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.

Interviewing a Homebirth Midwife (Part 5)

I'm continuing the line of questions as they come from the MothersOwnBirth.com site. I've found some questions are important and others useless. Here we go. 

"Do you keep statistics of your births and what happens at each one?"

As one wonderful LM I know said, one’s statistics do not really determine the safety of the midwife in question. Someone newer (like me) might transfer for something a more experienced midwife might feel comfortable keeping at home. Or, conversely, something an experienced midwife might transfer for, a greener midwife (not like me!) might not grasp the gravity of the situation and call for help. Therefore, a midwife’s statistics can be extremely misleading. If you are trying to see if you might be transferred for something, I would say there is zero way of knowing until after the birth. As much as any of us wishes it wasn’t so, birth can turn tragic (anywhere, not just at home) and help needed immediately. We certainly do all we can to eliminate risks, but there are simply unknowns that occur and, if I had to put a percentage on it, I would say almost all women (or babies) have the potential for needing help during or after the birth. This is why it’s so important to not go by something as variable and non-concrete as statistics. 

If, however, you want to know what she has transferred for, that’s an absolutely valid question. But, what do you do with the information? This is where the knowing what answers you are looking for comes into play again. Merely knowing why the midwife transferred/transported doesn’t answer how the situation came to be in the first place. For example, if she transported for fetal distress… was mom in labor for 25+ hours? Was she vomiting? Dehydrated? Starving? Wouldn’t change positions when asked to? Was there meconium? Was the baby post-dates? Early? Was there a nuchal cord or a compound presentation found afterwards? And we could go on and on. You see there isn’t just a cut and dry answer to many/most of the questions about transfers and transports. 

But, do you want to know the details? Are you prepared to sit and listen to case study after case study? Has the midwife’s sharing these details gotten approval from the mom? Is the midwife breaking her confidentiality agreement? This is an important part of her character, too. 

When you ask about transfers and transports, isn’t it true you are hiring the midwife to make these judgment calls? Your real question is, are you able to trust that this midwife will make the right decision for you if the situation calls for it… during your pregnancy, during labor and the birth, as well as postpartum. If you are unsure, keep looking. 

The same website above suggests you ask: 

"Are you a member of your state midwives organization?" 

Who cares? What does that have to do with anything? Many state organizations are a model of disarray and confusion. 

We all know the Better Business Bureau, right? How they are held up as a standard of how wonderful a business is if they are on their list? Did you know that to get on their list, all you do is pay a yearly fee? That’s it. Nothing more. When I owned my holistic healthcare center, I learned that everything from the Chamber of Commerce to getting articles in local papers was nothing more than paying for the privilege. Belonging to a midwifery organization is no different. One of the main reasons to join any group is to be on their referral lists. That’s it. No prestige at all in paying for your own advertising. 

"What is your hospital transfer rate (or, how many times have you had to go if it's low)?" 

We already went over this one above. 

"What happens if I go past 42 weeks?" 

As I mentioned in Part 2, you should already know what your community’s standard of care is on this issue. There is a lot more than comes before this question. 

“Do you suggest a vaginal exam when I get closer to term?” 

This lets you know she has a mindset that seeing what’s going on sooner than later can help know where the course of action might be headed. While I don’t think an exam should be done at 37-38 weeks like most OBs do, there is something to be said for one at 40-ish weeks. I’ve often said you can be 4 centimeters for four weeks and still hang out there for even longer or you could be long, closed and high and deliver by sunset, but the reality is those are the rare cases. The truth is that most women show early signs of “ripening” and these are helpful in determining what the midwife might start suggesting the mom do sooner than later. Some midwives suggest these “things to do” (Evening Primrose Oil [EPO] on the cervix, homeopathics if midwife and mom believes in them, encouraging a lot of sex and nipple stimulation, etc. starting at 37, 38, 39 weeks) for every woman either because they do not do vaginal exams frequently or because, in their experience, many moms benefit from these instructions. But, other midwives are of the mindset that the body will ripen in her own good time and these extras are superfluous for most women. These types of midwives still fall into two (or more!) categories; the never-do-an-exam-until-the-last-minute variety or the do-an-exam-and-let’s-see-what’s-happening-and-decide-with-the-information-what-to-do types. You get to pick who is a better fit for you and your baby. 

