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Reigning in the Renegades

This is a comment in the “Guest Post: From an Ex-(CPM)Apprentice” post but it needed to have its own light. This is the third such comment about risk in home birth. She writes:

“’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(s).

“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.”

Just before this comment came through, I got an email from a frustrated CPM who had some thoughts I’d also like to share. It seems she’s darn tootin’ tired of being lumped in with all CPMs, especially the ones that don’t adhere to accepting (and keeping) only low-risk women. She’s seen as a “medwife” whose standards are too stringent, yet all she’s really doing is operating within the boundaries of the laws in her state.

What is so wrong with having parameters? It’s what keeps women and babies safe. They weren’t created to annoy midwives or clients, but to make sure the woman and baby make it through birth safe and alive. Her (and my) wish is that these out-of-bounds, renegade midwives would get with the program and stay within the standards of care of low-risk clients. Mothers and babies would be safer and midwives would not be so reviled if they obeyed the rules.

Midwives are known for operating on the periphery of society, it’s a part of the natural birth culture. But, it’s time to strengthen the rules and (in my opinion) force midwives, through peer pressure that starts from the moment the student decides to be a midwife, to follow the rules.

It isn’t a bad thing to follow protocols! Our job is to help women and babies have great, safe, births, even if they have to happen in the hospital. We have got to stop apologizing for transferring and transporting women. It is a normal part of the possibility in a homebirth.

As always, the clients’ desires come into this discussion.

“But, what if the woman wants to have her twins/breech/VBAmC/etc. baby at home? Don’t I have a responsibility to serve her?”

The answer is no. If the woman is low-risk, perhaps yes. If she is high-risk, no. You have a responsibility to serve her correctly, within the normal and safe boundaries of birth. The line must be drawn somewhere and it must be drawn further back than it is at this point. Midwives all have boundaries they won’t cross, whether it’s a preeclamptic woman or a woman with triplets, there are lines they won’t cross. (Except for a couple of high profile midwives around the world.) Bringing the limitations inward can do nothing but keep women and babies safer as well as (not that this is the most important aspect, but it’s important nevertheless) helping our publicity problems. If a homebirth midwife was seen as careful and adherent to the low-risk status of women… what the studies watch for when they report on such things… then we can begin to save not only lives, but our own faces.

I think this new way of thinking would be hardest on the older (not age) midwives who’ve, through time and experience, had an edge over the newer women, both with skills and arrogance. They’ve never seen anything tragic happen, so nothing they’re doing could be wrong. When, in reality, it’s probably only a matter of time before something does… if they stay on the same track they’ve been on. And because it’s the older midwives who are the mentors, they’re teaching the younger, less seasoned women, things the newer midwives simply don’t have the skills or experience to understand yet. So much of home birth midwifery takes time to learn.

So what of the women who would be left out of home birth care if midwives tightened the parameters? I believe there would be a period of adjustment, a rash of women threatening to UC and women trying to strong-arm midwives into attending them. But, I think after the women in our country saw we were serious, they would deal with it, hire the midwife as a monitrice (who also stuck to her guns about no “surprise” home deliveries) or doula and had as decent a hospital birth as possible. I can see clearly the emotional blackmail that would ensue and it would be crucial for midwives to withstand the coercion.

Of course, in my perfect world I would also make hospitals welcoming, respectful, open to vaginal births after cesareans, vaginal twins and breeches when safe enough and having immediately lower cesarean rates so women wouldn’t be terrified to go into the hospital. I also think that many women are unnecessarily scared by hospital deliveries and midwives can have a hand in un-brainwashing that belief, too. Of course, they have to believe it first and that might be the biggest challenge of all.

Lastly, I want to see midwives who adhere to standards rewarded, not vilified. It shouldn’t be this way, but they are the brave ones in the bunch, the “renegades” of those that refuse to conform. Just because the majority are out-of-bounds doesn’t make them right. (And, in my experience, it is the majority that do not adhere to the strict low-risk standards.)

I was one of those midwives who took almost any client that asked and it’s a miracle a couple of those mothers or babies aren’t dead. I’ve witnessed midwives taking high-risk clients and again, it’s a miracle those women and babies are still here. I’m tired of seeing my “sisters” flaunt the low-risk standards we all know are the right things to do. For crying in a bucket, let’s do them.

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Reader Comments (13)

Barb thank you (and your commenters) for being willing to continue to share your experiences and thoughts on these issues. As someone who lost a baby to the mentality that it was better to preserve the vaginal delivery than err on the side of caution (among other issues) I am so glad there are people working to protect those babes not yet conceived or born.

