Tag Archives: Homebirth

Breaking the silence

I am happily coming down off the high of presenting at the Medical Students for Choice annual conference – I was part of a fantastic panel on Protecting Choice in Birth. I felt honored to be sharing the table with some brilliant people – two wonderful ob/gyns, two reproductive justice lawyers, and little old me. We talked about the legal and ethical underpinnings of patients’ rights and choice in birth: site of birth (e.g. out of hospital birth), VBAC, even use of a doula or refusal of certain interventions.

It was a wonderful experience. The director of MS4C told us the response was so overwhelming that the conference was buzzing about our panel, and we are definitely invited to return. I learned a lot from my co-panelists, and loved the enthusiastic response from the audience. One sweet medical student literally had his jaw agape when Farah Diaz-Tello, from the National Association for Pregnant Women, described a woman who had her baby taken away and put in foster care for simply wanting to postpone signing a blanket consent for any intervention or procedure during her labor and delivery. She had a healthy, spontaneous vaginal delivery with no complications during her SECOND psych consult (after the first psychiatrist deemed she was clearly mentally competent and allowed to refuse consenting to an unnecessary hypothetical cesarean), and apparently her six year old is still not in her care due to the red tape surrounding her case. Jaw dropping, indeed.

I talked about my journey, including being a patient, mother, midwifery student, doula and research fellow before becoming a doctor. I discussed the hostile-to-patient-autonomy atmosphere in South Florida, my fellowship research on labor interventions, and how to present risk to patients.

I almost burst into tears when my co-panelist, the lovely and dynamic Dr. Hanson, showed pictures of twins and breech births she has delivered all over the world. I did end up tearing up during lunch, not just because birth is moving and emotional, but because I am slowly accepting that I will most likely never be doing these difficult deliveries, and my wonderful copanelists innocently asked me about my residency plans. I may not be doing deliveries at all.

I got a decent amount of invitations to obstetrics residency programs. I am slowly canceling them, one by one. I simply cannot justify moving my two boys to a city where I don’t know anybody, then disappearing to work my ass off 80 hours a week at all times of day or night. I also don’t want to put them in public schools in the Deep South. When I got divorced during my third year of medical school I knew that would mean facing residency as a single mom. The divorce was worth it, but now that I have experienced the reality of how hard internship is, even with significant family support in my home town, I had to reconsider my options.

I will most likely be pursuing a family practice residency at a local residency program, probably at the hospital where I am doing my internship. Yes, obstetrics can fall under the family practice umbrella, but I would be the first family practitioner to get hospital privileges in the greater Miami area in recent or remote history. In other words, the chances of that happening falls between not likely and impossible. Yes, not even if I do an obstetrics fellowship, which would involve leaving town for a year. It’s just not the standard of care here, even if it’s normal in other parts of the country. And my custody arrangement stipulates that I practice here after training. So, even if I move for residency, I would have to uproot again and come back.

I can still do women’s health. I can still do prenatals. I can do lactation medicine, including the pediatrics portion. I can even be the medical director of a local freestanding birth center, just not their backup surgeon. Which, honestly, was never a huge draw for me. I want to be at the normal pregnancies, not a back up for the ones that go wrong. I can do family planning. I can still do academics, including medical ethics, which is an interest of mine.

So, most of the time I am ok with this. Most of the time. I have a lot to be happy about. I have great kids, good family support, a supportive director of my residency program, relatively good health, friends, a cute little house, a fuzzy loyal dog, and a blossoming (very tentative!) new relationship with a nice guy. And I’m a doctor, for Chrissakes. With a job in a shitty economy.

So, anyway, another permutation on the journey. Let’s see how it plays out.

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Reply turned post, from abortion to homebirth style

Hello! Hey, I’m a doctor!

Please go read this excellent article at RH Reality Check: Why Birthing Rights Matter to the Pro-Choice Movement.

Here is a great quote from the author Laura Guy, who is a doula (yay!) and a certified lactation consultant (IBCLC) (double yay!):

But let’s be clear about something. Reproductive justice means that everyone has complete control over if, when, where, how, and with whom they bring a child into the world. It means that people have accurate, unbiased access to information regarding all facets of their reproductive lives, from contraception to pregnancy options, from practices surrounding birth to parental rights. It means that our choices are not constrained by politics, financial barriers, or social pressure. In other words, how can the right to give birth at home – safely and legally – not be on a reproductive justice advocate’s radar?

