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Tuesday
Aug092011

Guest Post: Licensing Midwives

My dear friend Colleen Scarlett, LM, CPM in Miami, FL wrote a comment to my "Dandy Commentary Continued" post, but it's so fantastic, I needed to make it a blog post itself. Here, she says exactly what I wish I could say. Whatever she says below, hear me saying, "Me, too!"... because I am.

"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 ("Why state licensure is not the answer for midwifery"), an article ("Her Home-Birth Battle") 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 se is going to make a better midwife, I think across 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."

Goddess, I love you, Colleen. Thank you for speaking my mind. You're the best!

Reader Comments (37)

More education is better for midwives, better for mommas, better for babies. Thank you.

August 9, 2011 | Unregistered CommenterDawn

Bless BOTH of you. Absolutely.

August 9, 2011 | Unregistered CommenterDou-la-la

Yes, a fantastic post. I'm going to link to it on my blog.

August 9, 2011 | Unregistered CommenterAntigonos

Great post! My cousin and I are both doing the CNM route and we've both had home births. We've also both expressed concern that we'll ever be prepared/comfortable/ready to accept the responsibility of midwifery. I get the excitement, the passion, the wanting to get educated and get to work. I don't get wanting to take short cuts at the expense of the level of care I am able to provide. I don't understand not having a healthy respect for birth; knowing that if an emergency happens the midwife is the one responsible for shepherding woman and baby safely through it. Anyone can catch a baby. It takes education and experience to handle emergency and I just don't get not wanting access to every tool available when one happens.

August 10, 2011 | Unregistered CommenterKim

I think a lot of the fear over licensing is regurgitated fear of the hospital/OB system and its failure to offer reasonable choices for women. I live in a major metropolitan area (DC). There is ONE OB in the entire metro area who will "allow" a woman to attempt a vaginal breech birth. I would have no problem being risked out and transferred to a doc for a breech birth if I thought a doctor existed with the skills to attend a vaginal breech or the patience to at least wait until labor for the section in case the baby just might still turn. I don't think those options exist in my area. If you can't get the one doctor who will do it (not trained in the US btw), you are getting a section, probably well before 41 weeks. The lack of options in the OB sphere makes people more wary of options being restricted in the home birth sphere, even if it's not really safe.

I think midwives have a duty to make sure their clients understand the real risks--that some babies will die at home that would have lived in the hospital--and roughly where they fall on the risk spectrum. Risks should not be minimized or shrugged off. But I do think that a woman should have the ultimate choice of where to birth and there are good reasons to think that licensing might limit women's options. That doesn't mean I necessarily oppose licensing, but I do see some of the concerns as legitimate and troubling.

August 10, 2011 | Unregistered CommenterEmily

I agree with a lot of the sentiments in this post, but I think it's important that a clear distinction be made between the argument for licensure and the argument for standardized education. IMHO, these are two completely different topics that very often get lumped together. Education and experience will ALWAYS make a better Midwife, whereas licensure may or may not.

August 10, 2011 | Unregistered CommenterSummer

As an apprenticing midwife going on her sixth year, and a homebirthing mother of twins, this post is really sad. It is offensive to all homebirth midwives who choose not to license. I am beyond words.

Sarah Biermeier

August 10, 2011 | Unregistered CommenterSarah Biermeier

WOW! All I can think to say is "Amen, Sista!" just as loudly as I can!!!

August 10, 2011 | Unregistered CommenterKim

Yes, yes, and YES!

August 10, 2011 | Unregistered CommenterMary B.

Sarah B: I suggest you find words. I want to know WHY. I've not heard any valid reasons why licensing isn't a good idea. And tough crap if we step on toes; they need to be crunched.

August 10, 2011 | Registered CommenterNavelgazing Midwife

Thank you so much for a WONDERFUL essay! I have spent more than thirty years making arguments for midwifery licensure in my state. I have been a prosecuted midwife, an RN (who lost her license for a while for practicing midwifery) and am currently an attorney who counsels midwives and families throughout the U.S. This post was extraordinary -- thank you so much for expressing it so well!

