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Entries in homebirth advocacy (3)

Sunday
Aug072011

Why Licensing is a Dandy Idea

A couple of days ago, Birth a Miracle Services posted “Why state licensure is not the answer for midwifery,” a discussion (of sorts) arguing the point that is, well, in the title of the post. 

They (Naomi Kilbreth and Haley Grant) say: 

 “The assumption is that if a certified or lay midwife is required to be licensed by the state that they will all of a sudden offer better midwifery care, and that they will have better communication with medical care providers, and that they will be held accountable if they practice negligently.” 

I counter that with: 

If state and (hopefully) national licensing becomes standardized and enacted, midwifery as we know it could change dramatically –for the better. Homebirth non-nurse midwifery could, in my opinion, become a far more accepted profession. 

The acknowledgement that the safety of moms and babies is much more important than politics and dogma would speak volumes about homebirth non-nurse midwives’ motivations and goals. 

BaMS continues: 

“Licensure of midwives limits them to offer services only to the women AMA paid politicians consider good candidates, which rules out VBAC’s at home, and breech and twin births, even if the midwives had decades of experience in these situations.” 

I’m not sure where the idea came from that politicians decide who the good candidates are for a homebirth or not, but from what I have seen around the country (and I admit I am not an expert on midwifery law in the US), if anyone anti-homebirth is asked to define the scope of practice, it is doctors, not “AMA paid politicians.” But, I’ve seen midwives and consumers also be asked for input. And it doesn’t take an Act of Congress to know what the limitations on homebirth midwives would be; even midwives have a pretty clear understanding of what’s safe to –and not to- do at home. 

If midwives were all licensed, it is my hope that midwives would all operate within the standards of care that were (if I had my dream world realized!) developed by Licensed Midwives (and in conjunction with a couple of Certified Nurse Midwives) and acknowledged (not necessarily accepted) by obstetricians so women outside the standards (or who move outside the standards) are able to, gracefully and politely, slip into the obstetric system with the midwife giving a report that is believed and where women are treated with respect. And, once the glitch in the health of the baby or woman has passed, the obstetrician releases the woman back into the skilled and knowledgeable hands of the midwife. 

California Licensed Midwives were integral in the definition of our Standards of Care, including the, arguably, most important section in them, on page eight (emphasis mine): 

“Section V, Risk Factors Identified During the Initial Interview or Arising During the Course of Care, Part B, Client’s Right to Self-Determination: In recognition of the client’s right to refuse that recommendation as well as other risk-reduction measures and medical procedures, the client may, after having been fully informed about the nature of the risk and specific risk-reduction measures available, make a written informed refusal. If the licensed midwife appropriately documents the informed refusal in the client’s medical records, the licensed midwife may continue to provide midwifery care to the client consistent with evidenced-based care as identified in this document and the scientific literature.”  

I remember working on these Standards way back in 2004/2005, how even midwives who never interacted because of personality or practice clashes, worked tirelessly to create these Standards. We understood they would be created with or without our say and input. We also knew they would be binding for years ahead (and they have been). While what we here in San Diego presented to the creation committee was somewhat more liberal than what ended up in the law, we fought hard for the “Client’s Right to Self-Determination.” It was, for many (if not most) of us a non-negotiable part of what we would agree to. I don’t know if any other state has this right to self-determination, but I would beg anyone working on midwifery laws in their state to insist this be a required part of the wording of their law. 

What the right to self-determination does is give the woman the control over her own birth. If she is pregnant with twins and wants a homebirth, if her midwife gives her the proper education regarding risks and benefits… true Informed Consent… the woman can decide to continue with the homebirth, either with that midwife or another more experienced midwife, despite what the Standards of Care require. The same with breech births and VBACs. (Although our law does not overtly limit the right to VBAC at home [page seven].) 

BaMS makes the oddest claims about why a midwife, without a legal reason to stay within the parameters of safe midwifery, would “keep moms and babies safe.” 

“If a midwife has her license revoked, she can still practice midwifery if she finds clients willing to accept the risk. In comparison, a non-licensed midwife accused of malpractice will have her face plastered in every anti-homebirth website and may be jailed for “practicing medicine without a license”, even though midwifery is not medicine. Either way, licensed or not, a careprovider offering bad care will get a bad rep. Anyone wanting to keep their job is going to practice in a way that will keep their job, aka keep moms and babies safe.” 

A bad reputation? A bad reputation and the threat of being made a spectacle in the press is supposed to be incentive to keep moms and babies safe? That sure hasn’t worked so far! 

There are concessions one makes with rules and regulations. Midwifery isn’t a profession that believes any mother is a good candidate for a homebirth. Midwifery is an acknowledgement that homebirth is a safe location for low-risk women. And, hard as it is to admit sometimes, we all are pretty clear about what is low-risk and what is not. And when we aren’t able to decipher whether someone is low-risk or not, there are studies and even the experiences of others to turn to. It is in that research where we find that vaginal twins and breeches aren’t always the lowest of risk for either a homebirth or even a vaginal birth. Certainly medicine believes VBACs don’t qualify as low-risk, either, but many midwives and post-cesarean women themselves, disagree. I, myself, would fight for a woman’s right to VBAC at home. (Do I believe a VBAC to be low-risk? A low-enough-risk to deliver at home, yes.) 