As I commented on the article, I was thrilled when, during the keynote address at my first Medical Students for Choice meeting, the speaker mentioned out of hospital birth. Reproductive rights are full spectrum. They start before sexual activity begins – bodily autonomy begins with birth, stretches through childhood with protection from oversexualization, extends through accurate sexual education, includes contraception and freedom to choose when and how to become sexually active, and definitely doesn’t end once one decides to carry a pregnancy to term. The ability (or lack thereof) of women to choose the site and mode of their delivery, among other important issues of autonomy during pregnancy, are key ways that women’s rights are challenged daily in this country. Pregnant women are not human incubators.

So, seems like a bunch of mutual appreciation society activity here. Where is the angst that usually prompts the reply-turned-post? Well, on the RH Reality Check link of Facebook, one commenter says: “This is great and it’s also important for women to have the right to medical interventions (like elective C-sections) they feel are right for them.”

Here is my reply:

‎@Kathleen – within reason. Feeling something is right is one thing, but unnecessary medical intervention is not a “right” per se.

It’s a very nuanced issue that may not fit well in the comments section on Facebook. For example, evidence and expert position statements warn against early induction. Feeling like an induction is right is not enough of a reason to get one. Take it from someone who has been in the paper gown, sick of being pregnant, and in the white coat – many women feel like an induction before the end of pregnancy.

Also, someone who is a really poor candidate for vaginal delivery (placenta previa, for example), may feel like they want a vaginal delivery, but it is not medically advisable. Same goes for women who are poor candidates for homebirth. I think homebirth is an excellent option for good candidates. Not all. There is a role for practitioners to play here, too.

As a physician and most likely a future ob/gyn, I will be one of many practitioners who need to constantly work that balance between respecting a patient’s autonomy, providing good informed consent, and practicing good medicine with a good conscience. Medicine is more than ordering off a menu.

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Reply turned post, midwives are hacks style

When I signed onto Facebook this morning, a link showed up on my feed from a page that I don’t remember “liking”, but, as it is called “Nurtured Moms”, I can see it being a possibility.

The link was to an article by OB Management examining collaboration between ob/gyns, nurse midwives, and CPMs / lay midwives. The original article is actually not that bad, and does encourage collaboration with midwives (mostly with CNMs) and higher standards and licensing for CPMs, which I support. It didn’t accurately give the background on the Flexner Report, the purpose of which was to weed out inferior MEDICAL SCHOOLS, not midwives. But, I didn’t bring that up because I thought it wasn’t fully relevant to the discussion.

The posting on the Facebook page included the caption:

Exactly. In fact, it is even worse than the article suggests.

It states, “The North American Registry of Midwives’ Portfolio Evaluation Process requires midwives to be the primary care provider during 50 home births and to have 3 years’ experience. The average ObGyn resident gets this much experience in 1 month.”

However, this is not the requirement one needs to meet to become a CPM; this is the requirement to be a PRECEPTOR of CPMs — to pass your “knowledge” on to others!! In fact, to become a CPM, you only have to attend 20 births as a primary care provider. Also, just this year, they added the requirement for a high school diploma. For the last 15 years, you didn’t even need one to become a CPM. The most recent requirements are here: http://narm.org/req-updates/

The first commenter said this:

People need to understand that high standards do not limit choice for mothers. It boggles my mind when I hear lay midwifery apologists insist that making CNM the standard would “limit mothers’ choices.” Limit *what* choice, exactly? Oh right, clearly they want women to be able to “choose” substandard care (CPM) even though the very best (CNM and OBGYN) is readily available to everyone. It’s disgraceful that in America we allow uneducated hacks to practice medicine on the most vulnerable citizens. The ACOG is right not to “collaborate” with lay midwives.

I posted this:

The requirements for direct entry midwives are higher than that in Florida. Also, ob/gyn residents are already licensed doctors by the time they get that experience. There is no requirement for any specific clinical experiences first, although most medical students do at least observe a certain number of births.

