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Jul212012

Succinct Reasons CPMs/DEMs Need to Get Their Act Together

Before I begin, I feel it's really important to say I am not anti-midwife, not even anti-CPM. I am against the way things are at the moment and am for increasing the standards for all CPMs/DEMs and believe it will only help home birth in the United States. I felt I needed to clarify before you started this post.

Sara Larane Savel, answering a thread about Michigan’s introduction of Senate Bill 1208 which would, among other things,  limit midwives to those that are Registered Nurses first, not permit breech births or other complicated cases out of hospital and require them to carry malpractice insurance, created this piece she calls “Midwives: Bringing it On Themselves.” I rarely quote entire posts, but this was so spot on, I can’t help but write it all out for you here. I’m going to interject between her points. She says:

“As a Michigan tax payer, I support strict regulation of homebirth midwives if they are to receive Medicaid reimbursement and be covered by insurance. The truth of the matter is that the midwifery movement has brought this situation on themselves.

Sara was once an avid home birth advocate, in her words, “Before I got pregnant and had a baby, I was convinced that I was going to have an all natural midwife assisted birth. I knew lots of women who successfully homebirthed with lay midwives, and was close to a retired DEM. I knew all the catchphrases about birth being a normal event, about doctors being cut happy, and rambled on about the Dutch ad nauseum.” Like me, she became disillusioned by the Natural Birth Community (NBC) and has chosen to speak out about her discoveries. Her list of reasons CPMs/DEMs are in such negative light right now includes:

  1. Not transferring high risk clients to obstetrical care.

This happens all the time and is something I’ve done (not done) myself. I attended a twin home birth and the births of women with very large babies. It took a really out-of-range woman to get herself risked out. I’ve watched as midwives have taken and kept high risk women over and over again.

     2.   Describing many high risk conditions as "variations of normal" in order to promote an agenda that all birth is "as safe as life gets" regardless of the medical needs of individual mothers and babies.

Exactly. Saying that breeches and twins are “variations of normal” is absurd. Breeches and twins come with unique sets of complications that are anything but “normal.”

    3.   Refusing to set concrete and consistent educational standards for classroom and clinical training.

This has to be one of the most confounding parts of CPMs… why they can’t come up with standardized education requirements is baffling.

     4.   Refusing to require hands on clinical training in emergency births.

While there is some hands-on training, there isn’t nearly enough. I believe there should be some rehearsing at each monthly Peer Review or more frequently if your Peer Reviews are further apart. I believe different groups of midwives and students should work with each other in these scenarios so each woman gets an idea of how the other person works during an emergency because we never know who we might end up with at a birth. However, the midwives/apprentices that work together the most should practice so much each knows the others’ body memories and actions without thinking. I believe these scenarios should include shoulder dystocias, surprise breeches and twins (including calling 911!), postpartum hemorrhage, neonatal resuscitation, the umbilical cord falling off, a partial release of the placenta, placental fragments still inside the mom, mom freaking out, TTN, fetal distress, hypoglycemia in the newborn, calling EMS and role playing that scenario as well as giving report to EMS and RNs and OBs at the hospital. (I’m sure there are more I’m missing. But the Big Three [PPH, NR and shoulder dystocia] are often the only ones addressed. That has to end.) I believe the more experienced midwives should lead the charge to educate the less-experienced women and insist on these scenarios any time midwives, apprentices and students are in a group together, even if it is a social setting. Spend 20-30 minutes before or after a gathering to practice some scenario. In my experience and in talking to midwives, students and apprentices around the country, this aspect of midwifery care is sorely lacking.

     5.   Fighting every attempt to hold midwives accountable.

This is confounding! When a midwife does something wrong, for goodness sake, instead of holding a rally for her, hold her accountable via Peer Review and legally if necessary. What is with supporting all midwives merely because “there but for the grace of god go I”? It’s ridiculous and extremely unfair to the women who lose their babies or have their child damaged by an inept midwife… even if it was an accident. Sure, accidents happen, but we hold OBs accountable for accidents. Why aren’t we doing the same for midwives?

     6.   Fighting every attempt to regulate midwives.

Another confounding aspect of CPMs, insisting that all midwives receive the same education and skills training via the same mechanisms. It does suck there aren’t schools around the US for women to attend in person, but at least the ones that are out there could be similar in their classes and information imparted. That CPMs are permitted to take classes via mail from a variety of schools is just weird. At the least, they could all be MEAC-accredited schools, even though MEAC isn’t the be all and end all for the education of midwives in America.

     7.   Unconditional support for midwives under investigation or on trial when a baby dies. Creating a culture of animosity against mothers who speak out against dangerous midwives.

Mentioned above. And it is just awful mothers who’ve lost babies in home births are made to feel like crap for speaking out. We expect and encourage women to speak out about their hospital births… usually in the negative to validate the home birth culture… but any time a mom speaks negatively about home births, she is suspect and considered a troll or one of Dr. Amy’s minions. That has got to stop! Women who’ve suffered through their home birth experiences have every right to speak up just like women who’ve suffered hospital birth experiences. We would never consider silencing a woman telling her hospital trauma story. Why do we do that with our troubled/pained home birth mamas? It’s simply not fair.

