are you in Florida?
because Florida requires all midwives to carry malpractice insurance, but i believe midwives still do home births there-
http://floridamidwives.net/ looks like midwifery is alive and well there... i also know that in Florida all insurances cover home births and even Medicaid covers home birth!
i imagine this helps midwives generate the extra money to cover their insurance, sine they don't only have to take out of pocket payments (like in my state)
i don't know anyone, myself included, who planned for an adverse event. i was low risk i planned for a living, healthy baby. i did not get that. does that mean that if i sought compensation for my expenses i am i wrong?
you are very wrong. i know from my own experience and from many others i have since talked to that it is VERY difficult to get a lawyer to take a case against a midwife without insurance. even if you get a lawyer to take the case and win- she will not have the money to cover your medical expenses she will claim bankruptcy. medical malpractice insurance is what can pay if something terrible happens and the parents are left with huge bills. what do you mean by 'it will not pay damages"? where do you assume damages get paid from?
Is it true that all the homebirth midwives in Europe are also licensed nurses? I've read that somewhere, but I wasn't sure. It seems to me that they should be. That would be one way to definitely improve things.
As someone who is currently in nursing school in the U.S., I think that there's little benefit to midwives being required to have a general nursing degree. RNs need to know a huge breadth of things that are entirely irrelevant to midwifery, just to pass the boards. Chest tubes? Geriatric issues? Trauma? Oncology? Colonoscopies? Prostate issues? Orthopedics? Don't get me wrong, there's a lot of general medical knowledge that IS relevant, but there's a huge amount that someone wanting to specialize in women's health and midwifery doesn't need to have even the foggiest clue about. While I'm generally a fan of education requirements as part of provider accountability, I don't think this is a good one. Not that there are really better options available at the moment, though.
are you in Florida?
because Florida requires all midwives to carry malpractice insurance, but i believe midwives still do home births there-
http://floridamidwives.net/ looks like midwifery is alive and well there... i also know that in Florida all insurances cover home births and even Medicaid covers home birth!
i imagine this helps midwives generate the extra money to cover their insurance, sine they don't only have to take out of pocket payments (like in my state)
FWIW, I agree with you, and I would not retain a HB midwife if they did not have malpractice insurance. If that means I go to the hospital, fine, I'll go. I had my ds at a FSBC (a great choice for me at the time, I hope to have a homebirth sometime in the future), and I'm pretty sure they were required to have insurance although I didn't check.
I agree that malpractice insurance should be required, since birth is risky by nature and so many things can go wrong. I see absolutely nothing wrong with requiring medical practitioners to be on top of their game and requiring them to act in a reasonably manner compared to their peers.
I believe Pa CNMs need to have malpractice insurance; and there are 3 in this area that I know of that also do homebirths. My midwife said at my birth, 2 weeks ago, that she does 75% of her births at home. I just don't agree that malpractice insurance= no midwives since that is definitely not the case here. If its not required, it is used...my midwife has it and so does the other CNM I looked at initially. a litle googleing seems to also say that PA requires it for CNMs.
I think Canada has a pretty good model, and one of our strengths is that we do have minimum standards for entry level midwives, and that for the most part (and certainly dependent on your community where you practice) midwives work well with OB's and doctors so that in the event of a transfer, they can work together in the best interests of the client.
A degree is not necessary for practicing in Canada. However, it is the easiest route, but with bridging programs for foreign trained midwives, minimum standards are ensured, even for midwives without degrees. Also, there are very few reasons women cannot have a homebirth in Canada and are mostly for situations that are best off being dealt with in a hospital. Still, it is true that there are some midwives who are not comfortable with homebirths and will direct their clients to hospital births (which I don't agree with).
I think Canada has a pretty good model, and one of our strengths is that we do have minimum standards for entry level midwives, and that for the most part (and certainly dependent on your community where you practice) midwives work well with OB's and doctors so that in the event of a transfer, they can work together in the best interests of the client.
A degree is not necessary for practicing in Canada. However, it is the easiest route, but with bridging programs for foreign trained midwives, minimum standards are ensured, even for midwives without degrees. Also, there are very few reasons women cannot have a homebirth in Canada and are mostly for situations that are best off being dealt with in a hospital. Still, it is true that there are some midwives who are not comfortable and will direct their clients to hospital births (which I don't agree with).
