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AAP's New Home Birth Guidelines

The American Academy of Pediatrics came out with some guidelines for a safe home birth after first stating the safest place to deliver was in the hospital and in a birth center.

The guidelines, in bold italics, state; (my comments in afterwards):

- There should be no preexisting medical conditions.

This would rule out thyroid, heart, renal disease and more. Most home birth midwives wouldn’t have a problem with someone with thyroid disease, but would risk out for more serious diseases and conditions.

- There should be no diseases during pregnancy.

This would include not having women with diabetes in their practice. CPMs generally accept and keep women with diabetes as long as they aren’t on insulin. For the rest of the diseases of pregnancy, Preeclampsia, Pregnancy Induced Hypertension, HELLP Syndrome, etc., most midwives would risk out. There might be some midwives who wouldn’t recognize the lower levels of these issues and a few might not appreciate the gravity of the diseases, but most would.

- No one with twins, triplets or higher should deliver at home.  

We know this is one that is ignored too much.

- The baby needs to be vertex (no breech).

This one is also ignored too often, many/most midwives believing that breech is a variation of normal. It is not. The number one reason a midwife ends up arrested is because of a breech death. (This is my informal observation over the years.)

- The pregnancy should be at least 37 weeks, but no more than 41 weeks.

The 37-week limit is a common demarcation point although some midwives would deliver a woman under 37 weeks with specific clients, believing it’s okay to step out of the rule for special circumstances. This is one of the issues I have with CPMs; they don’t have hard lines, but find so much ambiguous. It’s part of what women want in a midwife, being seen as an individual, not a number, but there does come a time when hard lines should be drawn in the name of safety.

- The AAP says that labor needs to be spontaneous or induced as an outpatient.

Induced?! What were they thinking?

- Pediatricians should advise parents who are planning a home birth that AAP and ACOG recommend only midwives who are certified by the American Midwifery Certification Board.

This means they recommend only Certified Nurse Midwives, not CPMs.

- There should be at least one person present at the delivery whose primary responsibility is the care of the newborn infant and who has the appropriate training, skills and equipment to perform a full resuscitation of the infant.

This would include intubation, something the majority of home birth midwives do not do. However, even if one learns intubation, we don’t get a chance to practice it and it is a skill that requires constant practice in order not to injure the baby. It is a nuanced skill that nurses practice a lot and/or use more frequently than a home birth midwife would ever have the chance to do, mainly because most of the babies we see are from (or are supposed to be from) low-risk women. So the likelihood of ever being able to do this regularly is remote… something we might just have to scratch off the list of being able to do… keeping us from being 100% accepted by the AAP.

- A newborn infant who requires any resuscitation should be monitored frequently during the immediate postnatal period, and infants who receive extensive resuscitation (e.g., positive pressure ventilation for more than 30–60 seconds) should be transferred to a medical facility for close monitoring and evaluation.

30 – 60 seconds is too ambiguous and ambiguity is the hallmark of CPMs. I wish they had said 30 seconds and left it at that.

- Home birth mothers and caregivers also should take any infant with respiratory distress, continued cyanosis, or other signs of illness to a medical facility.

I’ve seen, many times, a baby with central cyanosis receive blow-by oxygen for extended periods of time. “The baby just needs to nurse!” is what so many midwives believe. Annoying. That the baby does transition eventually reinforces their actions, but what of the babies that do have problems that need to be watched by an NICU staff? What happens to them? They are delayed and delayed going in.

- All medical equipment, and the telephone, should be tested before the delivery, and the weather should be monitored.

This is always done in my experience.

- A previous arrangement needs to be made with a medical facility to ensure a safe and timely transport in the event of an emergency.

Something that cannot be done for many midwives whether because of legalities or hostilities in the community.

- AAP guidelines include warming, a detailed physical exam, monitoring of temperature, heart and respiratory rates, eye prophylaxis, vitamin K administration, hepatitis B immunization, feeding assessment, hyperbilirubinemia screening and other newborn screening tests.

