I got the piece below as a comment in the Dead Breech Babies post and felt it was too powerful to leave hidden amongst the other (equally great) comments. In this Guest Post, an ex-apprentice outlines her thoughts about the quality of midwives the license is producing and some random thoughts about where midwifery is headed if it stays on the same course. I believe what she says is right on for many, many Certified Professional Midwives (CPMs), my voice echoing hers in many respects. (Although she is echoing me since I said some of these things first, but who’s quibbling.)
On the same day I got her comment, The Daily Beast printed “Home Birth: Increasingly Popular, But Dangerous,” a scathing assault on home birth in general, but CPMs in particular. Reading as a normal, rational person, CPMs seem worse than fringe, telling women to put garlic in their vaginas instead of antibiotics for an infection (GBS) and ignoring red flag after red flag during complicated and even high-risk pregnancies, labors, births and postpartum periods. Sadly, as most of us reading this know, these are the typical truths, not the exception. No wonder more and more people are speaking out against the lack of education and skills training of CPMs and how they, in way too many cases, ignore the adage that midwives only attend to low-risk women. Low-risk, it seems, is subjective when, in fact, it is quite objective.
But, let’s listen to what one ex-midwifery apprentice has to say about her training and why she left the midwives she was working with.
I’ve been reading your blog for a few years I’ve really become interested in the topic of education and licensure of CPMs. I don’t believe CPMs should be vilified as they are by certain blogs on the internet but a critical look at their licensing and educational standards is in order. THANK YOU for being unafraid to voice your opinion about this. I, at this point, am too timid to publicly voice my deep concerns for the training of CPMs, the “standards” by which they practice, and the lack of accountability by the regulating body/bodies.
The breech post really struck a chord with me. I read the Ina May article in the New York Times and was surprised that she’d revealed a story about the delivery a breech baby under her care who became stuck and then suffered brain damage. Yes, most of the breech babies just “fall out” and so yes, most of the time anyone could attend the birth of a breech baby. And having witnessed dozens of breech babies falling out during delivery might give a midwife the false belief that “breech is just a variation of normal” - and because they went to a workshop given by a midwife who attended the Canadian breech summit that they are competent and skilled at attending breech birth.
As an apprentice midwife, I’d often asked myself “Just WHAT does it take for a woman to get risked out of a midwifery practice?” Because although midwives tout that they attend low-risk healthy mothers, the risk factors would pile up but never seem to push the clients into the realm of “high risk” or even “not low risk” and therefore not necessitate a transfer of care.
As a conscientious human being, I was acutely aware of my limited and outright lack of skills in high risk deliveries. As labors would progressively get more and more complicated over hours and sometimes days, I would run resuscitation drills in my head, recheck the postpartum anti-hemorrhagic meds, and mentally try to prepare myself for a true emergency situation where someone’s life was on the line. I knew I was labeled as “primary assistant” to the midwife, I’d be expected to attempt to perform life-saving measures in an out-of-hospital setting and I knew I was under-qualified for that job. Other apprentices were not so self-aware, and that was even scarier. They would be more attentive to the birthing music CD and keeping candles lit than understanding the complexity of the situation that was unfolding.
Then birth would unfold and with some gentle stimulation or a shot of Pitocin everyone turned out “Just Fine” and the midwife could then assert that that whole roller coaster ride of labor and birth was just a “variation of normal” and that the objective is not to transport when a midwife “gets scared” but to “trust birth” and would often belittle other midwives who were quicker to transfer care to a hospital when things weren’t going perfectly smoothly.
Back to the breech thing when I’d started midwifery training, I’d assumed that midwives risked out breech birth, no question. But it was slowly revealed that many midwives felt that breech was a “variation of normal” and they felt fully equipped and skilled to attend breech births of all variations - simply because they were midwives, they trusted the inherent birthing process, they’d read up on it, and seen some Ina May videos about breech birth. IS THIS NOT INSANE?
And there was a certain level of delight on the part of the midwife when a mother would want to have a home birth with a breech baby. Or when a woman would consent to home delivery DURING ACTIVE LABOR when a surprise breech was discovered. Tell me, can a woman truly understand the risks of breech birth at home when she first hears of it when she’s 7 centimeters dilated and has had not even considered the possibility this “variation of normal” for the entirety of her pregnancy? I don’t think midwives even consider that the baby could die when they agree to practice their substandard skills in attending childbirth with a breech presentation. Most breech babies just “fall out.” And the breech birth I witnessed as an apprentice was a case of the baby just “falling out.” But I am not lulled into believing that all breech babies come flying out this way. But I’m afraid that many apprentices will be lulled into this belief. As well as many midwives.