“Have you had any women or their families dissatisfied with their care? Please explain. How did you handle this?”

I’m not quite sure what the point of this would be except to possibly find out if the midwife gave money back to a dissatisfied client. A better question might be “If I’m dissatisfied with my care, how would we go about resolving the dispute?” The answers might be everything from taking it to Peer Review (where sister-midwives talk openly about cases and get advice from each other on what to do with complications or to process difficult births) to mediation. It is a rare… very rare… midwife who hasn’t had at least one person, for unexplained reasons, not be satisfied with her care. Each midwife handles it her own way and sometimes, the money is returned (or a portion of it), but not always. To me, as a midwife, if someone asks about disputes before care even begins, that’s a giant red flag against taking on that client, but not all midwives feel that way. And, as a pregnant woman, you certainly have the right to ask the question. 

A question not often asked is, “Do you have malpractice insurance?” The assumption is there isn’t liability insurance for homebirth midwives, but I recently learned that simply is not true. From the Midwifery Education Accreditation Council site:

“Do midwives carry professional liability insurance? 

“Most direct-entry midwives are not covered by professional liability insurance, unless it is required for practice in their state or for participation in healthcare plans. Some midwives cannot afford or choose not to purchase professional liability insurance, and at times it has been unavailable to purchase. Instead, most midwives rely on the personal relationships they have with their clients, conscientious practice, and the informed consent and shared responsibility with women and families that they encourage in their practices.”  

In other words, being friendly with clients is supposed to keep a midwife from being sued for negligence. I already mentioned how I feel about becoming friends with clients; it isn’t a surefire protection against losing a baby or a mother. Having malpractice insurance is not solely so clients can sue the midwife. It is also for times when a baby or mother have been damaged and need on-going care such as an NICU stay or a mother’s vaginal reconstructive surgery. Having liability insurance, to me, is the mark of a professional who takes her job and responsibility very seriously.

In my own state of California, I was led to believe no one offered malpractice insurance to Licensed &/or Certified Professional Midwives. Even the California Association of Midwives website makes no mention of liability insurance availability. If it weren’t for active consumers around the Internet dissatisfied with their homebirth midwifery care, I would still not know several companies offer insurance to homebirth midwives. Contemporary Insurance Services, Inc. is but one organization that sells insurance to midwives. While California’s midwifery law does not require malpractice insurance, it does require us to disclose whether we have it or not. I am currently not attending (as a midwife) homebirths, but I believe if I was, I would find getting insurance an important part of the professionalism of my practice.

Next: Skills Training for Midwives

Interviewing a Homebirth Midwife (Interjection)

I was asked a couple of days ago if I am anti-homebirth now, that this series sounds snarky and like I am really telling women that homebirth isn’t safe at all anymore. Really, really, if I didn’t think there were any homebirth midwives that were qualified to attend to women, I would totally say so. What I’m saying here is what I believe will help women find the right provider for themselves as well as finding one that can keep the woman and her baby safe.

When I talk about the midwife keeping the mom and baby safe and alive, I am not just speaking about during the labor, birth and postpartum time exclusively, but also during the pregnancy. It takes a great deal of skill and experience to catch the nuances of a pregnancy stepping out of the bounds of normal, too. Knowing when to intervene and/or refer to a doctor is a crucial skill. I’m writing this series for those that want a homebirth and who think they might want one… giving the insider information that can help aid a woman’s/family’s search.

As I’ve said before, there are trade-offs when choosing either home or hospital births. Each one has their complication factors, either created or surprise. Each woman has the responsibility (and right!) to weigh the risks and to decide for herself within which risks she is willing to work –and live with for the rest of her life. Many aspects of our lives are risky and we weigh them with the potential benefits every single day. This home vs. hospital choice is no different.

