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Tuesday
Jun262012

Guest Post: From an Ex-(CPM)Apprentice

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.

Brava!

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Reader Comments (14)

Two comments:
[1] How incredibly insulting that the writer can't even properly name Dr. Amy Tuteur, not to mention that she calls someone who deals only in facts and statistics, "sensationalis".
[2] All CPMs need to become CNMs, which means going to nursing school, and not only getting a Bachelor's degree, but a Master's [CNM being a MA in the US]. CNM isn't the "gold standard" for midwifery; it is the ONLY standard!

June 26, 2012 | Unregistered CommenterAntigonos CNM

I'm fairly new to the birthing scene. I've recently come across Dr. Amy's blog, and was wondering if her lash is directed towards all midwives or just cpms?

June 27, 2012 | Unregistered CommenterTCottrell

Thank you, Barbara, for sharing my words. Re-reading this, I realize I've been stuffing these thoughts for years - since I left my apprenticeship. I am friends with many midwives - and I am very reluctant to share my opinions with them so candidly - the hazing and bullying are real problems. There is whole culture of practice that is perpetuated by the home birth community because they are not opening their eyes and looking at it. But I want to thank you - because you trust that I am a real person - I do not know you, you do not know me - we live thousands of miles from each other and have never crossed paths in person. And if our opinions echo each others - it's because we've both experienced this culture of home birth midwifery and have personally observed similar things. This tells me these aren't isolated incidences. It's complicated - because I really hate the good/bad mentality regarding midwifery and home birth. It is not that simple. Some are better than others at elucidating the nuances of this important dialog. I hope those people (including you) keep raising your voice. Thank you.

June 28, 2012 | Unregistered CommenterEx-apprentice

I agree with SO much of this. I'm a CPM student, and it's really interesting to see the roadblocks that come up in my way of getting a really good education. For example, most midwives in my area refuse to take students from my school because they are threatened by the level of scientific education we're receiving. I myself have been unable to find a preceptorship because the midwives are only interested in perpetuating the apprenticeship model of education and aren't interested in taking on students who are learning microbiology and pelvimetry and "when in doubt, TRANSPORT." It's so frustrating, because a higher level of education is surely necessary to keep our profession safe and effective, but so many older midwives are so threatened by it!

June 28, 2012 | Unregistered CommenterEmily D.

EmilyD: It makes me so, so sad to hear how hard it is trying to find a more "medwifery" (I mean that REALLY positively)-style student. I'm just baffled how the midwives can't see what's happening, that people are going to *demand* more education and skills training, especially as the client base widens because of BoBB and the like.

TCottrell: Dr. Amy's tirades are towards CPMs and homebirths. She is comfortable with CNMs, but only in the hospital... from what I can tell, not even in birth centers.

Ex-apprentice: I *know* what you're saying is absolutely true because it is totally within my experience, too. There isn't one thing you've said that doesn't resonate over here.

I just heard from another ex-apprentice and am going to post that as an update on the piece. Thank you again for speaking up and out.

June 28, 2012 | Registered CommenterNavelgazing Midwife

I'm a student CPM in state that has licensure for homebirth midwives. I am working with a licensed midwife who is the exception to the generalizations listed above. We regularly evaluate each client for wether or not they continue to fall into a low risk category. We have definitely risked people out of midwifery care, both prenatally and during labor if complications develop. Examples? Client develops gestational hypertension, client is postdates or has a poor BPP, medium or thick mec in labor after SROM, labors that aren't progressing, maternal exhaustion (actually, we transport before maternal exhaustion).

The midwife is well respected at the hospital we transport to (I've heard the nurses and the doctors say that they appreciate that she comes in earlier than later when there is still time to do smaller interventions) and regularly consults with one of the OBs at that same hospital in cases where that is indicated.

As for breech birth, the midwife tells clients who ask this very common question "Do you do breech birth?" that the answer is "No", because what makes vaginal breech birth safe is an experienced practitioner, and she doesn't have the experience. This midwife also organizes local events for the midwifery community to evaluate new and current research and discuss evolving standards of care.

I also attended a MEAC-accredited school where we read and analyzed primary research, OB standards of care (here and in other countries), and were encouraged to actively risk-out clients who didn't fall into the low risk categories. We were also told "When in doubt, TRANSPORT", and did regular skill drills in handling the common birth complications. When I began midwifery school, I idealized the midwifery community and the "hands-off, trust birth" model of care. This is no longer my ideal.

Because of my education and the opportunity to work with two sane CPMs and a CNM in a hospital practice, I have embraced research and evidence based practice, and no longer feel that my goal is a homebirth for everyone. It is a safe birth. Always. And sometimes that means hospitals, pitocin, IVs, epidurals, and/or cesareans.

I had thought I would seek out a preceptorship that would teach me how to trust birth. Instead, I realized that what I needed more was a preceptorship that taught me one of the most difficult skills in midwifery: saying "It's time to go" to a mama who had her heart set on having the home birth of her dreams, a mama who we've grown to love. I am very grateful that that is what I've found.

I wanted to put out this different version of what CPM midwifery can look like. Unfortunately, I have also seen what is described in the post above. Luckily, I see the current generation of students mostly rallying against it. I have hope that the standards for the CPM can be raised. Midwifery education is and will continue to improve. There are midwives who want this, too, and are actively working on making it happen.