But, doesn’t the line have to be drawn somewhere? Aren’t there always going to be women just over (or under) the (risk/legal) line that will be left out of the homebirth they’re wanting? Is it the midwife’s job to please everyone or is it her job to oversee the safest pregnancy, labor, birth and postpartum for mom and baby? One of the hardest things a midwife has to do is to say “No” to a woman begging to have a homebirth. 

BaMS continues: 

“What about the bad birth stories? Yes, what about those stories? They happen far more often in the hospital, but those docs aren’t being publicized as negligent. Much of the war against midwives is by a group of people who think they must decide for women that their home is not safe to give birth in.” 

Instead of discussing the “bad birth stories,” BaMS deflects to the too-oft-repeated “It happens in the hospital, too!” This, in my opinion, is not a valid argument. What of the homebirths-gone-wrong? What about the midwives who were negligent and where babies were injured or died? Just because things happen in hospitals doesn’t mean we ignore what’s happening in our own communities. 

BaMS suggests: 

“Instead, home birth advocates should spend their time informing the public on how to have a safe home birth, how to find a good midwife, and teach responsible decision making.” 

It astounds me that this is where they suggest the energies be focused. Not on insisting midwives have more education and training. Not on looking for a way to elevate homebirth midwifery in the eyes of the masses… and the government they so strongly abhor. The government isn’t going away. Licensing isn’t going away. 

Women don’t need to be taught how to pick the best midwife if all the midwives have the same education and training. Women don’t need to be taught how to have a safe homebirth if the midwife they’re hiring understands and is able to provide the safe homebirth a woman expects and deserves. And midwifery advocates should be teaching responsible decision- making!?! Women hire midwives to help them make those decisions. Right or wrong, women depend on the midwife (or other care provider) to know what she’s doing and to guide them towards the healthiest and safest birth, whether that’s in the home or the hospital. 

After Business of Being Born came out, I started seeing more mainstream clients choosing homebirth. My most recent doula and monitrice clients saw BoBB and wanted someone to help guide them through the process, stopping just short of a homebirth. Interestingly, even though they’d been affected by BoBB, they still were reading mainstream books like “What to Expect.” 

In my experience, mainstream clients don’t ask the doctor what school they went to, what training they had or even how many babies they’ve had die. They don’t ask how the grievance process works because all of those things are a given. Their education is standardized, even as each school teaches a little differently. It is understood that each doctor has a level of competence before they ever see their first private client. 

It should be that way with midwives, too. Women shouldn’t have to learn to ask where a homebirth non-nurse midwife went to school, how she apprenticed or if she’s lost any babies. She also shouldn’t be baffled by the grievance process, confused at every turn with the midwife-in-question’s friends and colleagues in charge of “disciplining” her. Licensing can take care of all these areas. 

I’m going to close this part for now. There’s more in that blog post I want to address, but this has gotten long enough already. More soon.

Thursday
Jan132011

Defining Mid/Medwife

While the term “Medwife” is volleyed around birth circles on the Net and in real life world, I’ve wondered, for a long time, what the definition of each would be if we were to create/give them one. Sure, I’ve read numerous descriptions of what the differences are between the two, but never in a thread such as this (that I’ve seen).

I do know the strong feelings people have about these terms and really do want to continue the discussion, but ask everyone to please remain civil. (Isn’t it kind of sad that I even have to mention it?)

So here is how the thread went down on my Navelgazing Midwife Facebook  page. My comments/thoughts are interspersed through the piece in bold italics. 

DH1: MIDwives: Trust birth and do not interfere in the birth process unless absolutely necessary. They are highly educated and use that to their advantage in knowing when to or, more often, when not to interfere. They understand there is a wide variety of normal and that being "with woman" does not mean to control them.

MEDwives: Use the medical model of obstetric management to control birth using medicine, herbs, expectations, etc. for all kinds of ways to start, augment and speed the birth process. This variety is found more often than not working in the hospital setting although there are some still controlling birth in home settings as well.

KB: So do MIDwives convert to MEDwives and cancel out their trust in birth when the shit hits the fan on a perfectly unintervened birth and they need to resort to medicine and herbs?

JW: DH1 hit it with the control factor.

DH1: No. Midwives intervene as well but only when absolutely necessary... which is not very often. Medwives seem to intervene on a regular basis as "protocol". That is the different in my eyes.

KB: MEDwives are not as "highly educated" as MIDwives? Please explain that one.

RP: I have seen some "medwives" who you could not even tell the difference between them and an OB. In fact, my OB is more open to alternatives and has a lower rate of intervention than they do. I guess it was fairly obvious to me that there were what many would deem "medwives".

DH1: No, they have different training. Medwives are trained that the birth process is broken and needs to be tampered with in order to function properly. Midwives are trained to trust the birth process with a very thorough understanding of the physiology of birth, female anatomy and most importantly patience.

That you said “…trained that the birth process is broken and needs to be tampered with in order to function properly,” I really am baffled where that comes from. While I admit there are plenty of midwives who’ve been quick on the intervention draw (and I’m sure I’ve done that myself), having seen the curricula for midwifery schools (CPM & CNM), I have a hard time believing any midwife is trained or believes the birth process is broken. Maybe it would be easier if you could share some examples of what you mean.

I do think there are midwives who use technology for convenience’s sake, similar to OBs, but that’s different than believing the process is broken.

Also, if you’re looking at who has the more thorough understanding of the physiology of birth and the female anatomy from an educational standpoint, that is most certainly a CNM. CPMs get a fraction of A&P compared to CNMs.