July 13, 2012 | Unregistered CommenterJennG

I couldnt agree more!
I know that many HB who follow rules and protocols are shun as MEDwives, and it is a shame. There is a common ground where we can offer the safest scenario possible for mothers who wish to HB, and the best support to the women who are risked out of HB. Protocols and guidlines aren't there to oppress us, they are there to keep us safe, the day the HB community realizes that we can go somewhere!

July 13, 2012 | Unregistered CommenterFlorence

Thank you for this, Barb! Really great article.

I have often thought that the argument, "Well, if I don't attend this high risk birth, they'll UC," is disingenuous. Most women, if told that it is a danger to their baby or themselves to do something, will choose not to do it. One of the responsibilities of a midwife is to make sure her potential client is properly informed about risks!

If it is a sincere argument, on the other hand...well, if a woman tells you, "If you don't attend my risky homebirth, I'll just UC," it is akin to blackmail. Don't be taken advantage of in that way.

July 13, 2012 | Unregistered Commenterareawoman

I agree that in order for the best of all options folks need to feel safe in either (any) setting. I feared the reality I'd face for in-hospital vbac. (I'm a doula too & well know what I'd face in my local hospital) I choose HBAc because it felt right, and would not be waived because I feared th hospital option far more then my family feared homebirth. I also remained low risk, had only a moderate rise in bp near the end, added a bit of Cal Mag & stayed delightfully within all local safety parameters. Had I raised more... I simply don't know. (can't know what you don't experience) but I think I'd have stuck to my HB guns quite a bit further- because the other option for me was sooo invasive, so over the top cautious... it scared me more then what my situation warranted.
As a doula & apprentice (was shooting for cpm too, now single mom-ing & doulaing only sporadically) I believe the provider needs to draw a line at our comfort level also. Be straight with mom when you feel it's time to transport. I've been at some that spooked me, and some I thought we could go longer when mom was ready to move. I've been caught by surprise by a fetal distress that scared me big time. I respect a midwives/doulas right to say no I won't take this client, no I won't stay home longer without medical backup, it's time to transport. However, as the client, I reserved the right to say no to any procedure- including transfer. The only way we can address the split between HB provider comfort zone & mom's comfort zone & moms comfort zone is to keep demanding hospitals treat birthing women with respect & provide informed choices to all. As long as hospitals run like machines, many moms will fear them. If I knew I could say thanks but no thanks to repeat c/s after due to time limits, & freedom to move, and eat at will, and no IV if I'm drinking..... then maybe I wouldn't fear transport....

July 13, 2012 | Unregistered CommenterSonya

Midwives are known for operating on the periphery of society,

That is simply not true in developed Western countries apart from the US and possibly Canada. In the UK, Europe, Israel, and many more countries, the midwife is central to OB care. Up to a certain point, and within certain parameters, she practices autonomously within a supervised framework such as a hospital or health department; only when the parameters of normal pregnancy, labor and/or birth are exceeded, does she either hand over to a doctor or, more likely, work in conjunction with him/her. The governing body in the country in which she resides makes sure she is educated to a certain standard, can pass examinations, and her license is contingent on maintaining a certain professional level [and usually keeping legal records as well]. There is often a requirement for continuing education in order to renew one's license.

Only in the US -- and not in all states, either -- is it "anything goes", with the result that midwives are, with considerable justification, regarded as inferior.

July 13, 2012 | Unregistered CommenterAntigonos CNM

One of the paradoxes of midwifery is that the midwife declares that she is a "specialist" in "normal birth" -- and then proceeds to accept patients who are far from normal. Some midwives actually brag about beating the odds, when taking on a high-risk patient and somehow lucking out.

July 13, 2012 | Unregistered CommenterAntigonos CNM

I agree with Antigonos! I think there is a 3-fold element to a safe home birth. 1) A low risk mom, 2) a safe, competent midwife, 3) a collaborative relationship with a hospital/doctor where the mom will feel safe to transfer to. I was fortunate enough to have a home birth with all 3 of those things. If I had not been able to meet one of those criteria, then home birth would not have been an option for me, personally.

I refused to read any home birth horror stories while I was pregnant because I didn't want to fill my mine with fear (and I had already read the overall body of research and decided I would be fine). Now I am 6 months post-birth, I have finally "let" myself look at these stories. In EVERY SINGLE one I have read there has been a violation of one of those principles. There was a high risk mom/baby (breech, uncontrolled diabetes, untreated group B strep etc.), OR gross malpractice on the part of the midwife OR a botched hospital transport... or a combination of the above. Reading those stories actually made me feel safer because I realized that I would have never let myself birth if I had violated one of those 3 criteria I mentioned above.

