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Entries in Choosing a Midwife (1)


"Questions to Ask About Homebirth"

That was a recent post by Peggy O’Mara of Mothering Magazine. While I have long admired Ms. O’Mara… her words got me through many difficult parenting moments over the years…, I felt it was important to address this specific post.

After highlighting the safety of homebirth (many of the studies are, of course, debatable), she lists questions to ask your prospective homebirth midwife. What’s challenging about this, however, is that she doesn’t say what the answers should be. How is a novice birthing mom supposed to know what answers she needs to hear in order to have a safe birth? Does she go by what the natural birthing sites say are the right answers? Does she go by the medical standards?

How does she find the middle ground (if that’s what she’s looking for at all) –or the safest ground- if everyone answering has their own agenda?

I recently wrote a series of posts on this topic, but I felt it was important to address this again since it seems the more natural side of the coin has begun to understand women might want more than the standard, “Are you a hands-off midwife?” question.

Here are Ms. O’Mara’s questions in italics. My answers that might clarify things in standard text.

What is your midwifery education and experience? What certifications or licenses do you have?

What does she think the answer should be? An apprenticeship only? A Certified Nurse Midwifery education? A MEAC-accredited school plus apprenticeship? Knowing what the most education and skills training should be is crucial to answering the question.

How long have you been practicing? How many births have you attended?

Instead, “How long have you been practicing as a primary homebirth midwife?” is the way to ask that question. And instead of how many births have you attended, the question should be, “How many births have you attended as a doula? As an apprentice? A midwifery assistant? How many births have you been the primary midwife with supervision and then without supervision at a homebirth for? How many years have you been a primary homebirth midwife?”

Asking how many births have you attended allows a woman to fudge on her primary homebirth experience, leading the mother to believe she has been the primary for far longer and for far more births than she has been. I did this myself; I am clear it is done all the time. This does not, in any way, discount the midwife’s experience as a doula, especially as a doula in the hospital, because she will have seen aspects of birth she would rarely (if ever) see in a homebirth practice. Complications occur more often in the hospital, whether iatrogenic or not, they are still complications the later-on midwife will have seen and watched handled, adding to her overall education. Not skills training, but merely observational experience.

I can’t stress this enough, asking the midwife more pointed questions will give the woman more information than just, “How many births have you been to?”

But, what should the answers be? Because there is no standardization in midwifery education or skills training, the answer depends a lot on the woman.

In my opinion, arbitrary as it might seem, I believe a midwife should have at least a hundred births in the hospital as a doula or at least observer of much of a labor, birth and immediate postpartum time in the hospital. Some could be at home, but seeing more complications adds to the woman’s education more than learning how to sit on one’s hands. I also think the midwife should have about 40-50 assists and then another 30-40 as a primary with supervision before being let out on her own. Hiring a midwife who’s had this level of experience would make sure she’s had at least a couple of shoulder dystocias, hemorrhages, malpresentations and other more common complications, including several transports as the primary with supervision. Being the primary midwife with a more experienced midwife overseeing her is one aspect of midwifery skills training that is glaringly missing. More on this in another post.

Who is your midwifery back-up? Who is your medical back-up?

This is more a logistical question. While it’s important to know the education and skills training of the back-up midwives, it is rare the back-up midwife will be the one the client ever sees. Unless the potential midwife takes on more than 3 or 4 clients a month. In that case, be sure to interview the back-up midwives, too, asking these same pointed questions.

A note about pointed questions:

If you are embarrassed to ask the questions lest you offend the midwife, stop it. Any midwife who bristles about these questions needs to be left in the dust. She should have complete composure, no defensiveness and be clear and truthful in her answers. If she can’t act professional with you, how will she act with a doctor in front of her if you transport? It’s a midwife’s job to answer these questions; it’s your right to know the answers.

How often will I see you during my pregnancy? How long will prenatal visits last?

Truly irrelevant as a question. I’ve never known a midwife to see clients on anything different than the standard monthly until 28 weeks, bi-weekly until 36-37 weeks and weekly until the birth. Plus, appointments are almost always 45-60 minutes long, most of the time being spent on social interaction… getting-to-know-you aspects. The actual medical/technical part lasts less than 15 minutes. When going to an OB, the social aspects are what is missing. I’m not discounting the importance of a homebirth midwife knowing you and your family better. In fact, the appointments help the midwife know how you handle stress and learn the nuances of your personality, but they are not the meat of the prenatal appointments. Again, the length of time is the question and these two questions are, in my opinion, fluff and can be dropped from the list.  

How will my partner (and children) be involved in prenatal visits, during labor and at the birth?

They will be as involved as you want them to be! Another odd question that is pretty irrelevant in a homebirth setting. What midwife is going to say, “Your husband can’t do anything but sit there”? None.

Will you provide me with nutritional guidelines?

This is standard midwifery care. Dump the question.

