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Exposition Trail: Intro

It's true. I have real concerns about the level of education and training of many non-nurse midwives. I first confessed my beliefs in a 2008 post called "Midwifery Education." That post was so reviled and I was smacked so hard by the midwifery community, I pulled, then edited the piece, now called "Midwifery Education (Lite)." In that post, I said:

"I like that nurses all go through the same courses. They don’t all have the same experiences, of course, but all have the concrete base. All that “boring” stuff I mentioned above lays a foundation of commonality that continues into the Master’s Program a nurse enters to get her midwifery degree.

LMs and CPMs come from a wide variety of backgrounds and that can be great and not-so-great. Some, like me, tried the apprenticeship route, but found working with many different midwives was a better fit. I also didn’t have the foundation of a MEAC-accredited school, something I think is imperative today and something I definitely missed out on. I know there are non-MEAC schools and they might be phenomenal, but the way our society leans is towards accreditation and having the MEAC approval means the schools went through some pretty tight hoops to get where they are. I’ve considered going through one of the three-year schools even now, but know I want a different type of experience than what MEAC-schools have to offer."

I ended the post enrolled back in school, wanting to become an RN and then possibly CNM. I just knew I needed and wanted more education.

A lot has happened since then. To me and to others. I've kept my eyes open and have seen some rather harsh experiences in birth, too many at the hands of non-nurse midwives.

Below, I share a part of the birth story from Natural Birth Goddess' blog... the January 23, 2011 Homebirth of the Twins. Even though I've been formulating this series for some time now... and it's certainly picked up momentum since I've left homebirth midwifery behind... this birth story is the perfect springboard to emphasize the crucial importance of education and skill in a homebirth midwife. While this birth took place in a midwife-illegal state and many have equated that aspect as an excuse for the midwife's actions, I know (because I've heard it several times) the same sort of actions happen in midwife-legal states.

I'm sure to piss off a whole lot of folks by my trip down Exposition Trail, but so be it. I know my thoughts are the thoughts of others, women who spend time in my email and on the phone, not knowing who to go to or who to report their midwives to. And I have similar thoughts as other midwives who also think formalized education can transform homebirth midwifery. But that story will unfold with time.

For now, sit as I did, in disbelief at what I was reading.

"I got about 5 minutes to nurse both babies and cuddle them before the second placenta (Ariana's) was birthed.  I noticed, immediately, however, that there were some large blood clots that came with the placenta (the first placenta had not been birthed, yet).  That concerned me greatly...and although the midwife reassured me that all was fine (I mentioned it repeatedly that I was concerned about the blood clots) but she immediately started giving me herbal tinctures to help with contractions and stop bleeding.  I didn't think much of it at the time.  I was just focused on getting the first placenta delivered (and worrying about the blood clots). 

However, as I pushed, I would feel gushes of blood.  Since I had hemorrhaged before with the birth of my second child (Adrian), I knew the signs all too well.  I had mentioned the bleeding to the midwife and she was still reassuring me that all was fine.  She had me changing positions (standing, squatting, sitting, etc) and pushing.  Nothing was happening.  Nursing the babies didn't help, nipple stimulation didn't help.  I asked several times about the clotting and the bleeding and stated, "I'm hemorrhaging" and she reassured me that all was going along fine.  I got to the point where I felt like I needed to lay down (I was still in the bathroom).  My husband helped me to the bed where I laid down and pushed a few more times.  I remember feeling like my energy was slipping away.  I felt weak, I felt cold and I wanted to say something and I couldn't say a word.  I looked over in to the bathroom and was shocked at the amount of blood that was on the floor, the towels and the chux pads.  I tried to say something to the midwife about the blood, but I couldn't get the words out (I knew this was bad)...at that point, she put the oxygen mask on me. 

I remember my mom asking the midwife if she was going to call the ambulance.  I remember the midwife was sitting at the end of the bed and said, "I haven't decided, yet."  At that point, my husband grabbed his cell phone and called the paramedics.  My husband called for the ambulance at 7:05am.  Almost 35 minutes after I first noticed the blood clots.  As soon as the paramedics were called, the midwife and her assistant grabbed all of the bloody towels and put them in a garbage bag, mopped up the floor quickly, and threw away all of the chux pads.  The midwife even changed the chux pad that was under me, and full of blood. 

When the EMTs arrived, I had a little blood on the chux pad.  My husband had told them I had hemorrhaged and was losing a lot of blood.  I remember seeing 2 of the paramedics look at me (and the not very bloody chux pad under me) and look in the bathroom and not move any faster.  There was no urgency. 

After what felt like an eternity (they asked me if I was having problems with the last placenta, and the midwife mentioned I had been up for 30 hours--which was a total lie) they took my blood pressure (which was very high) and strapped me to the gurney, got me into a (very) cold ambulance.  The last thing I really remember in the ambulance is getting the IV inserted...and the one female EMT saying, "I think she lost a lot more blood than we saw..." 

When I was finally on the Labor and Delivery floor, we waited for the doctor to arrive.  Once she got there, I was given Cytotec (to increase the contractions--and it did this very effectively) and some pain killers (the contractions were that bad--and I could not imagine being induced with Cytotec, which is dangerous, anyways).  The placenta was delivered within a few pushes and I laid down on the bed.  After an hour or so, I wanted to get up to go to the bathroom (couldn't stand the thought of a bedpan) so the nurses helped me--reluctantly because they wanted me to use the bedpan--and I almost immediately passed out.  That is the last thing I remember until several hours later. 

