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Monday
Aug082011

Dandy Commentary Continued

Continuing with what Birth a Miracle Services said in the post “Why state licensure is not the answer for midwifery,” the owners, Naomi Kilbreth and Haley Grant say: 

“A key componant (sic) of home birth is the mother taking responsibility for her birth. That means going to the hospital if she feels something is wrong, maintaining a healthy lifestyle, and being careful about which midwife she hires (ie. one that is well trained and experienced).” 

It is the woman’s responsibility to take care of herself and to hire the appropriate care provider, that’s certainly true. But once the provider is hired, the woman is depending on the provider, in this case, a midwife, to be her advisor, not her friend. 

Midwives do tend to be friendlier than many other providers. I stand first in line, guilty of this provider-as-friend attitude, both being one and applauding them. As time has passed, though, and through my own and others’ experiences, I see that a friendly provider isn’t nearly as important as a skilled one. I’m even guilty of encouraging women to choose a provider based on personality. 

“Most of us have very similar training, so I encourage you to picture yourself in a small room with the midwife –for 20 hours. If a quirk bugs you in the interview, it’s going to be greatly exaggerated when you’re in labor.” 

How’s that for advice on how to choose a midwife? groan of embarrassment 

While we had somewhat similar training, our levels of experience were vastly different. How is a newly pregnant woman supposed to gauge which experiences are great and which are useless in homebirth? While the birth junkie might learn about things like shoulder dystocia and hemorrhage and what a midwife should know when dealing with them, birth junkies are almost always born after their own babies’ births. It’s hard enough trying to teach women they have choices in childbirth; imagine the greater challenge of teaching them to be their own midwives! And that is exactly what BaMS is suggesting. 

“That means going to the hospital if she feels something is wrong….” 

Pardon?!? 

Do you women (BaMS) honestly believe women who hire midwives are supposed to “feel if something is wrong?” I know that most women hire midwives to let them know if something is wrong. Believing that women can “feel” a baby in trouble is cruel to the women whose babies died without their feeling one blip of concern. And it’s flat out wrong. Ask any midwife who’s overseeing a woman in labor, everything fine and then, during the next 15-minute fetal heart tone check, she finds the heart tones down in the 80’s. How long were they there? Sure, there are things to do to try and resolve the low heart tones, but seriously, shit happens in birth. And shit can happen fast. Having a midwife who knows what to do is crucial; her friendliness irrelevant. 

And it’s baffling to me how you think a woman in the middle of labor is supposed to take her contracting butt to the hospital. Drive? Call an ambulance? You make birth sound like a giant UC (unassisted childbirth). And terribly, terribly unappealing. 

(The great majority of) Women aren’t looking for a midwife to make every decision for her. They are not abdicating responsibility to a midwife who uses them like a marionette. Women look to midwives as counselors, as the experts in an area they don’t know much about. 

When hiring a plumber… or a car mechanic… most of us couldn’t care less how the job gets done, just that it gets done right. There are others who think the process is fascinating and learn, perhaps, to do it themselves. They might need help when learning… books, the Net or even talking to the technician. They might even go on to become the expert, inspiring other would-be plumbers as they snake the random toilet. 

Birth, in its crudest form, is like this. And a midwife knows more than the client. She is being hired to know more than the client! That isn’t the remotest commentary on her intelligence or the knowledge she does possess, but who wants to learn to be an expert in every trade or profession we utilize in our lives? I sure don’t! 

It’s great that women learn about the interventions and technology that might be (will be) used in their births. They can always learn more information… if that’s what they want to do. Homebirth women tend towards the information-heavy, that’s true. But should homebirth women have to learn everything in order to protect themselves from the midwife? Or shouldn’t there be a minimum standard they can count on so they’re able to relax during the pregnancy, labor, birth and postpartum period, trusting that the midwife really is looking out for her best interest (and that of her baby)? 

As many others have said, we go to all sorts of people assuming they have a certain level of competence… dentists, accountants, lawyers… even nurses, repair people and barbers… all carry with them the burden (if you will) of a minimum level of professionalism and knowledge. It should be the same for homebirth non-nurse midwives. 

I want women to trust midwives to act and react in their best interests… and the interests of their babies. I hate that I’m writing a “How to Interview a Homebirth Non-Nurse Midwife” piece. I shouldn’t have to!

Yet, with beliefs such as the one quoted at the top of the page, it’s more and more clear how critical that hand-out will be.

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    - Navelgazing Midwife Blog - Dandy Commentary Continued

Reader Comments (10)

I'd be interested to read (or if you've already written about this before, reading that) your thoughts on the laws in Oregon which, from what I understand from looking at the chart on the MANA website, make DEMs legal with optional licensure. I would think that would be an optimal solution, as a woman would be able to hire whatever type of midwife she wanted, licensed or not. From what little I understand of the discussion in PA, many midwives here do not want to be forced into licensure. I'm hoping that an optional licensure is in our future so when I'm ready to train in midwifery, I can choose to be a CPM and practice legally.