August 10, 2011 | Unregistered CommenterValerie Runes, Esq., RN

I can't possibly love this post any more.

You had me at, "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."

From there, I agree with every single word you've written.

On a side note, Emily and Summer note that education and licensing shouldn't be considered the same issue, and that licensing has issues that need to be worked out. Agreed. And it's been asserted in the comments here, and in other online discussions I've read, that licensing may limit women's options. I assume this means that a diabetic woman with GD and GBS may not be able to have a HBA3C waterbirth of twins. But seriously...

I think it's important to ask what women have to lose and what they have to gain from licensing of midwives. My personal sense (and I don't have research to back this up) is that a small number of high risk women may not be able to have a birth in the location they choose with the provider they choose (and I'd like to note that location/ provider choice is often not an option unless you are a middle/ upper class woman). What do we stand to gain? Beside expanding the midwifery model of care, women would have the assurance that any midwife she chooses is deemed competent and responsible. For me, that's a worthwhile trade-off.

Time for more tea... hope this all made sense.

August 10, 2011 | Unregistered CommenterNico

Made perfect sense, Nico.

Valerie, bless you and thank you for your work. Sadly, I bet you're way too busy.

August 10, 2011 | Registered CommenterNavelgazing Midwife

Yes, Sarah, I would like to know what your thoughts are as well......I homebirthed 6 of my 7 babies at home with a registered midwife, and have attended close to 600 births in homes and birth centers. I'm really interested in hearing why licensing is a bad idea.....I may learn something.

Yes, licensing and education are two different subjects, BUT, they are inextricably entwined with each other.....licensing SHOULD require a nation-wide standard of education that ensures quality of care. Licensing SHOULD mean that the consumer has protection and recourse. Licensing SHOULD mean that the practicioner is also protected and has access to meds, and the skills needed to use them, and a support system within the obstetric community.
Whenever practically ANY profession seeks to practice in their chosen community, they are typically required to provide proof of their education and training...TCMs, Chiropractors, massage therapists, manicurists and hairdressers, for crying out loud, all are required to prove to their state's regulatory board that they have met the standards needed before they lay their hands on your body. If the person painting my toenails or dying my hair needs a license, shouldn't the person I am entrusting with the health and safety of myself and precious baby also be held to a standard?

August 10, 2011 | Unregistered CommenterColleen

It would be great it if was that simple. All lay midwives are bumbling idiots with no education and all licensed midwives are God's gift to women. But it isn't like that. I have seen some amazing traditional midwives and some really bad licensed ones. The truth is the woman makes the midwife. Not the training or the certification.

Honestly, homebirth should be all about less is more. Women should know more about herbal treatment of perineal tears rather than causing more trauma by suturing. Are there women who need to be sutured? YES! Of course. But most don't need it.

Breech birth is a variation of normal. You are condemning women to a surgical birth by placing them into a high risk category based on nothing but the position of their baby. That is wrong. Have another midwife who is skilled in breech birth attend the birth with you. Talk about the many ways to turn a breech baby. Twins are also a variation of normal. Have a third midwife attending the birth and only work with di/di. Have a time limit on the time between twins if you need to. Maybe six hours? Lumping breech and twins in with gestational diabetes and hypertension is wrong.

There is nothing wrong with setting your own personal boundaries on what you as a midwife feel comfortable with. Or even you as a practice. But to condemn a whole group of women choosing to practice without a license and say that you are better than them is bitchy and condescending.

August 10, 2011 | Unregistered CommenterSarah Biermeier

I wanted to add, I love that we have licensing. I think it is a great thing for every midwife to have as an option. I am heavily considering it for my own practice.

What I don't like are blanket statements like this one

"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.

I wish it were that simple. Every midwife should be free to follow her own path. Mine is a very tradtional apprenticeship. Because there are no classrooms, it will have been seven years of apprenticeship byt the time I sit for my test. I study with many midwives (CNM's, LM's and CPM's) and sit at clinical roundtables and learn from amazing women.

