Hello people 
this essay was written in response to things I've encountered and thought about for a long time as mom and mw, its writing today prompted by some recent events in my own life. It's long, even for talkative me! I hope it's useful to you all the same.
**********
Making the best choice of mw is important anywhere, but especially in states where midwifery isn't regulated. Even in states where midwifery may be 'legal, but unregulated', there is no State Board to oversee training, continuing ed, ethics, complaints, etc. There are no legislated policies/procedures governing midwives, and so, no one 'standard of care', or records of midwives' practice to rely on. Also, there is no guarantee of 'even application' of policy/procedure--where it's been created, and is upheld, by midwifery orgs themselves--when it comes to 'interventions' on mws. In unregulated states, midwifery can be a 'small world' where some mws receive biased treatment by the orgs involved...either biased in someone's favor for being well known, acceptable, etc; or biased 'against' because of being less well known or 'different' from the rest of the group...same reasons bias occurs in any human relationships.
Choosing a place of birth and attendants is an intrinsic right--families seeking, and receiving, truly informed consent from providers to assist in decision making, is a fundamental part of that right. 'Truly informed consent' can be elusive, no matter where you birth or with whom: hospitals keep statistics by law, but administration can make it difficult to access them. Often doctors are reluctant to share their personal stats. But in states where midwifery is not regulated, it may be hardest of all to get solid info about a mw's practice. And having enough information is so important to making a wise choice of care. So, I offer a few ideas on choosing hb care:
First, I refer you to the stickies in this forum, "homebirth helpful resources', where you will find lots of questions to ask prospective mws. And I highly recommend that you ask all prospective mws some questions, even if you have 100 friends who have happily used one mw. Birth is very well designed and works well most of the time, *with or without* a mw in attendance. If your 100 friends all had normal-enough births, then they can't really say how their mw operates under duress. They can't say how she handles complications, whether she accompanies transfer and how she conducts herself at the hospital, in the family's interests--important things to know. One mw I know likes to say 'having a mw is like having an expensive insurance policy; you might never need it, but if you do you'll be glad you got the best coverage.'
2nd. Even if your friends say their mw is 'the best', you might ask 'how do they know, if they never used anyone else?" Besides, *you* might like someone else better, for all kinds of reasons. You may have some different expectations than anyone else.
3rd: While you can find legal mws advertising in the yellow pages, etc, not all competent practicing midwives are legal. If you are willing to consider hiring a non-legal mw, then you may have to really hunt! There are usually State Midwifery Associations to be found, and/or State homebirth referral and advocacy groups, who can help you locate mws. But neither group necessarily knows all available mws. Nor does either group support/refer the practice of all hb mws--maybe d/t hearing too many complaints about a mw; OR, otoh, even if such orgs *do* trust a mw's practice, there may be political reasons to stop referring one...politics, like love, often 'has reasons that reason knows not of'
. Dig for info...
So--make posts in your tribal forum and others locally, or ask LLL chapters, or doulas, who may know of mws. Look in health food stores or chiropractor's offices for mw's card/flyer--or ask people there if they know of any mws.
4th: about 'talk': check it out! If a mw says anything about another mw, that is immediately suspect unless it's praiseful. Only a mw and her clients are qualified to talk about her practice, her training, what variations she works with (breech, hbac,...), her religous views, etc. So if you hear one mw say something about another, you might ask if she's ever worked with that other mw and witnessed her care? Any eyewitness can ethically speak of her *own* experience (but *only* of what she witnessed). If she doesn't have that experience--then you might ask her to focus her comments on her own practice instead. In this way you can help establish ethical behavior in your mw-community...sometimes mws need reminders . My favorite 'overhead comment: 'I didn't interview that mw, my mw said she talks about others behind their backs' (!