Update on Thursday, March 8, 2012 at 06:37AM by Navelgazing Midwife

Interviewing a Midwife (Part 5)

Interviewing a Homebirth Midwife (Part 4)

Beginning the Questions 

So, now you’re sitting in front of the midwife. Be sure to never ask questions that can be answered in the affirmative or negative: 

• “Do you attend twin births?”
• “Are you a hands-off midwife?”
• “Have you ever transported a woman during labor?” 

The biggest un-question of all is “Do you trust birth?” Asking this is opening the door to a dogmatic, cult-like belief in the minimization of all care, including care that is used in an emergency.

Open-ended questions are much better ways to learn about the midwife and her practice. 

From GentleBirth.org:

• What is your general philosophy about pregnancy and birth? 

This question is really broad and should not be answered with a rehearsed statement. It was one of the most ambiguous questions I was ever asked and wondered if I answered it right each time because the answer can be so expansive. And someone’s philosophy can be incredibly different than what actually goes down at the birth. 

Instead of “What is your philosophy?” asking “What does normal birth look like to you?” can give you much more information. 

Asking what normal birth looks like to the midwife can let you know where her parameters are. Does she say a breech or twin birth is a “variation of normal”? This lets you know she’s on the liberal side of midwives, more amenable to delivering breeches and twins at home. If she is on this side of the spectrum, you might ask these next questions. 

• “What is your experience seeing breeches and twins born?”
• “Have you ever assisted with them? Tell me about the experiences.”
• “Have you ever been the primary with them? How many and what were the outcomes?”
• “How did you learn your breech and twin skills?”
• “If we agree to birth either one at home, who else would you have at the birth?”
• “Does she also have hands-on skills? Where did she learn her skills.” 

Through these questions, you’ll be able to see her exact experience with breeches and twin homebirths, as well as getting to know a part of where she stands on “What’s a complication to you?” 

Later, I’ll talk about neonatal resuscitation and hemorrhage which are vital to be explored with both breech and twin births. 

If there is no experience and she lets you know twins and breeches are out of her scope of practice, move to these questions that refer to the pregnancy and transfers, more than the actual birth. 

• “What is the upper limit of a high blood pressure you would feel comfortable with at home? If my blood pressure started going up, what is the process towards eventual transfer?”
• “What do you consider a fever in labor and when do you transfer for one?” 

Remember to know the answer you're looking for. If you are looking for a conservative midwife, it's important to know the standard of care is to transfer a woman if her blood pressure is 130/90 or 30/15 above her normal blood pressures. (If your blood pressure is usually 90/56, by the time your BP is 130/90, you could be having a stroke!) If you're looking for a more liberal midwife, one who doesn't stick to the rules of what most (medical folks) would consider safe, then knowing her answers will help you here as well. How she answers gives you pieces of the total picture of the type of midwife she is and a decent guideline-roadmap for a normal and inching-out-of-normal pregnancy and birth. 

Gentlebirth.org suggests this series of questions: 

“What are your guidelines concerning weight gain, nutrition, prenatal vitamins, and exercise? What are your standards for pre-eclampsia?” 

I’m not terribly fond of this line of questioning because the way it’s worded, it presumes the midwife believes preeclampsia is nutrition-based, which, it has been scientifically proven, not to be. I guess if you want to know if she’s still of the belief that the Brewer Diet can help a woman avoid or if she has preeclampsia already, the Diet can relieve the condition, that would be good to know, demonstrating she is not an evidenced-based midwife (some of the links have been locked for privacy), despite her possibly saying she is. 

I encourage you to spend as much -or little- time while in the midwifery consult as you need. If after ten minutes, you realize she isn't the one for you, do you both a favor and end the interview as soon as possible. You can always just say, "Thanks for your time, but I can tell we're not a good fit" and be on your merry way. I used to limit the time with interviews, frustrated at hearing the same questions over and over again, ones that were so unimportant in a homebirth interview:

• Do you let the cord stop pulsating before you cut it?
• Will you let me move around in labor?
• Can I push in any position I want to?
• Can I keep the baby with me all the time?