While many home birth families refuse Vitamin K and Erythromycin eye ointment, midwives who can, do carry it for those that want it. When a midwife can’t do something, like the Hep B vaccine, she would send the baby to the pediatrician to have it done. Same with the bili checks; blood work is done via the pediatrician, so it isn’t ignored, just that we don’t typically do that lab test. There are home bili tests, but they aren’t as accurate as blood tests. In my experience, even with the home tests, if there is a question, the midwife would send the baby in to be checked by the pediatrician.

- The baby needs to be monitored every 30 minutes for the first two hours and consider transitional care to be 4-8 hours postpartum.

Midwives at home monitor more frequently in my experience. Not a complete newborn exam every 30 minutes but absolutely doing vitals. Most midwives stay at least 3-4 hours postpartum. Now maybe we should stay a minimum of 4 hours?

- If warranted, infants may also require monitoring for group B streptococcal disease and glucose screening.

This would be something I would hope all midwives do, but I know too many don’t even test for GBS in the pregnancy, much less treat with antibiotics in labor. This must change. I worry how may babies have to die of GBS before home birth midwives get the connection between testing and a live baby. Then there’s the LGA babies that need to be tested for glucose levels, but midwives often merely go by symptoms and even then don’t test. I would like to see glucose monitoring of newborns become more common.

- Comprehensive documentation and follow-up with the child’s primary health care provider is essential. They want to have the baby see  a pediatrician within 24 hours after the birth and again 48 hours after that first visit.

A variation of this is done by most midwives. Some will say the baby needs to be seen within the first three days and others within the first two weeks. I err on the side of caution and liked my clients to see the Pediatrician within the first three days. AAP takes a much more conservative take and wants the babies seen much sooner and more often,

As I’ve read through the articles about the new guidelines, there have been some comments from CPMs saying they are glad for the guidelines because all CPMs do them already. As you read above, that isn’t true at all. There are specific items on the list, namely risking out for diabetes, intubation and vaccinations, that most (if not the great majority of) CPMs do not do. These need to be known and if we want to win the hearts of the AAP (and the public), we might consider adding stringent limits with diseases and intubation into our repertoire. And many midwives are wont to limit their clients to normal, vertex, singleton mothers and babies, instead being led by clients and their needs, not adhering to what is proven safe for those wanting a home birth. It’s frustrating when midwives take these high/er risk women and things go wrong. It makes all midwives look careless and ignorant of risk. If we were able to adhere to strict standards, perhaps CPMs might finally be included in the professionals’ recommendations. I don’t see that happening any time soon.

When we get standards from others such as this and we’re able to compare the requests with the realities, it is perfect for giving the CPM areas where she needs to increase her education and skills training. I’m often asked what exactly do I think midwives need to learn and this post is perfect for that. Tops is learning to adhere to the Standards of Care of not step out of the boundaries just because the midwife feels sorry for the mother. There is nothing mentioned in this piece about malpractice insurance and that should be a requirement, too. I can see, with increased education and skills training and standardized education (not the haphazard methods there are now to become a CPM) and malpractice insurance, CPMs finding a more accepted place in states. But there are still too many challenges that don’t fit the exacting standards of ACOG or AAP. I hope we midwives strive for what their looking for, not minimize their requests. It is in our self-care that we will be able to garner more and more respect. With respect, we get laws on our sides, Medicaid payments, all states with CPM laws and a great reputation. It’s time we had a great reputation.


Amber Plyler Changes Her Mind

I got the most delicious email the other day. Sharing, with permission.

“Yep, it's me!  The dreaded GBS doula....  So much has changed since our last encounter on your blog, and I just wanted to share! 

I had completed 9 months of training to become a CPM when we had our 'encounter' on your blog about my GBS post.  I have since researched, read, observed, studied, prayed, and soul searched and have done a complete transformation of my path.  I quit the CPM program and am now pursing midwifery as a CNM instead.  I'm in nursing school and will be finishing up my nursing degree and then on to my masters in nursing with a midwifery specialty. 