Also, ob/gyn residents are not on labor & delivery every month. It depends on the training program, but most involve less than 100 vaginal deliveries a year.

Don’t get me wrong. I am a supporter of adequate training for CPMs/DEMs/LMs. I am also a supporter of accuracy.

Commenter #1 replied:

Accuracy? Lay midwives’ “education” pales in comparison to that of legitimate medical professionals. That’s accurate. Split all the hairs about med school that you like– lay midwives are still substandard, full stop.

I replied:

I am not splitting hairs. I am giving accurate information. A first year ob/gyn resident on her first labor and delivery rotation may have never caught a baby herself. She is a “legitimate” licensed medical professional.

Again, I am all for adequate training and licensing for CPMs. I do not think it is fair to call them all “hacks” or “substandard”. I also don’t think it is safe for ob/gyns or ACOG to not cooperate with lay midwives, nor is it accurate. ACOG does acknowledge that birth center births have been proven to be as safe as in hospital birth, and they support birth centers as a safe site of birth in their position statement, and most birth centers are run by CPMs or other types of lay midwives.

The best way to make homebirth and other out of hospital birth safe, other than adequate training of midwives, is to ensure seamless cooperation with other “legitimate” medical professionals when necessary. Anything less is unethical and unsafe for mothers.

Full stop.

I am not sure I am going to go back to comment on the thread, but if you follow the link to the new qualifications, 10 + 20 + 20 + 5 = 55 births required, not 20.

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Reply turned post, blame the mom or the system? style

My buddy Jill of The Unnecesarean has launched an awesomely Rad Pitt (inside joke, you’d get it if you were from San Diego or South Beach) new project called CesareanRates.com. She shared a top ten list from my lovely state of Florida on Facebook, which got, as expected, an avalanche of disgusted responses.

It is hard not to see rates of 50, 60% + without choking on your third cup of coffee. OK, maybe I’m the only one on my third cup of coffee. And I didn’t really choke, since I was well aware that some hospitals down here have had rates higher than that, as you can see by Jill and my silly little guerrilla action here, which was when we first became partners in crime.

Well, in the flurry of comments on her Facebook page, many people followed the familiar line of – blame the moms. Blame the women for not educating themselves. Blame them for choosing a hospital birth over a homebirth. Blame them for being all Hispanic (Mexicans and Brazilians in particular were blamed for our cesarean woes) and wanting a cesarean. Blame them and the OBs for creating an atmosphere of fearing birth, and forget about changing that system, because it’s a lost cause. There are plenty of good replies to this, but I am sharing mine here:

OK, diving in. First of all, the Mexican and Brazilian population in Miami and Broward County is pretty low. Cubans are by far the majority of the Hispanic population. Also, research shows that maternal request and ethnicity as factors influencing primary cesarean are both way overblown.(1) In fact, some research indicates that being Hispanic decreases your chance of having a primary cesarean in the United States.(2)(3)

Training as an OB in residency and insurance are not the primary reasons why OBs in South Florida don’t want to do VBACs. My assertion is based on as yet unpublished research from my fellowship project. Residency sites are probably the most consistent place you can get a VBAC in Florida – note that someone on this thread is going to do a VBAC at Jackson, which is the only OB residency in South Florida. Most OBs cite malpractice concerns as their reason for not doing VBACs, and that was very consistent with responses in my research. And, no tort reform is not the answer, because Florida has had some of the most extensive tort reform for OBs in the whole US – OBs here can and often do “go bare”, which means they don’t even have to carry malpractice insurance, and can limit their liability totals in various ways. Jackson has immunity as a public hospital, also.

I have to say, I am not fond of blaming moms, either for their site choice or their cultural backgrounds. I also don’t think it is effective to turn our back on changing the system. As Jill said, almost all women choose to birth in hospitals. Even with out of hospital birth rates increasing, we are still talking rates around 5%. Of course, I have to believe on changing from within, or else my life’s path is a waste of time.