It is constant and humbling, and it will make me a better midwife.

August 10, 2011 | Unregistered CommenterSarah Biermeier

As a mom awaiting the arrival of a new baby to be born at home I remember making sure I interviewed both licensed and traditional midwives to make sure I could know the difference and get a feeling for both.

What I found while doing my interviews was that it had nothing to do about whether they were licensed or not but how they made me feel about myself. I decided to choose to have an apprenticing midwife be my primary midwife who is being taught by a midwife who has been practicing for 30+ years.

I don't think you become a better midwife because you have a license or a certificate proving yourself you are a better midwife when you are educated, supportive and understand that every women has their own choice to make about their body.

Your whole article reminded me of how I felt when I met with the LM for the interview. That they new best and I wouldn't get a say in what I wanted. So for you to say that women would be better off if all midwifes were licensed you are taking away the womens choice to choose what best fits her. I am grateful that I get a choice how I want my birth to go and that is what we should all be fighting for in this community, giving back the women's right to choose how she wants to birth. Maybe before you decide you know what every pregnant women wants you should as them what they want.

I am 38 weeks a long and not once did I feel unsafe because they couldn't write me a perscription or stick an IV in my arm. Because of my choice to go with a TM I made sure to talk to my family doctor about my choice and keep in good terms with her. Making sure I was able to come to her if I was ever directed by my midwives to do so.

If your article was written in more of a factual and diplomatic tone I would have given you more credit but the fact that you think you are better then every midwife who is not licensed and know what is best for mothers with out asking them leaves me with little respect.

August 10, 2011 | Unregistered CommenterAlyssa

Sarah: You do realize that most women do not have either 7 years of an apprenticeship nor the opportunity to work with a wide variety of midwives, right? Your defense of your own training is *vastly* different than defending the training of the majority of CPMs. Please keep that in mind when you share your thoughts.

It's easy to see where your training lies, in the "Trust Birth" section of the room. Fine, but I suspect you'll grow beyond that when it is you in charge of the woman's and baby's life. I hope so anyway.

"Honestly, homebirth should be all about less is more. Women should know more about herbal treatment of perineal tears rather than causing more trauma by suturing. Are there women who need to be sutured? YES! Of course. But most don't need it."

Who says? You and your clients perhaps, but not all clients feel the way you do. And I'd looooooovvvvveeeeeee to know how many births you've been to to come to the conclusion that "herbal treatment" is better than suturing. Even your language is prejudicial; you know that, right? "Trauma by suturing" - tell that to a mom whose bottom is split from birth. It's actually a very rude way to speak of suturing. Suturing is an ART.

I can only hope your black & white viewpoints, including that those of us who want licensing believe licensing is a magic bullet for creating a magnificent midwife, soften with time. You're much harsher than any of us here have been towards unlicensed midwives. You project a helluva lot, hon.

August 10, 2011 | Registered CommenterNavelgazing Midwife

Come share *after* your baby's born, Alyssa... if you have a severe complication or your baby's life is in danger. Then tell me "but how they made me feel about myself" means squat with how they reacted to a hemorrhage or neonatal resuscitation.

If you want to make all the decisions in your care, why do you have a midwife? Why do you go to the doctor? If your autonomy is so vital to you, exert it with a UC! But, you're hiring a midwife for *something*. What is it?

August 10, 2011 | Registered CommenterNavelgazing Midwife

Wow, you are being so rude. To the point where I feel if I explain myself you still wouldn't understand. But I will say this:
My first child was born in the hospital I hadn't many choices and my doctor told me she would do what was most comfortable for her to do.
I chose a midwife so i could be more in control. Voice my opinions and ideas without being told no right away. I am not stupid and know there are risks with having a homebirth my midwives have been honest and straight forward. They have never promised me a perfect birth as long as i just "trusted my body". I think you have to be careful when you do a sweeping generalization as much as there are TM's who shouldn't be practicing I am sure there are some LM's who should quit their jobs as well.