RNK: With DH1 100%.

NgM: clapping hands Can't wait to get into this one later! grinning You all are wonderful! Thank you so much for your candor. This will be a hot button topic and already there's lively interaction. I think this topic is soooo worthy of discussion. Thank you, in advance, all of you willing to share your thoughts, even if they seem not to be the popular one.

KB: I wonder how you've been able to thoroughly assess the training modalities of "medwives" and "midwives" to come to that conclusion, DH1. And who are you talking about exactly. I've known many a "medwife" DEM and probably more "midwife" CNMs in my 10+ year career. I think it's a pretty faulty blanket statement to make and there is a lot of magical thinking going into the whole "midwife" vs "medwife" discussion.

AL: The difference is in the eye of the beholder.

Agreed.

VM: I think it all depends on the perspective of the person using the term. Where I live, there aren't many midwives who aren't CNMs. The CNMs are controlled via their practice agreements and must be "medwives" in many cases: intervening when it is questionable, whether it is necessary, bullying moms into tests and ultrasounds that aren't supported by evidence and not supporting VBAC. Supporting women in this environment, it would be very hard to call any midwife who attends a homebirth a medwife. Because at least she trusts the process so far that she is willing to attend in a home.

What does bullying a mom into tests and ultrasounds look/sound like?

JWP: I don't think training has anything to do with it in most cases. Experiences can shape people after their training, things they've seen can make them change. I'm doulaing for a mom anytime now who is using the known medwives of the area. They are highly watched and controlled by their backup Drs. So while maybe they believe this is the right way to handle a pregnancy, maybe they don't and they don't have many choices. It's either quit and leave even fewer midwives here, switch places of employment to the other MW office in town or just deal with it ‘til we can get laws changed for autonomous practice.

SGM: I think midwives are comfortable being "with women" and trust the process, their own skills and instincts. I think medwives are well meaning, but have been jaded by the OBs that "oversee" them, and the medical model of care in general. By attending to women in the hospital, some midwives simply acquiesce to the status quo, and unfortunately become medwives. They lost their passion along the way, and it has become just a job.

I think this comment alone confuses me more than any other. That a midwife in the hospital who adheres to protocols –that she believes to be true- because she does, you feel she’s lost her passion? That it’s just a job? How did you come to that conclusion? Because she doesn’t buck the system, she doesn’t have passion? Because she works with a degree within institutional walls, her entire practice is discounted?

I rarely see the acknowledgement that not all midwives enter the profession to Change the World of Obstetrics. Not all midwives, especially CNMs, believe homebirth is the safest place to birth. And, just because she doesn’t agree with you (global you), doesn’t mean she’s a shit midwife. She’s just not the midwife for you. And not all women who choose midwives are looking for the “enlightened, spiritual” birth experience. Many women do want the kindness and care CNMs offer, the respect for choices, the time with listening and the patience with interactions. A midwife who adheres to and honors protocols, in my opinion, is not the definition of medwife; it’s the definition of a midwife who feels the protocols and rules help keep mom and baby safe. Just as you might disagree with that definition, she, too, might very well disagree that not using protocols is the safest route for both mother and baby.

KC: Medwife - manages birth for her convenience (or fear), causes herself to be "needed" yet still, usually does so with the best but misguided intentions.

Midwife - keeps her hands to herself unless nature requires it, even when it’s hard not to meddle, she addresses her own fears internally and not externally on mom or baby. She lovingly "life guards". You know if a lifeguard tried to rescue a strong swimmer it would cause drowning, hence a need to be rescued because of the "rescuing'. My midwife crotchets baby hats to keep her hands busy when the urge to "help" gets strong. I am so grateful I can trust her to be a guardian not a manager.

How does a midwife manage birth for her convenience (or fear)? Examples would be great here.

And just as a point of arguing (more), a lifeguard who tries to save a strong swimmer would not, at all, cause a drowning. Bad analogy. (I’m a lifelong swimmer and a retired lifeguard.)

DB-H: K, a DEM (Direct-Entry Midwife) can still practice obstetrics-based care. It’s more of an attitude and approach than credentials.

There are DEMs who encourage augmentation of labor with natural means because mom's tired, baby is big, etc., that check dilation way more than even high risk OBs do. This to me is a medwife.

A midwife encourages the tired mom, telling her how important these last few days/weeks inside are for her baby. She watches the labor, only assisting when medically needed and not for the convenience of herself or others.

Where are all these midwives who encourage inducing or augmenting labor because the mom is tired or because the baby’s too big? Do you mean CNMs? I’ve known a lot of midwives (and have disagreed with puh-LENTY of them in how they practice), but cannot even think of one who practiced this way.

EM: Medwife is a boorish, annoying term made up by some midwives to criticize a colleague.

JD: I am in agreement with DH1, aside from the training... two women can have the same exact training, but come out the other end with different ideas.

K, I'm not seeing where anyone says midwife=DEM (or CPM) and medwife=CNM. I think we all know that isn't the case. However, it is known that CNMs (in the hospital) have more rules to follow.

RC: Where I live there is only one kind of midwife in terms of training and where they do births (both home and hospital). But the distinction stands. Medwives work from a place of fear. They transmit that fear to their clients. Fear breeds a need to control.

Describe the fear. How do they transmit that to clients? Please tell a story that shows a midwife feeding fear to the client.