(1)http://www.childbirthconnection.org/article.asp?ck=10372
(2)http://www.ncbi.nlm.nih.gov/pubmed/19788975
(3)http://mchb.hrsa.gov/research/documents/finalreports/declercq_r40_mc_08720_final_report.pdf

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Lamentations

Please, run, don’t walk, to the series called Lamenting the System at the Unnecesarean. It is a series of responses from practicing ob/gyns to an article called “An Obstetrician’s Lament” by Annette E. Fineberg, MD, which was published in the Green Journal (ACOG’s Obstetrics and Gynecology) this month. The Navelgazing Midwife reproduced the article in its entirety here.

Jill, blogmistress (I love that word!) at the Unnecesarean sent me a copy of the original article right before she started the series. It couldn’t have been better timing. My attending physician (in my pediatric ER rotation) was giving me a similar lecture to one I have gotten from almost every physician I have worked with – a lecture about what the “real world” was like, and how, in the “real world”, you couldn’t afford to offer VBACs. I argued about how VBACs were no riskier than primary vaginal deliveries, and how refusing to allow them flies in the face of expert consensus and ethical responsibility to the autonomy of the patient.

Then, I got the email from Jill. I eagerly read passages aloud to the intern sharing the service with me. She is a good friend and is leaving to start an ob/gyn residency in July. She is kind and open minded, but she did not have the benefit of training in a freestanding birth center with lots of spontaneous, natural births and plenty of successful VBACs, like I did. She has been subjected to as many if not more lectures on the “real world” as I have, and has probably only seen conventional hospital births with all of the constraints and interventions of modern obstetrics.

I read many passages, to her, including this one:

Each of these women deserves an honest discussion about the fetal and maternal risks of each birthing option. However, our lack of experience as obstetricians colored by our fear of liability is narrowing women’s choices, and sometimes motivating them to ignore fetal and maternal safety in an effort not to be coerced into unnecessary interventions. I sense a mounting tension, because many obstetricians do not have the willingness, time, or skills to provide maternal choices.

All of the articles in the series are good, but I especially love An Obstetrician’s Hope, the last one in the series, by David Hayes, MD. Every word in his piece spoke to me and to the type of practitioner I want to be. On the one hand, I am overjoyed to read of a physician supporting and attending homebirths, and even happy to see more obstetricians who support and attend homebirths in the comments. I am saddened, though, that he is leaving his practice here (although joining Doctors Without Borders is fantastic for him and the people he will help).

Here is an excerpt:

A woman choosing to have a home VBAC rather than be forced to have a repeat C/S in her local hospital is making a rational decision given the data we have available, a decision which we should be prepared to support if we cannot offer her a better alternative. I have delivered several hundred VBACs in the past several years without incident. In the same time frame, my local hospital has lost at least 3 mothers during or shortly following cesarean deliveries.

U.S. obstetricians have already come to the crossroads and have taken the wrong path. It can be fixed, but they need to start having honest and open discussions among themselves about the real maternal and fetal risks, about the rampant rate of unnecessary induction which leads to unneeded cesarean delivery, about the continued use of continuous fetal monitoring, restricted movement, withholding of nutrition, unneeded augmentation of labor, artificial rupture of membranes, epidural anesthesia and even multiple cervical exams, none of which have any proven benefit and all of which contribute to increased morbidity and even mortality.

Please go read the whole article, and the rest in the series.

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Catching Babies Blog Series

I am participating in a blog series on Catching Babies, a novel about obstetrics and gynecology training by health economist J.D. Kleinke. As a medical student on her obstetrics and gynecology rotation who is (hopefully!) staring down an obstetrics and gynecology residency soon, it really resonated with me.

Amy Romano kicked it off with an interview with the author on Science and Sensibility, and Kristen Oganowski followed up with a great back and forth with him on Birthing Beautiful Ideas.

Stay tuned for more great posts!

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So, I’m still here

Again I find myself apologizing for the blog silence. There are a few reasons I have been quiet.

First of all, my ex has been reading my posts and complaining to players in our divorce about what I write on here. So, I am not writing more about our divorce on here.

Secondly, I have been pretty busy. I have been doing the holiday thing with the kids, family and friends. I did get a few days off work. I am actually pretty happy to get back. I am enjoying pulmonology, and may look into doing a 4th year elective with the same attending physician. I am getting pretty good at ABGs.

