever asked and wondered if I answered it right each time because the answer can be so expansive. And someone’s philosophy can be incredibly different than what actually goes down at the birth. 

Instead of “What is your philosophy?” asking “What does normal birth look like to you?” can give you much more information. 

Asking what normal birth looks like to the midwife can let you know where her parameters are. Does she say a breech or twin birth is a “variation of normal”? This lets you know she’s on the liberal side of midwives, more amenable to delivering breeches and twins at home. If she is on this side of the spectrum, you might ask these next questions. 

  • “What is your experience seeing breeches and twins born?”
  • “Have you ever assisted with them? Tell me about the experiences.”
  • “Have you ever been the primary with them? How many and what were the outcomes?”
  • “How did you learn your breech and twin skills?”
  • “If we agree to birth either one at home, who else would you have at the birth?”
  • “Does she also have hands-on skills? Where did she learn her skills.” 

Through these questions, you’ll be able to see her exact experience with breeches and twin homebirths, as well as getting to know a part of where she stands on “What’s a complication to you?” 

Later, I’ll talk about neonatal resuscitation and hemorrhage which are vital to be explored with both breech and twin births. 

If there is no experience and she lets you know twins and breeches are out of her scope of practice, move to these questions that refer to the pregnancy and transfers, more than the actual birth. 

  • “What is the upper limit of a high blood pressure you would feel comfortable with at home? If my blood pressure started going up, what is the process towards eventual transfer?”
  • “What do you consider a fever in labor and when do you transfer for one?” 

Remember to know the answer you're looking for. If you are looking for a conservative midwife, it's important to know the standard of care is to transfer a woman if her blood pressure is 130/90 or 30/15 above her normal blood pressures. (If your blood pressure is usually 90/56, by the time your BP is 130/90, you could be having a stroke!) If you're looking for a more liberal midwife, one who doesn't stick to the rules of what most (medical folks) would consider safe, then knowing her answers will help you here as well. How she answers gives you pieces of the total picture of the type of midwife she is and a decent guideline-roadmap for a normal and inching-out-of-normal pregnancy and birth. 

Gentlebirth.org suggests this series of questions: 

“What are your guidelines concerning weight gain, nutrition, prenatal vitamins, and exercise? What are your standards for pre-eclampsia?” 

I’m not terribly fond of this line of questioning because the way it’s worded, it presumes the midwife believes preeclampsia is nutrition-based, which, it has been scientifically proven, not to be. I guess if you want to know if she’s still of the belief that the Brewer Diet can help a woman avoid or if she has preeclampsia already, the Diet can relieve the condition, that would be good to know, demonstrating she is not an evidenced-based midwife (some of the links have been locked for privacy), despite her possibly saying she is. 

I encourage you to spend as much -or little- time while in the midwifery consult as you need. If after ten minutes, you realize she isn't the one for you, do you both a favor and end the interview as soon as possible. You can always just say, "Thanks for your time, but I can tell we're not a good fit" and be on your merry way. I used to limit the time with interviews, frustrated at hearing the same questions over and over again, ones that were so unimportant in a homebirth interview:

  • Do you let the cord stop pulsating before you cut it?
  • Will you let me move around in labor?
  • Can I push in any position I want to?
  • Can I keep the baby with me all the time?

As if we were in the hospital. I felt bad that women expended worry and planning time on such basic questions that all have "OF COURSE!" answers. I most certainly answered the questions and also suggested reading materials so they'd get a better idea of what homebirth looks like, but wished I didn't have to go through them at all.

But now, I would take the questions and answer them with more inner patience, using the time to expose the type of midwife I am... one that sees/hears the same thing a thousand times and acts as if it is always the first time. I would not limit the appointments at all. I would not sigh if someone came in with a several page list of questions. I would not say, "We all pretty much have the same training, so pick the midwife you wouldn't mind spending 20 hours with in a small room" because it's not true. Choosing a midwife is not just about personality meshes. It definitely has elements of that, but it is not crucial to become friends with your midwife. In fact, I've found (through my own many mistakes) that not being friends keeps the boundaries clear and allows for decisions to be made autonomously by both provider and client. Each woman has the right and responsibility to keep mom and baby safe and having the space to give the sometimes difficult news of needing to transfer or transport can help the relationship stay in that professional -and trusting- place. There are no pity decisions being made, keeping a mom home because the midwife feels sorry for her, thereby risking the health and possibly life of the two clients. As I said, I learned this the hard way. More than once. If I were to begin my midwifery career again, it would include never (or only on the rare occasion) becoming friends with clients.