As if we were in the hospital. I felt bad that women expended worry and planning time on such basic questions that all have "OF COURSE!" answers. I most certainly answered the questions and also suggested reading materials so they'd get a better idea of what homebirth looks like, but wished I didn't have to go through them at all.

But now, I would take the questions and answer them with more inner patience, using the time to expose the type of midwife I am... one that sees/hears the same thing a thousand times and acts as if it is always the first time. I would not limit the appointments at all. I would not sigh if someone came in with a several page list of questions. I would not say, "We all pretty much have the same training, so pick the midwife you wouldn't mind spending 20 hours with in a small room" because it's not true. Choosing a midwife is not just about personality meshes. It definitely has elements of that, but it is not crucial to become friends with your midwife. In fact, I've found (through my own many mistakes) that not being friends keeps the boundaries clear and allows for decisions to be made autonomously by both provider and client. Each woman has the right and responsibility to keep mom and baby safe and having the space to give the sometimes difficult news of needing to transfer or transport can help the relationship stay in that professional -and trusting- place. There are no pity decisions being made, keeping a mom home because the midwife feels sorry for her, thereby risking the health and possibly life of the two clients. As I said, I learned this the hard way. More than once. If I were to begin my midwifery career again, it would include never (or only on the rare occasion) becoming friends with clients.

Next: More Suggested Questions from Various Websites & Why Not to Ask Them

Update on Thursday, March 8, 2012 at 06:39AM by Navelgazing Midwife

Interviewing a Midwife (Interjection)

Interviewing a Homebirth Midwife (Part 3)

Finding the Midwife to Interview

It’s true, a lot of my questions and thoughts are geared towards the actual birth and the ultimate safety of mom and baby during that time, but the truth is the midwife who takes that part of her job serious enough has surely also found it important enough to know the parameters of safety during the pregnancy as well. Not always so, but in my experience, prepared is prepared is prepared. And, in birth, it always pays to be prepared.

Moving on to when you meet the midwife face to face, please don’t take her office or style of dress as a clue into the type of midwife she is. Or her lovely website. You can get information about her practice from the Internet, though. From The Birth Survey to online forums, listen to the comments and reviews, but tailor their answers to what it is you are looking for. Extremely liberal midwives (in the safety sense, not the political sense) will be heralded on extremely crunchy sites and it might be harder to find information about midwives who are more middle-of-the-road or law-standard-compliant. Websites are just now coming into being that discuss the “radical” midwives and the “hands-off” care they offer/hands-on, life-saving care they didn’t offer, but they are few and far between. So, if your goal is the more experienced, perhaps even safer midwife, you might take a look at the midwife the crunchier sites tell you not to go to. If you want to throw out a question without getting flamed, but are looking for a midwife who operates within the recognized standards of care, you can say, “I’m having twins/breech/VBAmC and want a homebirth, but can’t find anyone. Anyone know who is out there for me?” And whomever they tell you to go to, stay away from! Who they tell you won’t do twins/breeches/VBAmC is most likely the midwife who tries to work within tight parameters of safety. Unless, of course, she has a great deal of experience with those different types of births, but that’s different and discussed above. 

And yes, safety is in the eyes of the beholder; you.

 

Update on Thursday, March 8, 2012 at 06:49AM by Navelgazing Midwife

Interviewing a Midwife (Part 4)

Interviewing a Homebirth Midwife (Part 2)

Standards of Care

One of the most important things you can do is prepare for the meeting. Find out what the laws are regarding homebirth midwives. Is midwifery legal in your state? If so, what are the legal Standards of Care? If midwifery is not legal, try and find out the community’s Standards, often discovered after several different midwife interviews. If you’re in a place with only one or two midwives and you are truly concerned about the safety of yourself and your baby… you are deciding between home and hospital based on the interviews, it’s vital to figure out what the community standards are, even if they are only based on one or two midwives. 

Some typical questions about Standards of Care:

• “Does this community support having twins or breeches at home?”
• “Does the midwifery community believe in ultrasounds if a pregnant woman delivers after 40 weeks?”
• “Do the midwives locally give IV antibiotics for GBS positive moms?”