I am not so good at EKGs. I did a module on EKGs using this ECG Wave-Maven, and I am really confused by a 5:4 AV Wenkebach. I could spot the MI’s, which is a relief, I guess.

So, there is more stuff I wish I had the energy to talk about. Mtv had an episode of “16 and Pregnant” called No Easy Decision in which one of the teen moms gets pregnant again, and decides to terminate the pregnancy. I have not seen it, but I think there are actually three young women who discuss choosing abortion. From what I have heard, it is a well put together show. Exhale has put together a site called 16 and loved that supports her coming forward with her story.

California Watch published a report entitled “As early elective births increase so do health risks for mother, child”. Thanks to Jill at The Unnecesarean for covering this.

CNN had an article on CNN.com called “Mom defies doctor, has baby her way” about a woman who had a home birth VBA3C (vaginal delivery after 3 cesareans). She was alternately painted as reckless and also as having no other option. How is a woman supposed to have a VBAC in a facility “with staff immediately available to provide emergency care” if practitioners who deliver in these facilities refuse to attend VBACs?

Anyway, I’m back, at least for the time being. I hope my son’s guardian doesn’t tell me he got an earful about my blog again. I am not airing all of our dirty laundry on here. Believe it or not, this is reticence.

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Reply turned post, conjecture about home birth mortality

I think that the more swagger and sarcasm involved is present in an argument, the less evidence there usually is to back it up. I find this post particularly disturbing in its tone, and its lack of real obstetrical knowledge to back up the assumptions mixed among the insults.

I am not happy with the extreme bias and apparent interest in just supporting a world view (while criticizing the same in others, ironically) as opposed to actual truth finding in the few posts I read at this site, and I don’t think this site is going to be worth much investment of my time and limited stress reserve. I was pointed at this post, which discusses a recent, flawed meta-analysis of home births that includes unplanned, precipitous births at home in its analysis, instead of using an “intent to treat” model. I felt the need to answer this particular post, which simply assumes at the end that precipitous, unplanned home births only happen in snow storms, and would have no confounders associated with poor neonatal outcomes. With no discussion of the pathology or etiology of precipitous delivery or neonatal morbidity, of course, and no citations.

“The Pang study, for example, contributed a large chunk of the population analyzed for neonatal deaths, but has been widely debated and criticized for including unplanned home births in its analysis of neonatal death at home birth.”

How could this possibly make a difference? It was limited to near or full-term deliveries. People simply don’t have many near full term at home accidentally. These have to be things like getting snowed in.

Do you have any data about what percentage this is? Did you know you can calculate how big the effect would have to be to shift the results. (hint: if it is huge, than it can’t make a difference) Have you done that? If you haven’t why do bring this up?

Here is my reply:

(Reposted with the html fixed)

I can tell you how it could make a difference, even at full term delivery.

First of all, especially if there is no trained attendant at the delivery, and/or if a labor is precipitous, it would be very unlikely that a GBS colonized mother would receive antibiotics, as per protocol. Strep pneumonia is the “leading infectious cause of neonatal morbidity and mortality in the United States”. This is an issue regardless of term.

The next few points are all taken from Gabbe’s Obstetrics. 2% of labors in the United States are precipitous. This is not just an issue during snow storms.

Another way a precipitous labor may be associated with poor outcomes? Maternal cocaine use is a risk factor for precipitous labor, and is independently linked with poor neonatal outcomes. And, it’s linked with not having adequate prenatal care or a trained attendant at the delivery.

Also, placental abruption is associated with precipitous delivery. Also independently associated with poor neonatal outcomes, including hypoxia. According to Mahon’s retrospective analysis of TERM precipitous deliveries, it is the ones that are really abrupt (above the 95%) that are associated with neonatal mortality. You know, the ones that come so fast you can’t make it to the hospital, and end up being unintended home births.

Also according to Gabbe, precipitous labor is also associated with uterine tetany, which may cause intrapartum fetal hypoxia or fetal distress, which are related to poor outcomes.

I would rather see citations than insults and conjecture.