Just after I passed out, I was started on blood transfusions.  I got 3 units of blood that day.  The doctor (who was absolutely great) wanted to keep me overnight for a 4th transfusion, but gave me the choice to go home since I  was eating, looked good (all my color was back and I was coherent).  I chose to go home that day because I wanted to get home to the girls since I had spent the first 14 hours of the girls' life in the hospital without them.  My blood count was in a "safe" range and the doctor was ok with me leaving. 

While I was in the hospital, I had 2 really good friends drop everything that they were doing to wet nurse the babies since I really wanted to avoid formula feeding them.  I cannot tell you how reassuring that was for me.  To know that the babies were being well cared for and fed while I could not be there just took so much stress and worry off of me and gave me the relief I needed to get well enough to get home to them. 

The next few days were a bit of a haze (as it is for any new parent).  The twins started out on very different sleep and nursing schedules that I was only getting about 45 minutes of sleep at a time.  I did have friends and family over all day long that helped with my other kids so I could spend all my time in bed resting and taking care of the babies.  It took about 2 1/2 weeks for me to really get used to having twins.  But I found, despite most other advice, that keeping them on their opposite schedules actually suited me (and my family) very well.  With not having to nurse, burp, and change 2 babies at the same time all the time, I have the time to really spend with each girl. I can nurse, change, and burp each individually and then cuddle with each one by themselves.  I really love the one on one time I spend with them. 

Overall, my homebirth was very good.  Excellent, even.  I did learn, though, that if there is any apprehension or concern about anything that is going on during the birth, you have to put your foot down and make the decision for yourself.  You are in charge of your birth, every aspect of it.  I should have told the midwife that I wanted to go to the hospital immediately when I saw those blood clots.  I don't, completely, blame the midwife for not transferring me sooner, but I do think she waited too long."

Mom wanted me to share the story. At first, the midwives she'd shared the story with told her everything was fine, to just move on. It wasn't until I read and commented on the story, followed by other midwives reiterating her midwife's egregious inaction that she began to believe she had a right to be angry. She has not seen or spoken to her midwife since the birth. I've counseled her to wait awhile, until she's somewhat healed from the anemia and twin birth before scheduling a sit-down meeting with her.

Mom also wants it known that she consciously chose to homebirth, that she felt her options were more dangerous in the hospital, a vaginal birth in the operating room or a scheduled cesarean, but she had discussed, at length, the seriousness of her hemorrhage history and how the midwife would handle a PPH if it happened again. She convinced the mom of her skill and experience in this area; she obviously lied.

I was shaking with fury for over an hour after reading this story. Part of my anger is the increasing frequency of these stories. Something has to be done. And the only people to do something is us... if we don't want to watch homebirth midwifery be illegalized everywhere in this country.

My writing is so we can talk, openly and transparently, about the changes we must make to homebirth midwifery... changes that, literally, saves the lives of mothers and babies.

References (1)

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Reader Comments (31)

And it's definitely not just homebirth midwifery. This kind of thing is happening in birth centers all the time, too. Midwives, licensed or not, are NOT listening to mothers. Unfortunately, along with a hard-earned midwifery education, midwives are getting a huge dose of ego, and they begin to believe that they know more about a mother's body than the mother herself. The mother is reprimanded repeatedly when she voices concerns based on her own instincts. "I am hemorrhaging," says the mother. "No, you're not," says the midwife. The mother assumes that the midwife knows best since the midwife went to midwifery school and the mama did not. So the mother shuts up, and then she hemorrhages.

It makes me absolutely sick to my stomach. The only way this is going to stop is if/when midwives let go of their ego and start LISTENING TO WOMEN. This is why we're midwives to begin with, isn't it?

To me, this has less to do with education and more to do with knowing your own limitations and when you have to let go. Midwives, be honest with your clients. Tell them the truth when they ask what your protocols are. Allow them to make the decision about whether or not they feel comfortable with you being their midwife--refer them graciously to someone else if they request. Know in your heart what you do *not* feel comfortable handling at home. The minute something comes up that is beyond your ability to manage, let it go--consult, refer, or transfer. Keep mamas and babies first. Forget about ego, forget about pride, forget about reputation. Learn from your mistakes, and take criticism as a chance to begin anew. This is what makes a good midwife.

Peace to all.

March 6, 2011 | Unregistered CommenterMelissa

Some day I am going to write about my thoughts for where I'd like the CPM credential to be headed...in a nutshell, I think NARM should voluntarily upgrade the CPM to a 4-year university degree in a series of steps. First step should be to require a bachelor's degree as a prerequisite to taking the exam and becoming a CPM (perhaps beginning with either associate's degree in nursing/midwifery or bachelor's in anything). Then we could start moving the CPM education process into the university setting, preferably a few state universities first with extensive online/distance learning components since many midwives are "non-traditional" students. So many of the relevant courses are already offered at state universities, from basic A&P to pharmacology to bioethics to women's studies. Anyway I have a lot to say about this...and of course it would only work once the CPM credential were close to universally recognized in the 50 states...but I think we've got to upgrade the CPM educational process, and soon.