KB: J, I know that no one has stated whether someone is a CPM or CNM, however DH1 did mention training so that is why I asked for clarification.

DD: To me, I thought I knew the definition of MEDwife. Then my cousin had her baby at the hospital with the "midwife" staff.

They are REALLY not midwives there, so now my definition of MEDwife is

MEDwife: Woman doctor who is called a midwife by the hospital so that they can pay her less. Due to being paid less, she develops a complex and must prove that she is more qualified and better than the attending doctor by performing more interventions and "saving" more babies than him.

Be wary the surgeon in midwive’s clothing Just because they're female doesn’t mean they are a midwife, no matter what the hospital says.

DH2: On paper, they are no doubt equally educated. In practice, some might be more willing (hopefully all good MIDwives) to use patient-oriented, mother-friendly techniques to help a mother get the birth she wants. A medwife, in my experience, is just an extension of the OB - who might not be interested in anything other than getting the baby out at any cost, usually at your expense, and call it a "good outcome." Grr.

MNK: Midwife describes a professional credential, which typically entails a set of knowledge, values, attitudes, skills and abilities. MEDwife is a stereotype that is often used by people who are labeling a group based on assumptions. Stereotyping fails to take into consideration the unique complexities of individuals.

Here, here!

KP: I've jokingly said that a "medwife" is anyone who is "too medically minded," based on the opinion of the person defining the midwife's practice style; and a "madwife" is anyone who is less medically minded than the person wishes.

To me, a "medwife" would include those who have a high induction and/or Cesarean Section rate, and who basically manage pregnancy as if they were the stereotypical high-intervention obstetrician.

BP shares a post she wrote on this subject.

MC: If a midwife can legally use medications in labor/birth as well as other medically minded interventions and she resorts to using the meds/interventions FIRST then she is a medwife. Midwife means with woman. Bringing her fears into the birth place with her makes her unable to truly be with the laboring woman. I agree with M, too- it is a stereotype we commonly use for CNMs.

Question: So if a midwife isn’t to use medications and interventions first, what is she to use? What situations are you specifically speaking about? Is there any situation where medications or interventions are acceptable as a first line of defense?

NgM: Very interesting, all of you.

I've heard the terms compared for many years now, have been called each myself. I've asked for definitions several times, but have rarely heard an answer. This is very helpful as well as enlightening.

I've even heard such a tight definition as any midwife who carries medications is considered a "medwife." I guess if a midwife carries meds, she doesn't Trust Birth enough? I absolutely do not understand that mindset.

My experience only: I don't think I've ever met a midwife (CPM/CNM) who pushed for unnecessary inductions or epidurals. Perhaps within protocols, but not just because a mom's tired of being pregnant or because it's convenient.

It confuses me that people get all cranky about protocols. We all operate in this culture within many different sets of protocols... rules of the road, the handling of money, the education system, our legal system and more. With some, there are accepted ways around/through them and there are certainly unacceptable ways to deal/cope with them.

How can women think there won't be protocols/parameters with something as crucial as the life and death of a baby? How can women think anarchy is acceptable in birth? I don't mean the pushing of constraints or questioning authority... not at all... but complete anarchy? (Is UC complete anarchy?) Are we to just leave birth 100% alone to do its thing without touching a woman at all? Ever?

The comments above speak about a midwife knowing when to touch a mom, when to interfere (hear the tone of that word?) to save a life, but the issue arises... WHO judges whether the midwife acted "appropriately" or was meddlesome? Is it the mom? The Medical Board? Grandma sitting in the room? The doula? Where does this judgment come from and why is someone entitled to confer the epithet of "medwife" on a midwife?

And, as I ready myself to leave homebirth midwifery, am I cranky about this topic because I've been called a medwife a lot? Does being a medwife have any part in my leaving midwifery? Leaving the practice of midwifery to women who don't think about the complications as deeply as I do?

Still listening and pondering.

MNK: Can you say dogma? I highly suspect that most of the folks touting this 'Medwife' dogma have probably never held the hand of a husband witnessing his wife suffering from DIC, having her uterus removed, and dozens upon dozens of blood transfusions after the 'Midwife' delayed transporting with a PPH, because she wanted to try to get the baby latched! (I'm an IBCLC, by the way) Part of being a MIDwife is recognizing when intervention is warranted and relying on your training and wisdom to guide your reactions (and certainly this doesn't happen by consulting with the 'family, and doula' (yep, I'm a doula, too) in the room!

Barb, this is your career, sorry to sound bossy here but don't allow other people to define your parameters. You have a solid head on your shoulders, skilled hands, and a generous heart. You, Barbara, are the epitome of a MIDwife in every sense of the word. As to who decides, well you have a scope of practice to adhere to and your training. I don't think you are giving yourself enough credit but that's my .02 worth. Trust Birth, , it usually works well, and when it all goes to shit, because it does on occasion, -and it will- trust your ability to recognize it and get the pair to a freakin' qualified Perinatologist. Don't let other people bully you either. Do what you need to and know is right. If it's not right for you now, take a hiatus, but if you want to persist in practice, go girl!

I appreciate that. As you know, the decision is made.

