I am finding all of this very interesting as I am interested in a HB.
Liz-hippymom, I am so very sorry for your loss. Your story is personal and has really given me a lot to think about.
I haven't read all 100+ posts; but I doubt that any regulatory agency could improve outcomes or safety.
Look at hospital births and "advanced" trained OB's outcomes. The US leads most countries in crappy birth outcomes. And we have fully regulated and "medically trained" providers attending 90% of all births in the nation. It isn't training or regulation which is the variable, imo. Birth is safe. Life has risks. I understand the desire to control the variables when life feels out of control.
Pat
Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing.
— Helen Keller
Look at hospital births and "advanced" trained OB's outcomes. The US leads most countries in crappy birth outcomes. And we have fully regulated and "medically trained" providers attending 90% of all births in the nation. It isn't training or regulation which is the variable, imo. Birth is safe. Life has risks. I understand the desire to control the variables when life feels out of control.
And, certainly, access to adequate education, economic stability and healthcare are issues to consider when comparing birth stats as well.
Liz-I gave birth a couple of months before you in 2009 and I remember reading your birth story when it first happened. My heart broke for you, Aquila and for your whole family. I am simply ashamed at how some in NCB community have treated you. I have heard the echo of your experience in the stories of other homebirth-gone-awry babylost mamas. As a member of that community I hope you know that I admire your strength, courage and fortitude. I understand why you want to reform homebirth-you don't want anything like what happened to Aquila and to you to ever happen to anyone else needlessly. I'm so sorry for your tremendous loss and congratulations on Baby Willow (love that name, BTW! It was very nearly Bridget's name)
Wow. I just finished reading this whole thread. This is an interesting topic but unfortunately I don't even know where to begin. There is some terminology being thrown around incorrectly, IMO. Several times I have read about a "CPM" practicing in a state that doesn't certify non-nurse midwives and getting into trouble for it. Does this mean the midwife is certified in another state and crossing state lines to practice or is she not certified at all? If she is not certified, she is not a CPM. CPM's in my state have a standardized education and are required to pass the NARM exam. They are then licensed through our state medical board. There are midwifery schools that are MEAC accredited and some that are not. If the school is not MEAC accredited there are more hoops to jump through to sit for the NARM and to earn a CPM.
Now, with all of that being said I would not feel comfortable attending births with the minimum requirements required to become a CPM alone. I have thought about this a lot and every time this discussion comes up and/or I hear a story like Liz's it makes me take pause. I want to become a midwife someday. If I ever did I'm still not sure what route I would take. There are so many different paths and they all have pros and cons. If I were to take the CPM route, I would attend a MEAC accredited school finish up all the requirements to sit for the NARM and then I would intern at a place like Casa de Nacimiento. My midwife who is a California Licensed Midwife, C.P.M. did an internship there and another local midwife interned there for 18 months. She wrote about her experience here: http://www.casamidwifery.com/interns/13.htm. There are many different midwives that have written about there internships at this busy birth center. Midwives from Canada and Denmark have chosen to learn there. Two seperate previous posters talked about what they feel would be important to be a better midwife and I believe they are both correct. One mentioned seeing normal so many times that when something is abnormal it is very apparent and another posted about seeing and working hands-on with abnormal. In a standard homebirth practice a midwife is going to see a lot of normal, low risk. In a place like the birth center mentioned above she will see a lot of everything and have to work with that hands on. As a birthing mother that is the experience I would hope my midwife would have and if I were to attend women duriing childbirth that is the experience I would require myself to have. I think it is very possible to be an excellent CPM and to perhaps have more experience with complication than a CNM, but at this time no such requirements exist for a CPM and that is a shame. At this point we have to just hope that CPM's will seek that extra experience in a learning environment before they start their own practices. Quite obviously, not all CPM's are making that choice.