     8.   Not speaking out against dangerous midwives. There is an intrinsic code of silence in the midwifery community. Even when they think a midwife is at fault, they will stand in solidarity with her because they mistakenly believe that prosecuting dangerous killer midwives in some kind of medieval persecution. The concept of midwifery is more important than ethics, safety, integrity, or human beings.

Again, mentioned above and agree 100%. I do think a large part is the “there but for the grace of god go I” mentality, but midwifery is still seen as a calling and with that brings an entire (often unspoken) spiritual aspect to the profession and it seems like heresy to speak out against the women who are a part of the group. It is disgusting to me how dangerous midwives are spoken about in behind closed doors yet are allowed to continue their path of destruction with women and babies. What about the protection of our clients? Don’t they deserve to know who is and isn’t operating within the standards of care and who flagrantly flaunts the boundaries of safety? Isn’t there a space between lying and slander? I believe there has to be.

     9.   Double standards:

These are brilliant.

-         Saying that birth is as safe as life gets, and then switching to the statement that birth is inherently risky when something goes wrong.

-         Blaming mothers for not doing "research" or "trusting birth" when a midwife fails to do her job.

-         Using scare tactics to keep women from going to the hospital or seeking obstetrical care, then blaming the mother for not transferring when something goes wrong.

-         Telling women that "babies die in hospitals too" when it is actually a midwife error that caused a homebirth loss, and had the mother been in the hospital the death would likely have been prevented because of the availability of technology.

-         Wanting to be considered "professional" birth attendants, yet refusing to hold to consistent standards of education, scope of practice, oversight, regulation, and ethics.

-         Wanting to receive Medicaid and insurance reimbursements but refusing to hold liability insurance.

-         Saying they are not health care providers and do not practice medicine, yet want Medicaid reimbursement.

-         Claiming to support women yet abandoning them if they speak out against dangerous midwives.”

I couldn’t have said this better myself.

Sometimes things we write take on a life of their own. Sara told me she scribbled these words down in a 15 minute break while her three-year old was watching Bob the Builder. Inspired, Sara… absolutely inspired. I wish I’d have said these words myself. Thank you for allowing me to share them here.

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Reader Comments (10)

Excellent post. But I still feel midwives need to be CNMs because even the most apparently low-risk women can have hidden pathology. I've had patients who, at some point in labor, have informed me that they had kidney or liver disease, or rheumatic heart fever, or some other conditions, as children, but "are all right now". No, they aren't, they need to be specially monitored and the midwife has got to understand the pathology. No form of purely midwifery education will give a midwife the necessary knowledge, but nursing does.

July 21, 2012 | Unregistered CommenterAntigonos CNM

Antigonos, even the ICM does not require midwives to be nurses. As a Florida Licensed Midwife, we are required to have three years of formal education, including physical assessment skills, and to have a risk protocol. Any significant history would require a screening by a physician, which would then determine whether or not the woman could remain in our care. All DEMS do not practice alike! I think the Florida licensure model, which in many ways is more stringent than NARM, is a very good one. (But not without major drawbacks...there is no perfect system.) I attended an Ivy League BA to CNM program, then switched to a now-defunct DEM program in Florida once I had finished most of the nursing courses. The only difference was the price tag and program emphasis. If anything, the CNM program de-emphasized clinical skills to focus on academic theory. Sorry, but knowing 10 different nursing theories does not do one damn bit of good when a woman is hemorrhaging at home. Plus home birth was not a major academic or clinical focus in the CNM program. How can you learn to practice safely in an OOH setting if you do not get extensive practice doing so? I just don't see how the "nurse" part makes any difference if the basic clinical and risk screening skills are there.

July 22, 2012 | Unregistered CommenterBocion

This is post is so clearly written. I hope changes can be made.

I don't understand how being an RN would help a midwife understand the dangers of childhood rheumatic heart fever. My husband is an RN (in an a ICU setting while working on a masters of nursing) and he doesn't know the complexities of the conditions listed by Antigonos CNM or how those conditions would affect a pregnancy/birth.

July 22, 2012 | Unregistered CommenterAnn

I agree with this post. I'm a CPM student at a MEAC-accredited school and I get frustrated by the knee-jerk reaction that everything is a variation of normal, when it obviously isn't. I'm grateful for my school, though, because they regularly have plenary sessions where they talk about our midwifery standards and why they were put there to protect us and how we should be practicing within them, even if we don't always agree with them, because the profession of midwifery and the safety of our clients are more important than our egos or our desire to "save" women from the system. I hope someday that people will call me a "medwife" - that'll mean that I'm doing my job right!

