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Radical Doula’s RHReality Check Article

Miriam Perez, whom I adore, wrote a piece July 17, 2012 entitled “Is it Safe? Asking the Wrong Question in the Home Birth Debate” wherein her contention isn’t that home birth is the issue, but that babies die in the hospital and that is where our focus should be. It’s surprising that Miriam would use the fetal death rate when, in fact, it’s the perinatal death rate that should be being looked at. The fetal death rate measures deaths starting at 20 weeks of gestation and ends at birth, with a stillbirth, whereas the perinatal death rate begins at 20 weeks and ends one to four weeks (depending on source) postpartum. Looking at this, you can see why, without batting an eye, why hospital births have many more deaths than at home; they include deaths before 37 weeks, which is when a midwife would typically begin attending the births. Let’s look at births in the hospital of normal, full-term babies and compare those to home births and see, use the ratio keeping them even and see who has the lower death rate. It’s unlikely anyone will be able to do this, but this would be the way to measure whose perinatal death rate is larger.

Miriam talks about the cesarean crisis and I agree the rate of cesarean sections is far too high, but she quotes the World Health Organization’s recommended rate of 15%, but neglects to mention WHO dropped that statement in June 2010, that statement saying there was no exact number that dictates what the percentage of cesareans should be.

Where we agree is that hospital standards need examining and revising, birth in the hospital should be civil and respectful (which, by the way, I see happening more and more as the years go by) and that those that make mistakes need to be held accountable. She mentions that deaths and accidents are hidden from view in the hospital, but that isn’t my experience. Families readily sue OBs and nurses, whereas that possibility isn’t available to those birthing at home. The most a mourning home birth family can do is go to the press and express themselves there. I believe that’s why it seems we hear more about home birth deaths than hospital ones.

Looking at the way hospitals operate is important, but for those of us who are immersed in the natural, home birth communities, it is those births that deserve our attention right now. Let’s get the non-nurse midwives more education and skills training as well as reign in the risks they/we take and lower our own perinatal death and complication rates. Then we can more evenly review what happens in the hospital and perhaps get that required-for-safety collaboration with the medical system.

I, for one, want it all.


Vanessa's Good News!

I love this one! Good job, Vanessa.

"My first baby was a homebirth.

"After reading all your thoughts on the CPM certification, I feared that as a young mom I had been naive and foolish. Did I choose my midwife wisely? So I decided to take a chance and google her (it has been many years and several babies since we last met, we both have moved to different states.)

"The first site was listed under her name and was a 'warning' site for moms and dads to avoid her. My heart sank. Then I read the site more carefully -- turns out this family was flaming mad because after 8 months of care she dropped them because the pregnant mother, who was older for having her first child, was having protein in her urine and high blood pressure. After trying diet and herbs, it didn't help, so my old midwife refused to continue care and sent them on to an OB and the women 'had' to have a hospital birth.

"YAY! I felt happy and proud. I really did try to research a lot before hiring her -- she had the CPM and LDEM certifications and had worked as an OB tech in a big area hospital. She did a lot of continuing education and gave us a huge binder of info when we signed on for our birth. I'm so glad to hear she is living up to the promises she made - to be a 'low risk' midwife who cares for mothers and babies more than her own reputation."


Sara's Good News

"My good news is that my son born on March 19th is doing awesome :) Like another poster, he is almost 21 pounds and 26 inches long. He was born at home after a quick easy labor weighing 7.4, so he's come a long way in such a short amount of time!"

Love it! Thanks so much for sharing with us, Sara.


Kendra Henry's Good News

Keep the good news coming!

Kendra says:

"I signed up for Certified Lactation Counselor training for this fall through the WIC office I work at. I can't believe it, but I've been there a whole year as a Breastfeeding Peer Counselor!

"I'm currently trying to get a mom's group, car seat and childbirth classes added to our breastfeeding class line up,  too. Not to mention a huge community world breastfeeding week picnic to get some positive spin in the community.




Another good news story!