August 8, 2011 | Unregistered CommenterJess

Thank you for this. As a Canadian living in Ontario, I had the option of choosing my GP, midwives, or an OBGYN for care during/after my pregnancy and birth. I went with midwives because we share similar core values, one of them being informed choice. I have always felt respected and valued, and very much in control of my pregnancy.

That being said, you know why else I went with midwives? Because I don't know everything. Because sometimes I get scared. Because I want someone with a high level of training and education to help me come to those informed decisions-I can't do it alone and I don't want to. I can do a ton of research on my own-I think I've ever every book on birth my public library has to offer-but in the heat of the moment I want someone there who can tell me if I need to go to the hospital, or who will suggest and facilitate a change in care providers should something fall outside their scope of practice. I trust myself, AND I trust my midwives.

Licensing works. I don't understand why midwives would be so opposed to licensing-although maybe that is because I am from a different country. In Ontario, to be a midwife you need a Bachelor of Science from one of three universities. There are other university programs of similar caliber, and I hope to see more degree programs expand as other provinces discover midwives (I'm looking at you, Atlantic Canada). I don't know if you have a post on this, but could you explain training differences between CPMs and CNMs, namely, the kinds of post-secondary programs available and what their training entails?

Like health insurance in the states, it's one of those things I just don't understand, because I've never had to deal with it before. I got pregnant, I wanted a midwife, I called my local community midwives, and two weeks late, I was a client. I handed my OHIP card to the office admin, and that was the last of my worries about payment. When my mother-in-law raised eyebrows about midwifery, I sent her links to the Ryerson and McMaster programs, as well as to the College of Ontario Midwives (our provincial regulating body). It's a licensed and regulated profession here. My mother-in-law was okay with it (although she admits it's not the choice she would have made, but that it's not her choice to make). I don't understand the opposition to licensing.

August 8, 2011 | Unregistered CommenterMary B.

“Having a midwife who knows what to do is crucial; her friendliness irrelevant.”

“When hiring a plumber… or a car mechanic… most of us couldn’t care less how the job gets done, just that it gets done right.”

Isn’t this what obstetricians are criticized for? Having well-founded opinions about what is safe, giving primacy to the safety of mother and baby?

If the care provider is going to be knowledgeable and care about safety more than feelings or personality, why not just seek the care of the knowledgeable and safety-oriented specialists, obstetricians?

Isn’t a woman who seeks midwifery a person who priviledges process over outcome, preferring a certain approach to birth and *accepting* the risk that she or her baby will suffer harm?

I’m not sure what your objections are. You believe there is a place for a third tier of midwife, one with less skill and training than a CNM and much less than an obstetrician. But you think that a woman who chooses the least-skilled, least-trained option for care should have an expectation of skill and training?

I don’t quite get it. If a woman doesn’t want a knowledgeable birth attendant she can have a UC. If she does, she can have a CNM or an obstetrician. But I’m not getting this middle ground you are reaching for with partially-trained midwives.

August 8, 2011 | Unregistered CommenterAlison Cummins

Jess: I haven't written on the laws in Oregon. I really know nothing more than what has been in the press in the last couple of weeks. I've just now got myself into this licensing discussion... have barely just dipped my toe in the midwives-need-more-education-&-training pool.

I would LOVE to know why you think licensing with an option to stay unlicensed is the optimal solution. I find it an awful compromise that keeps the under-educated and under-skilled practicing with acceptance, even if that acceptance isn't a license.

Mary B: There are several places to see the comparison of education between a CNM and CPM. Start here:

http://cfmidwifery.org/midwifery/faq.aspx

The middle ground comes because CNMs, within their licenses, are not (in most states) permitted to attend homebirths. In my thinking aloud, I'm imagining a midwife with education and training who also does homebirths. Homebirths are *not* going anywhere, no matter what anyone things or wishes, therefore there *must* be a way for the attendants to be highly educated and skilled in order to keep the mom and baby as safe as possible.

That's why.

August 8, 2011 | Registered CommenterNavelgazing Midwife

I guess I figured that if a woman wants to work with a midwife who isn't licensed, she would know that licensure was available and an option and perhaps this midwife chose to remain unlicensed for a particular reason. I don't know much about it, but my understanding of the situation here in PA is that many Amish midwives are against licensure because they are not really part of the greater community, they only take care of women in their own community so everyone already knows the midwive's stats, so to speak. I think, also, (but could be totally wrong) that Amish midwives make up a large percentage of lay midwives in at least the counties in PA where there are Amish populations, and they might drum up support against licensure.
Looking at my options as a potential midwife, much of the training path and practice of CPMs appeals to me much more than that even of a homebirth CNM, but I would not be able to practice legally in my state. My hope is that, by the time I were training, CPMs would be legal in PA, and it seems that voluntary licensure would allow me to become licensed as well as for Amish midwives to serve their communities.