)
However--there is an exception to that point: when a mw actually has reason to know that another mw's practice is unsafe (at least in some way), but the mw in question is 'under the radar' for any reason and it has been tricky to get any sort of intervention. If you're in an unregulated state, then everyone is under the radar (or hopes to be); if you're in a mw-legal state but a mw is not legal, then she may have been able to successfully avoid prosecution even if she isn't the safest mw around. Most mws do want to be the best they can be, and will confront issues, seek help--but not all do. So, if you speak to a mw and she has things to say about another mw, you might give it a hearing--but ask for ways to confirm things you're hearing, take it with a grain of salt but be open to learning more, for your own protection. Any mw who speaks of another's mws issues out of true concern is going to be very careful in her presentation...I think you will see the difference between that and simple backstabbing.
Or maybe you hear from a family about a mw. Ask if they've met her--worked with, or at least interviewed her. If so, then they can speak of their experience (but perspectives vary--you might *like* a mw for the same reason another family does *not*). If they haven't met her, you can ask where they heard that, so you can follow up the facts if you like. Sometimes people talk for the best of reasons--if they heard something about a mw from their own mw, or from a friend--someone they implicitly trust--they may tell you in good intentions to 'help you'. But talk can be false or misleading no matter what the source or reason--or simply might not apply to your own needs/preferences. Which leads me to:
4th. Any mw may be wonderfully skilled; she may do this work out of a sincere sense of spiritual calling...and all mws are *still* merely human, are just as subject to being competitive, gossipy, egotistical and every other human foible that every other human is subject to. She is really not a Saint , just a person. See her as such; treat her, and all she says, as such--you'll be doing yourself, your community--and even her-- a big favor.
This means 2 things--A. if you hear a mw talk about another's practice or personal life, it can be forgiven, but it's not in *your* best interests to give such talk any credence and well--it's only your interests that matter here. (except as noted a couple paragraphs above).
B. Also, her talk about her own practice should include all you need know to make the best choice. Any business person will 'put the best foot forward to get the most clients', of course. And you need to know a mw's full stats to make a good choice, not just 'how many total primaries' and other generalities. The more births a mw has handled, the more likely she's seen some hairy things--and should be able to speak about such births. If someone has managed hundreds of births, and doesn't have info to share on complications she's seen--complete with families who will speak for her care, well...I would wonder how honest she is being. I've heard some mws say 'I don't want to scare clients with talk of a hospital back up plan, or of complications or poor outcomes'. But providing only sugar-coated talk about homebirth, and sanitized stats, is not informed consent and will not help you make a good decision. A mw's avoidance of the uncomfortable topics of homebirth--sidestepping a question and changing the topic instead of directly answering, turning it around on you ('sounds like you're not comfortable with homebirth', 'you need to trust birth/trust your mw'), blaming others ('some mws envy me and want everyone to distrust me' 'I've only had problems when clients didn't follow my advice')...all this is avoidance, and should be a red flag to you.
On the other hand, maybe you really like a less-experienced mw--and she may be the perfect fit for you in various ways. Still, it's wise to discuss complications with her; you want to look for her mindful, cautious approach to complications or potential complications--her acknowledgement that she has not seen/handled all complications fully appreciates the implications and has thought about it. Being generally confident is one thing--but being 'over-confident' is quite another. Having a good personality fit is good, very good! And can't be the only thing that guides your choice, if you are to have the safest, happiest experience possible.
Finally--'question everything'. An example: 'mw X has seen 3 uterine ruptures in her practice, so I'm hiring her for my hbac--she has the experience handling UR that I want'. OK, 'experience'...but the next question is, how many total hbacs has she assisted? Knowing that will tell you about her overall UR rate, and whether or not it's within norms for UR. If it is, great--but if it's not, that says something *else* about a mw's practice, aside from that 'good thing' of experience handling UR...SWIM? Receive info critically, question everything so as to get the full picture.
Maybe it 'shouldn't be so much work' to hire a mw, but then again this all applies to hiring of any health care provider. Pregnancy is a time when we may be pulled forward into learning and thinking about new things--our self care, a birth plan, the future plan for our families, all kinds of things that will have a bearing on 'the rest of your life'. So, you might consider this somewhat of a 'primer' for your health care empowerment, for life
this essay was written in response to things I've encountered and thought about for a long time as mom and mw, its writing today prompted by some recent events in my own life. It's long, even for talkative me! I hope it's useful to you all the same.