What a WONDERFUL education you've gotten/are getting! I am so, so happy to hear about the midwives that are so passionate about safety and a mother's and baby's well-being (not just physical) that they work within low-risk protocols. Midwifery can be so loving and so kind *within* the low-risk framework, including risking someoneone out; I wish there were many, many more midwives like yours. Unfortunately, the majority that I've experienced and heard about over the years are like the ones described in the post.

I myself took on high-risk clients and made stupid, DANGEROUS, mistakes that make me cringe and thank the goddess for keeping mothers and babies alive. It's from this vantage point that I am hyper-critical.

June 30, 2012 | Registered CommenterNavelgazing Midwife

If only midwives would say to their patients up-front: "This is not about you having a perfect birth; this is about you having a safe birth."

July 5, 2012 | Unregistered Commenterthe problem child

I agree with the post, except that the fixation on CPMs as being the only folks lacking full education is a red herring. I have had to deal, as a consumer, with idiot medical providers of every stripe. Having a degree does not mean you're competent to provide care, or that you're conversant with the current research, or even that you should be allowed to be in the same room with a laboring woman.

I believe that it's consumers of health care services that need the education. They need to know how to ask the provider of their choice the questions that reassure them that they're paying someone for actual, current, topical, relevant knowledge. And the alphabet soup after the provider's name means practically nothing.

From another ex-apprentice: "I too quit because of that question 'just WHEN does someone get risked out?' "

"If not for HIPAA, I would list the scenarios I witnessed ..."

I had to read these words a couple of times to assure myself that they were not mine. I have felt/thought these exact same things. And yes, the lack of risking out criteria is the reason I left my apprenticeship. The home birth community is small, and describing some of the high-risk cases that I've witnessed handled at home would reveal too much - and perhaps the identity of the client.

Student CPM for Safety in Birth:

The experience you are describing is what I had hoped for when I started on my path to become a CPM. I was also enrolled in a MEAC accredited program. Unfortunately I cannot give MEAC accredited education a resounding commendation, nor can I give one for the apprenticeship model.

I learned wonderful, incredible things in my apprenticeship. I witnessed low-risk, attentive, appropriately managed home births. I learned some facets of midwifery care that I do not believe I would have learned in another setting with a different type of provider. BUT - there were some GLARING black holes: in risk management, in skills, in theory, in practice - that I could not ignore anymore - and I could not fill these black holes on my own. I also felt that parents and babies and families were being put at risk - and I didn't want to participate in that charade any longer.

I know there are midwives practicing with appropriate protocols and standards, who have been trained in evidence-based practice - it's just that the CPM credential does not guarantee that. (This took me a long time to learn and accept - as I was pursuing this credential). And I haven't seen even an INKLING that NARM or NACPM or MANA or MEAC whoever is working on this.

I would like to see the vision of Student CPM for Safety in Birth to come true. I would. CPMs - organizationally - need to take a good, hard, look at their practices and standards. But unfortunately, I don't see that happening.

I'm glad that the public - and home birth parents - are coming forward. I'm glad this discussion is happening. It should have been happening years ago.

Thank you NGM for providing this forum.

July 12, 2012 | Unregistered CommenterEx-apprentice

I'm working on a piece entitled, "Reigning in the Renegades" after a CPM emailed me to express her ongoing and increasing distress at the flagrant ignoring of the risk status of a woman. I hope to have it out in the next day or two.

July 12, 2012 | Registered CommenterNavelgazing Midwife

Thanks for this post, NGM, and others like it you've posted recently. When I decided to have a homebirth with a CPM I thought I was gettting someone, you, know . . . Professional. After all they do have a national credential, right? I realize now it's kind of a crap shoot. There are really good CPM's out there but there's some really scary ones and how in the world is a mom supposed to tell the difference? Especially if the CPM's don't even know what they don't know! I didn't ask my midwife all the questions I now realize I should have because at the time I DIDN'T REALIZE I HAD TO. I thought the licensing process was alot stronger than it is. Luckily I don't have a midwife horror story, but I feel let down by the whole homebirth/trust birth movement. I realize now that I took a much bigger risk with my son's birth than I was aware of at the time. I'm glad so many people are speaking out so women can really know the facts and make TRULY informed decisions about the kinds of risk they're willing to take on.

July 17, 2012 | Unregistered Commenternew mom

I disagree with Antigonos and agree with Just a Consumer: I have heard enough stories of CNMs who induce a client with Cytotec in out of hospital situations and then LEAVE THE WOMAN to labor! There are good CPMs out there, and i think a lot of it has to do with attitude. When you start thinking you know it all, you need to quit, because you're dangerous. I'm also thankful to have good CNM friends in hospital that I can call on with questions and even refer clients to, when appropriate. I have learned that low-risk = low-stress. That's when I get to enjoy trusting the birth process, because odds are good it will unfold just as it should.
I'm happy with my education but I will always be learning.

October 8, 2012 | Unregistered CommenterTX CPM

I am a CNM and I want to share that the concerns noted above do not only relate to CPMs. I was in a small practice with another CNM. We identified risk differently and that chasm deepened after each birth where a "variation for normal" was present. I refuse to put a woman's life, a baby's life, or (least of all) my license on the line for the sake of pride.

If home birth was integrated into the maternity care system (CNMs and CPMs), I would love to return to attending home births - but I will not return to home birth in the current culture. It is high time that we have these discussions, that we identify the breakdowns, and that we work collaboratively to make home birth as safe as manageable.

November 18, 2012 | Unregistered CommenterCNM

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