Johanna Holmes says:

"Philip, Mr. 10 lb 8 oz Leap Day baby, went to the doctor and is now coming in at 20 lbs 13 oz and is 28 1/2 inches tall (8 inches in 4 months?!?) at all of 4 months old.  He's wearing size 24 month outfits.  No oversupply issues, he's not even nursing between 10pm and 6am.  Here's a comparison shot with his almost 4 year old brother."

Love it!



Georgia's Nursing

I asked for good news and people are taking it to heart! Here's Mary J. Blakley's good news for us to read.

"I gave birth to a beautiful baby girl on December 29th, and saw two midwives for all of my care.  I had planned a homebirth but had to transfer to the hospital due to meconium in the waters,
and you know what?  I love the fact that Ontario has very strict guidelines for who can and cannot homebirth, along with reasons for transfer.  Was my birth everything I had wanted?  No, but that's okay.  I was well-respected and supported in the hospital, and our community midwives are well-integrated into the Ontario health care system (some places are still working out the kinks, but I felt my local hospital created a wonderful cooperative team environment
for midwives, OBs, nurses, and GPs).

"My good news is that my daughter is healthy, happy, and HUGE, and we recently celebrated the milestone of exclusively breastfeeding for her first six months of life.  It was a lot of work and involved so much support from so many people and resources, but I am thrilled that we accomplished this goal.  Georgia recently started solids, and does not appear to enjoy sweet potato.  I think my breasts are her favourite thing in the world."

Wonderful Mary! Congratulations to all of you.


Hormonal Menopause

I know this isn’t birthy information, but is women’s health and is me, so thought I’d share anyway.

I don’t know lots about menopause, just that I’m there not having had a period for over two years. I just had a vaginal ultrasound (consensual) and the lining of my uterus is thin, as thin as a woman in menopause, so I’m officially there. Well, have officially been there for awhile, but reaffirmed now. I mention about not knowing a lot because it wasn’t until recently that I learned of the intense hormonal depression many women entering menopause experience, my own depression perhaps having another explanation besides (or in addition to) the life changes I’ve been experiencing.

I was on progesterone for awhile, helping to take care of hot flashes and night sweats, but my newest care provider was concerned about the progesterone and felt I should be on estrogen instead, or at least with the progesterone. But in 2007, I had a Deep Vein Thrombosis (DVT) and blood clot from ankle to groin and estrogen is contraindicated in women who’ve had a DVT. I was almost completely bedridden when I had the DVT, so the provider (a Nurse Practitioner) sent me to a GYN for a second opinion. The GYN said no way on the estrogen and put me back on progesterone, again for the hot flashes and night sweats. They suck, by the way. Nothing like having to lay down towels on the wet bed just to finish sleeping.

I off-handedly mentioned my lowered sex drive and that I’d love to have some help with it and she easily prescribed testosterone cream. Wow! It had to be compounded and my insurance didn’t pay for it, but the container is enough for 4 months and cost a mere $28 ($7 a month!). It’s in a little deodorant looking vial and I make one rotation of the bottom and a little squirt of cream oozes out the top. I then rub it in a hairless part of my body. At first, I tried under the top part of my flappy underarms (not where deodorant goes), but have since changed to the inside of my right elbow. I have to be very careful with babies and moms and only hold babies on my left side, hence putting it on my right side. I’ve only used it for a few days and nothing so far, but I’ll report back if my sex drive, fantasies and orgasms increase. laughing I know you can hardly wait to hear.

It’s kind of weird, taking hormones. The hot flashes and night sweats have lessened, so that’s good, but I can’t help but wonder what all these hormones are doing to the rest of my body. Interestingly, the results are more important than long-term considerations. Clearly, I’m a want-it-done-NOW kind of person.

Okay, time to put my cream on. Later!


How to Put Twins in a Moby Wrap

Here's some good news!


Good News, Anyone?

I get sent all sorts of stories and newsbits, but they are overwhelmingly not the happiest pieces of information. I would love it if people sent me some great things. Anyone?


Biter Death?