Just those three questions alone can give you a feel for how the midwives in that area practice. Depending on the answers you are looking for will help you know if the community has the same mindset as you. If you wanted to spin the questions a little crunchier, you could ask:

• “If there is a problem… like a UTI in pregnancy or bleeding after the birth… and I want to use homeopathy or herbs instead of medications, will your community support you in this? Or will they have a problem with my not using antibiotics or Pitocin.”
• “If I went over 42 weeks and still wanted a homebirth, is this something normal in your midwifery community? Or is that frowned upon.”
• “What are your views on alternative methods of GBS treatment?”

When you know what style of midwife you’re looking for, knowing the standards of care in the community will let you know if the woman you end up choosing will be seen as a possible renegade or that her actions will be similar to the other midwives you might choose from. This information alone will help hone your choice of midwives.

Next: Finding the Midwife to Interview

Update on Thursday, March 8, 2012 at 06:50AM by Navelgazing Midwife

Interviewing a Midwife (Part 3)

Interviewing a Homebirth Midwife (Part 1)

Over the years, I’ve read and heard a slew of interview questions for doulas and midwives. Some are almost unanswerable and others, terribly irrelevant. Over the next few posts, I’ll take some of the different questions various sites say to ask and I’ll talk about how to change the questions to something relevant and will give the searching woman enough information for her to make a decision about the midwife for her… hands-off… hands-on… or someone inbetween. 

But, whomever you’re hiring, it is someone to, ultimately, save the life of you or your baby if a tragic emergency occurs. When a complication occurs in the hospital, there is a team of folks to do the various parts of the job in keeping someone alive. If there are mistakes being made, there is almost always another person there to see it and fix the mistake. In a homebirth setting, you have one, usually two and sometimes three people to save the life/lives. If each person isn’t meticulous in their abilities, there is no back-up team to take over or even witness the mistake/s. This is why choosing the right homebirth midwife is so important. 

It is vital for women and their families to understand that while having a baby at home can mean avoiding some too-common emergencies that happen in the hospital (fetal distress from Pitocin or a cord prolapse from rupturing the amniotic sac artificially, for two examples), there are also emergencies that happen in the home that would be able to be handled better and safer if mom and/or baby were in the hospital. If a massive hemorrhage occurs, there are no blood products in the home, nor are there the plethora of means to control bleeding like they have in the hospital. Also, if a baby needs more than minimal resuscitation, the hospital is the place to be for their teams of personnel trained to attend to such emergencies. If parents are able to face these realities and accept the consequences (and I do mean that going both ways: hospital and home), then moving forward to finding the right provider can happen. 

When a woman is birthing at home and interviewing a possible provider, it’s important for her to know the answers she’s looking for. For example, if you’re asking about postpartum hemorrhage and “testing” whether the midwife knows her stuff or not, you need to know your stuff in order to gauge the midwife properly. This is one aspect of care that doesn’t happen with OB or CNM care. You know they know how to attend to postpartum hemorrhage, not only because they work with it all too often, but also because their education was standardized and that all of them have the same base of knowledge. In addition, OBs and CNMs regularly attend drills, even if they handled a hemorrhage a day, at least once every 1-4 weeks, they practice with each other so the skills are body memories and each movement is acutely accurate. More on drills later. 

This client-as-expert can be one of the most exhausting parts of looking for a homebirth midwife. In the discussion of whether midwifery should be regulated or not, the belief that a client needs to interview the midwife to make sure she’s qualified to attend to her birth is often stated as a reason to not require licensing, that it is ultimately the woman’s responsibility to hire the right midwife, the one that knows her skills well enough to save a life. But, how is the client supposed to learn how to be a midwife and be able to gauge whether the interviewees are wise enough to fulfill their promises during their pregnancy – all the while getting care from these midwives? It’s absurd to expect a woman hiring a midwife to know more than the midwife herself. This is where a standardized education and skills system being in place can not only save the pregnant woman time and energy, but perhaps also her life or that of her baby. 