There were so many things that caused me to stop and think and change my mind - calling people out is tough.  For the one being called out and made a public spectacle, it feels horrible!  All eyes are on you as you are criticized, belittled, and attacked.  Many said I handled it with grace, but I almost cracked!!  That being said, it's those call outs that cause you to stop, think, and re-evaluate and maybe - just maybe - realize what you are saying and the direction you are going is dead wrong.  So thank you.  Thank you for being one of the one's to call me out, make me stop, think, and re-evaluate where I was headed. 

I'm blogging my journey and thought if you were interested in the mindset of a student midwife turned nurse midwifery student, I've poured my heart out in these posts..... 

Be the Change You Want to See in the World 


Lack of Standards

The “encounter” Amber speaks about was my “This is Informed Consent?” piece that comments on a post (since revised) she wrote about using Hibiclens in labor for GBS positive women. Amber, a doula and student midwife, was giving a lot of medical advice and very little fact to back things up with. Granted, I learned a couple of things in the same thread, namely that the Hibiclens “wash” is really a “douche,” which makes me like it even less. But, as I detailed my pretty pointed (even harsh) comment, I was read the flippin’ riot act about naming Amber, her business and her website in the first place. 

“I think it's a little harsh to call the writer out by name. In all honesty, it feels a bit dirty to me. Was it not enough to simply communicate directly with her? I don't quite grasp what there is to gain here.” 

“… just wanted to address the fact that I'm sorry that this discussion has been directed at a specific person posting...and by name. I believe it could have been done with more integrity had it been addressed off-line and Amber had remained nameless.” 

“To provide information is one thing. A post sharing these same thoughts could quite easily have been made and names omitted. To contact a person you do not agree with and share information is one thing. To publicly use their name and then post your opinion is another….” 

You get the gist.

I, of course, defended my calling her out and, happy to say, Amber was a part of the discussion throughout the comments… and she went and revised her post and I wrote about that, too; Babies in Bloom GBS Redux. Amber’s “Blossoming Babies” blog has since been taken down… replaced with Midwife{ology}

So, Amber, as I said on your blog, I am so proud of you I could burst! Thank you so, so much for sharing your path with all of us. I, sometimes more than others, totally understand what it’s like to just put yourself out there. You are a remarkable woman; never forget that. 

Sometimes being addressed by name isn’t the end of the world, but the beginning of a whole ‘nother one.


Guest Post: HBAC Story from CNM's POV

I don't often do Guest Posts (not sure why, exactly), but this new blogger, Dena Moes, CNM, asked if she might share a story here. Dena is a certified nurse midwife in Chico, California, Yale-educated with a history of hospital care, but now a homebirth midwife. Her fledgling blog, The Midwife's Desk, offers an interesting perspective. 

Here's Dena.

This post has been written with permission from the family involved. Names have been changed to protect their privacyMy intent is to inspire others to think through their choices and question the current limits on a woman's freedoms after she has had a cesarean.

Before I share Hannah's journey from a cesarean to a homebirth VBAC (vaginal birth after cesarean), let me discuss the current climate regarding VBACs. When I moved to Chico in 2002 and joined a hospital nurse-midwifery practice, VBACs were being done in all three hospitals in our county. It was understood  that VBACs were safe, as long as the surgical incision was the low, vertical (sic) kind (which most in the US are). These scars are less likely to rupture than the up-and-down kind. I went out on maternity leave, had my baby, left that job, and then started attending homebirths two years later. I began hearing that VBACs were suddenly banned from all three hospitals. As in, NO MORE VBACs were allowed, period.  Even if you had had a previous VBAC, making you a very likely candidate for another successful VBAC, you were told by your care provider "No,  I wish you could have a VBAC, but my hands are tied. I am not allowed to attend VBACs anymore. We must schedule your cesarean." If you said "But wait! I just had a VBAC right here two years ago with no problems. Are you kidding? ", you were told "There is nothing I can do. It is up to the hospital, not me." OUCH. What happened?

