we need GREAT midwives

This post is coming to you as I have had several days to think about the amazing reactions I’ve had to my most recent post My Thoughts on Home Births. The thing about midwifery is that there are way too many distinctions of different kinds of midwives. Just a few: Lay, Direct Entry, Certified Professional Midwife and Certified Nurse Midwife….the only thing you need to know is that a CNM is the ONLY type of midwife with a clinical degree in nursing. That means she (or he in some places!) has a high school diploma, bachelors in nursing, masters in nursing and nurse midwifery certifications and degrees. I’m taking a rather slow and easy road to midwifery, but if one is on the normal track to becoming a midwife straight out of high school, then she will have been in school for at least 6 years, if not more in some cases. She also must take continuing education in basic life support, neonatal resuscitation, suturing, etc. CPMs, Lay, and Direct Entry midwives may have some pre recs to take before entering a program and in less than 3 years they could be on their own catching babies, mostly at home. Those midwives are not certified to work in a hospital or in some birthing centers. All this to say…education makes a huge difference and as I said in the last post about home birth, I am a HUGE advocate for education, both of the provider and the patient.

I say this because, despite my not being a fan of home birth, our country still needs good great home birth midwives. People who want to give birth at home, educated or not, are going to give birth at home and they should do so with a great midwife. The most ideal home birth midwife would be a CNM. I know a few CNMs who actually attend births at home. This area gets sticky depending on different state regs, but in Colorado, it is allowable. Now, does she carry liability insurance? Probably not because it is too expensive to do so. Would I hire a midwife to attend my birth without liability insurance? No, because that also means that my insurance is most likely not going to cover a dime. Regardless, we need to accept that, while home birth is not the safest place to have a baby, that it’s still going to happen and they need to be attended by great home birth midwives.

What does a great home birth midwife look like? In a perfect world, she is a CNM and has experience working in a hospital setting. She has a relationship with the local hospital in which transferring is not looked at with such negativity and she carries liability insurance. She carries a post-patrum hemorrhage kit with her, along with a tank of O2, an IV kit with plenty of fluids and oxytocin. She has THREE assistants..not just one or two. These are also CNMs who have just as much experience and understanding in labor, birth, and newborn care. She also only takes on truly low-risk moms. In a perfect world, right? For now, our focus should be on having the same standard of midwifery care at home as we do in the hospital. That scope needs to include the same amount of schooling and continuing education that is required of CNMs today. If you know anything about education, you also know that those standards change constantly and in my experience, become more thorough and strict. That is great! Midwifery is a profession just like any other and you wouldn’t hire someone who was not fully educated to take care of you and your baby, right?

The reason we need great home birth midwives is because we need to lessen the number of neonatal deaths. Since families are going to make that choice whether I agree with them or not, we still need to have educated, great midwives attending those births. We need to continue to hold midwives accountable who have had deaths or complications made because of their lack of education or preparedness.

Remember, we don’t want to bury our babies twice, or even once if we can! #notburiedtwice

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18 thoughts on “we need GREAT midwives

  1. As a current Student Midwife studying to be a CPM I respectfully disagree with a few big things…. but I must say I truly admire your stance on advocating for midwives. When I first starting reading I felt a little pang of defensiveness but that quickly faded as I understood your perspective. Although I do believe that if women want safer more empowering births hey need to get away from the hospital, I will say this was very well written 🙂 Definitely planning on sharing.

    1. Thank you for your kind response. I’m glad you could see where I am coming from. I must say, however, that I had two safe and empowering births in the hospital. I encourage you to read them if you haven’t already.

      1. I didn’t word that properly… I had both of my girls in the hospital as well. I’m not saying there’s any right or wrong way to give birth. It’s certainly different for every mother. And what works for some doesn’t for others. As a birth doula as well, I like to tell my clients that 🙂 In the hospital or at home, squatting or laying… as long as women can make informed decisions and be knowledgeable then theres no wrong way to bring birth 🙂

  2. It is my understanding that a CPM, in the U.S., would only take on the task of assisting with births when it considered to be a low-risk pregnancy. The entire birthing process is a natural thing and when the mother is healthy and there are no issues with the baby, delivery when allowed to proceed on it own need only be “assisted” either it be a CPM, TM, or CNM. Some women deliver on their own completely. African American slaves even have stories of delivering the baby in the fields and going back to work. When “advanced” medicine interferes either it be through the excessive use of c-sections or counter-active measures such as using oxytocin, it appears that men are attempting to play gods when the body and life was already magnificently made.

