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Entries in midwifery education (5)

Sunday
Oct162011

Droplets in the Ocean

I was asked:

"Barb, is there anything we could say to homebirth midwives to wake them up to the fact that their education and training is deficient? Is there any way we could convince them of the value of experience?"

This is my answer. 

Starting with my background, I had been attending births in the hospital, birth center and home for 21 years before I got my California midwifery license in 2005. I’d doula’d about 400 hospital births before I started assisting, then acting as primary midwife (under supervision) at three different birth centers, two with CNMs and one with LMs, getting another 300 births under my belt before I became licensed. At that point, with about 700 births of experience, I’d attended many, many more births than the average newly licensed (or certified professional) midwife. Since receiving my license, I’ve either presided over or assisted at another 80 or so births at home. I’ve doula’d my own transferred/transported clients as well as acted as a private monitrice or monitrice-doula for another 120+ women in hospitals. I’m now at about 900 births attended.

I’ve also witnessed a maternal death, in the hospital, from an amniotic fluid embolism. I’d been attending births a mere four years, but it affected me for decades, causing me to say things like, “After seeing that mom die, I knew I wasn’t emotionally or spiritually ready to hold two lives in my hands, so it took many more years before I was ready to pursue a license.” Even as I studied, that death loomed over my concerns about being a homebirth midwife, but I felt I had a lot of previous experience, so was comfortable with my forward movement. I had a pretty decent idea of what was normal and what stepping out of normal looked like. But, as I learned, there is a huge difference between seeing and presiding. A life’s breath of difference.

Those who have read through my blog for a number of years, see how I’ve spoken to deficiencies in homebirth midwifery along the way. I’ve written about the incestuousness of apprenticeship, about how some midwives don’t carry the appropriate tools or meds, even writing about my own lack of skills or knowledge in many areas, including suturing and starting IVs. It is in this writing that helped me be ostracized from my own midwifery community, culminating in the formal removal from Peer Review a year ago and told not to attend community functions. I wrote “Why I Left Homebirth Midwifery” in answer to the midwives’ despicable behavior towards one of their own.

I’ve tried to speak to midwives’ lack of education and skills training many times, but it seems to fall on deaf ears far too often. But, I am finding some hope among those choosing to head into midwifery nowadays. Amber Plyer of Midwife{ology} initially began her walk, seeing a CPM certificate as her goal, but after some introspection, which, she admits, had aspects of my commentary of CPMs involved, she has chosen to become a CNM instead. I couldn’t be prouder if she was my own child! Amber is but one of at least a dozen women who’ve come to me, thanking me for speaking about the different types of midwives there are and that they’ve shifted from CPM-goals to CNM-goals, several already in nursing school.

I’d love to be able to refer to a homebirth education program that serves mothers and babies adequately. I have named four I thought gave at least decent training (listed here), but the reality is none of the schools is standardized and the graduates’ knowledge and skill are dependent on which mentor-midwife the student-apprentice works with throughout the education process.

So, to answer Dr. Amy’s questions:

"Barb, is there anything we could say to homebirth midwives to wake them up to the fact that their education and training is deficient? Is there any way we could convince them of the value of experience?"

Amy, I’ve tried. And while I seem to be making some inroads, they are, in my opinion, minimal. I’ve had my experience discounted because so much has been in the hospital, but no matter how much I state that it isn’t medical intervention that causes the sudden emergencies, too many roll their eyes and think I’m full of shit anyway.

I guess I haven’t been graphic enough about the emergencies that have happened in the home, even with completely “hands-off” labors and births, how very lucky I feel I was that no mother or baby died during the harrowing complications that happen at home as well as in the hospital. I really do believe less technology than the hospital typically uses, mixed with more hands-on care than many homebirth midwives are wont to use, can make each of the scenarios more palatable (in hospitals) and safer (at home). I can’t help believing both are possible.

But, if I, a very experienced in birth (comparatively) non-nurse midwife is shoved aside because I’m not saying all the pretty, flowery and idealistic unrealities in birth, how are the masses of non-nurse midwives going to comprehend the risks they are taking until they end up like Lisa Barrett, losing baby after baby when their luck runs out? I wish I had a magic wand, but for now, that wand is my “pen” and all I can do is keep writing.

Tuesday
Aug092011

Guest Post: Licensing Midwives

My dear friend Colleen Scarlett, LM, CPM in Miami, FL wrote a comment to my "Dandy Commentary Continued" post, but it's so fantastic, I needed to make it a blog post itself. Here, she says exactly what I wish I could say. Whatever she says below, hear me saying, "Me, too!"... because I am.