DH1: I think this matter is complicated as you so aptly wrote NgM. You are right, there is a lot of judgment in these words. I think it comes down to "Who's birth is it?" Is it the midwife's birth because she has protocols to follow and a practice to protect? Or is it the Mom's birth because she is the one birthing and this is her baby? Who is in charge here? One of them? Both of them? Who is MORE in charge? What about the baby or the partner? I'm not sure any of us have the answers to these questions as anyone deeply impacted and involved by birth would know there are no answers to these questions because every birth is different AND dependent on at least ONE person (mama, midwife and/or baby) trusting the birth process. If the "one in charge" does not trust the birth process, it is very likely the others won't either and this is where meddling comes in.

This birth trust does not come from credentials or training. I never said anything about CNMs or DEMs. It especially does not come from fear based on a few experiences gone wrong. We have to trust that women know what they want, they know how to give birth and their babies know how to be born - even after her birth attendant has had an adverse outcome with another woman. This does not mean she has to change her protocols for everyone thereafter. Every woman/baby is unique and every woman/baby deserves the chance to prove that interventions are not necessary without protocols being pushed on her because the "protocols, practice, law" says so. We all know right from wrong and can make educated choices that make sense for each situation.

I also agree that the distinction of medwife and midwife is painful to both parties (not to mention Mamas and babies). If we are to be honest with each other though there is a difference. It comes down to control. Who do you think is in control of this birth? Not responsible for, but in control of. Getting out of your own way to allow the birth process to unfold is what being a midwife "with woman" is all about.

After reading this comment, I started a post (that I haven’t finished yet) about how a bad outcome changes one’s practice. The short analogy is: if you sped through the intersection 1000 times without incident, but sped through once and had an accident that killed your child, how will that accident affect your driving forevermore, especially as you cross the intersection?

Watching a mother or baby die in birth cannot NOT affect you.

We are all products of our experiences. Women choose to UC based on previous experiences. Asking a midwife to not incorporate her experiences in birth, asking her to leave her accumulated knowledge at the door is absurd. We learn with each birth! Each experience builds on the one before, creating a block for the one that will come after. It is the midwives with many births under their belts, with many years of experience, that are most honored.

Regarding the control aspect, in the perfect midwifery/client relationship, each woman uses her strengths and leads her Self. The laboring woman is in control of her labor and birth. The midwife is in control of making sure the mother and baby stay alive… in fact, she was hired by the woman to do just that. And then, ultimately, the baby is in control… the baby guides the actions of the others around him/her. To me, this is symbiosis at its best.

SM: ‎"Blind maternalism is just as dangerous as blind paternalism" if I may quote one of my favorite OB/GYN buddies. I agree.

KB: ‎"Birth trust/Trust Birth" is a sales pitch and just as polarizing to this profession as the circular midwife versus medwife argument. It's interesting that not many midwives have contributed their two cents to this thread but lots of others have. I'd like to know when those of you who are the most critical plan to start your midwifery practice and if 5 years later you have a different opinion.

AHH: I agree with E and think that we midwives have enough resistance and criticism from the medical community in general and the last thing we need to do is echo their thoughts about us.

DH2: I'm just basing my ideas on the care I've received from midwives, versus what I read from very different midwives like Barbara and others. Very different care than what I received.

AKS: Honestly? I think it's a dumb distinction to make. There are good midwives and there are "bad" (unskilled, or controlling, or unkind, or a bad fit for a particular woman) midwives. I would guess there are DEMS, CPMs, and CNMs in both groups --and I would guess there are medically-minded midwives (who follow current standard medical practices, whether or not they are supported by evidence) and "alternative"-minded midwives (who also follow practices that may or may not be supported by evidence) in both categories.

NgM: It's been a hard day, so I'll try to keep my tone at a civil level.

1. We are all a product of our experiences. Anyone who thinks otherwise... or who thinks the experiences don't affect us every single day... is in serious denial.

2. There ...is NO WAY one (me) can watch a birthing woman die, right in front of her (me), and not have it affect her (my) practice as a midwife. The experience doesn't control my right hand and force it to rupture women's membranes or wrap itself like a boa constrictor around my head, controlling my brainwaves, but it most definitely colors my reality that women can -and DO- die in birth.

It (the memory) doesn't mean I sit wringing my hands, just waiting for my clients to have an AFE, but it does give me a gift (a GIFT)... the woman who died gave me a gift... of the deepest respect for life and its precariousness, even in birth.

I know there's so much more to say about this, but it's late.

And yes, #3 is it is so, so, SO easy for non-midwives to speak about what a midwife should or should not be doing at birth. I defy any critic to stand in my shoes... in any midwife's shoes... and then tell me what a midwife should or should not be doing.

My job is to keep two people alive. With that statement comes an endless list of scenarios and what-if's that cannot be rattled off in a Facebook (or blog) discussion.

DH2: Given what I know just from reading your blog and hearing you talk so passionately about birth, Barbara, I would not call you a "medwife." You respect birth, and do not a take a cavalier approach to it - with good reason (as you just stated). If someone hires you to help deliver their child and then calls you a medwife, then it sounds like what they want is perhaps an unassisted birth. Because you already sound pretty hands-off unless there is a reason not to be.

MG: I agree that the label is harmful. So often those who are labeled "medwives" are only following protocols they wish they didn't have to follow... so why are they hospital midwives? Because they believe they can make a difference in women's births by offering them hospital-based midwifery care even with those protocols as opposed to giving birth entirely over to OB's. And from what I've seen, they are right, and do not deserve to be insulted for going to the front lines for women who for whatever reason aren't having a home birth. They work hard for the benefit of women. And there are midwives who are disrespectful of women with any or no letters after their name and who work both in and out of hospital.