    Perhaps the U.S. can take an example from U.K. where CPMs are generally the primary assistants who see the mother through the entire process. If any risk to mother or baby are present then care is released to a doctor.

    Afterall, motherhood is a natural thing and birthing when given a chance to act on its own is instinctive.

    1. Maya,
      Thank you for your comment. I am perfectly aware of everything you mentioned and I do believe that birth is a normal, natural process, however it does not always happen like that and even the most low risk mom and baby could have a life-threatening problem during labor or birth in which case, transferring would take too much time. The point of this post is to note that, while home birth is not safer than the hospital setting, we still need good home birth midwives because people are going to give birth at home, regardless of what statistics and medical journals recommend. Also to note is the difference in education for CPMs and CNMs. I may feel more comfortable with home birth if EVERY SINGLE MIDWIFE was trained under the exact same guidelines, including a full scope of nursing skills, masters of science and certification in nurse midwifery. There are too many different credentials required. I’d guess that in the UK, your midwives may have more training than our CPMs and that therein is the problem in our country.

      1. Lets be clear. During childbirth anything can happen regardless if it is a low-risk or high-risk pregnancy and delay of action can lead to death. Who is to say that a CNM has more insight on the proper action needed than a TM or a CPA. Book knowledge and the acquisition of a Bachelors in Nursing does not equate one to being more skilled in their profession.

        If one were to look at the midwifery requirement under NARM as well as the schools, whether a University or Specialty school, one would find that the bulk of information provided to both the CPA and the CNM are the SAME. (Please also reference Direct-Entry modes). CNMs,TMS, and CPM all have areas of strength and weaknesses so to value one over can be taken as the equivalent of valuing one race or culture over another. Ever lived another country? Know a language other than English that you are able to communicate effectively with?

        Understand the “duty of care” principle highlighted in University law courses? Please look this up it is extremely important in understanding the view of a TM and CPM. We should all be open to learning from one another. Separation due to title can be extremely hazardous. As someone looking into midwifery and am a life-long learner your statements:

        “CPMs, Lay, and Direct Entry midwives may have some pre recs to take before entering a program and in less than 3 years they could be on their own catching babies, mostly at home. Those midwives are not certified to work in a hospital or in some birthing centers. All this to say…education makes a huge difference…” (Education should be a continuous them for all care providers whether it come from attending lectures guided by those senior in the field, take part in conferences, attending school for additional courses, self-study, etc.)

        “What does a great home birth midwife look like? In a perfect world, she is a CNM and has experience working in a hospital setting. ” (To whom? Under whose condition and authority?)
        and

        “Midwifery is a profession just like any other and you wouldn’t hire someone who was not fully educated to take care of you and your baby, right?” (This is the reason why CPMs in the U.S. obtain a licenses. Also, this is the reason why TMs have often been around for years, having acted as the provider for multiple generations as a TRUSTED provider and often obtain new clients via referral. Sometimes dealing with hospitals you do not know what CNM you will get. The one you have been confiding in or back-up for whom you have never met personally.)

        “I may feel more comfortable with home birth if EVERY SINGLE MIDWIFE was trained under the exact same guidelines, including a full scope of nursing skills, masters of science and certification in nurse midwifery. There are too many different credentials required. ” (Every mother, birth, social condition, etc will not be the same so to make everyone obey the same guidelines is not realistic. Specialize in what you know will benefit the mothers for the area, condition (home birth/hospital/ birth center/ side of the road in a village) and culture you service. Then extend this specialization even further by continuing to learn. There can never be enough that we can learn (credentials) and aspire to obtaining when mother and baby depend on it.

        These comments are terribly biased, condescending, and lack credibility. I can see how the CPA who commented above felt a certain type of way about them.

        The writing is quite objectionable and warrants more thought in content and tone. Which is the GOOD thing about it because more dialog is needed so that all respect one another. When everyone agrees with you ….you may be doing something wrong.

        Also, the UK basic curriculum regarding the training of CPM is the same as that highlighted by NARM which is the reason why if one goes to UK to complete practicals it is acknowledged by NARM.

        Sincerely,

        An advocate for all midwives regardless of class, race, culture, creed, color, or title.
        Maya

        Peace

      2. My only response to this is to remind you that I am not yet a midwife. Don’t speak to me like I am. I have a world to learn, though what I write, I do my best to back up with credible sources (see within many posts rather than just making a blank statement). Also, I work in a hospital where I see EVERYTHING. Yes, sometimes interventions can be the cause but most of the time, mother nature is. I don’t have the backbone to sit here behind a screen and argue with someone I don’t know. Let’s agree to disagree, as the previous poster was so kind to point out. Thanks.

