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Entries in midwifery licensing (2)


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.


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.