I’ve had ten people call/email/text me telling me that Dr. Biter (formerly, Dr. Wonderful) had a baby die in a home birth less than two weeks ago. I tried to wait until it made the papers (a couple said they were calling them), but I figured when it got to ten, several from very reliable sources, I could write about it and it wouldn’t sound like a crazy rumor. I’ve been told some of the facts, but those aren’t verifiable yet, so more information when I know for sure.


Binary Parenting

There’ve been discussions about raising children in a gender-free or gender-neutral environment, the most familiar being Storm, a baby being raised without the sex characteristics being publicized or known even amongst the closest of relatives. Before Storm was Pop, a Swedish child being raised the same way, all pronouns being gender-free. This must get extremely difficult, especially when there are groups who feel the same way, but there’s the Egalia Preschool in Sweden (“Sweden’s ‘gender neutral pre-school”) where they try to have balance in everything gender-oriented. Kids are called by their names, “friends” or using the newish gender-neutral Finnish word “hen.” I’ve not heard of any schools trying this here in the United States, but can certainly see it happening in the next few years.

Besides the parents making a choice not to disclose gender, there’s a movement that insists people might not even be one gender or another. The belief that there are only two genders is a Gender Binary System. Someone who has the sex characteristics of one sex (male or female), but the brain of the other sex is considered Trans* (the asterisk replaces the modifier of choice for individuals… i.e. Transgender or Transsexual). However, most trans*folks identify with the Gender Binary System. Those that do not are considered Gender Variant… not feeling or acting either male or female. In fact, there are some gender variants that don’t even use male or female pronouns, the common descriptors being them, they or their even when being singularly addressed. It’s getting confusing out there! (In writing, the gender-free pronouns tend to be sie or zie instead of he and she, and hir instead of him and her.)

In talking to Zack (my transsexual spouse), I asked about his childhood as a girl. He had an older brother and Zack (then Sarah) coveted his brother’s toys and pastimes. Many times, even in the very progressive household he lived in, he was pushed towards female things from toys to clothes. I wondered about other someday-trans* kids and how to help them have the most well-adjusted growing up time, what would Zack have changed (besides transitioning pre-puberty) to make things easier… and what are his thoughts on raising kids gender-free. He told me it would be awesome if kids were offered toys, books, clothes, etc. that were both genders and that any choice would be acceptable. This would be easier at home than out, especially for little boys who chose “girl” things. But, if there was a way to do so, this is how Zack said kids would be able to express themselves the best, as long as all choices were welcomed.

Z did look at me sternly and ask, “You aren’t suggesting kids be raised gender-variant/gender-neutral, are you?” I asked him why, what were his thoughts. He said this is a binary world and as hard as the them, they, theirs try to force people to acknowledge a third (fourth, fifth, etc.) gender, it is unlikely that will ever happen. He said he would imagine children not raised binary would be so confused as to not know where they fit in in our culture.

It sounds funny, a transguy talking about conforming to society’s expectations, but in order to not be humiliated in school, to be able to get a job, to not be continually angry (as so many them, they, theirs are), living in the binary world just makes sense.

I wonder what’s going to happen to Pop and Storm as they get older. Is their pronoun going to be them, they, their?

What are your thoughts? How are you raising your kids?


Cesarean Scar: Star

I am the biggest klutz on Earth. I can’t walk and chew gum at the same time. It’s pretty bad. Somehow, though, I had managed to make it to the ripe old age of 23 with no visible scars and no broken bones or surgeries. This was either through the grace of some higher power or because I never participate in sports. 

And then I got pregnant. I spent 40 weeks deciding that I was going to have a non-medicated hospital birth. My provider was onboard. My then-husband was on board. Everything was good. 

I wound up being induced due to some complications, and I walked around, and I used a birth ball, and everything was excellent.  Except my body did not cooperate. I never dilated past a 2. My ob told me she advised a c-section, and I cried. Big, huge tears. She sat on the bed next to me and hugged me and then gave me a few minutes to think about it. We went in the operating room, and I was scared. I remember telling my husband I didn’t want to do this anymore. A nurse had to come over and soothe me.