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Reply turned post, what a doula can do

Well, Rixa wrote an entire post about the physician who trashed birth plans and doulas on her blog. I tried to write a reply to it, but I was got an error message that said it was too long. So, I have published it here. I guess that’s how the reply – turned – post was born.

Aha! Here it is. Well, I answered this travesty of a comment on my blog.

I have a few other things to add. The grammar and spelling are irritating to me, but irrelevant. Don’t even bother expecting good grammar. I see spelling errors everywhere in the hospital where I am training right now. Worst of all, I see meds misspelled in charts! If there’s anything you want to spell right, it should be the name of a med! I see right and left mixed up all the time also. I am doing a tumor board presentation tomorrow, and the pathology report mixed up the right and the left. Scary.

I also wanted to add that one major purpose of a doula attending a hospital birth, at least when I am a doula, is to inform the woman what to expect when she is traiged and admitted to the hospital. Also, to give informed consent, hopefully prior to labor, on typical labor interventions, and to help the woman decide where her priorities are before she is in labor, and what she may want to discuss with her practitioner. If the practitioner doesn’t show up until the end of the labor, how is she supposed to discuss an order given over the phone to break her water and give her pitocin when she’s at 4 cm? I was clueless about what would happen to me, and most women are not informed at all about what it is really like.

Many women don’t know that your doctor most likely won’t be there until you are completely dilated (that is the standard of care in my area – not sure if it is in all areas, but it is something the woman can ask her practitioner about once the doula brings it up.)

Many women don’t know that they will need to have labs drawn when they show up – they think they are “preadmitted”. They will be asked the same questions about their history over and over again by multiple hospital employees. They will be asked invasive questions about their sexual histories, drugs, smoking, prior abortions, including exact dates. In front of their partner, mother, doula, whoever is there. Even women who want an epidural immediately will not be able to get one (see below), and will be asked these questions during contractions, regardless of if there is an issue that is concerning her about the way her labor is progressing (such as the baby being premature, there being blood, her blood pressure being high, etc.) No one will reassure her or care that she was just asked all the same questions, or that she is scared, or in the middle of a contraction, or doesn’t want to answer a question about an abortion in front of her mother. It may be a good idea to inform her doula or partner the answer to some of these questions, such as if she has ever had a reaction to anesthesia, or if she has false teeth, etc.

Nurses may be brusque and insist that she removes all of her jewelry and not wear any of her own clothing, and tell her it will risk her and her baby’s life if she doesn’t remove them. (Seen it).

If they are planning on an epidural, they WILL NOT GET IT RIGHT AWAY. This is a HUGE issue. Many women seem to think the anesthesiologist will meet them in the parking lot. My cousin Susan was told by her obstetrician that she “didn’t deserve to feel any pain.” Well, she needed to have labs drawn, and run, and then needed to have 2 liters of IV fluid infused before they would even consider giving her an epidural. Considering her entire labor was 4 hours long, she felt the pain for half of it the first time. The second time, the epidural only took on one side. Was she only half as deserving? Did she even know that epidurals don’t always “take”?

I have seen epidural informed consent that consisted of “it won’t effect your baby”, and then the baby crashed immediately after, since the woman already had low blood pressure and was flat on her back. I got the honor of explaining to them what happened. I have seen an anesthesiologist storm off angrily when another couple asked about the blood pressure drops associated with epidural and spinal anesthesia (she was there on a birth center transfer and was most likely getting a spinal and a cesarean) – again, I was left to reassure them.

I have seen women told that stadol will “take the edge of and help you relax a little” as the entire informed consent. This poor women effectively missed her delivery because she was too busy hallucinating, moaning, and drooling on herself. The baby was born depressed and had to be given narcan to cancel out the effects of the drug. I have learned from these experiences to inform all women, regardless of their professed desire to avoid meds, what the pros, cons and side effects are BEFORE we are there and someone tries to talk her into it.

Also, I didn’t know, and many women don’t know, that their baby is likely to be whisked away immediately following the birth, and most likely will not be returned to her until after a four hour “observation”. I was simply devastated when that happened, and cried until they returned the baby. Even women I have warned about that have cried with me while the baby is gone.

Anyway, this went on longer than I planned, but needless to say, doulas can provide information in a way that tends to be seriously lacking in standard hospital labor and delivery.