What happened has to do with ACOG, the American College of OB/Gyns , a powerful trade group for OB doctors. They are so powerful that their recommendations, which put the interests of the doctors FIRST, become national health policy. American obstetricians have developed this habit of inducing most of their patients. Because using the induction drugs on VBAC women was found to increase the risk of a uterine rupture by a significant amount, they recommended that all sites where VBACs take place have an anesthesiologist in-house and ready, in the event of uterine rupture. Well, smaller hospitals like the ones in my county can't afford to pay for an anesthesiologist to sit around while a woman is in labor. VBACs were banned in hospitals all across America instead. The result of all these inductions, and all these VBAC bans, is that one in three women in America today goes in to have her baby, and comes out having had major abdominal surgery.

Women in Chico who want a VBAC must either have a scheduled cesarean instead, or drive at least 100 miles to a larger urban hospital to have a VBAC. Or, they could find a homebirth midwife. Homebirth midwives put mothers and babies FIRST; not hospital rules, not malpractice insurers' rules, and not convenience for the midwife. (Cesareans are very convenient for the doctor - they last an hour, no one is groaning, grunting, or pooping, and the doctor even gets paid more than for a natural birth.) Hannah came to me about a year ago. She wanted a VBAC, and was considering her options carefully.  Her son had been born in NYC by cesarean after 30 hours of labor, but she felt that with more preparation and better support during labor, she could DO IT this time. Her husband Jason and the rest of her family were not particularly supportive of a homebirth. Hannah wanted me to do her prenatal care, and then she planned drive down to Berkeley, 3.5 hours away, to birth at a hospital where nurse-midwives attend VBACs. As her pregnancy progressed, Hannah became more clear that she actually wanted a homebirth. She educated herself and her family about homebirth, and finally her husband agreed. The Berkeley scenario was dropped, and we began to prepare in earnest.

We delved into the details of Hannah's previous birth. A big difference between hospital-based and home-based prenatal care is the attention homebirth midwives give to the position of the fetus. During the last two months of pregnancy, I pay careful attention to which way the fetus' back is lying, so we can be proactive about helping the baby into the best position for birth. This way, we are not surprised with a longer, more difficult labor due to posterior positioning of the baby. Hannah had started her first labor with her baby in the posterior position, and did not know it. Her doctor had never checked for that. Hannah and Jason had driven across the Brooklyn bridge at rush hour to get to the hospital, a major ordeal. When they got there and were checked, they were told to just go on back home, it was too early to be admitted to the labor floor. Well, Hannah was having the strong, painful contractions of back labor, and was not about to face another two hours of traffic. So she and Jason wandered the hospital, found an empty conference room, and spent the night there laboring away.

When they returned to the labor and delivery floor in the morning, more troubles arose. The "wrong" doctor was on that day, not the doctor Hannah had connected with and wanted. The nurse was kind and helpful, but then the doctor and the nurse "got into it with each other" and the doctor banished the nurse from Hannah's room!   Eventually Hannah pushed for three hours, all alone except for her exhausted husband and mother, with not even her nurse in the room to guide and support her. The doctor came in and out to watch for progress, and then took her in for the cesarean.  Afterwards, the doctor told her that surprise! the baby was posterior! Oh, well.

During her pregnancy I focused on four main areas of preparation.

1. Giving her undivided attention, love, and support so she could build trust in me and my assistants, and know that we will really, truly BE THERE for her. I imagined she would have another 30 hour labor, and mentally prepared myself to hang with that. If she needed to push for four, five, six hours, so be it.  

2. Fetal position! We used chiropractic care, specific exercises, and homeopathic pulsatilla to encourage that baby to rotate forward, not posterior. And she did.  

3. Healing the trauma from her previous birth. She wrote about her first birth and her deepest fears and we used Emotional Freedom Technique to address them. This technique uses the meridians and acupressure points of the Chinese Medicine system, to clear emotional trauma from the nervous system and tissues. Her biggest hidden fear was having to face her family and friends if her home VBAC "failed" and she ended up with another cesarean. She felt they would think "See? You should have just had the repeat cesarean. It would have been easier on everybody." She was so brave to stand up for what she wanted, outside the comfort zone of her intimate circle, while not knowing what the outcome would be.