But, for now, the woman does need to almost become a midwife herself before she can interview the midwife accurately. After reading the same midwifery books the midwifery students read, where does the mom begin?

Next: Pre-Interview Preparation

Update on Thursday, March 8, 2012 at 06:51AM by Navelgazing Midwife

Interviewing a Midwife (Part 2)

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.

Exposition Trail: Intro

It's true. I have real concerns about the level of education and training of many non-nurse midwives. I first confessed my beliefs in a 2008 post called "Midwifery Education." That post was so reviled and I was smacked so hard by the midwifery community, I pulled, then edited the piece, now called "Midwifery Education (Lite)." In that post, I said:

"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 and 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."

I ended the post enrolled back in school, wanting to become an RN and then possibly CNM. I just knew I needed and wanted more education.

A lot has happened since then. To me and to others. I've kept my eyes open and have seen some rather harsh experiences in birth, too many at the hands of non-nurse midwives.

Below, I share a part of the birth story from Natural Birth Goddess' blog... the January 23, 2011 Homebirth of the Twins. Even though I've been formulating this series for some time now... and it's certainly picked up momentum since I've left homebirth midwifery behind... this birth story is the perfect springboard to emphasize the crucial importance of education and skill in a homebirth midwife. While this birth took place in a midwife-illegal state and many have equated that aspect as an excuse for the midwife's actions, I know (because I've heard it several times) the same sort of actions happen in midwife-legal states.

I'm sure to piss off a whole lot of folks by my trip down Exposition Trail, but so be it. I know my thoughts are the thoughts of others, women who spend time in my email and on the phone, not knowing who to go to or who to report their midwives to. And I have similar thoughts as other midwives who also think formalized education can transform homebirth midwifery. But that story will unfold with time.

For now, sit as I did, in disbelief at what I was reading.

"I got about 5 minutes to nurse both babies and cuddle them before the second placenta (Ariana's) was birthed.  I noticed, immediately, however, that there were some large blood clots that came with the placenta (the first placenta had not been birthed, yet).  That concerned me greatly...and although the midwife reassured me that all was fine (I mentioned it repeatedly that I was concerned about the blood clots) but she immediately started giving me herbal tinctures to help with contractions and stop bleeding.  I didn't think much of it at the time.  I was just focused on getting the first placenta delivered (and worrying about the blood clots). 

However, as I pushed, I would feel gushes of blood.  Since I had hemorrhaged before with the birth of my second child (Adrian), I knew the signs all too well.  I had mentioned the bleeding to the midwife and she was still reassuring me that all was fine.  She had me changing positions (standing, squatting, sitting, etc) and pushing.  Nothing was happening.  Nursing the babies didn't help, nipple stimulation didn't help.  I asked several times about the clotting and the bleeding and stated, "I'm hemorrhaging" and she reassured me that all was going along fine.  I got to the point where I felt like I needed to lay down (I was still in the bathroom).  My husband helped me to the bed where I laid down and pushed a few more times.  I remember feeling like my energy was slipping away.  I felt weak, I felt cold and I wanted to say something and I couldn't say a word.  I looked over in to the bathroom and was shocked at the amount of blood that was on the floor, the towels and the chux pads.  I tried to say something to the midwife about the blood, but I couldn't get the words out (I knew this was bad)...at that point, she put the oxygen mask on me. 

I remember my mom asking the midwife if she was going to call the ambulance.  I remember the midwife was sitting at the end of the bed and said, "I haven't decided, yet."  At that point, my husband grabbed his cell phone and called the paramedics.  My husband called for the ambulance at 7:05am.  Almost 35 minutes after I first noticed the blood clots.  As soon as the paramedics were called, the midwife and her assistant grabbed all of the bloody towels and put them in a garbage bag, mopped up the floor quickly, and threw away all of the chux pads.  The midwife even changed the chux pad that was under me, and full of blood. 