March 6, 2011 | Unregistered CommenterRixa

Barbara, I share your concerns and am always suspicious when my friends tell me their home birth midwife is direct entry. I'm hesitant to start asking too many questions about their experience and education because in most cases my friends have already bonded with them and become defensive when I start to ask questions.

In your opinion what is the very best route for someone to take to become a midwife? Right now I'm only just beginning my doula training with DONA but I have some birth experience observing birth in women since I was little and assisting farm animals give birth since I was 12 years old & I also worked as a CNA for 2 years. However, there is no way I would ever try to pass myself off as any kind of midwife! I very much would like to become a midwife but only with the confidence of extensive schooling under my belt.

March 6, 2011 | Unregistered CommenterRain

I think this story illustrates why midwives need to be integrated into the health care system, including collegial relationships with back up docs and hospitals. I am a midwifery student in WA state, and my preceptors are able to call 911 and transfer a client to the hospital or call their back up docs for non-emergent transfers. Granted, it's always a stressful situation when you have an emergent transport, but they don't hesitate to call 911 and they can communicate to EMS as a health care provider (e.g. giving the mom's estimated blood loss, pregnancy history, etc.)

In Canada, midwives agreed to a required university-based education in order to integrate into the health care system. It's not perfect there and they had to make concessions, but their care is much more widely available than midwifery care in the U.S.

I think we are also headed in the direction of college or university-based midwifery education. Perhaps community college-based didactic learning paired with clinical preceptorships.

I hope the mom and her family are doing well.

March 6, 2011 | Unregistered CommenterEmi

I don't know if you are aware of Liz P's story, but her daughter died during labor at home because her CPM in TX missed clear signs of chorio and abruption. If you want to read Liz's story, it's on her blog at ecmama.blogspot.com. And she went through the proper channels to report her MW, and the midwife got off with a fine. She is still a *preceptor* for other midwives, and obviously isn't required to disclose what happened with Liz's baby.

For my CPM story, my most recent birth was at home and it pretty much went to hell in a handbasket. Too fast a birth, not great Apgars, then my baby seemed to be coming around and then she crashed and stopped breathing. We called 911, and the paramedics were getting us into the ambulance but wanted us to grab the carseat for transport (which was dumb, but whatever.) The CPM (whom I had never met, and who was present as an assistant) literally was standing in the driveway arguing with the paramedics. Between the delay going for the carseat and the delay because of the arguing with a newborn in respiratory distress, it took us a lot longer to get to the hospital than it needed to. I didn't *care* about the stupid carseat drama. I was scared and needed my baby to a respirator ASAP. I didn't need someone on my care team fighting with paramedics over something ludicrous.

March 6, 2011 | Unregistered CommenterHBMomma

Its a shame that CMs are only licensed in 3 states (NJ, NY, RI), because I think that is the best for midwives who do not desire to become RNs first. Personally, I think LMs and CPMs should be given so many years to get the education and pass the exam and become CMs. Philadelphia University has an online CM program. The requirements for admission are pretty extensive.

I think it is incredibly important to discuss DEM's qualifications. Not all programs are created equal, and its important to have balance between the extremes.

March 6, 2011 | Unregistered CommenterJen B

Thank you for keeping this discussion alive, Barbara. As a candidate for the Master of Science in Midwifery Program at Bastyr University, I am very interested in the educational requirements/expectations of licensed midwives. I already have a B.A. in Gender Studies and Spanish (double-major), but needed to do five science classes as pre-requisites for the Bastyr program. Most of my classmates are hoping to go on to nursing school.

We have a great CNM program at nearby University of Washington, but I am not interested in being a nurse. I want to be a midwife. I am so thankful for Bastyr's science-based, 3-year program. Aside from being excellent preparation for practice, I feel like it is a great step toward professional recognition amongst others in the birth vocations. I want my education to be rigorous and scientifically-based. I want to feel like I have a solid foundation when I enter practice. I want the perception of "midwife" to be elevated to the level of professional practitioner that one should expect in any healthcare provider.

I understand that there is a great deal of knowledge and wisdom that comes from outside the classroom, so I have mixed feelings about lay midwives. I would like to see an educational process that incorporates the wisdom of people who started practicing long before there were educational requirements, but I believe that we would all (practitioners, mamas, and babes, alike) benefit from a standard that requires higher education in the field.

March 6, 2011 | Unregistered CommenterArya

I read the birth story - and gasped a little. We don't have home birth in our community right now due to a midwifery shortage for midwives in our community (laws and legislation which has made midwifery a funded practice also outlawed any practice of midwifery at all until it could be re-invented, kind of like the wheel). I don't *think* it will happen once it comes back, I know the current plan is to re-work and get the program up and running with two midwives attending each birth (and not a birth attendant/second assistant/RN trained in NRP etc).

Working in health care - I've seen fellow degree nurses make some hasty decisions in emergent situations. Not necessarily birth, but other situations. Recently two nurses in our area were given their jobs back after initially being fired for putting babies on pediatrics in closets to cry. It's ignited discussion in our community about the travesties of health care. It does happen in other cases where health care professionals are negligent. Do they ignore the signs? Do they ignore their training? Are they perhaps above their patients and providing excellent care? I think so.