The ACNM (American College of Nurse Midwives) used to have two titles that were recognized. Of course one was the CNM and the other was a CM. A CM (certified midwife) received her education in hospital but was required only to learn about complications, assessments, and the normalcy of birth without becoming an RN. To me, this was a very good way and was a step in the correct direction but that license was only available in one state and it was difficult to find a school that offerred programs in which one could earn a CM. That title has fallen away now and is no longer available. I'm really not sure why it didn't catch on in more states. It seems to be closer to the model of midwifery education in other countries that some of you have mentioned. So my purpose for writing all of that is that I disagree that the whole CPM title neds to be thrown out. I would like to see more rigorous requirements, though. Bring back the CM would be great, too!
In Florida, how does the malpractice insurance work?. I don't know much about malpractice insurance and maybe someone here can clarify for me, but aren't some states more litigious than others and in those states wouldn't malpractice insurance cost more? California has A LOT of attorneys and as such has a lot of court cases civil and otherwise. My three youngest children were born at home with the same midwife each time. At the first prenatal appointment I signed a piece of paper stating that my midwife had informed me that she did not have malpractice insurance and that I was taking financial responsibility for the outcome of the baby's birth. That is a scary piece of paper to sign, but I did so I absolutely was informed of the fact there was no financial safety net. I know in talking with my midwife that she would rather have malparactice insurance but in our state it is more than prohibitively expensive. I'm not even sure if it is available here. The reason that I believe this is true is because when I asked my OB to be my back-up for my first homebirth, she said that while she didn't have any issue with me having a homebirth(based on my obstetrical history), her malpractice insurance prevented her from providing any care for me. If something did go wrong and she was associated with my homebirth not only would her malpractice insurance not cover anything but they would cancel her policy. Obtaining malpractice insurance as a homebirth midwife isn't as simple as some in this thread are making it sound. At least not in California. Quite obviously things are different everywhere. I'm not sure how, exactly, this could be changed.
Another thing that is bothering me is the incongruencies in the CPM model of care. How many of you had only one midwife at your birth? There were always two midwives at my births and a third was on alert if needed. The reason my midwife practices this way is because one midwife is observing/treating the newborn and one is observing/treating the mother. How in the world could one midwife properly care for two lives at the same time? It is a VERY common sense protocol to have a care provider for each, the mother and the baby.
On the issue of peer review, I only know what I have heard from my midwife. They have peer review every month. I know there is some division in our homebirth community. I know that some midwives practice too cavalierly for the liking of some of the other midwives. If something happens, they all go over the chart and give recommendations for what could have been done to prevent the problem or change the outcome but ultimately I don't believe they have the power to strip any midwife of her license to keep her from practicing. The state medical board is the issuing body, wouldn't that be up to them? Liz, in your and Aquila's case you mentioned that no attorney would take it because of her lack of malpractice. Did you ever call the district attorney to see if there was a criminal case that could be filed? There has to be some avenue for situations like this. Is the problem that all of the other peer reviewing midwives are protecting her and saying that she didn't do anything wrong? Surely some other birth professionals could look over the chart and see where things went wrong. I'm asking these questions out of curiosity and because it seems preposterous to me that there isn't any recourse for you if she was so negligent.
Again, this is such a complex issue but I do believe talking about it is the first step toward realizing safer births for mothers and babies. That is what ALL care providers should be striving for.
I haven't read all 100+ posts; but I doubt that any regulatory agency could improve outcomes or safety.
Look at hospital births and "advanced" trained OB's outcomes. The US leads most countries in crappy birth outcomes. And we have fully regulated and "medically trained" providers attending 90% of all births in the nation. It isn't training or regulation which is the variable, imo. Birth is safe. Life has risks. I understand the desire to control the variables when life feels out of control.
Pat
Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing.
— Helen Keller
If you read up on neonatal mortality rates in the U.S. instead of infant mortality rates you will see how much better the U.S. stats look. Infant mortality includes all deaths in the first year. Neonatal mortality is in the first 30 days so is much more telling of the safety of birth in the United States.
Kythe is correct in that all countries have different ways of compiling birth data. Data is funny that way. We begin to compare apples and oranges. It is very easy to manipulate numbers. I'm not saying we don't have work to do but some of the countries that look really good on paper may actually not be.
Another argument I have heard is that in the United States we have more African American mothers and for some reason (the doctor who explained this to me told me they are not sure why this is) African American mothers and their babies have more complications. Apparently compared to other industrialized nations we have a much higher black population and because they have more complications this inflates our neonatal, infant and postpartum mortality and morbidity rates.
