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Entries in direct-entry midwives (2)


Succinct Reasons CPMs/DEMs Need to Get Their Act Together

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

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

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

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

  1. Not transferring high risk clients to obstetrical care.

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

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

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

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

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

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

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

     5.   Fighting every attempt to hold midwives accountable.

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

     6.   Fighting every attempt to regulate midwives.

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

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

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

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

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

     9.   Double standards:

These are brilliant.

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

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

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

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

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

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

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

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

I couldn’t have said this better myself.

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


Kneelingwoman's Post

So, I try to be eloquent, but sometimes another blogger puts what I want to say so perfectly, I am almost embarrassed that I tried to stutter the words at all.

Kneelingwoman - Michelle - wrote a post that got eaten the other day, but, happily, she re-wrote the entire long piece. (We told her to write in Word!)

Please, please go read the entire post - Back to the Garden. No matter your stance on midwifery education, you are sure to be reminded of - or learn - something that will impact your calling/profession immediately.

Excerpts (and I did take a lot of her words, but there are more... wonderful words on her blog. Please go read them):

- We are a fractured profession with relationships constructed around a false front of unity in a central theme; but not of a shared reality.

- ...I see Midwifery taking on the dynamics of a highly dysfunctional family. Midwives who "color outside the lines" or who fail, in some way, to ensure that "outsiders" don't know "our" business; are threatened, bullied, maligned, blacklisted or, in some other way, isolated and rejected by their peers. Just as in family systems where whole lives are lived in closely guarded spaces of secrecy and anger and the one who begins to tell the truth becomes the scapegoat; so it often is in Midwifery. In an ironic twist; all of these things are fueled by fear and, as all Midwives know, fear is the enemy of birth--of a person, an idea or a profession.

- moving to another letter written to me by someone in the Midwifery leadership a week or so ago that tells me that "the BMJ study proves that more education doesn't improve outcomes" and "I don't see that CNM's have any more economic security; a lot of them are losing their jobs so I don't see how a University education of the kind you're proposing insures anything". Sighing deeply, I respond that I hadn't thought that the BMJ was designed to prove that contention and therefore, can't. I comment that a CNM, as a Registered Nurse, is still very employable, with a well paying credential as a Nurse even if she can't, regretably, find a job as a Midwife. A direct entry midwife, in contrast, may have nothing else, no other education or training, with which to make a living. I think that's a very big problem and I find it very concerning that the people in "leadership" positions in Midwifery can make such unsupportable comments or fail to see the connection between a broader, more diverse education and a more viable and sustainable, Profession.

- We need a midwifery that is cooperative and accountable to the other health care professions with whom we MUST collaborate and work alongside to ensure safe practice!

- The fear that drives the rejection of examining new models or promotes a rigid clinging to concepts of "apprenticeship" and "woman centered care"as sacred cows; or the idea that altering our education to meet new needs and desires takes something away from midwifery, is preventing the labor from bringing something to birth! We are a "post dates" pregnancy holding off any intervention until there are no more choices left. That is not wise. That is not being "with women". It is telling the women--the vast majority of women, that what matters in midwifery is the midwives alone; our comfort level and our standards. It seems, and is, inflexible and exclusive; not diverse or expansive.

- Midwives have to stop fearing that our inner-workings can't bear the scrutiny of physicians, legislators or the public. Sending up a warning flare or browbeating midwives who speak to these issues into submission and retraction does not solve a problem related to how we are perceived by those who will, in large part, determine our future. We have to remain transparent and open and accept criticism if needs be. We may need to change the way we do some things if we want to grow and remain viable. We should not fear hearing those criticisms nor should we attempt to restrict those who think we really need to take a second look at how we're doing things. We cannot continue to practice in isolation from the rest of the health care system while insisting that they include us! Midwifery is not an island and it most certainly is not some maternal paradise where all women are safe and welcome! For many women, mothers and practioners alike; midwifery becomes a place of uncertainty, financial and social insecurity and professional stagnation! That is not a sustainable vision; these are the marks of an unsustainable profession that won't get serious about examining it's preconceptions and conclusions to see if they work over time.

- We have gone overboard in telling women to trust their bodies and birth and we have not done a good job educating women about the inherent wildness and unpredictablity of birth. We seem to not know how to backtrack on this position without risking a wholesale return to the idea of allowing fear to dominate women's thinking about birth and the resultant potential "loss" of midwifery clientele. My response to this is, very clearly, "we have to find a way" because babies are dying and women are suffering because they are not taking any risks into account when they plan these births.

- I feel like the woman 'stuck' at 8 cm's who has moved every way she can; changed positions over and over, moaned and rocked and, now, reaches out for the hand of her midwife, her mate, her friends nearby.......there is no comfortable place until the deeper movement begins; the pushing and the force that brings birth.

- I think most of you know, by now, that I never write to inflict damage or pain but, sometimes, as in all birth, there is pain. I have found it deeply painful to see what I've had to see over these last two weeks. To not speak to it would be to reinhabit an old life; a way of being learned in childhood--of secrecy, of never owning my own ideas and thoughts because I believed the threats and the attempts to control and I believed that my voice didn't matter........we grow up and, if we're lucky and someone helps us, we learn that these things aren't true.

- We have to set an example of peaceful reconciliation and inclusivity; a true and generous inclusion that knows that all birthing women matter and knows, as well, that Midwifery is a wise, old woman---a Crone now---who can embrace paradox, hold the tension between conflicting and overlapping needs and become a true force for good for women and families.

(end quotes)

Michelle's words, so poetic and enfolding visions of birth, touched me deeply. Not only because she quotes me and knows of my own experiences in my pulled down piece ("Midwifery Education,") but because she, a "seeing" woman, recognizes nuances I had never considered.

As a woman who was abused as a child, I absolutely see the Truth in what she says regarding our speaking out about the need for more education in midwifery is exactly parallel to a child spilling the beans about incest; disgust, disbelief, anger, manipulation, teasing, threatening and withdrawing of love, support or even acknowledgement. How is midwifery supposed to survive at all if the participant midwives can't even speak with kindness to one another? What happened to human decency? My initial responses, even, mimicked that of a hurt child... apologetic, thinking I was wrong, embarrassed that I'd opened my mouth and feeling shame that I betrayed The Sisterhood.

But, I shook my head and cleared the angry fog out of my brain and saw that I hadn't done anything wrong! I spoke my Truth. MY. MINE.

Listening to those that critiqued my removed piece was a really interesting study in human communication. I see where some people could feel anger and frustration at what I wrote and that I was "dissing" midwifery altogether. I'm hoping my WHO piece puts that to rest. I do acknowledge I probably could have written a (somewhat) less inflamed post, but I wrote what I felt/feel. And, after all, it is a blog - MY blog - and my opinion isn't the be-all-and-end-all to midwives, students or apprentices. Sometimes, my writing provokes. I'm certainly not trying to provoke violence (of which I feel some people danced quite near to), but am wanting to provoke thought, wonder, curiosity and solutions. What the heck is so wrong with that?

I'm not wanting to sit here and defend myself (again), but it's all tied in together. This educational component and the subsequent disturbance of the mention of such education reflects on ALL of midwifery - those that agree and those that don't.

What I am coming to realize is that maybe it isn't just education that midwifery needs, but some serious classes in Ethics and Professionalism.

More on that in a soon-to-be post.