July 13, 2012 | Unregistered CommenterRebecca

This is a great article, and I would love to see this topic in more places. Sadly, too many MWs think that everything is a variation of normal, and the ridiculous rates of death and disability show this is not true. I

f HB MWs stuck to JUST low risk moms like they are suppose to (and other countries MWs do), then they would get more respect, and people like me wouldn't fight against HB. Sure, HB won't ever be as safe, but it would be reasonably close if procedures were followed.

But what are CPMs doing instead? They are FIGHTING to have even these minimal standards removed all over the USA. Take AZ for instance- they are fighting to be allowed to take breech, HBAC, and all the things that cause DEAD BABIES. They are fighting to be allowed to care for women even many OBs send off to the MFMs! WHY? WHY can they not stick to low risk moms?

One more thing-

HBAC is NOT safe at home, the rate of rupture is ONE in 200 (.05%) MINIMUM, AND THIS IS DEADLY OOH. Just because the other 199 do fine (whether hbac or transport), doesn't make it safe. I cannot fathom trading possible poor treatment for the risk of my baby's death (and my possible PPH). I cannot imagine trying for a VB is so important anyone would take this risk. I

Sadly, I have a friend that lost her baby in a BC (someone else's living room, basically) HBAC, so YES, it happens. And she had a skilled CNM! Its not like no hospitals do VBAC, you just have to travel (to be fair, I'm sure there are some areas without a hospital option, but this doesn't make HBAC OK)

July 13, 2012 | Unregistered CommenterStaceyjw

This is where the uk system of Supervisors of Midwives works so well. We do have tightly controlled criteria for homebirth. But in the UK women have the right to chose their place of birth. It is their decision.

If a woman, wanting a homebirth, falls out side the criteria. Then, in addition to normally midwifery visits, she is visited by a Supervisor, who will make sure she understand the risks of delivering at home. And a plan is made, with her, not for her.

At the end of the day UK midwives have a duty to attend, and the system of Supervisors of Midwives, is there to protect both women and midwives.

It is a good system!

July 13, 2012 | Unregistered CommenterCanuGess

I *love* the UK system, but it just wouldn't work with midwifery in the shape it is in here in the US.

And yes, I should have prefaced it all with "Here in the US...." because I do know midwives are an incorporated part of the obstetric system in many other places.

While I'm really glad to see the supportive comments, I am REALLY surprised there aren't screams from midwives and clients. Is this really such a great idea that everyone's 100% behind it? I doubt that. ;)

July 13, 2012 | Registered CommenterNavelgazing Midwife

I'd like to see more by-the-book midwives comment.

As for the "renegades"? They might not want to reveal themselves as being more ....er... "patient-centered" than standard-of-care centered.

July 13, 2012 | Unregistered CommenterAnj

Not on the periphery in Aust either. My third son was born in a hospital. All my prenatal care was done by my hospital midwife and she was the attendant at my birth with another member of her team of three midwives (she also did all the post natal care for my baby and I).The ob popped his head in twice, answered questions for my midwife once when she was unsure about something and that was it. Oh, and this was a syntocin induction at 37 weeks when labour failed to start 48 hours after SROM. Three weeks later my midwife performed the same role for a woman having a VBAC.

One way to make the hospital system more accepting of the important role provided by midwives is to actually give them some confidence in the professionalism and competence of the midwives.

July 13, 2012 | Unregistered CommenterMJ

Thank you for using my words. I do feel alone. And I have felt alone in my opinions about OOH midwifery for a long time.

I hope my opinion is not a single outlier among midwives and among student midwives. And yes, I know far more midwives who will take breeches/twins/VBACs/VBAmCs than those that won't. Far, far more. I'm struggling right now to think of ONE who won't do this. The peer pressure is to take these cases. That is what exists in OOH birth right now. It is unwritten peer pressure. And it appears to exist all over. Not just isolated in one geographic area of the US.

I bite my tongue when speaking with friends - midwives. Over the years I have developed a lot of friendships with midwives - and I'm not a midwife - I'm just a former apprentice. And if I question protocols or safety, I'm reprimanded for not being qualified to ask those questions.

I have a few midwife friends - 2 when I think about it - one CPM, one CNM, with whom I can have honest discussions about midwifery without fear of being cut down to shreds. It takes courage to critically evaluate one's own practice, or the practice of a group of professionals without getting into blaming or shaming or bullying. There is a lot of defensiveness.

I don't know what the answer is. I know what my frustration is. I really appreciate being part of this discussion.

July 14, 2012 | Unregistered CommenterEx-apprentice

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