Forgive me-I just stumbled upon this thread and your third point really resonated with me. I understand your point.
I hear from so many birth professionals-mainly doulas-that we, as birthing mothers, need to take responsibility for our decisions. However, no one seems to really want it pointed out that so many of us young moms who are having our first child-who so sorely want to do what is best for our babes and ourselves-have any kind of "legacy of birth knowledge" to draw from. Let's face it-we are flying blind in this country until we have that initial experience for better or worse that leads us on a path for more knowledge. For most of us-there is no neighborhood granny midwife to be directed to (or steered from) when we need knowledge. Our cultural wisdom of birth has been hijacked for profit and expediency. So-what is a new pregnant mom to do? We are bombarded with so many messages-about doing it the "safe" way. "Safe" means different things to different people-just ask a new mom with a traumatic birth experience.
IMO-We can't even have an honest and open discussion about sex while underage in a public school-let alone- childbirth choices! We are left to wander into knowledge as opposed to being led by the wisdom of any matriarch. Hey some of us are lucky and have a close female family member or friend who shares. For most of us, I fear we are catapulted by our first birthing experience into finding more knowledge to carry into the next experience so it will be better.
Most of the seminal questions that need to be asked before our first birthing experience don't get seeded until that first birth experience has been had--we are doing our girls and women a grave injustice by not allowing this topic to be relevant at the onset of puberty if not earlier. This is such a huge part of our being-why are we not giving it more attention and nurturing well before we are on the verge of bearing our children? This needs to change-and until it does we will have more damaged Mamas and babies who are trying to recover what has been denied them! Choice-something that should be a birth right for every one of us-KNOWLEDGE-about our bodies and choices in birthing children. It was never my decision to deny this right to women-but I am trying to recover it for my children-by example-by home education. This is very much a societal and human rights issue. These are very important and necessary topics for discussion. I could type so much more but I should stop now:)
Liz-HippyMom-I am so very sorry for your loss. You trusted in the MWs ability and she failed you. I wish you peace and comfort. May you find the knowledge you seek.
Best, Rosa
Mama to 4 beautiful babes.
3. We have a culture of giving up responsibility to the "experts" - this topic has been hashed out here plenty of times. But one key issue is that of a woman's first birth. I went into mine well read and educated, yet I was not a mother yet. I really didn't know what I was in for. I wasn't a mother bear yet. I had to learn that. I was still in a way, a girl, and the birth was my final passage into womanhood. The stakes are high. I thought I was taking responsibility for my choices, and I was, but I was not yet at the point where I could stand and roar and get things done. I looked to the midwife. I eventually was able to act, but it definitely was not immediate. I had no cultural background on how to choose a midwife, no encouragement from others on how to act, just nothing really to draw on. Basically, the message was that I should have chosen the standard OB route since nobody knew what else to do. Wow, I can't believe how disjointed I am with this point, I'm having trouble explaining it. I guess what I'm trying to say is that we have nothing to rely on except the standard route of care, and if we believe that is not the best, we're really on our own. I chose my midwife based on my very thin criteria (um... I liked her... our values meshed... she had delivered the baby of someone I knew... she called herself a midwife... eh, good enough). Imagine if my mother, grandmother, aunts, whatever had been able to prepare me all my life for what to look for, with their own stories. There's just none of that - we just go to the doctor, and our stories are about what the doctors saved us from and not about "look for this, don't get taken in by that, this is a red flag." We're just supposed to trust. I was a first time mom starting from scratch, and I was really on my own since I didn't want to just trust.
Another thing that is bothering me is the incongruencies in the CPM model of care. How many of you had only one midwife at your birth? There were always two midwives at my births and a third was on alert if needed. The reason my midwife practices this way is because one midwife is observing/treating the newborn and one is observing/treating the mother. How in the world could one midwife properly care for two lives at the same time? It is a VERY common sense protocol to have a care provider for each, the mother and the baby.