When the EMTs arrived, I had a little blood on the chux pad.  My husband had told them I had hemorrhaged and was losing a lot of blood.  I remember seeing 2 of the paramedics look at me (and the not very bloody chux pad under me) and look in the bathroom and not move any faster.  There was no urgency. 

After what felt like an eternity (they asked me if I was having problems with the last placenta, and the midwife mentioned I had been up for 30 hours--which was a total lie) they took my blood pressure (which was very high) and strapped me to the gurney, got me into a (very) cold ambulance.  The last thing I really remember in the ambulance is getting the IV inserted...and the one female EMT saying, "I think she lost a lot more blood than we saw..." 

When I was finally on the Labor and Delivery floor, we waited for the doctor to arrive.  Once she got there, I was given Cytotec (to increase the contractions--and it did this very effectively) and some pain killers (the contractions were that bad--and I could not imagine being induced with Cytotec, which is dangerous, anyways).  The placenta was delivered within a few pushes and I laid down on the bed.  After an hour or so, I wanted to get up to go to the bathroom (couldn't stand the thought of a bedpan) so the nurses helped me--reluctantly because they wanted me to use the bedpan--and I almost immediately passed out.  That is the last thing I remember until several hours later. 

Just after I passed out, I was started on blood transfusions.  I got 3 units of blood that day.  The doctor (who was absolutely great) wanted to keep me overnight for a 4th transfusion, but gave me the choice to go home since I  was eating, looked good (all my color was back and I was coherent).  I chose to go home that day because I wanted to get home to the girls since I had spent the first 14 hours of the girls' life in the hospital without them.  My blood count was in a "safe" range and the doctor was ok with me leaving. 

While I was in the hospital, I had 2 really good friends drop everything that they were doing to wet nurse the babies since I really wanted to avoid formula feeding them.  I cannot tell you how reassuring that was for me.  To know that the babies were being well cared for and fed while I could not be there just took so much stress and worry off of me and gave me the relief I needed to get well enough to get home to them. 

The next few days were a bit of a haze (as it is for any new parent).  The twins started out on very different sleep and nursing schedules that I was only getting about 45 minutes of sleep at a time.  I did have friends and family over all day long that helped with my other kids so I could spend all my time in bed resting and taking care of the babies.  It took about 2 1/2 weeks for me to really get used to having twins.  But I found, despite most other advice, that keeping them on their opposite schedules actually suited me (and my family) very well.  With not having to nurse, burp, and change 2 babies at the same time all the time, I have the time to really spend with each girl. I can nurse, change, and burp each individually and then cuddle with each one by themselves.  I really love the one on one time I spend with them. 

Overall, my homebirth was very good.  Excellent, even.  I did learn, though, that if there is any apprehension or concern about anything that is going on during the birth, you have to put your foot down and make the decision for yourself.  You are in charge of your birth, every aspect of it.  I should have told the midwife that I wanted to go to the hospital immediately when I saw those blood clots.  I don't, completely, blame the midwife for not transferring me sooner, but I do think she waited too long."

Mom wanted me to share the story. At first, the midwives she'd shared the story with told her everything was fine, to just move on. It wasn't until I read and commented on the story, followed by other midwives reiterating her midwife's egregious inaction that she began to believe she had a right to be angry. She has not seen or spoken to her midwife since the birth. I've counseled her to wait awhile, until she's somewhat healed from the anemia and twin birth before scheduling a sit-down meeting with her.

Mom also wants it known that she consciously chose to homebirth, that she felt her options were more dangerous in the hospital, a vaginal birth in the operating room or a scheduled cesarean, but she had discussed, at length, the seriousness of her hemorrhage history and how the midwife would handle a PPH if it happened again. She convinced the mom of her skill and experience in this area; she obviously lied.

I was shaking with fury for over an hour after reading this story. Part of my anger is the increasing frequency of these stories. Something has to be done. And the only people to do something is us... if we don't want to watch homebirth midwifery be illegalized everywhere in this country.

My writing is so we can talk, openly and transparently, about the changes we must make to homebirth midwifery... changes that, literally, saves the lives of mothers and babies.

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.