On another note, using medication to save lives and interventions to avoid larger interventions is prudence, not over-medicalization. 

One thing is clear: Medwife is an epithet, hurled at a midwife who, for whatever reason, isn’t aligned with the woman spitting out the word. As KB says, this is one of those circular discussions and I’ve been watching it go ‘round and ‘round like a playground ride for years. I don’t expect it to stop anytime soon.

Wonderful midwife Pamela Hines is more diplomatic than I am (as usual). She says:

"There are midwives for every family. If you have specific expectations, only communication help you decide if that midwife is right for you. While I do hear of midwives with a bit of a 'bait and switch' persona in labor versus prenatally, this is not the norm. I hate that people decide that their idea of care should be the norm for every other woman in the world."

Brilliant.

    Me doing a vaginal exam on a mama who was pushing for quite awhile with no forward movement. We eventually transferred to the hospital where she did deliver vaginally; baby'd been quite acynclitic. Anecdotally, this was the one baby I caught in the hospital.    
                                                                                                                                                                                      

Friday
Jun202008

Response to ACOG’s & the AMA’s Homebirth Resolution

The resolution says, en toto:

Whereas, Twenty-one states currently license midwives to attend home births, all using the certified professional midwife (CPM) credential (CPM or "lay midwives), not the certified midwives (CM) credential which both the American College of Obstetricians and Gynecologists (ACOG) and American College of Nurse Midwives (ACNM) recognize[1]; and

Whereas, There has been much attention in the media by celebrities having home deliveries, with recent Today Show headings such as Ricki Lake takes on baby birthing industry: Actress and former talk show host shares her at-home delivery in new film [2]; and

Whereas, An apparently uncomplicated pregnancy or delivery can quickly become very complicated in the setting of maternal hemorrhage, shoulder dystocia, eclampsia or other obstetric emergencies, necessitating the need for rigorous standards, appropriate oversight of obstetric providers, and the availability of emergency care, for the health of both the mother and the baby during a delivery; therefore be it

RESOLVED, That our American Medical Association support the recent American College of Obstetricians and Gynecologists (ACOG) statement that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers [3] (New HOD Policy); and be it further

RESOLVED, That our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers. (Directive to Take Action)

Fiscal Note: Implement accordingly at estimated staff cost of $1,929.

Received: 04/28/08

[1] http://www.acog.org/departments/stateleg/MidwiferyYearinReview2007.pdf, accessed March 18, 2008

[2] www.today.msnbc.msn.com/id/22592397, accessed March 18, 2008

[3] www.acog.org/from_home/publications press_releases/nr02-06-06-2.cfm, accessed March 18, 2008

I respond:

It’s true. Hospitals are a safer place for mothers and babies to be during labor, delivery and postpartum. If unexpected emergencies appear, as they sometimes do, hospitals have more personnel, more medications and more opportunities to save a mother’s and baby’s life (cesarean deliveries, hysterectomies, ICU, etc.). Simply by virtue of being in the hospital, women have every medical, surgical or practical tool at their disposal; this spectrum of options cannot possibly be offered in the home.

When women having homebirths have complications, where do they run? To hospitals.

I can understand the thought process of doctors:

How come hospitals are so sucky as a rule, yet they are the gleaming white knights in an emergency? Why do we have to “clean up” the mess made at their beloved homebirths? Why do we legally risk ourselves when too many midwives don’t even have malpractice insurance? Why are we expected to accept patients whom we know nothing about in the middle of a life-threatening crisis and the midwife is able to release accountability and become the woman’s doula? Why, when a homebirth transport comes in, do the women still think they have a right to force us to adhere to an unrealistic and sometimes absurd birth plan? (I know you all certainly wonder) Why do women listen to midwives – women with far less education and experience than we have? How can women implicitly trust a woman with no license or a license that isn’t even nationally recognized or accepted? What do they say to get women to be so militant against doctors, hospitals and medicine?

The answer?

Nothing.

Hospitals and doctors make their own beds with their actions and words.

I understand there is very little to be gained on the economic front and that is not your motivation. I understand your heart-felt concern is for the life and health of the mother and baby. I understand that you feel any inconvenience should be tolerated and the “birth experience” is ancillary to the final outcome.

But, you see, the hospital “experience” is abhorrent to many women. When the experience includes procedures, medications and a dismissal of a woman’s individuality, the risk of being at home doesn’t seem so great after all. When women describe their hospital birth experiences in terms of “birth trauma,” “birth abuse,” and “birthrape,” something is terribly wrong with the system.

It is the hospital system itself that writes the homebirth script. If you want women to stop having homebirths, you are going to have to make some major changes in how you operate. I firmly believe if the hospital and physician care weren’t so egregiously offensive, cruel and inhumane, the Unassisted Childbirth (UC) movement wouldn’t be accelerating.

It is in the typical birthing experience in our country that sends women away from medical care and into the hands of homebirth midwives or planning UCs.

If I were on the committee to re-vamp the hospital system, being blunt with ACOG and the AMA, these would be my recommendations:

1. Stop de-personalizing women by putting them all in hideous hospital gowns.

I know you are probably rolling your eyes, but women HATE those gowns and understand that whatever they wear (of their own clothes) will be tossed into the garbage after the birth. Removing personal articles from women is tantamount to institutionalizing her. It’s vulgar.