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I get mail!

I got two emails on the same day, asking me for advice! I feel like mighty Isis. I’m not going to start call you “my little muffins”, but I am going to answer them on the blog, like she does.

Since the letters are so similar, I am going to answer them both together.

Letter writer #1 writes:

I’m just curious what made you decide to move from an education in midwifery to medical school. I’m at a bit of a crossroads. I’m about to finish my MPH and had been planning on applying to medical school this summer. I already have the MCAT and all prerequisites under my belt. However, I recently became really interested maternity care and midwifery. Now I’m confused about whether I should pursue an education in midwifery or go into medicine as an OB and support natural birth practices and midwives.

Letter writer #2 writes

I am currently a doula and CBE and the more I get involved with birthwork, the more I see that overall we need way more options out there for respectful, compassionate, Care Providers who practice evidence based medicine.

So naturally I thought, OK go be a midwife. … There’s a great program in Chicago for those of us with generic Bachelor’s degrees to jump right in get the RN and then do a master´s in midwifery in 2-3 years after that. So with another year of pre-reqs at a community college, it will take me 6 more years (at least) to finish.

Now we are moving to Oregon which opens up the CPM route if I wanted (just means I can’t move back to IL and practice legally if that’s what I choose)….

I see how regulated and pushed around midwives are here in IL. There are only about 5 in the Chicago area who will do home births and even then b/c they work all over the Chicago area it’s difficult for the to build up a rapport with the staff at the hospitals b/c there are so many and a necessary transport can be difficult which puts moms and babies at risk.

So then I was thinking about medical school to go the OB or the GP who also delivers babies route. But then that means at least 2 more years of pre- reqs before I can even apply for medical school. And then med school plus residency. (And I haven’t even mentioned the loans I’d have to take out).

One other option my aunt threw out there was a Physician’s assistant. I have never heard of them delivering babies, but she seemed to think that might be a possibility…I know this has been a huge ramble, and I guess I’m writing b/c I’d like to get some slightly objective input. What factors influenced you to dive all-in to med school instead of midwifery? What kind of practice do you think you’d like to be part of?

Ha, well, I don’t know if I am a good example when it comes to planning a career in medicine. Not unless you want to be the non-traditional student everyone else seems to think they are. (Not that there aren’t other non-trads, but most students seem to think they are non-trads even when many of them seem really trad to me).

I didn’t choose to train as a midwife. It is one of the best things I ever did, but it kind of happened to me. I had my first son with a CNM at a hospital. I was not a birth activist at the time. I was the first of my friends to become pregnant. It wasn’t a particularly great birth, and it certainly didn’t make me want to be a midwife.

I was interested in natural medicine originally, after helping diabetics in the health food store where I worked right after art school. I originally considered going to Bastyr University to its naturopathic physician program, but, much like the CPM dilemma mentioned in letter #2, an NP can only get licensed in a dozen states, which is even less than a CPM/LM. Considering how tenuous that seemed, I decided going for a conventional medical degree would be more safe, and then I would be able to practice as holistically as I chose, while also able to be the primary care physician, regardless of where I ended up living.

I had both of my children during my pre-medical journey. I had to take a significant amount of prerequisites, and I only went to school part time. If I had it to do over again, I would have taken more classes and taken out loans. I was five months pregnant with my second son when I interviewed for medical school for the first time. I had no clinical experience, and talked about using natural supplements for diabetes in my interview. I also was wearing a much more casual suit than the other applicants, and stood out like a sore thumb in many regards. I didn’t get a spot.

I was devastated. For my pregnancy, I was seeing a direct entry midwife practice (in Florida, they are licensed as LMs, in other states, they are often licensed as CPMs) associated with a freestanding birth center and midwifery education program. I loved the atmosphere and the women-centered medical practice there. I was also adrift, not sure if I could or should reapply to medical school with an infant. I had planned on having two potty trained children by this point in my training, but a miscarriage, divorce, and remarriage postponed that a bit. I remember asking the director of the program if she would hire me as a physician’s assistant. She asked me why I wouldn’t just apply to the midwifery program.