    2. “It is my understanding that a CPM, in the U.S., would only take on the task of assisting with births when it considered to be a low-risk pregnancy.”

      That is not correct. Many CPMs, LMs and lay midwives take on high risk pregnancies. MANA and NARM do not advocate against high risk pregnancies at home. There are no standards, no guidelines. It’s a free-for-all. A look at the new (under-reported) MANA survey shows that plenty of high risk home births are happening. And the outcomes are AWFUL. The low risk outcomes are better but still bad. You can see that outcomes for VBAC, for example, are far worse at home:
      http://whatifsandfears.blogspot.com/2014/04/mana-study-part-4-vaginal-birth-after.html

      Excessive c-sections can be problematic. ACOG has recently released a new bulletin to raise awareness that we should be working toward safely reducing the primary c-section rate.

      Pitocin has its place and can make the difference between a live and dead baby. It is not attempting to play god by utilizing the advancements we have to save lives. It is finding a balance from not over-using and not under-using. Not many would opt to go backwards to hundreds of years ago when our maternal and perinatal mortality rates were much, much, much higher than they are now.

      CPMs don’t practice in the UK. It is a different training/education system. In the USA, the majority of all currently practicing CPMs have gone the PEP route…. which is an apprenticeship-only program: no educational standards, no hospital experience. Their neonatal resuscitation experience is limited to getting certified (meaning, practicing on dummies and never seeing or using the skills in real life before working on their own). You can read more about how low the standards are here:
      http://safermidwiferyformichigan.blogspot.com/2012/09/cpm-education-bar-is-too-low.html

      Here is a great post about the differences in midwives around the world:
      http://safermidwiferyformichigan.blogspot.com/2013/04/the-education-of-midwives-around-world.html

    3. And to reply to your second comment, Maya:

      As I said in my previous comment, the most popular route for CPMs and the route that most currently practicing CPMs have taken is the PEP route…. which is an apprenticeship. That’s it. Even the “school” route is not legit. MEAC schools are not actual colleges/universities. CPMs do not have hospital privileges….. because they have not EARNED hospital privileges.

      There should absolutely be separation of these different types of midwives. Just as the word “doctor” means different things. People deserve to know what they are getting. Informed consent.

      Women should know that if they are looking at studies regarding home birth that have been done in other countries, they need to know the differences between how home birth works in those countries versus how home birth works in our country. Differences not only in how midwives are trained/educated, but also, differences in how midwives are integrated into their health care systems. And what if there is a bad outcome at a home birth? How would that be handled in another country? How is it handled here? There is no accountability for midwives here… NARMs accountability is a joke (it’s non-existent) and there is no insurance – no option for a family to collect. Why would a family need to money? If a child is injured at birth…. brachial plexus injury after shoulder dystocia, for example, or cerebral palsey due to birth injury, for another example….. having insurance to offer a family compensation to deal with the lifelong medical needs of their child can make all the difference in the world.

      The standards are not high enough for CPMs. Outcomes with non-CNMs are horrid. If we want good outcomes, then home birth should be functioning under the guidelines and standards that birth centers in the 2013 Birth Center study followed. Look at the differences between outcomes for LOW RISK women in the MANA survey (majority CPMs), the Johnson & Davis study (aka CPM 2000 study; 100% CPMs) and the Birth Center study (majority CNMs):

      MANA survey = 1.62/1000

      CPM 2000 study = 1.7/1000

      Birth Center study = 0.87/1000

      Twice as many babies (born to low risk women) die when born at home to a CPM, compared to being born in freestanding birth centers attended mostly by CNMs.

      Here are links to the studies:

      http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12172/full

      http://www.bmj.com/content/330/7505/1416

      http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full

      1. These are all nice posts and I will check them out. Science is never a certainty. I stand by and will remain support for all midwives who are practicing with the mother and baby’s interest at heart. There is a reason why women choose TM’s and CPM’s and we should respect the trend as to why they are doing so.

        Arguments can be made for all sides and as mentioned all have their strengths. Let me add that all also have their weaknesses.
        The fact that we can debate will allow the mother to choose what she believes is best for her and her baby.

        You mentioned the fatality rate, which is twice 1/1000 vs 2/1000 and acknowledged the cesarean rates which I respect. I read the following and although some may not agree (the wording at the beginning kind of made me feel a way) I believe the Dr statement should be acknowledged

        http://seebaby.org/news-a-media/midwifery-today-article

        “There is no such thing as high risk! What I do is put risk into context. ”

        “They need to listen to the patients! Don’t try to challenge the trend, but be more open to dialogue. What I tell my colleagues is, “Ask yourself why is that trend there. Why would a mother want to have a homebirth? What is it about a hospital birth that would make her want to spend her own money and take what 99% of her peers see as a risk and have a homebirth? Something must be going on, guys! Ask those questions — and ask them without being cynical or disparaging or condescending.”