I have to agree with Bocion, as well. There are several nurses in my CPM program, and they say that they didn't feel that a CNM's education would adequately prepare them for a homebirth practice. I do think that midwives should have a stronger science background than they do though, the same way that you have to take pre-requisites before applying to medical school or nursing school. My undergraduate science degree has helped me every single day that I've been studying midwifery.

July 22, 2012 | Unregistered CommenterEmily D.

To give a very simple example, a laboring woman with a history of rheumatic heart fever needs to have prophylactic penicillin in labor. Further, of course, one has to be alert for signs of cardiac decompensation, and fluid intake and output needs to be carefully observed.

The worst case of HELLP Syndrome I ever saw, with the woman hovering between life and death for nearly 2 weeks, began with a "perfectly normal, low risk" patient arriving for an unmedicated, low-intervention birth [the hospital where I was working at the time specialized in "natural" births]. During labor she developed not just severe pre-eclampsia, it progressed to eclampsia with great rapidity. When her parents arrived in Israel some days after the birth, when she was still in ICU, her mother said to her, with me in the room, "Didn't you tell them about the kidney disease you had in high school?"
She hadn't.

There's no reason that an RN would make associations between several categories of illnesses and the particular problems they can cause in pregnancy and birth unless that RN was continuing to a CNM.

The bottom line is that the CNM is competent to care for ALL pregnant women. A DEM is not. It's a bit like being the chef of a steak house who only knows how to prepare desserts. It's all food, isn't it, so that's OK? Besides, even steak houses offer dessert, don't they?

July 23, 2012 | Unregistered CommenterAntigonos CNM

Antigonos, I think we're hijacking this post on a sidetrack here. Nevertheless, I still don't understand how your examples contradict my point. In the first example, you have a client who required specialized care during labor. I probably would have risked that woman out of my care. Therefore, she would have been under a CNM or MD care during labor anyway. If I were a CNM I could have cared for her in the hospital, but that's an argument for continuity of care, not safety. For the second example, you have a client presenting with HELLP. If she developed severe pre-eclampsia during labor, then I assume her blood pressure spiked. Since I take periodic BP measurements in labor, and transport at the first sign of anything alarming, I'm not sure how my being an RN would benefit that client. Unless there is something magical about an RN license that enables one to take accurate BP measurements that I don't know of? (Because taking a BP is not rocket science, and I can do it just fine, thank you.) If you're arguing about PLACE of birth, that's a whole other argument. But if it's the CNM/DEM thing OOH, I'm afraid you'll need to give me an example of ONE skill that can only be conferred by an RN license that would save a client's life. Critical thinking, BP taking, fetal monitoring via Doppler, administering meds in the case of hemorrhage, knowing and respecting one's own limits, etc., etc. etc. are not the sole province of nursing school.

July 24, 2012 | Unregistered CommenterBocion

It's an okay discussion. Just stay civil or they won't be approved. Thanks.

July 24, 2012 | Registered CommenterNavelgazing Midwife

As someone who reluctantly chose the CNM path and wound up really valuing the nursing part of my education, in general, I feel that I had a "holistic" training. Holistic in that I was taught to look at the entire body and the entire lifespan before the midwifery training started and focused much more intensely on women's reproductive health. Women are more than reproductive organs/hormones. It fits into the larger picture of the body. That's a big lack I see in CPM education. At least I'm not aware of any programs that give substantial time to physiology not directly related to reproduction.

July 24, 2012 | Unregistered CommenterKatie

Just wanted to mention that most HB MW's don't carry liability insurance because most insurance won't cover anything you do out of a hospital/surgery center/office. I am a physician and I will say the only reason that most physicians carry malpractice is because it is required by the hospital. Otherwise when you don't carry insurance you often won't be sued because most lawyers don't want to go after something as unprofitable as a single physician -- it's the dr's INSURANCE and ESPECIALLY the hospital's insurance that makes the real $$.

July 29, 2012 | Unregistered CommenterRebecca

i was pregnant with twins. i have seen breech birth videos of healthy vaginal deliveries. i have seen videos of vaginal twin births. Yes there are certain different complexities with twin pregnancies and birth. however a vaginal birth of twins is natural and can be done safely. I was monitored very closely by ultrasound throughout my pregnancy. my midwife was confidant that i too could have a vaginal birth of my twins. even if the second was a breech. however we found out that one had valementous cord insertion and passed away at 21 weeks gestation. i still had a vaginal birth of both my girls. everything turned out fine. it offends me that anyone would say twins are unnatural. women for thousands upon thousands of years have been giving birth. i am pretty sure it's natural to give birth to twins or breech babies vaginally. on an ending note. my midwife was very diligent about making sure i was safe and that my pregnancy was safe enough to be birthed at the center instead of the hospital. she also had an emergency plan of transporting me. she also has emergency equipment that she was trained to use in case. for me and for baby. the only thing i didn't like about my midwife is that she had a bad bedside manner and said rude things about me while i was in labor. but, she was very experienced and trained.

October 30, 2012 | Unregistered Commentermonica

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