I think there's a problem with a shortage of Midwives. I see a practice where there are two midwives and a student midwife. because they are the only midwives in the area, they take turns being on call, so there's one midwife and the student at each birth. the call schedule keeps them from getting as worn out, as they'll take on more births a month than could be covered if they were both going to each and every birth. (I think they have 8 due in March). I'm more comfortable than just one fully trained midwife plus a well-trained student who are well-rested than I would be with two midwives who are exhausted. now, if there were more midwives in the practice or they were able to take on fewer births because they weren't the only game in town, they would be able to manage two full midwives at each birth. I think there are a lot of areas where there is only one midwife to attend births, though hopefully in that instance they can find someone to be an assistant trained to do resuscitation etc.
Another argument I have heard is that in the United States we have more African American mothers and for some reason (the doctor who explained this to me told me they are not sure why this is) African American mothers and their babies have more complications. Apparently compared to other industrialized nations we have a much higher black population and because they have more complications this inflates our neonatal, infant and postpartum mortality and morbidity rates.
I have issues with this argument. yes, statistically in this country African Americans have a higher rate of complications, but I think it may point to some socio-economic issues in the US. African Americans as a whole have a lower level of education, are more likely to be low-income, have less access to good pre-natal care (all three of these factors are also linked to higher complication rates), and don't always receive the same level of pre-natal care as women of a different race would from a care-provider.
I don't have anything to contribute to the discussion, but I wanted you to know how very, very sorry I am to hear of your loss. I have had a number of early pregnancy losses, but I can imagine that the devastation you have suffered must be even worse. I wish you healing.
Wow. I just finished reading this whole thread. This is an interesting topic but unfortunately I don't even know where to begin. There is some terminology being thrown around incorrectly, IMO. Several times I have read about a "CPM" practicing in a state that doesn't certify non-nurse midwives and getting into trouble for it. Does this mean the midwife is certified in another state and crossing state lines to practice or is she not certified at all? If she is not certified, she is not a CPM. CPM's in my state have a standardized education and are required to pass the NARM exam. They are then licensed through our state medical board. There are midwifery schools that are MEAC accredited and some that are not. If the school is not MEAC accredited there are more hoops to jump through to sit for the NARM and to earn a CPM.
To address this one point: Yes, that is precisely the situation in my state. All the CPM's I've known here are, in fact, licensed in another state, usually a neighboring one, since all our neighboring states license CPM's.
I have issues with this argument. yes, statistically in this country African Americans have a higher rate of complications, but I think it may point to some socio-economic issues in the US. African Americans as a whole have a lower level of education, are more likely to be low-income, have less access to good pre-natal care (all three of these factors are also linked to higher complication rates), and don't always receive the same level of pre-natal care as women of a different race would from a care-provider.
Marissamom-I completely agree that socio-economic issues may very well contribute to the higher level of complication in the African American population. When I heard this argument used I had all of the same reactions that you have. The physician that used this argument in discussing U.S. birth statistics said that women of African descent in other countries also have higher rates of complication, it is not just black women in the U.S. However, because we have a higher popluation of black mothers than say Ireland or England, our mortality and morbidity rates are higher, in part, to that fact. That was the only point I was trying to make.
I think there's a problem with a shortage of Midwives. I see a practice where there are two midwives and a student midwife. because they are the only midwives in the area, they take turns being on call, so there's one midwife and the student at each birth. the call schedule keeps them from getting as worn out, as they'll take on more births a month than could be covered if they were both going to each and every birth. (I think they have 8 due in March). I'm more comfortable than just one fully trained midwife plus a well-trained student who are well-rested than I would be with two midwives who are exhausted. now, if there were more midwives in the practice or they were able to take on fewer births because they weren't the only game in town, they would be able to manage two full midwives at each birth. I think there are a lot of areas where there is only one midwife to attend births, though hopefully in that instance they can find someone to be an assistant trained to do resuscitation etc.
Marissamom-I just wanted to clarify that in all three of my homebirths, there was one LICENSED midwife and one student midwife just like yours. I wasn't clear in my previous post. In Liz's case, I didn't hear mention of a student midwife being present.
yep, no other midwife of any kind was there, or was planned on being there.