August 8, 2011 | Unregistered CommenterJess

Yes. I am a mother who gets far, far away from the area where the baby is coming out. I get confused in labor. I get easily led in labor. I get scared in labor. I worry in labor. I say weird things in my head in labor. I think things I should ask for but don't. I worry what people think of me when I'm in labor. I also fight hard in labor. I rock, I cling, I dance, I lean. I need in labor. I experience a lot of raw in labor, a lot of proper pain, a lot of focus and breathing, a lot of trying to control, a lot of letting go, a lot of talking, a lot of silence, a lot of moaning, of surrender, of taking it easy. So much going on, I need medical staff or a midwife paying attention to their job. They need to help me get there, support me, but they also are responsible for my life and my baby's life. I cannot see what's happening "down there." I don't know if a contraction pattern is odd (because frankly time is so weird when I'm in labor). I don't know if I am giving cues that allow the midwife to know I'm in a weird way in labor. I cannot feel my baby's head/butt/shoulder/or other presenting part. I cannot know why my baby might be stuck, or if that heartrate I hear going slowly is mine or the baby's. The midwife is responsible to figure all this out and to let me know the best strategy to get me to a healthy baby and healthy me if possible.

I want to trust my provider, but if I am being unreasonable, I want that provider to let me know too and is real trust. If I must have interventions, I want to know the provider/midwife used them because I needed them or chose them. No hesitation. If I want something not possible, not best, I want the midwife to be frank with me. Professional.
Be warm and fuzzy at prenatals and when I'm meeting with you after baby is born. Be supportive while I'm having the baby but also always be professional. Just like the teacher at school (you know that high school teacher that helped you grow the most). There has to be a level of professionalism, a level of trust, a level of friendliness...but there has to still be a line. Otherwise, we could have our best friend catch the baby...

August 8, 2011 | Unregistered CommenterDawn

The licensing situation in OR is a mess because it means there is basically no consequence for gross malpractice. You can strip a midwife of her license for having a trail of morbidity and mortality, but then she can practice unlicensed. And if she was unlicensed to start with, there's basically no way to track her performance. She can SAY she's a great midwife with tons of experience and low m/m rates, but you have no way of verifying. Even licensed midwives are hard to track due to the way our licensing laws work. I recently started a blog to track the OR midwife situation for anyone who is interested:

http://oregonmidwifereviews.blogspot.com/

On my blogroll is a similar site for Washington state.

August 8, 2011 | Unregistered CommenterAnonoregonian

Jess: It's important to know that too many women don't know there are differences between licensed and unlicensed midwives... or that there is even a choice for a midwife to make between being licensed or remaining unlicensed.

As hard as it is for you to explain why a midwife might consider remaining unlicensed, it's 100x harder for a lay person to grasp. They aren't stupid, they just don't know.

AnonOR: Thanks for your work. I'll pop over early tomorrow to see what y'all are doing. Great job!

August 8, 2011 | Registered CommenterNavelgazing Midwife

I'm definitely for licensure, I guess I was seeing voluntary licensure as a win win without looking at the possible negatives. I'm looking forward to reading the OR website and learning more.

August 9, 2011 | Unregistered CommenterJess

I wrote a loooong reply to the first post....not sure if you got it. But now that I have had a moment to calm down, perhaps I can be more eloquent.

I'm trying to understand the logic behind not licensing midwives. What I hear, when you get past the rhetoric, doesn't make sense to me.

When I hear "Licensing limits who we can take care of!" I hear, "I want to be able to take on high-risk cases!" Because, having a license has allowed me to take care of any woman who CAN be expected to safely birth at home, including women on Medicaid and with insurance. While yes, women expecting twins, breeches, and who have hypertension or diabetes cannot be taken care of at home, SHOULD we actually be doing that? And, aren't low income women especially deserving of midwifery care? Do they KNOW what low income women go through seeking out a provider? Or how they're treated like cattle once in the obstetric system? Or does freedom of choice only apply to the middle- and up class? There's a reason why the vast majority of women having home births are white, middle class, and college educated.

When I hear, "Licensing midwives doesn't honor the traditional paths into midwifery!" I hear, "I can't be bothered with devoting time, money and effort into midwifery school,.....I want to start as soon and as cheaply as possible!" The fact that someone can "self-study", catch a few babies, sit a ridiculously easy exam, and call herself a midwife makes me cringe. The fact that a midwife can start practicing and not know how to start an IV or suture makes me want to scream.