I don't know that certification/regulation is always the answer, but I'm sure it provides recourse in some situations and accountability to the public. Unfortunately I still think it will happen.

March 6, 2011 | Unregistered Commenterrhonda

I think Melissa's comment is a good one. I am someone who became a supporter of homebirth because she appreciates the scientific evidence in support of no-/low-intervention birth for low-risk women (and doesn't see this happening easily in most hospitals, etc.) I am in support of homebirth in the US BECAUSE my mother is a doctor, and a scientist, who loathes unnecessary interventions in medicine and throwing scripts at patients, no matter what the medical specialty.

As such a woman, I am frustrated and nearly-baffled when I see women say things like, "Oh, I trust my midwife" when that MW suggests (what appear to be) dangerous or unnecessary courses of action on either end of the spectrum. I'm not interested in herbs if they haven't been proven to be non-harmful and/or been proven to be helpful. Not any more than I'd be interested in drugs (it's a fine/legal line between the two anyway). I don't want my MW to "trust birth" so much that she makes a grave error-- or even just tells me I'm not feeling what I'm feeling (say, an inordinate amount of pain)-- just as I wouldn't want an OB or L&D nurse to push drugs on me because I "must" be feeling tons of pain, when I'm coping well. I'm not going to allow my MW to dictate non-emergent courses to me any more than I would an OB. And conversely, I am not going to do something highly-interventionist and unnecessary because it comes from a MW's mouth instead of a doctor's*. YKWIM?

On some level, of course, one does have to trust one's care provider-- to some extent. But in some cases-- I think sadly, frustratingly-- MWs are just as arrogant and dictatorial and pigheaded as the worst OBs. And, though I am loathe to harp on "personal responsibility," some women are happy to abdicate responsibility to a MW as much as they would be to an OB. In a way, I don't blame them-- we have all been indoctrinated with this mindset from birth. But that's what it is-- the same "doctor as God" mindset. Just because it's dressed up in a long skirt doesn't make it more trustworthy, natural, or better.

But we are in a bad position-- even where midwifery/homebirths are legal, mothers are afraid of discontinuity of care, of being ridiculed or abused if they need to transfer, etc. Not to mention-- women in labor or just having given birth are not necessarily in the most rational state of mind (duh). So I can see why someone would hesitate in this kind of situation-- to "want to believe." :/

*Just thinking here of a woman I know whose story was a classic case of the cascade of interventions, ending in a C/S for "FTP/CPD" after 30 minutes of pushing. Induction at 39.5 weeks in a FTM with no indications of any issues, baby was 6 lbs, 12 oz., etc., etc.-- like I said, classic case, at least from the details I heard, which were many. But the woman told me she was sure the C/S was necessary specifically because she had a CNM, and MW's don't "lie" "like doctors do."

March 6, 2011 | Unregistered CommenterDreamy

This is why I love your blog. You don't allow allegiance to a "side" prevent you from looking critically at things that go on in homebirth and natural birth circles. I have read quite a few stories where midwives did not transfer despite there being warning signs of a problem and they always really upset me. How can we expect those in hospital obstetrics to look at what they are doing and change it if it is not what is best for women and babies if we are not willing to do the same? I think you are right that midwifery education needs to change. If I eventually decide to become a midwife, I will probably go the CNM route, though I really wish we had a training system here in the U.S. where midwives could get experience in both in-hospital and out-of-hospital birth, like they have in many parts of Canada.

March 6, 2011 | Unregistered CommenterBirth Unplugged

this gal got lucky.

Barb, please keep up the truth telling.It is the only way this will change.
I adore your new trajectory.

March 6, 2011 | Unregistered CommenterAnonymisssmartypants

This was an absolutely fascinating article, on a subject which I've really never considered. Our CPMs out here in Arizona are so incredibly professional and well-trained that I've never really heard of a case like this. I'll be interested to read more comments and to see what you have to say in the future. I took this link from a comment above (http://ecmama.blogspot.com/) and spent an hour reading that story as well. Do you have any comments on that situation as well?

Thanks always for what you do!

March 7, 2011 | Unregistered CommenterDiana

Yeah, I've been in touch with Liz (Aquila's mom) and what's the most wonderful about that situation with regards to homebirth is she doesn't believe homebirths are inherently bad/wrong, but that midwives need *much* more training and that they need to disclose their skill level... HONESTLY disclose it.

Lucky you not having heard of cases like this. Interestingly, women are coming to me for second/third opinions about their births, giving me access to their medical/midwifery records, asking for help processing the experience and I've even now begun helping women formulate formal complaints to midwifery and medical boards.

Is it really so hard to find a midwife to believe these women? Apparently, it is.

March 7, 2011 | Registered CommenterNavelgazing Midwife

This speaks volumes to me. And gets my BP up. So I'm going to rant a little. Skip reading if that bothers you. :-)

First rule: ALWAYS LISTEN TO THE MOTHER! PERIOD. Awesome revelations come from mothers' mouths during labor and delivery, and wisdom is sifting through the usual "I can't do it" during transition, and hearing the important words being spoken. Those words should give you chills up your spine - you can't miss them if you are listening. Education cannot give this to you (and may in fact beat it out of you, replacing it with the arrogance of "knowledge"), you must develop within yourself the ability to truly hear.