2. Stop calling women “Momma,” “Mom,” “Mother,” and use her name.

It is rude at best to diminish a woman to a universally used word instead of acknowledging her individuality by remembering her name, not just the vagina, in front of you.

3. Since birth plans are so similar, perhaps listening to what the majority of them ask for would be prudent.

You know the drill… no continuous monitoring, encouraged (not just “allowed”) to ambulate in labor, encouraged to eat and drink in labor (and not assume every woman is headed to the operating room), no routine IV (most women are cool with a saline lock)… and how about bringing in birth balls, huge tubs and the accoutrements that homebirths and even in-hospital birth centers provide. If LMs, CPMs, CNMs and CMs can learn to maneuver around water labors, ambulating women and women on hands and knees, then surely educated physicians such as yourselves can.

4. Stop offering medications when women ask for them not to be mentioned.

We all know medications and epidurals are an inch away; we don’t need to be asked, “Where is your pain on a scale of 1 to 10?”. Women who want a natural birth work hard to not think of labor as pain. Again, if women in the hospital want something for pain, they darn well know they can ask for it. It is extremely disrespectful to a woman’s desire to re-frame her perception of pain in labor, all this Pain Scale stuff.

5. Educate nurses and yourselves about the importance of reverence in labor and birth.

Speak softly, knock before entering the room, look in a woman’s eyes, SLOW DOWN, listen when she speaks and THINK before you do; stop when she asks you to stop (touching her, the vaginal exam, lying to her, etc.). While this might be the 20th baby you’ve “delivered” today, it is that woman’s ONLY birth that day… perhaps the only baby she will ever have.

On the same note, when you are the surgeons during cesareans, SHUT UP about day-to-day topics and remember where you are – standing at the birth of a human being. Imagine the doctors and nurses yacking about the best sushi restaurant of the moment while your daughter (or spouse or mother) is taking her last breaths on earth. That is exactly what it feels like to many women when you act like you are cutting on an anesthetized woman. This woman lying there feels – perhaps not the skin incision; her heart and spirit are not numbed. The same respect and consideration are due humans joining the earth as humans leaving the earth.

6. Stop using your status as a means to manipulate or lie to women when they ask you questions.

Educated women are so tired of “the dead baby card.” There are times when life and death occur, but there is an enormous leap between, “We need to rupture your membranes so we can put an electrode on the baby or your baby might die,” and an abruption. Your exaggerations and attempts at –or out and out manifestations of- risks must stop. I believe the manipulations are one of the major reasons women ignore what obstetricians (and many nurses) say. If you always spoke the truth, your word would stand stronger. Crying wolf takes on a whole new meaning with physicians in the baby business. Nowhere else in medicine can you find this level of untruth streaming towards patients.

Just today a woman told me about her two mild decelerations in an eight-hour period that caused a doctor to take the husband outside and say the over-used phrase, “If she were my wife….” The doctor insisted on an “emergency cesarean,” yet the woman didn’t find herself in the operating room for another 4.5 hours. Interestingly, her surgery was at 5:00 pm. Coincidence? We are sure not. How can you wonder why she wants an out-of-hospital birth this time? Such absurd scenarios pepper your medical records; we see it all the time. Stop it.

7. Find a way to open your hearts to the pain and sadness in women whose births don’t go the way they expected.

Of course women “shouldn’t” have a cement-set vision of their births, but many women do have desires and wishes and it is deeply sad for them when things turn out differently. Try and talk to her like a human being in pain, not just a physical body that can be repaired with staples and numbed with Vicodin.

I understand your belief in the impossibility of seeing each woman as a human being. I understand you think if you hear every woman’s fears, pains and concerns you will surely commit suicide from all the pain foisted upon you. I understand that you think you just don’t have the time for all that emotional stuff. I understand that you believe listening is for a therapist, not a technician like a doctor. I understand you are busy, busy and just can’t possibly have any more time to offer women so they can whine and cry about this or that.

But, you are wrong.

The best and most beloved of doctors touch their clients… if not physically (although many do this as well), then emotionally. They take a few extra moments to listen to women, not just hear them. Re-frame your own perceptions of women speaking about sad, painful or difficult topics. It isn’t whining; she is speaking from her heart.

The great part of all of this, though, is that when you open yourself to a woman’s pain, you also have given her the space to share her joys, laughter and triumphs. It isn’t all negative “energy” that comes from pregnant, birthing and postpartum women. It is a mix of emotions, just as life is a mix of joy and sadness.

Through exquisite sadness comes exquisite joy.

8. Demand more (compassionately-trained) nursing staff in Labor & Delivery units.

Women know one reason they are encouraged to have epidurals is to keep them immobilized and quiet. (Did you know that?) It is much easier to staff a unit with women who don’t wander the halls or moan with each contraction. We know it can be disconcerting to watch women give birth without medication, especially when you believe women are suffering needlessly. But, one reason women choose midwives is we are able to BE with women in their transitory state of labor towards becoming a mother (or mother again). Being able to not just tolerate, but embrace an unmedicated woman’s labor is a wonderful gift of understanding and kindness to women. It’s okay if she’s loud. If she “scares the other women,” take the lead and explain the wonder of an unmedicated labor and birth to the frightened patient. People reflect the emotion you express, so express goodness instead of disgust or dismay when speaking to other patients regarding unmedicated laboring women. And really, if it’s so distressing to everyone, sound-proof the rooms; technology abounds.

