Tag Archives: Midwifery

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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Awesome free resource!

I am so thrilled with the free books available at Herperian.org. They are designed for ease of use and medical accuracy, and take into account limited resources in remote locations. Each of the books is available in multiple languages.

squatting position for pushing stage

I downloaded “Where There Is No Doctor”, “Where Women Have No Doctor”, and “Book for Midwives.” I haven’t had time to read them completely. Each one is more than 500 pages! I glanced through the midwifery book first, and was thrilled with what I saw. The section on the second stage of labor discourages frequent cervical checks, for example. It also has illustrations of alternative pushing positions, or in this case, physiologic pushing positions. The section on breastfeeding has accurate, non alarmist but very true information that formula can be harmful, including an illustration of an emaciated baby with diarrhea, warnings about unclean water sources, and the valid point that formula companies use predatory advertising practices to sell their product.

“Where Women Have No Doctor” has some overlap. There is a great section on abortion, with nonjudgmental language, and emphasis on safe abortion and management of complications. the chapter begins with reasons why some women choose abortion, and the first one is “She already has all the children she can care for.” Many people ignore the fact that most women who choose abortion are already mothers, and in developing countries with high maternal mortality rates, there is real danger to their already living children if their mother has an unwanted pregnancy. The midwifery book has a training chapter on manual vacuum aspiration.

Safe abortion is a safety net

Both books have good sections on family planning. Even though they are designed for practitioners in remote areas and perhaps minimal training, there is a good balance between necessary actions and not overstepping and perhaps causing harm by doing interventions with a lack of training. For example, the section on IUD insertion states that insertion can cause injury or infection, and should be inserted only by someone who is trained, but does not have alarmist contraindications. And, the book warns against putting in IUDs without permission, and the right to refuse an IUD.

The women’s health book also has a nonjudgmental section on sex workers, with information on risk reduction and negotiating condom use. It also has a section on women with disabilities.

I downloaded the Spanish version of the women’s health book. I figure I can read it to improve my medical Spanish, and I may be able to use it as a translation tool.

OK, I have gushed about the books enough. Go check them out!

Thanks, KK!

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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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Conversations after the survey

I have been doing a recruitment push for obstetricians to take my survey. I originally planned on doing qualitative interviews with some of the physicians, and using them in the discussion. Although I eventually decided to only do quantitative research, I still get to have some really thought provoking conversations with the physicians once they complete the survey.

I have gotten great responses from the obstetricians. Of course, I wait until they have completed it to discuss it, and let them lead the conversation. I don’t want them to think I have enormously strong opinions in any direction. I discuss methodology, survey validation, and sometimes share anecdotes, but don’t make any soap box speeches.

One physician took the survey today, and said he thought it showed a slant toward midwifery. I found this interesting, since there is no mention of midwifery in any of the questions. I asked him what he meant, and he said that the questions about upright positioning and doulas were the sorts of things that midwives would do.

Now don’t get me wrong, I loved talking to this physician. He showed a genuine concern for autonomy of the patient, was not at all interested in forcing procedures on anyone, and thought “we should be humans first and physicians second” when dealing with patients, especially during pregnancy. I told him “In the same vein, we should treat our pregnant patients like mothers first and patients second.” He said he thought the ideal model for maternity care was the cooperative midwifery based model of care in the United Kingdom.

He also said the most important thing to consider is: the mother is leaving and taking her baby home, regardless of the mode of delivery. She lives with the the birth the rest of her life, not the obstetrician. He said yes, you can get sued for 18 years, but he knows, as do most obstetricians, that most cases don’t end up winning if you didn’t screw up. He thinks the litigation issue is an exaggerated scare story, and he has been sued. He said it’s about doing a job well, not an investigation of the essence of your soul, which is how he sees many obstetricians react.

But, as I complained in this post, those exact practices, upright positioning and using a doula, are more evidence based, according to the non-midwifery based United States Preventative Services Task Force, than the other interventions I ask about (continuous external fetal monitoring, routine artificial rupture of membranes in active labor, episiotomy, etc). But, somehow, simply including them in this survey, with no mention of the word midwife once, makes my survey somehow biased toward midwifery.