        “Here’s where my hope and inspiration lie: the homebirth midwives. Forget the OBs. I know there are little pockets across the country, a few here and there, who are trying to maintain normalcy. But there is a steep rise in first-time moms choosing homebirth. That gives me hope. But my real hope is in the homebirth midwives. Hope for normalcy to be preserved.”

        Another article with some interesting comments at the end of the article by the readers:
        http://msmagazine.com/blog/2011/01/31/midwives-fight-for-the-right-to-deliver/
        “However, as medicine became increasingly professionalized, the male-dominated world of physicians gradually squeezed midwives out of the mainstream health system. Today, the standard regimen of drugs and emergency rooms dominates maternity care. The movement toward home births marks a subtle rebellion against the inertia of a bloated, profit-minded medical infrastructure.”

        There are so many articles, research reports, studies debating home-birth to under TM, CPM,CNM as being safe/unsafe and so the circle never ends.

        I do have a question about NARM though, is there a certain reason why you are saying it is a joke? Please see my prior mention of the “duty of care” with regards to your insurance statement. The model basically states that citizens have a lower “duty of/to care” when their risk of personal accountability is at hand. Take car insurance for example. The people in states where car insurance is not required by the DMV tend to have lower accident rates because they know that if they get into an accident all liability is on them. There is that incentive for drivers in that area to take precaution for the welfare of themselves and those in the society.

        For a midewife to take on a homebirth that is what she feels is beyond her limit is a haphazard/unethical/ and immoral. The same can be said of those in birth centers and hospitals and extend to the doctors as well. Malpractice occurs on both ends.(Lots of studies on those as well).

        The main thing that I would like the reader to take away is that there are sides to every story/position. If I offended Sarah I offer my apologies. This is all new to me as well (72 hours to be exact). I am in the process of researching for myself what would be the best course for me to pursue midwifery and the demographic to work.

        I will allow the floor for others to respond. It is nice to hear many perspectives.

        Thank you

      2. Maya, I too support midwives, hence the reason for this post. The problem is that there are midwives in our country who have had problems with deliveries, failed to transfer in time, babies have died, moms have died, and NO ONE is being held accountable. That is the reason for malpractice insurance which CNMs carry and why insurance companies rarely cover midwifery care in the home. I have seen cases where insurance companies will reimburse the patient after a safe, healthy delivery has occurred. I have no idea if their claims would be denied if something bad happens.
        While I believe in a woman having and making her own choices when it comes to anything regarding her birth, etc, I continue to disagree that giving birth at home is safer. It’s simply not.
        There are many things that are appealing about giving birth at home. No wonder the rate of home birth is going up. While I used to believe this to be a good thing, I know now that it is not, as seen by the fatality rates. Giving birth in my home because I don’t want to be around the monitors and such is not worth risking the life of myself or my baby.
        There absolutely are high risk pregnancies and deliveries. Certain preexisting conditions for mom may increase that, number of fetus’, too low or too high amniotic fluid, fetal anomalies…the list goes on.
        The entire point of this post, which I feel you are still missing, is that despite the fact that home birth is not safer than hospital delivery, it can be made as safe as possible by good midwives and the training and education of such midwives needs to improve if our mortality rates are to decrease. People are going to make the choice to birth at home, and that is their choice, I just hope and pray they have a well-trained, good midwife who can determine an emergency before it’s even life-threatening.
        Dani will have to explain her statement regarding NARM, however my only comment is that the clear as day difference between lay and CPMs vs CNMs is the nursing degree and background. The years of training and experience that a nurse alone gains is priceless when it comes to midwifery, labor, delivery and neonate care.
        In Colorado, a home birth midwife cannot take on a patient who is high risk. I’m pretty sure this is standard nationwide with possible differences in what qualifies “high risk”.
        Maya, have you read my son’s birth story? I really encourage you to do so. If we had been anywhere but a hospital, he could have died. Also I am not offended, however I am not really one to get argumentative. I realize that I am sharing an opinion and one which not everyone will agree with so I’m setting myself up for it, but I only ever mean well, as it seems you do too.  Curious, what do you mean this is all new to you? Do you have a personal blog? Are you just venturing into midwifery? I’d like to know more. Thanks. -Sarah

    4. I can’t hit “reply” to your last comment for some reason. Anyway.

      I am an advocate for well-trained, well-educated, respectful, ethical, non-philosophy driven care providers who give informed consent — at home and in hospital.