Second, question and comments:
Why didn't the midwife have Cytotec...and pitocin...and methergine both oral and injectible, in addition to the herbs? I carry all of those including the herbs, and damn well would have used them the minute nipple stim and gentle fundal massage did not work and/or the mother expressed concern. No way would one of my moms be gushing blood for longer than the few seconds it takes to grab something to stop it. And if pit doesn't work because the oxytocin receptors are already maxed out, I go instantly to something else. I'll patiently wait eons for a placenta, but only milliseconds for bleeding to stop. How else would you rule out a more serious complication in time, that DOES actually need transport??? My motto is "No drama, no trauma - just fix it, quietly and fast."

Also, why were the EMTs not informed of the amount of blood loss???

I know there are "legal" midwives out there who might do something similar, but probably not if they are allowed by law to carry the right meds and be trained to use them. Being legal and having the authority to use the things you need to use are NOT the same thing, as some states are short-sighted enough to not even let midwives carry oxygen, as if they are TRYING to set them up to look incompetent. So I do feel like this is a state law issue, like most home birth midwifery problems are. In her state the midwives are not legal and so of course are not allowed to use anti-hemorrhagic meds, nor required to demonstrate the training to do so. In my state we are allowed by law to use them, and very much expected to if the situation indicates the need. So we do, and don't transport moms for LITTLE things like hemorrhage (that can turn into a big thing if your laws are messed up) because we stop them ourselves before there is much blood even lost.

I suggest bombarding the legislature in your state with information from midwives in states where we have lots of authority, like Washington, to show them how to write better laws to protect mothers and babies.

I am not a CNM, I am an LM in a state where the requirements to be licensed are actually tougher than they are for a CNM, and we have more autonomy to show for it. I do believe in very tough testing for licensing. I do not feel like I missed anything by not going to nursing school; my daughter is in a "good" nursing school and says their clinical program is determined to create the blustering Nurse Ratchet attitude (their motto is "fake it til you make it") - she is top of her class but hates it, finds the training to be very patient-unfriendly and not promoting safe practices. Also a 4-year program would have been cost/time prohibitive for me; a good 3-year+selective-prerequisites gave me plenty of subject-relevant education and thank goodness it wasn't longer. My main preceptor was an OB and I ended up being put on as a staff OB/GYN provider at the large clinic where I trained. (How's that for breaching professional-cultural walls?) That said, I am now totally a home-birth midwife. I am fortunate to have a great partner LM, who can be trusted to make excellent (and fast) clinical judgments without me, and feels the same way - listen to mothers and never let a problem develop, and if you do that then you can interfere as little as possible for the best outcome. Letting a problem fester, until you have an anemic mother or have to transport, is not the best outcome or the least interference!

Stories like this are totally unnecessary, and should never happen. This was not something difficult to handle, it was an emergency that never should have developed - it should have been stopped almost immediately. Very sad to hear, and makes me mad. Change your state's laws!!! I know it isn't easy, but the ammunition is out there. Those congresscritters are not special, they are mere mortals and did not pass an IQ test to be elected - go demand that they do their jobs, and take a few hundred home birth mothers to the state capitol with you to get their attention.

Sorry to be so practical, but...well...I actually live by my motto. :-)

March 7, 2011 | Unregistered CommenterHighlandMidwife

Barb, I really appreciate your thoughts on this and agree that more uniform and higher educational standards for non-nurse midwives would be good for women and for the profession. However, I remain unconvinced that improving education requirements is going to cure the problems you seem most concerned about. We're always hearing about how much education obstetricians have but we know that doesn't make them better attendants for normal birth. It does better equip them to deal with complications and life-threatening situations... but it doesn't mean that none of them ever do poorly in those situations. I've also read of plenty of instances of CNMs practicing in homebirth who did things in emergencies that seemed super-sketchy. Or CNMs practicing in hospital, for that matter. I'm just not sure that "more education" or "a college degree" or "a standardized, college-level science curriculum for all midwives" is ever going to eliminate a problem of midwives acting irresponsibly in emergency situations. I'm sure there's a lot that can be done to REDUCE that happening, but you'd still be able to find stories to get outraged about, right? Just some thoughts.

March 7, 2011 | Unregistered CommenterNora

Why in the world would we want to skip this comment?! It was fabulous. Thank you for taking the time to write it out.

"... would have used them the minute nipple stim and gentle fundal massage did not work and/or the mother expressed concern...."

Remember, in this case, there was still a placenta inside, so massage could have been disastrous. With singletons, absolutely.

Your style is more like mine. I have a zero tolerance for hemorrhage. I think I might have gone through more pit in my midwifery career than any other 6 or 7 midwives. Part of that is I am not an herb-user (clients know this), so am sure that makes a difference, too.

You say, with regards to moms telling the provider something is wrong:

"Those words should give you chills up your spine - you can't miss them if you are listening. Education cannot give this to you (and may in fact beat it out of you, replacing it with the arrogance of "knowledge"), you must develop within yourself the ability to truly hear."

Of course I will dispute the education beating the trust in women's words out of you. Listening to women's words is a WHOLE lot different than intuition, which *can* be over-ridden by "knowledge." If the education is appropriate, listening is a vital part of the class. If the midwife doesn't listen, she's deaf and missed a crucial day/week/year/lifetime of lessons in midwifery.