In the recovery, I found my scar to be an ugly, horrible, wretched thing – made worse by all of the people who told me what an idiot I was for letting my terrible OB cut me open, and how I hadn’t had birth like a real woman. If I was more educated, if I was in better shape, if I was more prepared…

Flash forward three years to kiddo number two. I’m in the best physical shape of my life, having lost 170 pounds and developed a 6 day a week gym habit. I’m determined to have a VBAC. I do everything I’m supposed to. At 40 weeks, I start encouraging labor in every possible way. Nothing.  41 weeks. Nothing.  I have a brief period of regular contractions, and go to the hospital. They stop. At almost 42 weeks, I have a not-encouraging nonstress test. I agree to c-section number two at 42 weeks, thinking that I am a failure. That I am a joke. That I am not a real woman. The surgery goes easily, with everyone being incredibly nice and the anesthesiologist cracking jokes with me when I got nervous. Recovery is not really a huge deal. I actually start doing some light jogging 4 weeks postpartum. I still feel very conflicted when I think of the birth or look at my scar, though.

But the more I think it over, the more I love my scar. It’s awesome. The 4-5 inch shiny white line is where my children were born. They are alive because someone discovered that you can bypass the vagina and take babies out another way. In the past, we might have died. 

My scar also says that I can roll with the punches. I allowed something that I swore I wouldn’t, for the better of my babies and my own health.  Isn’t that what we do, as moms? Don’t we look at our unique children and situations and do the absolute best for our own families? How can doing that ever be a bad thing?

My birth experiences weren’t what I imagined, but I was always surrounded by a caring team of individuals who did anything they could to honor my wishes, and I have two gorgeous, healthy, perfect children that light up my life every day.  If that’s not what we all hope for as moms-to-be, it damn sure should be.


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.


Reader Question: CPM or CNM

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.



Home birth: Increasingly Popular, But Dangerous” in the Daily Beast by Michelle Goldberg started the hoopla.

For many parents, home birth is a transcendent experience, and they’re profoundly grateful to have been able to have their babies on their own terms. Yet as the number of such births grows, so does the number of tragedies—and those stories tend to be left out of soft-focus lifestyle features. Now a small but growing number of people whose home deliveries have gone horribly awry have started speaking out, some of them on a blog, Hurt by Homebirth, set up by former Harvard Medical School instructor Amy Tuteur. “These people are beating themselves up over this,” says Tuteur, perhaps the country’s fiercest critic of the home-birth subculture. “They did it because they thought it was safe, and it wasn’t safe.”

Out of 39 paragraphs, Dr. Amy Tuteur (the Skeptical OB) is quoted in four and mentioned in a fifth, yet the afterquakes have, almost exclusively, have centered around including Tuteur as a source for Goldberg’s article.

In fact, in The Slate, Jennifer Block’s piece entitled, “How to Scare Women: Did a Daily Beast story on the dangers of home birth rely too heavily on the views of one activist?” contains 16 paragraphs and Tuteur is highlighted in ten of those, not including the obvious reference to her in the title.

Goldberg's reliance on Tuteur is an interesting choice. Also known as “Dr. Amy,” Tuteur let her medical license lapse in 2003 and created the blog Home Birth Debate in 2006, which she used to advocate for her position, which is basically: Home birth kills babies. “Even the studies that claim to show that home birth is as safe as hospital birth actually show the opposite,” she'd frequently post in response to a challenge, smearing the researchers of those studies in dedicated blog posts and igniting flame wars in the comments section. On other sites, including Nature and RH Reality Check, her comments have been flagged and removed for being defamatory or basically spam.

The back and forth continues with Goldberg defending her original piece with “Michelle Goldberg Answers a Critic’s Distortions of Her Home-Birth Argument”, naming Tuteur in nine of the 21 paragraphs.

Let’s start with her primary criticism—my use of Dr. Amy Tuteur, a figure anathema to the home-birth community, as a source. Now, I think Block overstates my reliance on Tuteur; there’s a difference between agreeing with her after doing my own research and repeating a “Tuteur talking point,” as Block accuses me of doing. But leave that aside, and let me explain why I’m not convinced by Block’s attempts to impeach Tuteur’s expertise.