Have nursing staff attend doula trainings to develop the compassion necessary for work in L&D units. Seeing birth from another angle can do nothing but expand her capabilities with unmedicated and medicated women alike.

9. Institute doulas in all L&Ds.

When the above goals are met, doulas become the physical and emotional augmentation for nurses in the unit. If the woman no longer has to hire a doula to fend off the medical interventions, she becomes what she was designed to be… the loving support person for the laboring couple.

10. Remember that birth is unpredictable.

You chose to be obstetricians. Birth happens during the entire 24 hour day and night. If you are one of the many that “nudges” women to birth during the daylight hours, whether with pitocin or cesareans, shame on you! If you are tired, either suck it up or find more help in your practice. If you are on-call, sit yourself at the hospital for your call time. Coming and going, wooshing in at the last second of birth, discussing a woman’s care via telephone and forcing women to stop pushing until you arrive are incredibly insensitive and sometimes cruel ways to treat a woman birthing a human being. Probably the number one complaint I hear about obstetricians is their absence in birth. Women are shocked at how little they see their doctor – any doctor - once in labor. A major reason women hire midwives is because they are physically present for labor, birth and postpartum. A nurse is not a replacement for your care. If you feel labor sitting is beneath your skills and a waste of your time, perhaps losing the OB portion of your title is called for. Women pay for your care. Isn’t it time you care?

11. Accept that as long as the System remains the way it is, women will continue having home and unassisted births.

There will always be a segment of society that desires homebirths and it behooves the medical world to do what it can to make the emergency transition from home to hospital palatable. While hearing “We want you to see we aren’t monsters in the hospital” when a woman moves from home to your L&D units is less than comforting, the sentiment behind it offers a moment of understanding in why some people choose homebirths in the first place. If all of you really want us homebirth advocates to not see you as monsters, quit acting like ones!

None of the above requests include anything about the prenatal and postpartum period. Often, your prenatal demeanor belittles a woman’s questions and concerns. It isn’t uncommon for your appointments to last mere moments after the multi-hour’d waits in the waiting and exam rooms. Calling a woman by her name and looking her in the eyes as you speak goes miles towards building trust and goodwill. Women who trust sue less. If there is no other motivation to humanize your demeanor, consider that studied fact; women who know their doctor well typically do not take them to court.

One reason midwives are rarely sued by the client, much to your bafflement, is exactly because communication between midwife and client is so extensive. Communication builds trust and trust allows the care provider to say, “We really need to do a cesarean,” and the client/patient saying, “Okay.” I know it sounds simplistic… and it is really that simple.

Risk is a part of life and those that choose homebirth are accepting that risk. Women don’t just want an “experience,” they want compassion, respect, some semblance of autonomy and the knowledge they are being seen as an individual, obtaining individualized care. It might seem selfish or bizarre that someone would take that risk, but it seems a risk to step into the hospital and be put on the production line that includes unwanted (and often unneeded) medications that are used to speed up the production line, being pressured to immobilize and be silenced and strong-arming that all too often ends in a cesarean.

While it seems I am only focusing on what you all need to do, I also know homebirth midwives could always use more education. The schools work hard, and are working harder, to include the vital information that keeps a woman safe at home and to know when a transfer/transport are necessary long before it gets to the critical stage. Midwives don’t wait until the last second; we understand the time element that can be crucial in life and death.

A glaring error in your Resolution says that CPMs are “lay midwives.” That is incorrect. A lay midwife has no formal education in midwifery, but only learns through apprenticeship or even on her own, rarely studies birth as is done now. It is rare to find a lay midwife, even in states where there is no licensing. In California, the National Association of Registered Midwives (NARM) exam (which, if passed, creates a CPM credential) is accepted by the Medical Board of California as the bar women must leap over in order to be licensed in the state. The same can be said for other states that have adopted the NARM exam as acceptable for licensing. Licensed and Certified Professional Midwives are not lay midwives. Using that sort of inflammatory language leaves the homebirth/natural birth advocates shaking their heads knowing you still don’t understand even the basics of what women want or need. I am the first to say licensed and CPM midwives’ education doesn’t equal a certified nurse midwives’, but we do have book learning, CPMs now graduating from accredited schools. We also have experience in natural birth and in knowing normal birth, we are hyper-aware of when birth deviates from the norm.

Another issue I have with your Resolution is your acceptance of out-of-hospital births with CNMs. Do you not know we carry the same equipment and medications (except for sedatives and an isolette) as what sits inside a free-standing birth center? Once again, having all the correct information before writing public pronouncements would help your image amongst those that have issues with you.

Instead of bashing midwives, wanting to outlaw homebirth and perpetuate half-(or un-) truths, understand we aren’t going anywhere and it might better serve women and babies if you supervised us (as CA law requires) or at least collaborated with us. Talk to your insurance carrier, create a resolution that you cannot be sued when patients transfer care from a midwife without taking that fact into account, find a way to tolerate (at least!) midwives so the relationship doesn’t have to be so antagonistic. We’ll also do our part in continuing to educate ourselves, create increased opportunities to practice vital skills and work towards licensing in all 50 states.

I know this is long, but I hope it’s been at least somewhat enlightening. Please consider the requests above. They will fast forward the goals you desire - to have more women birth in the hospital; the location we all know is the absolute physically safest place to have a baby. Physiologically, probably not. Interpreting the difference is paramount.