And in all the reading I've done about this birth, one thing I haven't seen is the woman shouldn't have HAD to tell the midwife something was wrong, even once (afaic). She hired the midwife to tell HER something was wrong and then ask quick permission to treat/help and then DO IT.

Sure, moms *do* tell their providers something is wrong, but that's usually with an occult something, not a visually obvious problem.

Re: marching on the Capital in the states where midwifery isn't legal, it isn't the Legislators that are the problem, it's ACOG and their very wealthy Lobbyists. Sure, the Legislator is the one who speaks for the people, but the people they tend to speak for have the most money. Disgusting, but all-too-true as we've seen in states that get *this close* to legalizing midwifery and then it's blocked at the last minute.

I wish it was as easy as gathering a hundred-plus women to march on the Capital steps.

March 7, 2011 | Registered CommenterNavelgazing Midwife

Nora: It would be pretty stupid of me to think education is The Cure All for midwifery gaffes and mistakes, but I've *gone* through the education and *lived* the midwifery life with it for 5 years and, as I said somewhere else recently:

Solo on-the-job training is not the appropriate way for a midwife to gain experience in birth.

It's tough for me to understand how I/we could be set loose with "minimum" standards of knowledge and skill. How could one mock shoulder dystocia replace watching, then participating in a true shoulder dystocia? How can it be that women can go through school and an apprenticeship and never suture? (In legal states, I mean.) If the apprentice is in a small enough practice, she might not see a suture-able tear for a year or more.

And the newest concern I have... how, if we're all now pretty judicious with vaginal exams, how does a student learn the wide variety of labor's variations on women's cervices if they are only doing 10, 20, 30 in a full apprenticeship? It takes knowing nuances to determine a baby's position; how does a student learn those nuances from the sidelines? This is quite the ethical dilemma I don't see addressed at all.

No, education isn't the Be All and End All to midwifery. But, it sure is a great way to have a common starting point.

March 7, 2011 | Registered CommenterNavelgazing Midwife

I totally agree. There is a lot that education can accomplish and I think it's up to the midwifery community to take the lead in improving education standards for midwives. And I definitely hear what you're saying as far as, if x, y, and z are things that midwives rarely do, then how are student midwives supposed to learn them? I wish our system was more integrated such that student non-nurse midwives had more opportunities for working with nurses and obstetricians as well as with non-nurse midwives. I'm deeply uncomfortable with the idea of midwives out there who have never sat in a college-level science classroom or who have only worked with one preceptor in a tiny homebirth practice.
I just wonder, looking at the specific story you told here, if you can really make the argument that what this midwife lacked was a better or more standardized education. It doesn't read like she didn't understand the seriousness of the pph. It reads like she was trying to cover her butt and that was more important to her than the mom's safety.

March 7, 2011 | Unregistered CommenterNora

"This is why I love your blog. You don't allow allegiance to a "side" prevent you from looking critically at things that go on in homebirth and natural birth circles. I have read quite a few stories where midwives did not transfer despite there being warning signs of a problem and they always really upset me. "

Hear hear.

I also agree with Jen B.'s comment re: wishing the CM option were more readily available.

March 7, 2011 | Unregistered CommenterDou-la-la

So scary.

It's just hard to know how much regulation is enough and how much is too much. I'm in NC and we are pushing hard to recognize CPMs. We really need them and we need to know that an HB midwife is qualified. I was blessed to have possibly the most qualified midwife in the SE (except Ina May, of course). All the other midwives and apprentices say she is the best and that they would not even HB if it wasn't with her. All women need that assurance when they choose HB.

I also hemorrhaged with my first so I was very careful with my HB. Knowing my midwife carried Pitocin made me comfortable with it, and she administered it to me. But, since CPMS are illegal here, she had to get it through back doors. That's not right. I would not have been safe without a midwife who carried Pit.

March 7, 2011 | Unregistered CommenterMeg

Abuse is abuse, and this midwife abused her client. Then she tried to hide it. Not good, not cool, and very unfair. What if the father hadn't spoken up for the mother? How arrogant.

Education is important. I do not think a midwife need be a nurse, but I sure do believe a midwife need to at least have OB nurse education. Does this make sense? She need not know geriatrics, but she better full well know women's health in the fertile years. I also believe a non-nurse midwife should have some sort of relationship with a hospital or an OB...somehow that should be a must. Who is her back up? My CNM had back up.

At the very least, the midwife in this birth needed to check her ego, and needed also to behave in a professional manner. The mom obviously had great amounts of blood everywhere, and the midwife knew it. Ethics classes seem to be most needed.

March 7, 2011 | Unregistered CommenterDawn

You can't legislate brains.

In my story, as a consumer, not as a midwife, the fully-licensed, hospital-integrated CNMs that attended my first birth botched it as completely as you can and still end up with a live baby at the end.

My second and third births were attended by a deeply-motivated, well-read, fully conversant with the research CPM, who was so much more competent than the freshly-minted idiots of CNMs it was astonishing.

What matters is not that the midwife attended a given school; what matters is that she cares enough to stay completely current, to self-educate with passion and determination. The letters after her name make absolutely no difference. My body bears the scars that are the truth of that; had my CNMs read anything after they graduated, they'd have known how to properly handle my birth.