4. Filling her with positive images, stories, and vibes to promote a sense of well-being and optimism about this birth.

Ten days after her "due date", I got the call at 4:30 am. "Hannah is having very strong, close contractions" Jason told me. I heard her moan in the background. I was on my way. I arrived a little after 5 am. Hannah was on her hands and knees in the kitchen, working with contractions every two minutes. This all had started just an hour ago. She had literally just woken up a hour ago. I could tell things were cooking along and readied my supplies. 45 minutes later, her water broke, and she had a strong urge to push. I checked her and she was completely dilated. We moved her to the rug in the living room where she pushed on her hands and knees for twenty minutes and gave birth to her eight and a half pound girl. She had been awake three hours, and I had been there for little more than an hour!

Well, talk about thrilled, shocked, and delighted! Jason and Hannah snuggled up with their baby and giggled and smooched while she nursed. "That was it?" they kept saying. "Really, that was it????" Her whole labor had lasted three hours and she had barely needed to push. Their eyes were shining with joy. They were both transformed by the experience. Jason was in absolute awe of his wife, so strong and powerful and looking gorgeous lying with their baby in the dawn light. They wouldn't have even made it, driving to Berkeley! It would have been a travesty for her to have had abdominal surgery instead of this experience! As we all ate bagels and eggs, I thought about her two births. Why are one woman's two births so different? Can love, support, and the comfort of one's own home REALLY make such a difference? What do you think?


Midwifery Education (Lite)

I’m a Licensed and Certified Professional Midwife. I haven’t had a standardized, university-based education for midwifery. I would do almost anything to obtain one, though. I’ve even considered traveling to SUNY New York for a couple of years to become a Certified Midwife, but the license is worthless (legally) here in California. At almost 47 years old, do I want to devote more time to formal education that isn’t going to mean squat in my state? Probably not.

Twenty-one years ago, I met Mary Carole Akers, a Certified Nurse Midwife in the Army and talked to her about becoming a midwife during Sarah’s prenatal visits and my own postpartum visits. My biggest concern was if there was such a thing as a lesbian midwife and she laughingly (and lovingly) told me I had nothing to worry about, that there were plenty of lesbian midwives out there. (She’s right!) I whined about having to do all that nursing crap... geriatric care, tending to post-op patients, blah blah blah... B-O-R-I-N-G! Why did I have to listen to a thousand hearts and lungs that had nothing to do with listening to a newborn? Wisely, she looked at me and said, “When you listen to a thousand normal hearts, you quickly learn to distinguish the not-normal one.” Snap!

When thinking over my life, one huge regret that’s cropped up over and over is my not pursuing a degree in Nurse Midwifery. I adore homebirth and am proud I have a license and am a Certified Professional Midwife, but know I would be a wonderful CNM.

In the hospital, I could to be a midwife for Bradley clients, homebirth transports and transfers, for women who don’t even know how great birth can (and should) be in that location – with the right provider. I’d love to be able to take Medi-Cal/Medicaid and be a midwife for women for whom English is not their first language. Speaking Spanish, I crave the opportunity to use my skills with pregnant and birthing women.

I would love to be a midwife in a birth center. I always loved working clinic days and then being on-call to tend to whichever woman might come in during the night. I loved the surprise factors of the number of women that might deliver on my 12-hour shift. While I don’t mind call at all, even after all these years, it was really a different experience to have off-call days and come back to find your favorite client had had a marvelous birth experience with another midwife. I always thought it was great to be able to be with more than one woman in labor at a time, with each of them next door to each other, a mere few steps away. The births were still low-tech enough that I wasn’t sitting and watching a monitor in a remote location, but the option of being with more than one at a time was possible. In many ways, being a birth center midwife is my ideal.

I’d love to be a CNM and a homebirth midwife. I’d have to let go of the idea of insurance, but I would appeal to a wider audience. I’d have different experiences to draw from and would be able to stand toe to toe with the hospital personnel because I could be one of them if I wanted to be. Many women would love to have the option of a homebirth with a CNM, but there are so few CNMs doing homebirth, many women think there are none. CNMs in homebirth can take military insurance and even find their way into the Preferred Provider status with insurance companies. How great would that be? CNMs are reimbursed more often than a CPM.