August 10, 2011 | Unregistered Commenteralyssa

I am licensed in a state that has voluntary license. My decision to get a license was carefully thought out. However, I do not discount the midwives in this state who do not have a license. Most of them have been practicing for a LONG time and have vast amount of experience and knowledge. They are the sorts of midwives that every community wishes they had. These midwives could be LMs if they filled out the paperwork, but have their own reasons for not doing it. In this state, the restrictions on LMs are not all that restrictive, so I really don't practice any different with the license than I would without it. The LMs in this state are fantastic as well. Gosh, this is just the greatest state for midwives, I do believe :)

One thing I would love to point out is that people are really answering this license question based on the benefits of license within their own state. Here in MN we do not get coverage through medical assistance, we cannot give IV antibiotics, I can not call in a prescription for a client, etc. I can suture and give specific meds for a PPH and lidocaine for sutures. I can order lab work, but to be honest, I got a lab account without a problem prior to getting my license. When my license showed up in the mail, I was not suddenly a better midwife..... I was still just me :)

As a midwife I have no problem continuing my education and training. I have no problem having a license. As a mother, the license thing means very little to me. I am currently expecting and hired a midwife without a license to care for me. I trust her experience and abilities to care for me. Whenever this license debate comes up I just find myself wondering why we can't just get along and work together.

August 10, 2011 | Unregistered CommenterErika Urban, CPM, LM

In Minnesota, I would say it is actually very normal for a traditionally trained midwife to take six to eight years to train. We also are up to date on our neonatal resuscitation certificate and adult/infant CPR.

I am very open and honest about not suturing during interviews. Families might choose me because of that actually. They also know that if they would like to be sutured, that is available to them. 95% of women who tear choose to heal in an alternative way and not be sutured. I do think that inserting a needle into flesh is traumatic. I also agree that it is an art. One day I hope to learn it. However, I will still choose to give both options, and I will trust that the many perineums that I have watched heal without suturing will continue to happen. It goes hand and hand with having a mom stay down and take really good care of herself. (I am not saying that a sutured mother won't.)

As far as how many births I have been to...how many would be enough for you to give me any credit? I have been to enough to know that women heal.

August 10, 2011 | Unregistered CommenterSarah Biermeier

These echo many feelings I have about midwifery.

I would love to see a system where doctors and midwives work together rather than against each other. That way, if a woman needed to transfer her care, she would not have to worry about whether the doctor will frown on her for going the midwifery route. I want to see a system where midwives can deliver at home, birth center, or hospital. But alas, we don't have that yet.

Thank you for this! I am nine weeks pregnant with my first child, and I am planning on delivering in a hospital with CNMs. I decided this after much research and thinking.

August 10, 2011 | Unregistered CommenterLaura

"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?"

As one of those women, thank you both so much for this and continuing to speak out.

Alyssa: I pushed in labour for four hours, the last two on a wave of feeling great about myself and my ability to connect to my "woman power" as the birth attendant put it, talking me through every single push by increasing my self-esteem and self-confidence.

(at 2 hrs, I had asked to see the OB about a c-section)

Sadly, during those last two hrs of pushing, my daughter's heart was increasingly unable to pump due to the lack of blood coming through the constricted cord around her neck. At the 4 hour mark I gave birth to a flat baby. She was revived and died 4 days later.

I would very much have appreciated feeling less good about myself.

Birth is great and natural until it's not. When the stuff hits the fan, that is when it no longer matters how you feel about yourself. I highly recommend hiring a doula to make you feel great about yourself - and the most highly trained professional you can manage to ensure your safety.