March 8, 2011 | Unregistered CommenterLaureen

I'm sorry for your awful experience, Laureen, and am really glad your next time was much better!

No, you can't "legislate brains," as you say, but it *does* take brains to go through school and there is a *lot* to be said for someone who has the tenacity and committment to geting that education.

I hope you understand that your experience, while absolutely valid for you, is not the typical experience with CNMs. That you offer caution is great... and that *does* go for *every* provider... Caveat Emptor!

I stand by my belief that a standardized, university-based education system will transform midwifery so we can stand toe-to-toe with European and Canadian midwives.

There will always be crap midwives (and docs and nurses and doulas, etc.), but proportionally is the question. If you were reading my email, you would know the proportion of non-nurse midwives who have made fatal (or near fatal) mistakes to midwives who have is far, far more. And even if we only use birth trauma... physical or emotional/mental... doctors win that one, then non-nurse midwives and then CPMs after that.

I guess I should keep a tally.

Again, I'm so sorry about the pain you've experienced... and do hope your second birth was at least somewhat healing. And I totally thank you for sharing your story... it definitely needs to be heard.

March 8, 2011 | Registered CommenterNavelgazing Midwife

In addition to needing to increase the quality of education of midwives, I think we seriously need to consider how we can develop/improve relationships with OBs and hospitals. Obviously, improving the quality of education is a huge step, but its the first step of a long and winding road. CMs are legal to practice in my state (NJ), but its almost impossible to practice because difficulty in getting a collaborating OB and liability insurance, etc. CMs are also legal to practice in hospital in NJ, but must have a waiver from the hospital, which they never give. Uh, its frustrating! And one of the major reasons I am getting my RN first. Opens up all the doors, even though the education is identical (post-RN, I mean). I am currently reading about midwives in UK, and it is amazing the differences between their system and ours (and not just that its a NHS). I may just have to move...just kidding!

March 8, 2011 | Unregistered CommenterJen B

My (wonderful) home birth was attended by an LM and a CPM. They work in a practice that also includes a CNM, one of two in my city who will do birth center births as opposed to hospital or home. (I thought I was having a birth center birth until they were full, and we converted to home birth when my ctx were 5 minutes apart.)

I was initially nervous about not having a CNM intimately involved in my care, but what took the worry off my shoulders was that my midwives met when they were working in a developing nation where midwifery care is the standard option for pregnant women in all kinds of risk groups. They delivered a lot of babies; they did breech deliveries, they did twin and triplet deliveries, they delivered babies with life-threatening abnormalities. They delivered babies -- lots and lots of babies -- from mothers with uncontrolled GDM. They had seen it all and had done it all with virtually no OB backup, and that's what gave me the confidence that they would be absolutely competent and confident to handle my birth. And they were.

If you're a midwife and you want an opportunity to broaden your experience AND help women who desperately need you, consider working with Doctors Without Borders or other organizations that provide care in developing nations with underdeveloped infrastructure. I bet the experience you get could be literally lifesaving.

March 8, 2011 | Unregistered CommenterKathryn T.

And in all the reading I've done about this birth, one thing I haven't seen is the woman shouldn't have HAD to tell the midwife something was wrong, even once (afaic). She hired the midwife to tell HER something was wrong and then ask quick permission to treat/help and then DO IT.

As someone on the patient/consumer/birthing woman side of this, that was the first thing that jumped out at me about this story. I bled pretty badly after my last birth (my husband said it looked like a faucet opened up all the way), but it didn't get anywhere close to an emergency because it was handled appropriately. The thing is: I had no idea that I was bleeding too much. I was looking at my baby, who had been stuck at the shoulders, so glad she was out and that she seemed mostly okay, but also a little worried about her color and the way she seemed a little snuffly (did fine with a little stimulation). But I was oblivious to what was going on with me. I had no idea that the amount of blood was unusual. And I shouldn't have to be. It's the midwife's job to be aware and to take appropriate action.

I'll also add that uncertainty around the educational requirements behind the CPM title is a big deal to me. I'm sure there are great CPMs out there, but CNM gives me a lot more confidence. It doesn't guarantee a good experience, but it guarantees that certain minimum standards were met. And I LIKE that many of them have worked in hospitals and seen high-risk situations, but more than anything, I like that they've seen A LOT of births.

March 9, 2011 | Unregistered Commenterchingona

I read this story with the same shock and disbelief as everyone else, but I have to say that I don't get the same message out of it. I would say that this woman had a bad midwife, plain and simple. That doesn't necessarily have anything to do with her credential, does it?

One of the things that I love about midwifery is the individuality of our practice. We don't make the same sweeping generalizations that many medical professionals do. We get angry when the entire profession of midwifery is discolored by a single story of a midwife who practiced poorly, yet are we doing that right here?

I'm a CPM student at the Nizhoni Institute of Midwifery, which is MEAC-accredited. I have a Bachelor's in Biology with a minor in Chemistry from Saint Olaf College, Magna Cum Laude. I chose to go to midwifery school instead of medical school (I originally wanted to be an OB/GYN) because I believe that midwifery is the future of birth and because I dislike the medicalization of childbirth. I do not want to become a nurse because I do not want to be a nurse. I want to be a midwife. I believe that a well-trained CPM is just as capable as a nurse midwife, with her scope of practice of course.