I would be a wonderful Certified Nurse Midwife. After 25 years of working in birth, much of it in hospitals and birth centers next to amazing doctors, nurses and CNMs, I know I have what it takes to be a really wonderful CNM.

I know all the arguments against going to nursing school. I’d lose my heart, my homebirth mentality, my patience with women, patience with The System. I’d lose trust in birth. I’d see only the potential for complications every time I was with a laboring/birthing mom.

I believe that I have been around birthing women enough to be pretty set in my belief in the normalcy of birth while also acknowledging the possibilities for complications – and perhaps it has taken me so long to get to the place of really knowing I can do school as I wanted to be sure “they” can’t beat the wonder of birth out of me.

I like that nurses all go through the same courses. They don’t all have the same experiences, of course, but all have the concrete base. All that “boring” stuff I mentioned above lays a foundation of commonality that continues into the Master’s Program a nurse enters to get her midwifery degree.

LMs and CPMs come from a wide variety of backgrounds and that can be great and not-so-great. Some, like me, tried the apprenticeship route, but found working with many different midwives was a better fit. I also didn’t have the foundation of a MEAC-accredited school, something I think is imperative today ad something I definitely missed out on. I know there are non-MEAC schools and they might be phenomenal, but the way our society leans is towards accreditation and having the MEAC approval means the schools went through some pretty tight hoops to get where they are. I’ve considered going through one of the three-year schools even now, but know I want a different type of experience than what MEAC-schools have to offer.

As a nurse, I will plod through the rigors of the basic skills of care-taking for a human being, regardless of gender, age, ability or language. Doing something by rote will imbed the information into my hands, eyes, ears and brain. Taking 10,000 blood pressures on normal arms will guide me when I hear the “sound” of Pregnancy-Induced Hypertension. Being able to change wound dressings after surgery will afford me the information I need when I am presented with a client’s abdominal incision or an oozing perineal repair. Working with patients on the orthopedic floor will allow me to observe, first-hand, what a broken clavicle or dislocated hip might look, feel and sound like.

Once I’m in a midwifery program, depending on the location, neighborhood or hospital I work in and the preceptors I might have, I might see loads of easy-going births. If I go through the Frontier Nursing School’s program, one of the preceptor sites here in San Diego is a free-standing birth center. I would love the opportunity to work there.

However, if I chose to work in another location such as Grady Memorial in Atlanta, I would see and work with (what most homebirth midwives would consider) high-risk clients. This type of environment would be phenomenal training for me! The midwives I know that trained at Grady speak of the majority of clients having some complicating factor like PIH, Gestational Diabetes, asthma, drug addiction, being very young, having a diagnosed mental disorder or you-fill-in-the-blank. Most homebirth midwives would rarely, if ever, see or accept this type of client. For me, seeing such a wide variety of differences brings home the fact that what seems so rare most of the time might not really be so rare after all.

I have known CNMs who saw so many HIV+ women they weren’t considered high risk either! Can you imagine the amazing amount of information I’d have to know to take care of a “normal” HIV+ woman? It astounds – and excites – me.

Birth in a homebirth setting is slower-paced and it is different focusing on one woman at a time, but as a doula, I only had one client at a time and was usually with her for many hours at a time, so I understand the one-on-one aspect of homebirth midwifery. At home, we also don’t have the same resources available compared to a hospital, but the equipment and resources are very similar to what is available in the birth center setting.

Where birth occurs can affect the actions of the family, the woman and even the midwife. The location can mean more or different equipment. There is no doubt there is more equipment and more medication and more personnel in the hospital. If a woman were having a complication or a complicated pregnancy and/or delivery or if the baby needed help, the location can make a huge difference, but that is why we offer Informed Consent to our clients. They weigh the pros and cons of where to deliver and, since my clients are homebirth clients, they definitely lean towards avoiding the rollercoaster ride of the hospital while believing/knowing what I offer is as safe as an out-of-hospital birth can be as well as the good sense to call for help if necessary.