August 10, 2011 | Unregistered CommenterJenn

Something that I'd be interested to read discussion on is where the line is drawn for who is a candidate for home birth or birth in a birth center as opposed to hospital birth? I would agree that things like hypertension and GD qualify as higher risk, but what about breech, twins, VBAC, obesity with no other health problems, first time mom, etc? Would a GBS+ mom be risked out to the hospital? How long would a woman have after her water breaks before labor starts and still be able to birth at home? Would a woman be able to birth at home postdates if her BPP, U/S, etc. were all normal? How far postdates?
Are any of these situations part of the normal birth that a non-nurse midwife would be familiar with and be able to handle at home, or would a licensed midwife be so limited that any variation of a strict set of "normal" would be risked out to the hospital? Would licensure mean that a non-nurse midwife would potentially be able to help women deliver in the hospital, possibly in concurrent care, in a higher risk situation?

It's so frustrating to me that non-nurse midwives are illegal where I live, yet drive 30 minutes and over a bridge, and they're licensed, legal and accepted. I really appreciate these posts and comments. I feel like I'm learning so much and refining my opinions.

Previewing the post, I saw Erika's about state-by-state licensure differences. That's kind of what I'm referring to when I say it's frustrating that the nearby state has licensure, but PA doesn't. It's frustrating knowing that there is no continuity and possibly never will be because licensure is a state issue, not a national one. Why would a midwife in NJ be any more skilled in using pitocin, oxygen, whatever, than a midwife in PA if they've gone through similar training? Why would a midwife in one state have the ability to order labs, prescriptions, etc. and a midwife with similar training but in another state have to refer to an OB? Would it be the same with the specifications of who is eligible for a home birth? Would someone in one state be eligible only if they travel to a neighboring state?

August 10, 2011 | Unregistered CommenterJess

When did I say I was better than everyone else? When did I lump all DEMs into one large heap of incompetence? Gosh, what a load of projecting going on here! When I say midwives need more training and skills before being unleashed on the unsuspecting public, I mean myself included. Goodness, after I sat the NARM, I walked out of there absolutely THROWN that I was considered a safe, skilled midwife, ready to practice! And by the time I sat the NARM, I was still 6 months away from finishing my midwifery program, but already had 50 primaries and 25 assists under my belt. Suddenly, I was faced with this huge, scary sense of responsiblity, for not one, but TWO lives! I became acutely aware of how much I DID NOT KNOW.

Now, Sarah, you are on your 6th year of apprenticeship.......but what does that mean? How many births have you actually attended? 6 years sounds impressive, but how much of those 6 years have actually been taking care of women and attending their births? This is one of the problems I have with the lack of standardized education......a 6 year apprenticeship sounds like a lot of time spent learning skills, but a 6 year apprenticeship, in many parts of the US, can also mean less than 20 births.

We have been hearing "Breech is a variation of normal!" repeated so often and so loudly we're actually convincing ourselves and others that is is, in fact, normal. It isn't. Vertex is normal. Breech is not. Do I think every breech needs an automatic c-section? No, I do not. Do I think that breech carries more risk than a vertex? Abso-freakin-lutely. Do I think more providers need to be skilled in vaginal breech delivery? Hell to the yeah. Do you know what a Blunt Hook is? Or a Blots Arrow Perforator? How about a Braun's Cranioclast? Google them.....it's a bit shocking, but these instruments were used at a time when vaginally was the ONLY way out for a breech baby and EVERYONE who attended births was "skilled at breech".

Let's talk about suturing, and the "trauma of suturing".....is there any other part of our bodies we think should be spared the "trauma of suturing"? Arms? Legs? Heads? If any of us, or our loved ones, suffered a laceration the length and depth of a perineal lac on our foreheads, you bet we're going to run to the closest ER and get sutured. This is her VAGINA, for God's sake! I'm guessing she would like to be able to use it again, and have her midwife respect it enough to want to put it back together for her. You're fooling yourself if you think herbal remedies are just as good as some well-placed stitches, or if you think the trauma of suturing is worse then the trauma of incontinence.