I laughed and told her no. Honestly, and this will probably sound funny coming from people who know me now, I thought “Vagina and screaming all the time – who needs that??” Then, I went home, and reconsidered. Becoming a PA would leave my scope of practice very limited. Becoming a ARNP (or CNM) would take almost as many years as medical school, and I would have to be a disrespected and overworked nurse first. Becoming an LM would take 3 yrs, and the director told me I could bring my baby until he was crawling. I signed up for the midwifery program.

Studying to be a direct entry midwife was one of the best and most trying experiences of my life. I can’t and won’t go into all the details. I was attended more than 50 births, five of which were my own catches. Many of these were VBACs. I finished two of the three years of classes. I was trained and worked as a doula and as a lactation consultant. I loved the holistic atmosphere, the (usually) woman-centered care, the wonderful patients, the normalization and success of breastfeeding. I did not love cleaning the toilets and floors, doing “hell week”, or witnessing the ethical issues when it came to the gray areas of what was safe care within the legal limits of midwifery practice. I also wanted to be an abortion provider, which would not be legal under a direct entry midwifery license.

Amy Romano does a good job of describing what the legal and collaborative climate can be like for midwives. I replied on her post (and here), and described what it was like to be at a legally scrutinized birth center with problems getting doctor back up. One night, the director faced having five years of her records pulled, including all of her active clients, because of a compassionate delivery of a known intrauterine fetal demise (IUFD) because it was, technically, out of her scope of practice, based on the letter of the law. I know how hard it was for her and every midwife and student to stare at those 700 charts and wonder how many other technicalities could be found in them. I left that night knowing I couldn’t continue at the center, risk it being closed down, risk being implicated in any findings, and face being a marginalized and severely limited practitioner.

I had already been thinking about returning to medical school. The midwives and students had remarked how I seemed like I should be a physician and not a midwife, mostly due to my love of clinical research and academic journals, and my cynicism towards some of the more “woo” aspects of the midwifery community. I didn’t want to have to transfer every stalled labor. I didn’t want to have to have a physician back up my practice. I didn’t want to find out that a patient that I referred to a physician because she was risked out of my practice for something minor had been pressured into a non-medically indicated induction, episiotomy, or cesarean. I wanted to be able to deliver twins, and breech babies. I wanted to be able to practice like the physicians I observed in the hospitals and in the community – they seemed to have a wide level of autonomy, authority, respect, and freedom of practice.

I was afraid, and still joke about having a “midwife crisis” and “crossing over to the dark side.” It is hard not to adopt the paradigm of the system in which you are completely immersed. I am desperately searching out progressive residency sites. I am terrified of being stuck at a program in which I am ostracized or constantly in confrontations about standards of care and evidence based practices. I have to bite my tongue when interacting with some members of the medical establishment. But, I had to do that with some midwives. I adore some members of the medical establishment, and adore some midwives, too. I hope I can go to or even attend a homebirth every once in a while, but I can survive with just backing up midwives and working with midwives. There are physicians who attend homebirths. I have never heard of a PA delivering a baby, but I am not an expert.

Anyway, I ended up having to take the MCAT again. It had been 2 years and 3 months since I had taken it, and one of the schools, the closest one I applied to and the one I am now attending, wanted a score within two years (I have since heard of people getting around this, but I wasn’t able to, even though my score was more than decent for the program’s admission standards). Medical school has been challenging but doable. It has been far more enjoyable and varied than I thought it would be. I am only half way through, and would be a practicing midwife by now if I stuck with the midwifery program. A midwife who graduated after I would have has moved and opened a birthing center. I will not be practicing on my own, out of residency, for at least another six years.

I hope I would have made a damn good endocrinologist, or a damn good midwife. But, I have to say, despite how much of a runaround my training has been so far, I love having the direct entry midwifery experience and doula experience and think it is a definite advantage to me in medical school. I have had more than one physician look over his glasses at me and say “Aren’t you the one who was a doula?”, with a not exactly favorable expression, but for the most part, my knowledge and comfort with the subject, and experience with patient contact and basic skills has been nothing but a boon to my training.

Well, this post is about as long as it can be. I hope this helps! Please keep me up to date, letter writers!

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