I have two apprentices right now. One has been with me for two years and is in a school that is close to being MEAC-accredited. The other is just beginning and wants to start school in the next few months. I want them both to have a plethora of hospital experiences so they can see more and more births there. Both are hired out as doulas, but one of their main jobs while in the hospital is to soak up every nuance they can – learn those machines, learn the lingo, learn what a fetal monitor strip looks like, watch IVs put in, ask questions of helpful practitioners, examine the suturing that goes on, listen to the other women in labor, guesstimate where they might be and how they might be better supported without an epidural. Her first responsibility, of course, is to her client in front of her, but part of being a homebirth midwife (a midwife in general?) is to absorb the nuances of the surroundings and use them in your on-going/final judgment calls. If I could get them onto the CNM track, I would, but neither wants that, so I do the best I can with what I have available.

I want my apprentices to learn to be graceful in the hospital, to learn the language of nurses and doctors and to know what all the equipment is and what it’s used for. It can be very uncomfortable transporting a woman and then not being able to explain thoroughly what exactly is going to happen next.

Why do homebirth midwives have to learn so much about the hospitals? Even if we have a very low transfer/transport rate, some of our women are going to find themselves in the hospital and it helps them so much if we are able to offer them information along with our support.

Through the years, I’ve heard others say there is no need for formal education for midwives, but it is my belief that some sort of organized education is a must. I definitely missed out not having one. Even though I got my license through the challenge mechanism (I challenged the exam through testing and hands-on examinations), I know I would have greatly benefited from a more organized book learning. I know it can be hard when states require 3 years of school before being able to sit for the midwifery exam, but I believe it really lays a wonderful foundation for the educated midwife.

An apprenticeship is only as good as the preceptor. I want to be a wonderful preceptor! Even as I go through school, I will be able to teach my apprentices, neither of whom wants to go through nursing school, great pearls of wisdom. They will surely benefit from my nursing school experience.

I also am a firm believer in getting as much experience from as many places as possible. I love when I hear about midwives (or student midwives) going to Casa de Nacimiento or Maternidad la Luz in El Paso, Texas. If they go to Jamaica, India, Africa, Indonesia, Mexico or any other location that will accept students and midwives into their maternity systems, they most certainly learn skills that aren’t typically taught (or experienced) in the United States. I think once a midwife steps out of her comfort zone, she begins to see how much she really still needs to learn. The higher risk the women she can see and care for the better. My apprentices know they will be going to other locations for experience and tutelage from other midwives. I absolutely do not know all the things they need to know! I want them exposed to a wide variety of midwives, settings and experiences.

I believe that midwifery education doesn’t end with the license or certificate. Along with CEUs, if midwives are able to advance their knowledge with experiences, all the better. When I got my license, I became a midwife with entry-level skills. I know that, even with all my previous experiences, I had a lot to learn. I still do!

I’ve wished, for over two decades, I had become a CNM. Their numbers have grown (even if not always in power or control). I have no illusions of fixing a system that is ingrained and seemingly immobile, but I do want to learn more of their world. I’ve let math and science stand in my way, but now, the fear of not going to school is greater than the fear of the subjects that give me a distinct challenge.

It’s time for me to shine the light on the fears I’ve harbored for all these many years. I often use the analogy of a fear looking so, so large standing over there in the corner... its shadow giant against the wall. But, when we take a flashlight and shine it on the shadow, it so often becomes a mouse of a thing we were once so frightened of. I’m living my own analogy.

I’ve enrolled in school.

I’m almost 47 years old and it might take me another several years to get through Nursing School before I even catch a whiff of Midwifery School, but I am going to walk towards that CNM – or die trying. I’ve danced around becoming a CNM for 20 years, learning great amounts of information that I wouldn’t otherwise have had as I am heading into nursing school, but I want still more!

I know being a CNM isn’t for everyone. I acknowledge the challenges ahead of me. I don’t have (m)any idealistic thoughts about the ease or simplicity of nursing and midwifery school. I know I will have to contend with egotistical teachers, long-time nurses and doctors, but I also look forward to learning from the kind-hearted in each profession… those jewels in the sea of the salty ocean of difficulties. I am on the look-out for knowledge; I know I can find it.

Imagine the things I’ll be able to write from the other side of this wish!

I can hardly wait to get started.