Where did I say my clients have no choices, or that I know what's best for them? Good lord, I said that midwives need to know how to perform pretty basic skills so they CAN offer them choices. How is not being able to offer antibiotics giving her a choice? How is not being able to suture giving her a choice? How is not being able to give her a shot of pitocin offering her choice?

Basically, what I am hearing is, she is given a choice based on the midwife's limitations......a midwife who can't start an IV is not going to offer it as a choice, is she? What she's going to offer is based on the limits of her practice and skills....maybe a Hibiclens douche......maybe a "wait and see" attitude.

A midwife who can't suture is not going to offer suturing as a choice, now is she? She's going to slap some nori on that laceration and pray it heals ok.


A midwife who can't carry pitocin is not going to offer it as a choice, right? She's going to give her some herbal tincture and hope it stops the bleeding before she goes into shock.

It's not about choice for the mother, it's about manipulating her into making choices based on what the midwife can or cannot actually do.

And THAT, is bullshit.

August 10, 2011 | Unregistered CommenterColleen

You beat me, Colleen!

Choices? CHOICES?!? If you don't know how to *do* something, you are, most assuredly, NOT offering anyone any choice. It is quite the mind game to get to where you think you are, but just because you've convinced yourself of it, doesn't make it so.

And the breech and twins being a "variation on the norm" - that was probably a saying invented by a midwife who wanted to make a name for herself and tackle one or the other at home. By definition ("usual; regular; common; typical"), breeches and twins are NOT normal. Does that mean I don't think they should be done vaginally? Of course not. In my perfect world, women could deliver vaginal breeches and twins in the hospital and it SUCKS there aren't many practitioners that know how to do this anymore, but there really are added risks that, if it were me, would take some serious consideration before doing them at home.

This is one area where the hard-liners (all breeches, twins & VBACS in the hospital) and I diverge because *this* would be the exact example of where the "Client's Right to Self-Determination" would come in. I think it sucks royally there are extremely limited choices for a vaginal breech or twin birth (and in too many places, even VBACs) and I would struggle between finding an Ina May vs.a c/s. And believe me, if I was going to have a home breech or twin birth, I would want someone *really* skilled and experienced in them... someone that had trained or practiced outside the US in clinics far from hospitals, preferably. If I couldn't find anyone that skilled, I'd try and find a doc over 80 years old still practicing. I *might* travel somewhere to find a provider. But, if I didn't feel safe with the provider... 100% sure of their skills and experience, I'd rather have a c/s (not scheduled) than risk my baby's life on an educated guess.

Every woman has to make these choices when she gets pregnant. Not every woman HAS these choices to make, however.

And the absurd reality that Erika speaks about, the looking at this issue from our own state's laws... THAT'S THE PROBLEM!!! And Jess, you're absolutely right! Why is a midwife able to start IVs in one state and not in another? Why can one state's moms easily get antibiotics for GBS, but the next state forces women to make the "choice" between a substandard treatment or hospitalization? It's utterly ridiculous. It's this exact situation that Colleen and I are speaking about.

Yes, education and licensing are two different topics/issues/problems, but they are inextricably braided together and each feeds upon the other to help keep moms and babies safer and, as a side effect, gets midwifery known in a better light, thereby making it more accessible to women simply because they've heard great things about it.

Midwifery could use a publicist. But, not until she has her make-over.

August 10, 2011 | Registered CommenterNavelgazing Midwife

Jess: I encourage you to look over the CA state Midwifery Standards.

http://www.medbd.ca.gov/allied/midwives_standards.pdf

They'll give you a really good idea of what is normal and what is typically outside the scope of a homebirth practice. We worked bloody hard on these!

August 10, 2011 | Registered CommenterNavelgazing Midwife

Barbara-
We have talked about the Trust Birth model before. Although now, I feel a little bit that you have an issue with the WHOLE picture of it. I get it, some of the people that come out of that group are a bit too much. Some even think that no matter what, Birth is safe and that if something went wrong, then you as a mother or someone as a birth attendant were not trusting enough or there was too much interference. However, I do know the premise of Trust Birth is a good thing. I just dont think its fair for you to totally dismiss anyone even if you *think* they are part of that movement (AFAIK, Sarah is not!). In fact, I dont know many midwives that are. They DO trust birth but they are not a part of Trust Birth, IYKWIM.