"I'm trying to understand the logic behind not licensing midwives. What I hear, when you get past the rhetoric, doesn't make sense to me.

When I hear "Licensing limits who we can take care of!" I hear, "I want to be able to take on high-risk cases!" Because, having a license has allowed me to take care of any woman who CAN be expected to safely birth at home, including women on Medicaid and with insurance. While yes, women expecting twins, breeches, and who have hypertension or diabetes cannot be taken care of at home, SHOULD we actually be doing that? And, aren't low income women especially deserving of midwifery care? Do they KNOW what low income women go through seeking out a provider? Or how they're treated like cattle once in the obstetric system? Or does freedom of choice only apply to the middle- and up class? There's a reason why the vast majority of women having home births are white, middle class, and college educated.

When I hear, "Licensing midwives doesn't honor the traditional paths into midwifery!" I hear, "I can't be bothered with devoting time, money and effort into midwifery school,.....I want to start as soon and as cheaply as possible!" The fact that someone can "self-study", catch a few babies, sit a ridiculously easy exam, and call herself a midwife makes me cringe. The fact that a midwife can start practicing and not know how to start an IV or suture makes me want to scream.

When I hear "It's the woman's responsibilty to make the right choices for herself and family!' I want to scratch my eyes out. Yes, she IS responsible, but SO. ARE. WE. We are ultimately responsible, for her health and safety, and for her baby's. We need to be able to provide her with good, safe care. We need to be able to work with the system, not against it. We can kick and scream about how horrible the obstetric system is til we're blue in the face, but it sure is nice to know they're a few miles down the road when the shit hits the fan.

I LIKE being licensed. I LIKE being able to have take Medicaid and insurance, because more women can choose a home birth without denying herself and her family, or stressing about paying their bills AND me.

I like being able to have a lab account, and a nifty lockbox on my office door, and I like being able to run labs and cultures in my office or at a clients home, and not having to send her to a clinic or doctor.

I like being able to call a back up OB and know a prescription is being faxed over to the client's pharmacy of choice.

I like being able to order, and adminster, IV antibiotics for GBS+ women, and not having to pretend GBS is no big deal because I don't know how to give an IV or because it's illegal for me to have them.

I love the fact that I can carry pitocin, and methergine, and O2, and sutures and Xylocaine. I love that I don't have to pretend herbs are just as effective in stopping a hemmorhage, or that seaweed is an acceptable alternative to suturing.

I like being able to walk into a hospital with a client in labour, with her chart in my hand, and I like being able to give report without fear of prosecution. I like the fact that in the rare instances of emergency transport, I don't have to make up a story for the EMTs, or clean up the evidence before hiding in a closet before they arrive. I like being able to ride in the ambulance with her, and monitor heart tones. And honestly, the EMT's would rather have some one that knows how to take care of a labouring woman, because Lord knows, they don't know jack about catching babies, and would seriously rather not have to contemplate that during a transport.

I like not having to wait, agonizingly, until she's a train wreck before I make the decision to transport.

Maybe those who try to convince everyone to "trust birth" are trying to deflect the attention away from what DEM's are lacking.......education, skills, legality, access to medications.......perhaps those who try to convince others that midwifery without collaboration with the obstetric system is more "authentic" or "traditional", to make up for the fact that they have no access to it? Some sort of delusion that all you need for a safe birth is enough trust, and if something goes wrong, it's actually the WOMAN'S fault, for not trusting, for having fear, for not speaking up, for not listening to her instincts.

I know when I first started my midwifery education, I was enamored with the concept of the "Traditional Midwife", the Mountain Granny with her herb garden, teas, tinctures amd poultices, her gnarled hands with years of oral tradition and apprenticeship under her ample apron, her basket of knitting by her rocking chair while she patiently waited for the baby to come. But then I grew up.

Our amazing tradition of midwives, our Martha Ballards, our Anne Hutchinsons, Miss Mary Coleys and our Gladys Miltons, our Ina May Gaskins, have given us centuries of knowledge and skills, our philosophy that birth is natural, woman and family centered, and that skilled hands can save lives. But none of these great women EVER balked at the idea that more education, training, and skills were a good thing. And the beauty of learning from our past is that we can intergrate, learn, and apply our knowledge. That we can continue to learn, and grow, and provide increasingly better care to our women and babies.

