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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.