Regarding suturing, I believe if the tear requires more than a few stitches and some inside stitching, I would just as rather go to the hospital for something that bad. I know I had some minor 2nd degree tearing and my fabulous LM told me bedrest for a week and no hard labor. You know what? I healed fine. I felt fine and I am SO GLAD I didnt get stitches. ITs a matter of preference and I do not write someone off for not wanting to promote suturing or even do it in their practice.

August 10, 2011 | Unregistered CommenterRandine

I so desperately wish that there were national standards for midwifery licensing. That way, women like me could interview midwives and know that each was qualified to attend my birth.

I want midwives licensed because I *want* them to be able to suture. I *want* them to carry lidocaine and pitocin. If she cannot do those things, then I don't even want to talk to her as a potential midwife--she's not for me and I am CERTAINLY not for her. I want to have a pretty good idea what I'm getting at the outset, then I can spend time thinking about the "woo" of it all. I chose to have my second child in a state I detest because if I move home, my only birth options are homebirth midwives without drugs or the hospital. No, thank you.

I do find it. . . disturbing? objectionable? ...that there are women out there who are offering their services as midwives who cannot suture. I mean...perineums tear sometimes. A bummer, but true. If a mother doesn't want suturing, fine. Delightful. Viva la difference! But what sounds like no big deal at 8 weeks pregnant is a very big deal when you have a large tear in your vagina.

And neonatal resuscitation? Training in that should not be a selling point of a midwife. That seems like such a no brainer that it should be beneath mention. The fact that it isn't is profoundly distressing to me.

If women want to catch babies without going through the strictures of licensure or limiting themselves to a scope of practice and attendant ethics, then fine. I support a woman's right to engage them as birth attendants in the same way I support a woman's right to UC. I don't think it is a particularly good idea, but I support women's righst to make all sorts of choices.

However, I hope for a time when I can get look at a midwife's business card; see the letters after her name; and know that she has demonstrated proficiency in the things most likely to be needed to keep me everybody alive.

August 10, 2011 | Unregistered CommenterKate

Hey, Randine! Long time no see. I hope you're doing well.

I do understand the difference between the trust birth philosophy and the Trust Birth dogma. I understand there are off-shoots where women hear about "trust birth" (or "Trust Birth") and grab onto the concept, usually as a part of their path towards balance, but not always. There are some who become Trust Birth acolytes and those are the all-or-nothing women you spoke about.

All over the Net, you can hear when women are walking the path of midwifery and been dunked in the waterfall of Trust Birth. They usually dry off, taking with them the wonderful parts of the message, but leave the black & white of it, the either you do trust birth -or you don't trust birth. It's the women who regurgitate the Trust Birth mantras and beliefs when they really don't know the full weight of the words they're merely repeating because they heard them from a charasmatic "sister."

So, I won't apologize for calling out women who are parroting someone else's belief, especially when it's glaringly obvious where it comes from. As I've said many, many times:

I JUST WANT WOMEN TO THINK (for themselves).

Kate: Exactly!

August 10, 2011 | Registered CommenterNavelgazing Midwife

:)

August 10, 2011 | Unregistered CommenterRandine

I have no idea what Trust Birth is? Is it a movement? Is it someone in particular? Can someone direct me to a link?

Kate ~ I am (and I would assume ANY apprentice as well as midwife, licensed or not) trained in neonatal resuscitation and keep up my certification every two years. I would agree that it is a no brainer and it is a standard that NARM has set for everyone, as far as I know.

August 10, 2011 | Unregistered CommenterSarah Biermeier

First, can I just say how much I love you guys! YOU ROCK! You two are saying everything I feel, just in a more concise, and educated, way.