So, why am I up at 2am counting paragraphs in tit-for-tat articles? First, because I cannot believe the energy spent on Dr. Amy… so many people arguing for or against her as a source. It’d be amusing if it weren’t such a serious topic. It’s really important for people to know that Dr. Amy isn’t going anywhere and that she will continue to be used as a source protesting Certified Professional Midwives and much of home birth. I know women who begin reading an article or post and if Tuteur is mentioned, abruptly end their reading session. Dr. Amy has been a source in over a dozen articles, from the Los Angeles Times, the New York Times and Time.com; it’s unlikely she’s going anywhere.

Something else you’re unlikely to see again is the debate about using Tuteur as a credible source. I just don’t see Newsweek debating the Times of London about whether she should be believed or not. I have the distinct feeling this back and forth of the last few days will be a rarity and limited to smallish, women-oriented ezines. Large magazines don’t have time for such nit-picking and have editors to determine whether a source is adequate or not before they ever make it to print. Apparently, Tuteur has passed muster more than once.

I wonder if the detractors think if they make enough noise, Dr. Amy won’t be used as a source anymore. I believe the louder they become, the more often she will be quoted, clearly annoying the home birth contingent; the press loves conflict.

As much as Dr. Amy Tuteur makes some people crazy, she has proven she is not a force to ignore. While I have issues with her delivery and am unsure about all she professes as fact, the woman has things to say that need to be heard and she’s going to be heard, whether we like it or not. Instead of trying to make her go away, how about we find people who can argue with/speak out against what she says in the same articles. And for crying in a bucket, debating statistics is not the way to do it! If you haven’t figured it out yet, the stats’ results are in the eye of the beholder, so finding alternative discussions is crucial. One of my favorite topics is why women want an out-of-hospital birth in the first place. And then it needs to move quickly to choosing safe home birth midwives. I believe until we have clear, fantastic midwifery education and a way for them/us to learn the advanced skills necessary for out-of-hospital births, we’re fighting a losing battle. Dr. Amy has the information about CPMs down to a sound bite; we better have an answer about them/us when asked.

I see people trying to shut Amy Tuteur up like trying to put out brushfires when the wildfire is just down the street. She isn’t going away. Deal with it.

NOW what are we going to do?


Spanking & Mental Illness

The other day, a study came out about childhood spanking and its connection to adult mental illness; “Spanking Kids Might Lead to Adult Mental Illness” outlines what the information said.

“Childhood punishments such as spanking, slapping, and hitting – even in the absence of full-scale maltreatment – are associated with an increased risk of mental disorders in adulthood, researchers reported. 

“Adults who reported such punishments in their childhood had a greater risk of mood disorders, anxiety disorders, alcohol and drug abuse dependence, and several personality disorders, according to Tracie Afifi, PhD, of the University of Manitoba in Winnipeg, and colleagues.”

I fit this study to a tee.

I wouldn’t say I was abused, but I was smacked, hit and slapped throughout my childhood and early teen years. Dad’s military belt, hairbrushes, wooden spoons and fly swatters were all too familiar on my butt and legs.

So, 40 years later, as I climb my way out of the worst depression of my life, I can’t help but wonder just how much of this bipolar disorder was inherently going to show up in my life and how much came from being hurt and humiliated as a kid.

When I had Tristan (who’s 30 this year), I began parenting the way I learned (I was going to say taught, but it certainly wasn’t a conscious teaching or learning), smacking the poor child on his bottom and hands. Then, when I had Meghann 19 months later, I’d begun learning a new way to parent… a gentler way. Through the books at the La Leche League meetings, I learned I didn’t have to hit to get a child that would “behave.” It took a lot of unlearning and a lot of conscious not hitting, but I did a damn good job of not hurting my kids. Now, I’m sure if you asked them, they’d have great examples of mom’s misbehavior as a Good Mommy… I certainly yelled a lot more than I ever should have. (If I had it to do over, I would have meditated, taught the kids to meditate and I would have chilled out about the small stuff. I freaked out about far too many things and do apologize to the kids for my missteps.)