I can't imagine that traditional midwives, all over the world, would NOT want to have access to hospitals, doctors, medicines, clean instruments, IVs, and the support of their governments health care system.......we have become so distant from the reality of childbirth, how many of us actually KNOW (not know OF, actually KNOW) a woman or baby who died, from a preventable cause, during or right after birth? How many of us go into our pregnancies filled with dread that we may not make it? We take it for granted that we, and our babies, are going to be just fine BECAUSE we have, maybe too much, access to modern medicine.

In the blog post ("Why state licensure is not the answer for midwifery"), an article ("Her Home-Birth Battle") is linked about a Massachussetts baby who died from GBS sepsis. I can't help but wonder, if the midwife was licensed and regulated, would she have screened the mother for GBS according to Mass. Department of Health and ACOG guidelines? Would she have had a back up OB, because the mother was a VBAC? Would she have sent her in for biophysical profiles and non-stress tests every 2-3 days when the pregnancy went post-dates? Would she have administered prophylactic antibiotics when the mothers membranes ruptured 3 days before labour started? Would she have been required by her laws and rules to transfer this mothers care to her back up OB when she began to show signs of infection? If she had, most likely this woman's baby would have been born alive.

I keep hearing, "Licensing does not make better midwives!" and it's true. I know some LMs who lack skills and judgement. And while I don't think licensing per se is going to make a better midwife, I think across the board, standardized education that meets, not just the minimum, but NECESSARY skills. Unfortunately, for the less than motivated, that means going to 20 births and reading some books is not going to cut it.

I love the profession of midwifery, I love our tradition, our philosophy, our dedication....I would really like to see us around for a long, long time."

Goddess, I love you, Colleen. Thank you for speaking my mind. You're the best!

Thursday
Mar272008

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.

Tuesday
Mar252008

WHO's Midwife

Who is a midwife?

Many definitions abound, including the root of the word, “with woman.”

Is the term “midwife” self-defined? Would a midwife be someone who attends births… having had training or not? What if the training is adequate for one part of the world, but not another? Could there be a universal definition of who a midwife is and what her skills should be?

I thought I’d focus on the World Health Organization’s definition since it seems most closely aligned to my own.

From Chapter One of the “Care in Normal Birth: A Practical Guide.”:

"The midwife: the international definition of the midwife, according to WHO, ICM (International Confederation of Midwives) and FIGO (the International Federation of Obstetricians and Gynaecologists) is quite simple: if the education programme is recognized by the government that licenses the midwife to practice, that person is a midwife (Peters 1995)."

Does that mean if the person doesn't have the education a government sanctions that the person is not a midwife? Hmmm... something to consider, right?

"Generally he or she is a competent caregiver in obstetrics, especially trained in the care during normal birth. However, there are wide variations between countries with respect to training and tasks of midwives. In many industrialized countries midwives function in hospitals under supervision of obstetricians. Usually this means that the care in normal birth is part of the care in the whole obstetric department, and thus subject to the same rules and arrangements, with little distinction between high-risk and low-risk pregnancies."

"The effect of the International Definition of the Midwife is to acknowledge that different midwifery education programmes exist. These include the possibility of training as a midwife without any previous nursing qualification, or "direct entry" as it is widely known. This form of training exists in many countries, and is experiencing a new wave of popularity, both with governments and with aspiring midwives (Radford and Thompson 1987). Direct entry to a midwifery programme, with comprehensive training in obstetrics and related subjects such as paediatrics, family planning, epidemiology etc. has been acknowledged as both cost-effective and specifically focused on the needs of childbearing women and their newborn."

There’s been discussion of whether peds, family planning or well-woman care is a part of midwifery. It seems WHO believes it is and I agree with that. I definitely know I could use more training/information in those areas. I look forward to my upcoming Anatomy & Physiology classes to aid in my increasing comprehension of the nuances of a woman’s body. I know some (CPM/LM) training programs spend time on these topics and I applaud this. I believe all schools should have comprehensive information and require experience in these areas.

More important than the type of preparation for practice offered by any government is the midwife's competence and ability to act decisively and independently. For these reasons it is vital to ensure that any programme of midwifery education safeguards and promotes the midwives' ability to conduct most births, to ascertain risk and, where local need dictates, to manage complications of childbirth as they arise (Kwast 1995b, Peters 1995, Treffers 1995)."

I think these are phenomenal recommendations. I like, so much, that they understand that different locations will create different midwives.