I am only days away from officially starting my midwifery education. I am taking a non-nurse pathway, but as a CM, not CPM. When I think about my philosophy of midwifery and birth, I think that I don't, in fact, *trust* birth! But I do respect the hell out of it. Birth to me is like a horse. I have ridden and owned and worked around these beautiful animals since I was a kid. I even raised one from a weanling. They are domesticated, gentle animals that allow us to sit on their backs and tell them where to go and what to do. I love them, but I don't *trust* them. They are half-ton animals, and can inflict a lot of harm, even if not intentionally. I don't make sudden movements, approach them from the rear, or let my daughter run around their legs. I was taught, and I am teaching my daughter, that horses must be respected for the creatures they are. Similarly, I respect birth, as a natural, physiologic process that usually goes pretty smoothly, but has the potential to inflict a lot of harm on families if we let down our guard too often.

I have never had a homebirth, although it was considered in my first pregnancy. (I would have been risked out because of placenta previa.) 3 of my friends have had/are having homebirths. I am so excited for them! If i have another child, and opt to have a homebirth, I for damn sure want a midwife that can carry meds, prescribe, suture, and knows every (or almost every) variable that can occur in birth and knows what to do without hemming and hawing about it. I think a homebirth midwife should be *more* prepared and knowledgable about variables in birth than a purely hospital based midwife. In a hospital, a CNM has back up and second opinions aplenty, should something get a little sketchy. A home-birth midwife doesn't have that as handily. A hospital based CNM has tons of medicine and technology at the ready, but a home-birth midwife does not. A homebirth midwife really needs to know her shit when the shit hits the fan.

What I have read of NARM's standards is a little shocking to me. The fact that its not really standardized at all means that you are going to get midwives who are all over the spectrum of skills and knowledge. I would like to think that licensing would solve the problem of non-nurse midwifery education, but unless the state's licensure requirements are stricter than NARM's I don't really think that will help. Don't get me wrong, I totally support mandatory licensing. But I think the root problem, and the solution, lie in the quality of education of non-nurse midwives. Licensing and education are different things, but are so commingled that its difficult to separate them. I think the issue with licensing is just a symptom of non-standardized education. Until NARM improves its standards and requirements, we're not going to get anywhere, and we're certainly not going to be respected by mainstream society.

(I hope this makes sense, because its almost 1:30 am here in NJ, and I am really tired!)

Thank you for being so honest about non-nurse midwifery's shortcomings. These open discussions are vital to midwifery's progress. You are doing us all a favor!

August 10, 2011 | Unregistered CommenterJen B

Wow, I couldn't agree with this post and many of these comments more. Thank you, thank you for speaking out!!

August 10, 2011 | Unregistered CommenterHeather

Jenn wrote:

"Birth is great and natural until it's not. When the stuff hits the fan, that is when it no longer matters how you feel about yourself. I highly recommend hiring a doula to make you feel great about yourself - and the most highly trained professional you can manage to ensure your safety."

I wanted to highlight Jenn's point again, because I think it may have gotten lost. Yes, my heart is glad when I hear of midwives empowering women. It's GREAT that you (Alyssa) love your unlicensed midwife. HOWEVER. Midwifery skills and doula skills are not the same, though many practitioners embody both.

August 11, 2011 | Unregistered CommenterNico

alyssa - I truly hope that you will not end up needing an I.V., or pitocin to stop a massive hemmorhage, since your midwives are unable to do this for you. Those who post here regularly know what happened to me. I had a totally unmedicated birth with CNM. No heplock/I.V., freedom to eat and drink during labor, changed positions as needed, etc. My midwife described my labor as "textbook." And then I delivered the placenta. I had a massive hemmorhage caused by a cervical laceration, an extremely rare complication. Had my midwife not been able to diagnose it quickly and get me into surgery, I would not be alive today to enjoy my beautiful son. It's easy to be naive about birth until you've seen just how quickly a normal birth can become an absolute emergency.

August 17, 2011 | Unregistered Commentermoto_librarian

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