Marissamom-I just wanted to clarify that in all three of my homebirths, there was one LICENSED midwife and one student midwife just like yours. I wasn't clear in my previous post. In Liz's case, I didn't hear mention of a student midwife being present.
Marissamom-I completely agree that socio-economic issues may very well contribute to the higher level of complication in the African American population. When I heard this argument used I had all of the same reactions that you have. The physician that used this argument in discussing U.S. birth statistics said that women of African descent in other countries also have higher rates of complication, it is not just black women in the U.S. However, because we have a higher popluation of black mothers than say Ireland or England, our mortality and morbidity rates are higher, in part, to that fact. That was the only point I was trying to make.
I've just heard that argument from someone as a way of completely explaining why the US has worse birth statistics than other countries. "we have more black women, it's not our fault". I am curious how the rates compare between countries, because if (I'm just pulling numbers out of thin air here) most countries have a .05% increase in complications among black populations as compared to other races, and the US has a .5% increase, then obviously there's an issue.
Interesting articles about the African American infant mortality question:
http://www.arc.org/racewire/030210z_kashef.html
http://journeytowellness.com/childhood-health-article/infant-mortality-and-african-americans.html
Marissamom-I just wanted to clarify that in all three of my homebirths, there was one LICENSED midwife and one student midwife just like yours. I wasn't clear in my previous post. In Liz's case, I didn't hear mention of a student midwife being present.
Same here, one licensed Midwife and one student.
Why did you put African-American in quotations? When you say birth rates what do mean? We are talking about neonatal and maternal morbity and mortality rates, not birth rates. If their neonatal (not infant mortality) mortality rates are seemingly low, you may want to dig a little deeper to see how early they count a fetus as a birth. As some mentioned above, we include still born babies from 20 weeks on in our statistics which makes our neonatal and infant mortality rates look worse in comparison to country that count those babies as miscarriages. Cuba's maternal mortality rate is MUCH higher than ours is meaning you are more likely to die in childbirth or near that time in Cuba than you are here.
I would not say that it completely accounts for the discrepancy in mortality and morbidity rates in the U.S. compared to other industrialized nations but it may have some bearing. Just out of my own curiousity I looked at the total population of Ireland in 2000. It had roughly 3.8 million inhabitants compared to the U.S. having 281,422,000. The same year only 1200 of Ireland's nearly 4 million inhabitants identified themselves as black while in the U.S 36.4 million (or 12.9%) identified themselves as black. If the demographics were similar Ireland would have around 490,000 of it's population identify themselves as a black person. 1200 is only a small fraction of 1%. So you can see how such a large discrepancy may affect the neonatal, infant and maternal morbidity and mortality rates. And that is just Ireland.
Please don't misunderstand me, I love homebirth and I think that we need to make changes in the way we care for pregnant women and newborns and how we treat them in birth. I used to only look at infant mortality rates and believed that that was the gold standard in determining whether or not a country was treating its newborns and mothers well. After researching and learning it has been proven to me that infant mortality is NOT a good way of making that determination. As natural birth advocates, we have to be educated with facts and not just spout the natural birth "party line" Look all this up. Ask these questions and you will find what I have found. That doesn't mean that we can't do better, it just means we are not as unsafe as some would have us believe.
Liz-I'm sorry this thread has been sort of hijacked, but I think this information is important for everyone to know.
I just wanted to chime in with a bit of a different perspective, perhaps. I don't know a whole lot about this issue, as I am just learning about birth now.
Mostly, I just want to say one thing: I live in a remote area of Canada. There are licensed midwives in my province, but they are (not surprisingly) in the cities, where the demand for them is highest. I understand that in a highly regulated environment, there will be less midwives. That means that there are areas that lack access to them completely. I am in one such area. Reading Liz's story, reading this thread, and just thinking about it over the last few days, I've come to the conclusion that I prefer it this way. I would rather live in a highly regulated environment with regards to birth than in one that is unregulated enough that negligence is ignored, even if that means that I have much less choice about where and with whom I birth. I might feel differently about it if I didn't know that there was at least one really good doctor in town, though.
That's the only relevant point I have to make. Thank you for having this discussion.
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