One of my thoughts is that here in the United States, we see so many different cultures that it is really imperative that we learn as much as we can about them all. I am so glad when I hear midwifery schools talk about multi-cultural issues, but also hope they discuss the nuts and bolts aspects of diet choices, physical customs and the hierarchy of the family. I know that I learned the hard way that not all men are (or want to be!) a part of the birthing process.

I remember a dad who chose to sit in the reclining chair in the labor room, leaning back and snoozing. Judgmentally, I was angry at his lack of participation until a kind nurse took me aside and explained to me that in his culture, men were typically not anywhere near a woman in labor, so his being in the room was tremendous support for his wife. Once again, I had my veil of ethnocentricity pulled back, exposing me to ways that were not my own, but were/are just as valid nonetheless.

I adore what WHO says about midwifery. I encourage every midwife, midwifery supporter and every wanna-be midwife to read the entire text of “Care in Normal Birth: A Practical Guide.” Without knowing it, the words, beliefs and desires contained inside the text are exactly how I feel.

WHO acknowledges community midwives and stresses what type of education those midwives should be obtaining. A community midwife is a midwife who works outside of the hospital, but might work collaboratively with physicians. Sometimes, community midwives are far from any medical care and might be called on to perform skills some of us might never encounter. A community midwife is different than a Traditional Birth Attendant. TBA’s typically have very little training other than experience. It isn’t uncommon for a TBA to have learned her craft only through apprenticeship, many times female generational (grandmother to her daughter to her daughter).

WHO has a vested interest in midwives earning and retaining the respect of physicians around the world. In every crevice of the world, it is the physician that can save the life of the woman or baby who needs more care than a midwife can offer. Midwives need obstetricians. If only we could have more on our side. In a few places, OBs work beside midwives in a spirit of cohesiveness and collaboration; each profession respecting the others’ roles. I would love to see the same thing – and (idealistically) I believe it can be done. The more a midwife’s education level grows to look like something the medicos recognize, the higher the level of respect we will have. We are well on our way with MEAC-accredited schools and the homogenization of midwifery education.

I know that, for some (many?) homogenization seems a negative, even awful, but in our growing need for acceptance because of legislation and tightening rules, being alike can work towards our benefit. The definition of “midwife” becomes completely understood – in any context.

WHO says, “…the midwife appears to be the most appropriate and cost effective type of health care provider to be assigned to the care of normal pregnancy and normal birth, including risk assessment and the recognition of complications.” (From what I can decipher, the term “Direct-Entry Midwife” was changed to simply “Midwife” in 1995.)

Among the recommendations accepted by the General Assembly of the XIII World Congress of FIGO (International Federation of Gynaecology and Obstetrics) in Singapore 1991 (FIGO 1992) are the following:

• "To make (midwifery) more accessible to women in greatest need, each function of maternity care should be carried out at the most peripheral level at which it is feasible and safe."

I absolutely agree with this. I believe this is saying midwives should be the care providers for normal birth and obstetricians reserved for high risk pregnancies and births. You bet!

•"To make the most efficient use of available human resources, each function of maternity care should be carried out by the least trained persons able to provide that care safely and effectively."

To me, this speaks to the doctors, nurses and hospitals in our communities (and insurance companies?) that midwives need, if not deserve, support even though we/they might not be operating inside the hospital. Of course, this is if the first two points are being accomplished as well.

“These recommendations point to the midwife as the basic health care provider in obstetrics delivering care in small health centres, in villages and at home, and perhaps also in hospitals (WHO 1994). Midwives are the most appropriate primary health care provider to be assigned to the care of normal birth. However, in many developed and developing countries midwives are either absent or are present only in large hospitals where they may serve as assistants to the obstetricians.”

According to Nurses and Midwives for Health: A WHO Strategy for Nursing and Midwifery Education:

“…health care does not take place in isolation from political, economic and cultural realities…,’ so nursing and midwifery education and practice do not take place in isolation from the political, social, economic, environmental and cultural realities of the Member States; neither must they be seen in isolation from the various stages of health care reform and the dynamic nature, or otherwise, of progress.

I think this is part of what I am saying… that in today’s environment, we need to have as much education as is possible. If more education is needed for LMs/CPMs, finding a way for that to occur is really important. The political climate for midwives is changing and we need to change with it in order to keep up – and stay alive!

Instead of arguing for mediocrity, let’s move forward towards more knowledge and experience.