One of the major ways I realized my need to change was in remembering what it felt like to be hit as a kid. It was humiliating. In my new thinking, I couldn’t come up with a reason to make the children I loved more than anything in the world feel that horrible feeling of humiliation. That was the driving force of my transformation as a parent.

So, when I see studies like these, I am going to be vocal in their information. I’m almost as bad as Intactivists when it comes to hitting children.

Now, I’ve heard the arguments about discipline, not hitting a child in anger (which is absurd to me) and Look-How-Fine-I-Turned-Out, but they ring hollow for me. I beg people who were hit and who hit to tap into that child inside and see… no, feel… what it felt like to be hit. Not try and justify it with, “It was the only way I would listen,” or “That’s the way we do it in our family,” but to feel the feeling a child feels when he or she is hit. Why would you inflict that horrible feeling on a child you supposedly love more than life itself? It makes zero sense.

I’m glad this study came out. I’m glad when pieces of the puzzle are unwrapped every once in awhile so we can talk about this issue. “Discipline” isn’t a topic discussed as often as some others, so I’m glad to see this being aired right now.

If you hit, spank, slap, give the silent treatment or have discovered the various ways to manipulate children’s behavior, I pray you’ll stop and think today about how you 1) want to care for your children in the most loving way possible 2) want your children to be as adults. If there is a propensity for mental illness in your family, perhaps it’s the hitting that shoves the depression over the edge, dooming them for a life of difficulties through mental illness. Also, how do you want to be remembered when your kids tell stories about you? Do you want them telling a therapist how you mistreated them? Telling your grandkids how you shoved them in a cold shower with their clothes on? Is this the legacy you want to impart? I sincerely hope not.

I wasn’t a perfect parent and have written about when I’ve terribly failed… the one time I was hitting Meghann and Zack came and pulled me off of her… I had totally lost control and still remember it to this day. The time I went crazy because Meghann cut her own hair; poor Meghann… I’m sure she’s still traumatized by that incident. Even with my missteps, I’m so thankful I unlearned the horrible behaviors I was taught. My kids got a lot less abuse than they would have had I not stumbled on La Leche League and Bradley classes.

One more note. While I’ve had a ton of therapy, much of it discussing the hurt and humiliation as a child, I have come to a place of peace with my mom and dad, knowing they did the best they could with the information they had at the time. I was hit far less than my mom was and her parents were hit less than their parents, so at least the abuse was lessening over the generations. Perhaps Gabriella won’t ever have to endure a smack; one can only hope! Mental illness is rampant in my family, as rampant as the hitting, so it’s impossible to say if one would have been illuminated without the other. I can say that, so far, my own kids have bypassed the trips to the psychiatrists and therapists, so anecdotally, we’re spot on for staving off the mental illness. And that alone is cause for celebration.


Cesarean Scar: adrienne's cesarean scar story

my cesarean scar is a reminder to be grateful.

i lost my first daughter during labor at an out of hospital birth center. heart tones were lost on her mere minutes before she made her entrance to the outside world. she was unable to be resuscitated. her absence in my life is felt each and every day.

when i became pregnant again, i wondered if i could go through another vaginal delivery. my body took a beating during my first labor...severe laceration, bladder damage resulting in a month's worth of self-catheterizing at home, post partum hemorrhage resulting in multiple blood transfusions, and a surgery to remove my retained placenta. all on top of losing my first born child.

in the end i opted for a cesarean delivery, and it was the best choice i could have made. my cesarean was awesome! it was over in 28 minutes (compared to my first 48 hour labor) and my daughter was alive!! my daughter was placed immediately on my chest and she was able to stay with me while i was sewn up. after getting checked out by the nurses, my daughter was placed back in my arms and we ere wheeled back to our room together. we nursed together right away, and snuggled all night. it was beyond perfect. and the cherry on top was that my recovery was a breeze compared to my first delivery.
just the other day i complained to myself about my cesarean scar itching. then i reminded myself to be grateful. a baby--my beautiful daughter--was born through that incision. a big thing happened there!
its ok to be upset over the appearance or the itch of my scar. as long as my next thought is to be grateful. grateful for life. for my body. for cesareans. and the people who perform them. and for my living, breathing baby girl.