**********
Making the best choice of mw is important anywhere, but especially in states where midwifery isn't regulated. Even in states where midwifery may be 'legal, but unregulated', there is no State Board to oversee training, continuing ed, ethics, complaints, etc. There are no legislated policies/procedures governing midwives, and so, no one 'standard of care', or records of midwives' practice to rely on. Also, there is no guarantee of 'even application' of policy/procedure--where it's been created, and is upheld, by midwifery orgs themselves--when it comes to 'interventions' on mws. In unregulated states, midwifery can be a 'small world' where some mws receive biased treatment by the orgs involved...either biased in someone's favor for being well known, acceptable, etc; or biased 'against' because of being less well known or 'different' from the rest of the group...same reasons bias occurs in any human relationships.
Choosing a place of birth and attendants is an intrinsic right--families seeking, and receiving, truly informed consent from providers to assist in decision making, is a fundamental part of that right. 'Truly informed consent' can be elusive, no matter where you birth or with whom: hospitals keep statistics by law, but administration can make it difficult to access them. Often doctors are reluctant to share their personal stats. But in states where midwifery is not regulated, it may be hardest of all to get solid info about a mw's practice. And having enough information is so important to making a wise choice of care. So, I offer a few ideas on choosing hb care:
First, I refer you to the stickies in this forum, "homebirth helpful resources', where you will find lots of questions to ask prospective mws. And I highly recommend that you ask all prospective mws some questions, even if you have 100 friends who have happily used one mw. Birth is very well designed and works well most of the time, *with or without* a mw in attendance. If your 100 friends all had normal-enough births, then they can't really say how their mw operates under duress. They can't say how she handles complications, whether she accompanies transfer and how she conducts herself at the hospital, in the family's interests--important things to know. One mw I know likes to say 'having a mw is like having an expensive insurance policy; you might never need it, but if you do you'll be glad you got the best coverage.'
2nd. Even if your friends say their mw is 'the best', you might ask 'how do they know, if they never used anyone else?" Besides, *you* might like someone else better, for all kinds of reasons. You may have some different expectations than anyone else.
3rd: While you can find legal mws advertising in the yellow pages, etc, not all competent practicing midwives are legal. If you are willing to consider hiring a non-legal mw, then you may have to really hunt! There are usually State Midwifery Associations to be found, and/or State homebirth referral and advocacy groups, who can help you locate mws. But neither group necessarily knows all available mws. Nor does either group support/refer the practice of all hb mws--maybe d/t hearing too many complaints about a mw; OR, otoh, even if such orgs *do* trust a mw's practice, there may be political reasons to stop referring one...politics, like love, often 'has reasons that reason knows not of'
. Dig for info...So--make posts in your tribal forum and others locally, or ask LLL chapters, or doulas, who may know of mws. Look in health food stores or chiropractor's offices for mw's card/flyer--or ask people there if they know of any mws.
4th: about 'talk': check it out! If a mw says anything about another mw, that is immediately suspect unless it's praiseful. Only a mw and her clients are qualified to talk about her practice, her training, what variations she works with (breech, hbac,...), her religous views, etc. So if you hear one mw say something about another, you might ask if she's ever worked with that other mw and witnessed her care? Any eyewitness can ethically speak of her *own* experience (but *only* of what she witnessed). If she doesn't have that experience--then you might ask her to focus her comments on her own practice instead. In this way you can help establish ethical behavior in your mw-community...sometimes mws need reminders . My favorite 'overhead comment: 'I didn't interview that mw, my mw said she talks about others behind their backs' (!