  3. Maya,

    You said “There is a reason why women choose TM’s and CPM’s and we should respect the trend as to why they are doing so.” and also you said “There are so many articles, research reports, studies debating home-birth to under TM, CPM,CNM as being safe/unsafe and so the circle never ends.”

    Yes, there are many people who are choosing home birth with CPMs and other non-nurse midwives. I was one of them who originally made that choice. I am quite familiar with why women are choosing home birth. Unfortunately many are doing so because they have been misled. I know plenty of women who chose home birth without realizing exactly what they were choosing – low risk women and high risk women. There is unfortunately a lot of misleading information out there…. information that is twisted and turned to scare women away from hospital birth. For example, using maternal mortality rates and infant mortality rates to scare women away from hospital birth — without giving context to the maternal mortality rates and without realizing that infant mortality rate is not the correct statistic to use for a reflection of maternity care.

    You said “There are so many articles, research reports, studies debating home-birth to under TM, CPM,CNM as being safe/unsafe and so the circle never ends.”

    That’s why it’s important for women to beware of agenda and to read the studies and look at the numbers themselves. Because there actually isn’t a circle. The truth is, we have just over a handful of studies regarding home birth in the USA… and they EACH show the steep increase risk to babies born at home. Now, if people are reading articles about the studies and not the studies themselves, then the information can look conflicting…. even though it’s not. The new MANA survey, for example. If someone read the study themselves and compared numbers, they would see the large increase risk for babies born at home in our country. However, if someone only read the MANA press release about the survey, then they would think “see! home birth is safe!”

    I was interviewed by SteadyHealth regarding a lot of this and instead of regurgitating what I’ve already said, I’ll just share the article here:
    http://www.steadyhealth.com/articles/doula-dani-homebirth-after-c-section-a-gamble-a3842.html

    Why is NARM a joke? Because there is no accountability and because the process to become a midwife is not nearly rigorous enough. Have you heard of the Sara Snyder / Greenhouse Birth Center lawsuit? Her care was completely lacking, disgustingly so. She had CNM and CPM for their birth. Her baby died because they 1. did not give informed consent regarding the risks of breech vaginal birth and 2. were negligent in their care of the birth. They were so negligent, in fact, that a judge awarded them $5 million — none of which they will see because the midwife who took the fall – the CNM – filed bankruptcy, as did the birth center. Check out “From Calling to Courtroom” for a guide for midwives on how to get out of being held accountable: http://www.skepticalob.com/2012/12/lie-to-your-patient-and-other-homebirth-midwifery-wisdom.html

    The CPM in the Snyder case got off free and clear. NARM did nothing. The CNM was retiring anyway so she took the fall as she knew she’d lose her nursing license. That’s there M.O for NARM. There’s case after case of CPMs getting away with negligence without so much as a slap on the wrist. They want to protect the midwife and protect the reputation of home birth midwifery at all costs.

    You said “For a midewife to take on a homebirth that is what she feels is beyond her limit is a haphazard/unethical/ and immoral.”

    But the problem is, many midwives don’t know that the choices they are making are unethical. This is the problem with the PEP. When a midwife is only learning under one primary midwife, the student midwife will obviously be very susceptible to the philosophy of the preceptor…. and if that’s a dangerous philosophy……..

    When Ina May Gaskin — CPM and the queen bee of all midwives in our country — is taking on high risk home births, don’t you think that says something to inspiring midwives and vulnerable pregnant women?

    Do you know there are women out there who want to become a midwife and choose CPM solely because it’s the quicker, less expensive route?

    Do you know there are preceptors out there who will lie on the behalf of a student midwife (about experience during the process) for the right price?

    Do you know there are a growing number of CPMs and lay midwives who are coming forth, admitting that their training process was no where near enough to prepare them to become a midwife?

    1. Dani,
      I can testify to having the same thoughts, which I shared in my original post about home birth. It is so EASY to get sucked into the facade of how amazing it would be to birth at home and how comfortable and on and on…Who DOESN’T want to be at home when they are most vulnerable? I get it. Also, I too looked into the CPM route a few years back JUST BECAUSE the amount of time and training was less. Admitting this makes me want to vomit as I cannot even imagine hiring anyone to do any kind of service for me, especially health related, who took the easy way out.

  4. “we need to lessen the number of neonatal deaths”
    you’ve got my attention!
    -From the writer of the blog
    The Midwife from Hell

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