Placentas in the Igloo

My son Tristan turns 30 this October. (I can’t believe he’s already that old. That makes me… older!) He’s finally ready to have kids (still needs the female part of the equation, however, so it’ll be awhile), so we’ve been talking about different aspects of his childhood and what he’s hoping for when it comes to being a father. It’s a delightful time with my baby boy.

He called the other night to tell me he went to an art show where many women attended and the topic of birth came up, so he mentioned his mom was a midwife, the women circling around and they began asking questions.

“What happens to the umbilical cord? Does it just suck back up into the baby?”

“How does a woman have a home birth without an epidural?”

And then there was the “What does your mom do with the placenta?”

Tristan laughed and told them we always had placentas in our freezer. “Watch out for the placenta! Make sure it goes back in the back when you get the popsicle out.” He told them he remembered women bringing me their placentas; I used them in childbirth classes to show the miraculousness of the organ and also demonstrate the uniqueness of each one. (We didn’t encapsulate them back then.) He said it was years before he realized an Igloo (a cooler) was used for something other than transporting placentas. The funniest part of that conversation was when he told them he was in his mid-twenties before he knew most people didn’t have a placenta in their freezer. I told him I could certainly get him one for his if he wanted one. He declined.

These talks with my kids are so awesome. They were always delightful as kids, but as adults, they are amazing. I love my babies. Can you tell?


Cesarean Scar: Kathryn

I was young, newly married and ecstatic when I found out we were expecting our first. I never dreamed I'd have any problems, I always pictured this perfect vaginal birth where the baby would be placed on my chest and would nurse right away. My mother had had 10 uncomplicated vaginal births, 1 UC birth at home; I didn't think I would have any problems. At my 36 week checkup the doctor told me I had pre-eclampsia and that he wanted me to stay on bed rest for the week. I had to have a nurse come to my home every day and check my blood pressure and swelling. Four days later I went back to the office for a checkup and he told me that he was sending me to the hospital; I would stay overnight and then would be induced in the morning. So off to the hospital I went. Heartbroken that I wouldn't be starting labor on my own when the time was right.

That night they gave me cervidil. In the morning things drug on and on. They finally hooked up my IV at about 10:00. I don't remember much of what happened after that, I do remember that the contractions were hard and strong and that they hurt, horribly. A little before 2:00 the doctor came in and sat by my bed for a few minutes, I remember him leaving the room and then all this commotion as the nurses rushed into my room. Apparently his heartbeat was dropping. I was rushed off to the operating room. I remember laying there on the table totally naked, alone and scared. First they told my husband he could suit up and come in and then they told him he couldn't come in.

I remember feeling the sting as they put in a few shots of local anesthesia on my lower tummy. And then the burn as they started cutting. I was going to do a drug free birth so I didn't have an epidural. When the call went out the anesthesiologist was five minutes from the hospital. I was later told that he got there just as they were cutting into my uterus. I remember a nurse standing at my head telling me to breathe in, and then I was gone.

When I woke up my baby was in the nursery. He wasn't doing too well and had to have some oxygen. I honestly don't remember much of what they told me was going on with him. I just remember I hurt like nothing I had ever felt before. I'm not sure how long I was out but it was awhile. They finally brought my beautiful baby boy to me. He was so tiny, 5 lbs. 9 oz. and 18 inches long. I know now after having more children and having them vaginally that I didn't have the same bonding with him as I did them.

Even though it was medically necessary to have him by c-section, the cord was in front of his head being smashed every time I had a contraction, I still feel like I failed in my birthing experience. My scar says I failed. I also feel like I failed at nursing him. At three weeks old he was admitted to the hospital because of failure to thrive. I have never felt like more of a failure then that day when I found out I was starving my child because my body wasn't doing what it was supposed to.

I have since had 6 vaginal births and have had a lot better experience.


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.


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