What is your philosophy about prenatal testing?

How are you supposed to know what answer you’re looking for? Instead, research and you decide what you want to do. Do you want the AFP test? Tell the midwife that’s what you’re doing. If she balks or tells you it’s unnecessary. Listen to her side of it and if you still disagree and she tries to talk you out of it, walk out. If you don’t want the test after researching and she believes it’s necessary, listen to her, decide if you want it or not and if you still disagree, leave. Don’t waste anyone’s time because if you disagree on something as small as prenatal testing (and the AFP or even prenatal testing doesn’t have to be your litmus test; pick your own), there will definitely be other things that you won’t gel together on. However, if she accepts your decisions gracefully, there is hope for an amicable relationship.

Do you offer childbirth education classes?

Who cares? You can find childbirth classes anywhere.

Will you suggest non-drug soothers, and different positions during labor?

If you’re interviewing a homebirth midwife, you will have someone who suggests “non-drug soothers” (what an odd way to say non-medical pain relief) and different positions in labor. The only midwife I can think of who wouldn’t would be a staunch hands-off midwife and you were asking a test question to see how hands-off she really is. If a midwife doesn’t offer assistance, she is, in reality, not being much of a midwife at all.

How long after birth is the umbilical cord cut?

This might be a relevant question during the pregnancy, but seriously, not as a midwife determination question. You can discuss this and any midwife worth her salt is going to adhere to your wishes and really, most midwives that I know do not cut the cord early at all. If anything, the medical establishment would have hairy cows about how long a homebirth midwife leaves the cord attached. (Wrongly so, too.)

How long will you stay at my home after the birth?

This is so arbitrary it would be hard to get a real answer. Perhaps the right answers are: “As long as you and the baby need me.” Or “Until you and the baby are stable and you are able to take care of yourself.” That doesn’t mean you might not need help, but if you need help getting to the bathroom because you’re continuing to faint, you need to be in the hospital. (Fainting once, especially after peeing, isn’t the most unusual. However, if you have bleeding and faint, that is a serious red flag and needs to be addressed.)

What emergency equipment do you carry?

Finally, an important question! But I’d expand it to “What equipment do you carry?” The answer should be: Doppler (preferably waterproof) with extra batteries, blood pressure cuff (two sizes), thermometer, glucometer with in-date supplies, lancets, IV equipment with in-date fluids (Lactated Ringers, Sodium Chloride, Dextrose 5% Lactated Ringers are the most common types of fluids needed in birth), in-date Pitocin (which is supposed to be kept cool), Methergine (IM and tabs), Cytotec (for postpartum hemorrhage), in-date lidocaine, in-date sutures of at least two sizes (one smaller one for the labia), in-date Erythromycin eye ointment and Vitamin K for the baby, in-date antibiotics for GBS+ women, scissors, needle holders, forceps (not the kind that pull babies out), oxygen (I always carried two tanks… one for mom, one for baby), a bag and mask with new masks for each baby (they are marketed as disposable; most midwives I knew re-used the masks [after cleaning]), in-date blood draw supplies, in-date catheters, a Sharps container… I may have missed something… anyone else think of something?

While it can be hard to know what answers you’re looking for when you ask a midwife about various complications,  it is easy for midwives to show their integrity and trustworthiness by their equipment and not-expired medications and sutures.

Again, if you’re worried about insulting her by asking these questions, that’s what you need to look at… and whether you’re ready to have a homebirth or not. Any midwife worth her salt will welcome these questions. If the woman in front of you balks, get out of there. Fast.

What back-up hospital do you use? Under what circumstances do you transport? What is your rate of hospital transport?

I’ve always felt these questions were kind of odd. The list of transportable reasons is endless and it’s the midwife’s job to know what they are. Listing them all out for you, you might as well read William’s Obstetrics (an incredibly technical book). The midwife will surely say something like, “Breeches, twins, high blood pressure, a fever...” things like that, but do you really want to hear, “If there’s unresolved tachycardia, if the baby’s baseline fetal heart tones continue declining, if mom can’t pee for several hours (and the midwife can’t or doesn’t use a catheter), if mom won’t eat for a certain length of time (to be determined in the moment),” and the list, as I said, is endless. We’re hired to know when to transfer (non-emergency) and transport (emergency).

A back-up hospital? How about, “What hospital will I go to in a transfer?” In a transfer, picking a hospital can be done. However, in a transport, the ambulance decides almost always.

Regarding what the hospital transport rate is, this can be taken any number of ways. Low transfer rate? She only takes very low-risk women, maybe none who’re having their first baby. Or, maybe she stays home hoping complications will resolve (which often enough do, but that’s just luck and not something to gamble on) or she’s afraid to transport. Maybe she has a lot of experience and takes appropriately low-risk women. How are you to know why she has a high or low rate of transfer? You can’t; it’s all in how she sells herself.

I hope these discussions are helping.