)However--there is an exception to that point: when a mw actually has reason to know that another mw's practice is unsafe (at least in some way), but the mw in question is 'under the radar' for any reason and it has been tricky to get any sort of intervention. If you're in an unregulated state, then everyone is under the radar (or hopes to be); if you're in a mw-legal state but a mw is not legal, then she may have been able to successfully avoid prosecution even if she isn't the safest mw around. Most mws do want to be the best they can be, and will confront issues, seek help--but not all do. So, if you speak to a mw and she has things to say about another mw, you might give it a hearing--but ask for ways to confirm things you're hearing, take it with a grain of salt but be open to learning more, for your own protection. Any mw who speaks of another's mws issues out of true concern is going to be very careful in her presentation...I think you will see the difference between that and simple backstabbing.
Or maybe you hear from a family about a mw. Ask if they've met her--worked with, or at least interviewed her. If so, then they can speak of their experience (but perspectives vary--you might *like* a mw for the same reason another family does *not*). If they haven't met her, you can ask where they heard that, so you can follow up the facts if you like. Sometimes people talk for the best of reasons--if they heard something about a mw from their own mw, or from a friend--someone they implicitly trust--they may tell you in good intentions to 'help you'. But talk can be false or misleading no matter what the source or reason--or simply might not apply to your own needs/preferences. Which leads me to:
4th. Any mw may be wonderfully skilled; she may do this work out of a sincere sense of spiritual calling...and all mws are *still* merely human, are just as subject to being competitive, gossipy, egotistical and every other human foible that every other human is subject to. She is really not a Saint , just a person. See her as such; treat her, and all she says, as such--you'll be doing yourself, your community--and even her-- a big favor.
This means 2 things--A. if you hear a mw talk about another's practice or personal life, it can be forgiven, but it's not in *your* best interests to give such talk any credence and well--it's only your interests that matter here. (except as noted a couple paragraphs above).
B. Also, her talk about her own practice should include all you need know to make the best choice. Any business person will 'put the best foot forward to get the most clients', of course. And you need to know a mw's full stats to make a good choice, not just 'how many total primaries' and other generalities. The more births a mw has handled, the more likely she's seen some hairy things--and should be able to speak about such births. If someone has managed hundreds of births, and doesn't have info to share on complications she's seen--complete with families who will speak for her care, well...I would wonder how honest she is being. I've heard some mws say 'I don't want to scare clients with talk of a hospital back up plan, or of complications or poor outcomes'. But providing only sugar-coated talk about homebirth, and sanitized stats, is not informed consent and will not help you make a good decision. A mw's avoidance of the uncomfortable topics of homebirth--sidestepping a question and changing the topic instead of directly answering, turning it around on you ('sounds like you're not comfortable with homebirth', 'you need to trust birth/trust your mw'), blaming others ('some mws envy me and want everyone to distrust me' 'I've only had problems when clients didn't follow my advice')...all this is avoidance, and should be a red flag to you.
On the other hand, maybe you really like a less-experienced mw--and she may be the perfect fit for you in various ways. Still, it's wise to discuss complications with her; you want to look for her mindful, cautious approach to complications or potential complications--her acknowledgement that she has not seen/handled all complications fully appreciates the implications and has thought about it. Being generally confident is one thing--but being 'over-confident' is quite another. Having a good personality fit is good, very good! And can't be the only thing that guides your choice, if you are to have the safest, happiest experience possible.
Finally--'question everything'. An example: 'mw X has seen 3 uterine ruptures in her practice, so I'm hiring her for my hbac--she has the experience handling UR that I want'. OK, 'experience'...but the next question is, how many total hbacs has she assisted? Knowing that will tell you about her overall UR rate, and whether or not it's within norms for UR. If it is, great--but if it's not, that says something *else* about a mw's practice, aside from that 'good thing' of experience handling UR...SWIM? Receive info critically, question everything so as to get the full picture.
Maybe it 'shouldn't be so much work' to hire a mw, but then again this all applies to hiring of any health care provider. Pregnancy is a time when we may be pulled forward into learning and thinking about new things--our self care, a birth plan, the future plan for our families, all kinds of things that will have a bearing on 'the rest of your life'. So, you might consider this somewhat of a 'primer' for your health care empowerment, for life