“Likewise, nurses and midwives do not practise in isolation from their colleagues in the other health care professions. Although each profession contributes unique knowledge and skills to health promotion and the care of patients, there is a need for much more multidisciplinary and interdisciplinary work, in a spirit of recognition and respect for each others’ authority, responsibility, ability and unique contribution. Thus, nurses and midwives must be educated to take their full part as members of the multiprofessional health care team, sharing both in the decision-making and, when appropriate, in taking responsibility for leadership of the team and for the outcomes of the work of the team.”

And, sure! The medicos need to acknowledge this as well. I agree!

“In the face of fundamental health care reform the complex factors depicted in Figure 1 and the resulting social transformation, and because nursing and midwifery education and practice are at very different stages of development in the Member States, it is timely that the professions be proactive in preparing a WHO European Strategy for Nursing and Midwifery Education. This Strategy is intended to be applicable today, but it also looks ahead to the twenty-first century. Although the focus of the Strategy is on preparation for entry into the professions of nursing and midwifery, this education must be seen as the first step in a journey of lifelong professional learning. As research-based knowledge of nursing and midwifery education and practice grows, so all practising nurses and midwives must continue to learn throughout their professional lives – in some cases developing new knowledge for specialist nursing and midwifery practice, in others deepening their knowledge of an existing field of practice.”

In the “Purpose and Objectives of the Strategy,” WHO says, “…it is essential that the nursing and midwifery professions be committed to the need for change in nursing and midwifery education and practice, and that nurses and midwives themselves become more actively involved in the change process.

One of the issues I have with non-CNM midwives (that I’ve not yet seen discussed) is the tendency to embrace statistics/news that encourages letting go of technology whereas if statistics or news encourages more technology or a more hands-on approach appears, it either evaporates into the ether or is discounted en toto.

For example, in my on-going discussion about midwifery education, several people have brought up the World Health Organization’s statements that a midwife “…appears to be the most appropriate and cost effective type of health care provider to be assigned to the care of normal pregnancy and normal birth, including risk assessment and the recognition of complications.

However, in October 2006, WHO strongly advised the Active Management of Third Stage of Labor (AMTSL), but I haven’t heard of community midwives adopting that stance at all! AMTSL includes giving a medication to contract the uterus (Pitocin, Methergine or Cytotec), delayed cord clamping, controlled cord traction and uterine massage after the placenta is born. This is counter to what most midwives (myself included) are inclined to do (except for the delayed cord clamping), but here, sitting in front of us for over a year, is extremely well-documented information that, as far as I can tell, midwives aren’t listening to.

When it came time to toss aside the bulb syringe, most of us didn’t hesitate. Even when the information came out that oxygen isn’t the be all and end all in the first minute of resuscitation – that seems to have been easier to let go of for many midwives. The DeLee causing more problems than it helps? It disappeared from birth kits everywhere. Again, these are procedures that were on the more-invasive side and I find it’s not so painful to let those go. But, picking UP procedures is another story.

Why do any of us hesitate to utilize the information we have for the health and safety of our clients? It seems to run counter to being an LM or a CPM, but perhaps looking at new information is a part of our jobs, yes? What I would love to know is how many non-CNM midwives even know about AMTSL – and then, how many utilize it. Do non-CNMs utilize the information regularly? What do you tell your clients about it? Do you have a consent form detailing the options for AMTSL versus physiological third stage?

(It would be great to know how many CNMs also utilize AMTSL. Is it hard to do it after being so hands-off during the labor and birth? Has it changed the way you “manage” or not-manage third stage? What do the back-up docs say about it? Did you find out the information when it initially came out? Did you change your behavior/actions overnight?)

For my clients, I think I’m going to print out the information and make it a discussion topic during prenatals. I like that WHO says they specifically used the word “offer” instead of “use” so women could have the option of saying no, they didn’t want to have active management. Informed Consent, right?

In a time when so many midwifery websites quote the World Health Organization’s stand on midwifery, I would like to see us embracing their definition of a midwife. How many people who quote the statement that midwives should be the first line of defense for normal births have actually read through the entire treatise? I hope midwives and birth advocates will now go and read through it and really listen to what it says about risk, back-up, what is normal, how to attend to a myriad of situations and how vital midwifery is in our world today.

On every count, I couldn’t agree more.

Wednesday
Mar192008

Midwifery Education (Lite)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I’ve enrolled in school.

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

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

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

I can hardly wait to get started.