Next: More Suggested Questions from Various Websites & Why Not to Ask Them

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Reader Comments (6)

so... off the topic a bit here... but do you believe that pre-eclampsia is not at all related to diet? I do think that certain folks (mom + dad) have a strong disposition towards it (AEB current research in the field), but diet plays an important role. So.many.more. of our clients are at least mild pre-e at the hospital it seems. I do think it has a correlation to the diets/exercise and amount of self-care (and education regarding such) they have. Diet seems to be a strong piece of the puzzle, even if there hasn't been formal research into the role of diet in the broad sense. While the Brewer-diet is not EB, diet as a whole, as far as I know, has not been r/o as a contributing factor.

...It's important to realize that many of the practices we have are not EB- in and out of the hospital. They are tradition and culture based. And, most importantly, many things are not EB YET. Because some smart and forward thinker has to think "hey! this change in practice might help somebody!" and then put it into practice in their own microcosm of practice, devise a study, get backing, get funding, gather data, compile results and get published before it can be officially "evidence-based".

Also, I don't know if those two questions are meant to be run together. On their own, they seem very reasonable questions. I know of midwives that wouldn't have you in their practice if you didn't take eighteen bajillion different vitamins at different times of day and swear of juice for eternity. And I know of midwives that (erroneously/dangerously) believe that pre-e doesn't exist.

October 9, 2011 | Unregistered CommenterL&D RN

Good questions and thoughts, L&D RN!

Considering the risk of PE goes up with women who are obese and obese women typically have worse diets than "normal"-weighted women, diet, I believe, *does* have a place in the prevention of some/many cases of preeclampsia, but I do *not* believe the Brewer Diet itself, with the massive amounts of protein involved, can neither prevent nor, most especially, CURE, PE.

And yes, I *totally* understand that before there can be EB information there has to be discovery and testing and I of course do *not* believe there isn't new (or old) knowledge that hasn't been discovered or tested yet so it *could* get the EB distinction, but when they *are* shown to be erroneous and *do* have EB information and are ignored/denied, the person doing the ignoring/denying is not acting in the EB manner of care.

Does that make sense?

October 11, 2011 | Registered CommenterNavelgazing Midwife

Yes. I think that those questions are absolutely reasonable and give the client an idea of what to expect, and what is expected of them, in the care of that particular midwife. If they want to question and know about specifically the Brewer diet and the midwives' feelings about it to get a back-handed idea of whether or not the midwife is up-do-date on current research, they could just ask directly: "do you keep abreast of recent articles, studies and information related to midwifery? what professional journals/memberships do you subscribe to?" or something along that line.

Also, yes, obesity can have serious complications in r/t PE, wound infection, etc., but many of the people I see with pre-e, eclampsia, etc. are not obese. They have crappy SAD/fast food diets, and it's not uncommon for them to have them to be eating their burger king and dr pepper while we've got them on mag (usually this is a PP occurrence as they arent allowed to eat during labor [which is not EB, btw!]). uggh.

Also just realized you were writing that obesity increases risk of pre-e, not pulmonary embolism! doh! (although it does increase the risk of pulmonary embolism, esp s/p c/s!)

October 11, 2011 | Unregistered CommenterL&D RN

Yeah, I've seen the PE confusion before. ;)

And yes, better to be direct than underhanded, that is true. However, I cannot tell you how many providers would say they *do* stay up-to-date and not... who wants to admit they don't read squat after passing their exam? No one I know.

October 11, 2011 | Registered CommenterNavelgazing Midwife

agreed! however most obs don't keep up either :)
while I think that direct-entry midwifery is severely lacking in educational uniformity, this one isn't limited to CPMs :)

October 11, 2011 | Unregistered CommenterL&D RN

Thanks for this series of posts. Although I don't anticipate selecting a care provider (barring an oops caboose pregnancy...pretty cool trick for someone who's had fertility issues) I am sending friends who are considering midwives this way.

October 12, 2011 | Unregistered CommenterJenn

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