With permission from the author:
“I read your blog often, and would like to pick your brain on a question if you have a moment. I'm a mom and a big believer in women's right to choose where, how, and with whom to birth. I am also an aspiring midwife, and I feel stuck between a rock and a hard place, so to speak, in choosing the right path for me. So I'm writing for some advice. Are there any direct-entry programs in the US that you feel provide adequate and appropriate training for midwives? I have considered doing the CNM route, but I do have doubts about my ability to work in a hospital as a nurse, and about that kind of training as well. Will it be as holistic as I hope? The CNMs I've met tend to be more obstetrically-minded than I'd hoped (though maybe this limited experience has biased me unfairly).
Anyway- I want to be as well prepared as possible. I realize there is real risk inherent in birth and I know I won't be comfortable with myself as a care provider unless I feel I've sought the best training possible. I'm sure a lot of this is in the apprenticeship/clinical portion, but I know the formal ‘schooling’ is really important too. Any advice you might give would be much appreciated. Like I said, I read your stuff often, and appreciate your skepticism.”
I share this email because I’m being asked this more and more. And while I’ve addressed it a couple of times, it seems the cycle has come around again to talk about it.
First, the only complete education and skills training program I think is more than adequate is Florida’s process to becoming a midwife. The Florida School of Traditional Midwifery (which happens to be MEAC-accredited as well) is the school I’m most familiar with. If there had to be a litmus test of other schools, it would be that they are MEAC-accredited and cost a buttload of money. $20,000+ gets you a pretty decent education. Beware the discounted and we’ll-get-you-through-fast programs. The road to becoming a midwife should be long and arduous. And expensive. There’s a reason for that. It is only through time does a woman witness a great variety of births and birth scenarios. Hypothetically, a midwifery student could attend 40 homebirths and never see anything more dramatic that sticky shoulders or a woman needing pit to stem a mild hemorrhage. It isn’t until the real difficulties occur –and many of those are so subtle as to be easily missed by the novice- that a midwife learns her skills.
Women wanting to be midwives (and I know there’ve been a few men interested, but in general it’s women) seem to want to zippity-doo-dah through the process. I know I sure did. I thought I’d seen enough already, that I knew so much, it was a mere technicality towards my having a license. How wrong I was. So much more responsibility is necessary than even I thought (and I’d already been to about 700 births by the time I got my CPM). There’s a world of difference watching/assisting and being responsible for the two lives. Only experience can develop that reality. And not being the Primary midwife, but a Primary Under Supervision of a very experienced midwife. It disturbs me, midwives who’ve had less than ten years of experience teaching apprentices. How can they teach when it isn’t even ingrained in them yet? (And I had an apprentice when I first got licensed. One of the stupidest things I ever did was believe I could teach someone the gamut of midwifery skills when my own weren’t even honed.)
So the reader’s questions aren’t black & white answers.
If you are more holistically-minded and think you will be brainwashed in Nursing School, perhaps you aren’t so strong in your beliefs or Nursing School has a lot of reality to teach.
If you find a great school to attend… MEAC-accredited, expensive and extensive… you will still need to find an experienced midwife to apprentice with. And your apprenticeship needs to be years long in order to get the proper and adequate education.
If this sounds daunting, good! It should be.
Now, looking at becoming a CNM, all schools to become a nurse and then midwife share the same quality education. You can pick a school anywhere in the country and know you’ve chosen well. Then, when you are doing your skills training, you know that almost all teachers have a certain level of knowledge and training themselves. If you happen to get a crappy mentor, wait a few weeks and you’ll get a different one. You learn from many different mentors, not just the one or two you apprentice with as a home birth student midwife.
Each non-CNM midwife has what I call “black holes” in their education and skills training. When they teach, they also teach the black hole… or rather, they leave out the knowledge of the black hole, thereby passing on the black hole from generation to generation of apprentices/midwives. Unless a student/apprentice has another midwife that accidently fills in the black hole, she can go her entire life not knowing about something. For example, I just reported on a study that showed “Heat Wave May Make Womb a Dangerous Place,” that heat was positively associated with congenital cataracts. When I reported on it, I noted that I’d not known babies could have congenital cataracts. Another midwife was surprised (understatement) that I didn’t test for them, looking in the newborn’s eyes with a flashlight to look for the “red reflex” (you can bet I know about it now!). I’ve had at least ten midwives teaching me how to do newborn exams and I can’t remember even one of them telling me about the red reflex. Clearly, this was a black hole in my education… and one I passed on to my apprentice as well. Hopefully, she’s learned about it since then. As an aside, I’m reading the new edition of “Heart & Hands: A Midwife’s Guide to Pregnancy and Birth” to review it here on the blog. H&Hs was a staple in my midwifery education, we nearly memorizing it for our NARM exam. I’m assuming Anne Frye’s replaced H&Hs, but know this is still an extremely important text for student midwives. In here it says:
“Check the eyes for red spots, hemorrhages of the sclera due to pressure in the birth canal. Also look for evidence of jaundice: (sic) the whites of the eyes should be white, not yellow. Check to see if the pupils are equal in size and reactivity when exposed to light. Check for tracking by moving your finger back and forth close to the baby’s face. Check the shape and spacing of the eyes, noting any irregularities.”
Then it goes on to erythromycin in the eyes, but nothing about red reflexes. It bothers me that it isn’t in there and disturbs me that I never checked a baby’s eyes for cataracts. I can only pray none of them had one or the Pediatrician found it if there was. That was a roundabout way to explain a black hole, but there you have it. It is unlikely this would happen in nursing and midwifery school.
I believe CNMs tend to be more medically-minded because they see far more than a home birth midwife does and understand the necessity of being on your toes in birth. One of my favorite midwives, who was also one of the most laid back, had an amazing education at Grady Memorial in the heart of Atlanta, attending to HIV patients and a wide variety of not-really low-risk clients, but learning what was normal and what, most definitely, was not normal. She was one of the best midwives I’ve ever worked with, gentle with clients while making sure they were safe and healthy. And then there’s the “hands-off” midwife I once was who didn’t listen to fetal heart tones because a mom didn’t want me to. You tell me who was acting correctly in birth. Just because I was filled with woo didn’t mean I was doing the right thing. There is balance and balance can only be found with education and training.
You have to know it all (or as much as possible) in order to make informed choices. That goes for midwives as much as it does our clients. If we aren’t aware of all our choices, how do we offer our clients the best care out there? We can’t.
It’s true. I am all gung-ho for CNMs now. Actually, it’s for their education. It’s just the more I know and the more I hear, the less I like the CPM education. It scares me in many ways. Most of what scares me is the arrogance of the groups behind the education process. Instead of seeing the gaping holes and trying to fill them, they pretend to fill the hole with a teaspoon of dirt. Why can’t NARM see that Biology, Anatomy & Physiology and other science classes should be required for the CPM license? Why, when they had the chance to add classes, they chose a class in cultural sensitivity? (Not that that isn’t important, but so are basic classes like the ones mentioned above.)
Dear reader, if you’re looking for the most comprehensive education process, there is no question. You will learn more, see more and do more in any CNM track than you would if you were going through the CPM path. While the argument is often said that CPMs learn normal birth whereas CNMs learn more complicated, medicalized birth, I’ll say that when the shit hits the fan in birth… and it does… knowing normal birth doesn’t save the lives; knowing complicated means does.
I look forward to your thoughts about what I’ve said. As well as others, too.