I do believe that women have the right to birth their babies, even their breech babies, vaginally. They are entitled to full informed disclosure of the risks of breech delivery and the experience of the provider. They should have access to skilled, capable providers for vaginal breech births and I think it’s a crying shame that women do not have these options in hospital settings. They are also entitled to compassionate and respectful care.
My interaction with midwives has shown that they are incredibly compassionate, caring and attentive providers. But these skills, though vitally important to the midwifery model of care, cannot replace critical life-saving clinical skills. And midwives who attend hundreds of births where babies, vertex and breech, just “fall out” will never gain these skills.
I feel like I need to add my voice. These stories about midwives attending breech and high-risk deliveries ring too true to what I’ve experienced in my years as an apprentice midwife. I’m glad these issues are being brought to light. It’s time.
And a second comment from the same woman goes on:
CPMs need to understand statistics. They need to grasp the statistical (un)importance of an anecdote. The professional organizations representing CPMs need to educate the membership about real statistical risk to the profession when individuals take on high-risk cases. The professional organizations have to stop bullying members and engage in true critical and thoughtful discourse regarding the profession of midwifery and let go of the emotional ties to former styles of midwifery that are no longer valid or acceptable in today’s world.
I’ve noticed a lot of burying heads in the sand when it comes to looking at practice standards and education of CPMs. No one wants to examine where the CPM credential falls short. They just want to get louder and blindly proclaim its inherent worth, fight for licensure, and assert that the end (CPM) justifies the means (apprenticeship, correspondence course, what-have-you) in training midwives.
What is unfortunate about this burying heads in the sand is that CPMs are not participating in this raging discussion regarding their own professionalism and competency. This discussion is largely being defined by Dr. What’s-Her-Name and other sensationalist voices. It’s creating a false black and white dichotomy and painting ALL midwives as incompetent, ALL midwives as bad, ALL midwives as heartless self-centered egomaniacally superstitious pseudo healthcare providers. And this is not true. Mothers who have been misled by midwives are bravely coming forward and it is incredibly disheartening that CPMs and CPM professional organizations - are not the FIRST in line to hear these stories and to address the issues brought forward by them.
Anyone read MANA (Midwifery Association of North America) news lately? Is there even the faintest whiff of the negative publicity that homebirth and CPM care has been receiving in the past months? Year? Is there any inkling that MANA (oh, MANA represents all midwives, not just CPMs, right. How do I keep forgetting?) is responding to the lack of educational standards, lack of professional standards and the stories of poor outcomes? Are they even acknowledging the theory-practice gap that is rampant in midwifery practices? Low-risk is the theory. High-risk is the practice.
No just the endless hollow sing-song of “I am a midwife….” “We need more midwives!” “License CPMs!”
If CPMs want to thrive as a profession, their professional organizations need to step up and start addressing these difficult issues on a professional level. They need to participate in this discussion. They need to let go of their emotional gut reactions, stop attacking each other, stop being afraid of asking the hard questions (For instance: is the current CPM educational pathway sufficient?) and react accordingly not only to benefit the profession of midwifery, but to the families they serve.
I would love to see this happen. I don’t want midwives go away. I don’t want home birth to become illegal. I don’t want to see the CPM credential disappear. But I would like to see it improve. I believe it is possible. But CPMs need to be on board. And that hasn’t happened yet.
After I posted the above piece, I got this email from another ex-apprentice, also unable to share her name and location because she’s been bullied and shamed for leaving the “sisterhood.” This has got to stop.
“We've talked about this issue of the CPM training before and your words are some that I go back to when I need to remind myself why I quit my apprenticeship. I too quit because of that question 'just WHEN does someone get risked out?' It was a question my mentor midwife never seemed to be able to answer. Another midwife in the community was hassled for transferring too many women. I knew that every transfer was warranted even if there were more than two or three in a row. I was told transferring a woman shouldn't be based on a midwife's fear, but I wasn't ever told what they were based on since they took on so many complicated (not low-risk) births. It's nice hearing the ex-apprentice in the post say she's heard the same thing.
If not for HIPAA, I would list the scenarios I witnessed before finally realizing that I am not cut out to be a CPM if being a CPM in my state means letting women who are not low risk 'talk you into' allowing them to birth at home or whatever excuses I used to hear for why such and such person was allowed to, regardless of their actual risk factors. Even the conservative midwives in my area routinely accept higher-risked women. The ones who are negligent are far worse.
So anyway, thank you for posting that blog post. I'm 'just' a doula now, but have hopes of becoming a CNM someday. I hope more women speak up; the more there are, the louder we become.”