I agree that CPMs need more regulation in their educations, but I don't think making sweeping generalizations about the CPM's lack of qualifications is going to help with that. I'm not a CPM yet, but I know what it looks like to have a really good, thorough education, and I know that's what I'm receiving right now.

I love your blog, NGM, and I think incredibly highly of you. This blog, in fact, is one of the reasons that I chose midwifery over medicine. However, this post really made me feel like all of my education and hard work is somehow lacking, simply because of the letters that I chose to place behind my name. I don't criticize you for posting this, and I appreciate your honesty and the conviction behind your words. I merely implore you to consider whether you really want to let this post become a series of CPM-bashing comments. Perhaps there are exceptions to the apparent rule that CPMs lack appropriate education? Maybe some of us really are qualified? As it stands, I feel like this is a smack in the face.

March 11, 2011 | Unregistered CommenterEmily

Emily: I don't even know how to answer your comment because, right up there... RIGHT THERE! This is what I say:

"LMs and CPMs come from a wide variety of backgrounds and that can be great and not-so-great. Some, like me, tried the apprenticeship route, but found working with many different midwives was a better fit. I also didn’t have the foundation of a MEAC-accredited school, something I think is imperative today and something I definitely missed out on. I know there are non-MEAC schools and they might be phenomenal, but the way our society leans is towards accreditation and having the MEAC approval means the schools went through some pretty tight hoops to get where they are. I’ve considered going through one of the three-year schools even now, but know I want a different type of experience than what MEAC-schools have to offer."

Where in the world are you seeing that I am bashing CPMs?

This is getting ridiculous, being accused of things that simply do not exist. Pardon me for being cranky, but I've spent the better part of my night "defending" myself from exactly the same accusation, just like here, in my own community! If it wasn't so serious a charge, it's be hilarious. But, I don't find it amusing in the least.

If you truly appreciate who I am and my writing and *really* really thought I was bashing CPMs, I encourage you to 1) read slower 2) talk to me about it.

March 11, 2011 | Registered CommenterNavelgazing Midwife

NGM - You're absolutely right, the comment that I attributed to you was written by someone else, and I really apologize. I did get the feeling that you don't hold direct-entry midwives in high esteem from this post, but you're also right that your previous posts bely that, and I'm sorry. I think by the time I got down to the comments section I had read so many distrustful comments from other readers that I internalized their replies more than your original post.

I do reiterate, though, that lumping all CPMs together as lacking in education is very unfair. That isn't aimed as much at you as some of the other commenters I've seen who seem to equate the CPM credential with lay midwifery as it was, say, 30 years ago. It's hurtful to read so many comments by women who automatically prefer a CNM over a CPM, without a second thought, despite the incredibly intensive and extensive training required to gain the credential. I will humbly and apologetically admit that I responded from that hurtful feeling of being rejected out of hand. I'm sorry that I angered you. That is the last thing that I ever wanted to do.

March 11, 2011 | Unregistered CommenterEmily

I read this when you posted it but needed to 'mull it over' for a few days. I don't know, NGM. I think this is a pretty 'easy' HB experience to hind-sight quarterback - a pretty easy target. It does illustrate that just about anyone can think they should help birth babies . . . and that no amount of training and/or education will ensure that people won't make mistakes and try and cover up or minimize those errors.

And what about all of the wonderful birth experiences - in hospitals (gasp), birth centers, and at home? I'd assume there'd be a higher ratio of satisfaction and expected outcome at home and in birth centers than in the hospital, but don't you think these horror stories are being amped up a bit? I agree with a PP that bad outcomes have always happened; we just have more ways of finding out about them now. (And keep in mind that we're reading filtered birth experiences . . . a perspective . . . not necessarily exactly how things go down.)

My hospital 'birth' with a CNM was a disaster from start to finish, but I did get my healthy baby and a lovely life-altering scar. I really had no viable options for my twin VBAC, so not only did my OB start to lose his nerve when Baby B flipped breech at 33 weeks, but also, no one was willing (or probably even capable at this point) in 'delivering' term footling breech twins. Plus, OBs aren't insured for vaginal breech birth across the board. How convenient. The OB who did the c/s punctured my bladder. The on call OB the next day suggested that I should be ready to go home 48 hrs after that c/s.

It's the whole system that is FUBARed. I'm maintaining shadow care through this pregnancy ONLY because if I need to transfer, I'll be treated like a human being. I hate that I can't have an honest transparent relationship with a CP in this town.

I haven't read anything here, there, or anywhere that seems acceptable. I am an interesting breed - I have a doctorate . . . but am at this point fairly wary of the way most of us are trained to do our jobs (as clinicians in any field). A lot of that I blame on $$, politics, and institutionalization.

I guess I woke up on the jaded side of the bed this morning. (Thanks a lot daylight savings.)

March 13, 2011 | Unregistered Commenterlabortrials

Besides saying it was an easy target (which is pretty duh in my book); almost anything I would examine/pick apart is probably an easy target... to *someone*...

... besides that comment, I think you were spot on and didn't see it "jaded" at all.

I, for one, am glad there was DST... even if it was just for this.

March 13, 2011 | Registered CommenterNavelgazing Midwife

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