When I hear "It's the woman's responsibilty to make the right choices for herself and family!' I want to scratch my eyes out. Yes, she IS responsible, but SO. ARE. WE. We are ultimately responsible, for her health and safety, and for her baby's. We need to be able to provide her with good, safe care. We need to be able to work with the system, not against it. We can kick and scream about how horrible the obstetric system is til we're blue in the face, but it sure is nice to know they're a few miles down the road when the shit hits the fan.

I LIKE being licensed. I LIKE being able to have take Medicaid and insurance, because more women can choose a home birth without denying herself and her family, or stressing about paying their bills AND me.
I like being able to have a lab account, and a nifty lockbox on my office door, and I like being able to run labs and cultures in my office or at a clients home, and not having to send her to a clinic or doctor.

I like being able to call a back up OB and know a prescription is being faxed over to the client's pharmacy of choice.

I like being able to order, and adminster, IV antibiotics for GBS+ women, and not having to pretend GBS is no big deal because I don't know how to give an IV or because it's illegal for me to have them.

I love the fact that I can carry pitocin, and methergine, and O2, and sutures and Xylocaine. I love that I don't have to pretend herbs are just as effective in stopping a hemmorhage, or that seaweed is an acceptable alternative to suturing.

I like being able to walk into a hospital with a client in labour, with her chart in my hand, and I like being able to give report without fear of prosecution. I like the fact that in the rare instances of emergency transport, I don't have to make up a story for the EMTs, or clean up the evidence before hiding in a closet before they arrive. I like being able to ride in the ambulance with her, and monitor heart tones. And honestly, the EMT's would rather have some one that knows how to take care of a labouring woman, because Lord knows, they don't know jack about catching babies, and would seriously rather not have to contemplate that during a transport.

I like not having to wait, agonizingly, until she's a train wreck before I make the decision to transport.

Maybe those who try to convince everyone to "trust birth" are trying to deflect the attention away from what DEM's are lacking.......education, skills, legality, access to medications.......perhaps those who try to convince others that midwifery without collaboration with the obstetric system is more "authentic" or "traditional", to make up for the fact that they have no access to it? Some sort of delusion that all you need for a safe birth is enough trust, and if something goes wrong, it's actually the WOMAN'S fault, for not trusting, for having fear, for not speaking up, for not listening to her instincts.

I know when I first started my midwifery education, I was enamored with the concept of the "Traditional Midwife", the Mountain Granny with her herb garden, teas, tinctures amd poultices, her gnarled hands with years of oral tradition and apprenticeship under her ample apron, her basket of knitting by her rocking chair while she patiently waited for the baby to come. But then I grew up.

Our amazing tradition of midwives, our Martha Ballards, our Anne Hutchinsons, Miss Mary Coleys and our Gladys Miltons, our Ina May Gaskins, have given us centuries of knowledge and skills, our philosophy that birth is natural, woman and family centered, and that skilled hands can save lives. But none of these great women EVER balked at the idea that more education, training, and skills were a good thing. And the beauty of learning from our past is that we can intergrate, learn, and apply our knowledge. That we can continue to learn, and grow, and provide increasingly better care to our women and babies.

I can't imagine that traditional midwives, all over the world, would NOT want to have access to hospitals, doctors, medicines, clean instruments, IVs, and the support of their governments health care system.......we have become so distant from the reality of childbirth, how many of us actually KNOW (not know OF, actually KNOW) a woman or baby who died, from a preventable cause, during or right after birth? How many of us go into our pregnancies filled with dread that we may not make it? We take it for granted that we, and our babies, are going to be just fine BECAUSE we have, maybe too much, access to modern medicine.

In the blog post, an article is linked about a Massachussetts baby who died from GBS sepsis. I can't help but wonder, if the midwife was licensed and regulated, would she have screened the mother for GBS according to Mass. Department of Health and ACOG guidelines? Would she have had a back up OB, because the mother was a VBAC? Would she have sent her in for biophysical profiles and non-stress tests every 2-3 days when the pregnancy went post-dates? Would she have administered prophylactic antibiotics when the mothers membranes ruptured 3 days before labour started? Would she have been required by her laws and rules to transfer this mothers care to her back up OB when she began to show signs of infection? If she had, most likely this woman's baby would have been born alive.

I keep hearing, "Licensing does not make better midwives!" and it's true. I know some LMs who lack skills and judgement. And while I don't think licensing per say is going to make a better midwife, I think a cross the board, standardized education that meets, not just the minimum, but NECESSARY skills. Unfortunately, for the less than motivated, that means going to 20 births and reading some books is not going to cut it.

I love the profession of midwifery, I love our tradition, our philosophy, our dedication....I would really like to see us around for a long, long time.

August 9, 2011 | Unregistered CommenterColleen

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