He didn’t mention the word “bias”, but another physician did mention the word “bias” after taking the study. (The responses have been overwhelmingly positive. Neither of these two physicians found the amount of alleged bias very problematic). I just think it’s strange. The USPSTF, Cochrane reviews, etc. examined the body of literature and then concluded there are evidence based benefits of doulas and upright positioning, but even asking about that seems questionable to some practitioners.

Well, I was setting out to examine the disconnect between evidence and knowledge and attitudes of practitioners. I guess I have found it.

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It’s National Midwifery Week

Hooray! It’s National Midwifery Week!

Hug a midwife before October 10th.

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Speaking of research

Check out Amy Romano’s latest post at Science and Sensibility about new, good research on homebirths.

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Others write letters, EBM style

Go read this excellent letter of support on behalf of a physician who is being harassed by his hospital for supporting midwives, VBAC attempts and vaginal breech deliveries.

Here is an excerpt:

When medicine is practiced primarily for profit, convenience and out of fear of litigation it is not good medical practice nor is it evidence-based medicine. The c/section rate in this country is nearing 1/3 of all births. While the current hospital model will profit from this trend you must ask at what cost? Evidence is clear that repeated c/sections put women at greater risk and the evidence mounts that babies born this way have higher rates of breathing difficulties, breastfeeding difficulties and learning disabilities. Doctors and midwives who stand up for patients rights are often the target of ridicule and harassment by the very hospitals and organizations that their hard work supports. Does this sound like what is happening at your facility??

Another part I like is this line:

“If a hospital is not safe to have VBAC, it is not safe to give birth.”

It is so stunningly simple. I may have even heard it before, but forgotten, but right now it sounds incisively brilliant.

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This made me happy

I would like to work with a birth center as an obstetrician. All of the signatures and comments on this letter supporting birth centers made me all misty eyed and hopeful. Especially since one of the places I would like to apply for residency had a lot of representation on the list.

(H/t Our Bodies Our Blog, a while ago. I am still catching up!)

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Midwives and abortion

I wanted to post this reply to a commenter who wanted to tell me not to link midwifery and abortion in the spectrum of reproductive choice and good reproductive medicine on my own blog.

With all due respect, many people do think the two are intimately linked as the full spectrum of legal reproductive rights. I am happy the journal and the American College of Nurse Midwives took this position. They are supporting medical care above ideology.

There is a difference between being pro-life personally and being for making all forms of induced abortion illegal, which increases maternal death (and cannot be pro-life) and does not reduce abortion rates. If it can be legally and safely performed for any of a variety of reasons, which it thankfully can be in our country, I am for midwives being trained to perform them and licensed to perform them, if that is what they consider to be in their scope of practice. First trimester abortions, which constitute 95% of abortions, are simple, safe procedures that can easily be done by a midwife.

All health care providers get to decide what we consider to be ethical practice. Some may refuse to deliver homosexual or transgender patients, some may refuse to perform abortions, some may refuse to attend illegal aliens. Some may refuse to provide birth control.

I will personally refuse to do circumcisions. If any patients ask my opinion on it, I will tell them. Female circumcision is illegal in this country, so I will not refer out for it. Male circumcision is still legal, so I will refer out any patients who wish to circumcise their male infant.

Deciding to limit one’s own practice does not give anyone the right to unilaterally remove an issue one personally finds offensive from everyone’s discussion.

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I heart midwives!

The Journal of Midwifery & Women’s Health sent me a table of contents alert to my email inbox. Wheee!

I was so thrilled to see a progressive editorial (pdf) about supporting abortion choices and performing abortions. I was especially pleased to see the recommendation that “women with limited means should have access to financial resources for their reproductive choices” and that “every woman has the right to access factual, unbiased information about reproductive choices, in order to make an informed decision”.

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