I actually think that is very professional of them. If a midwife is not comfortable treating a patient with a set of circumstances, then it would be unethical for her to take that patient. Making referrals to other HB midwives would be great, but I would have a big problem with midwives taking patients that they were not comfortable treating for whatever reason (as long as it was due to health concerns that the midwife maybe didn't have enough experience with or something, and not something discriminatory).
Liz-What part of TX are you in? Have you seen this? http://www.ipetitions.com/petition/texasmidwives/ I agree, all insurance should cover MW regardless of place of birth. But I don't think that was the original question.
1-I think that MWs should in no way be afraid of transfer. It's hard to get this question honestly answered when interviewing MWs. I would interview a few, and get their response, and if they all end up saying they transfer to the same location with the same OBs during a HB, I'd say that's a good start. We had a HBAC that turned into a transfer due to bleeding, and being 30+hours and me being exhausted, and turns out we had a partial abruption. It was an 'emergency', but it was handled smoothly and the hospital we transferred to and the OBs on call all have a high respect for the MWs in our area, and that respect is mutual. That's important.
2-I agree that if a MW doesn't feel comfortable taking on that mama, she needs to refer her away. It would be very very silly and flat out dangerous to take her. IMO if a MW is uncomfortable taking me on, due to my specific situation, she doesn't have the training needed to be my MW (for that situation that is). For EX, I was a HBAC. I interviewed 9 MWs before choosing one and a few of them seemed very uneasy with me HBACing. A few even said if your baby is breech I don't know if I'm comfortable with that. I didn't choose them. I chose a MW who was comfortable with VBAC because she had worked with so many and it also helped that she flat out believed in my body to birth (even though I didn't get a vaginal birth)
3-Malpractice. I think this is totally a different subject. Not about safety, more about compensation, but I do see how they go hand-in-hand. I think that, yes, some MWs will become fearful and have more transfers, and more interventions, and I think that a mom should consider that carefully when picking a MW. Some won't be swayed and really just have insurance to cover those 'fluke' instances. It IS very expensive, and hard for MWs to have. BUT I know some do, and some must, so therefore it IS possible, and if a MW wanted it, she would get it. If it was required, she'd have to have it. I don't know how much having malpractice ins. will improve birth outcomes, except for maybe that fear that drives more transfers will put those crazy 'fluke' births in obstetric care where an OR is right down the hall when needed. So, I see both sides.
I think in the southern area of the US (excluding NM), mainly TX and Eastward, MW if tough. They don't have as good support, and they don't have good reputations, and they are still looked at poorly in general in that society. I think that's something that will change with time, more OBs seeing how safe MW is, etc. It's a shift that won't be done easily.
I think the CNM credential is superior. They see more complications due to required clinical experience. And transport is terrible in this country, especially in states where homebirth with a CPM is illegal or alegal. I have felt these pressures first-hand. Moms reluctant to call, midwives reluctant to transfer. It is terrible.
In Canada, the UK, the Netherlands - the system is so different. Midwives are well-educated and trained, and follow their patients to the hospital and have hospital privileges. The system here is broken.
This is not a criticism of very well-meaning CPMs. But the ones I truly respect admit that the minimum requirements for the credential are more than insufficient. And there is a terrible, erroneous group-think phenomenon among many NCB/homebirth advocates.
I say this as a woman who has had two homebirths and believes in the right of women to choose that option and know what they're choosing and have it be as safe as possible. There is no doubt whatsoever in my mind that homebirth is, in this country, more dangerous than hospital birth, in terms of neonatal/perinatal death. Unfortunately. And every woman has the right to know that. Otherwise, we are liars when we say it is about informed choice.
One more thing - MANA needs to man up and PUBLISH ITS DATA (both of my homebirths being a part of it), whether that data is good for MANA or not. Women have a right to know. We're talking about the health of women and babies here. That should take precedence over the promotion of homebirth - no matter who you are - if you have any scientific, medical or ethical credibility whatsoever.
I think the CNM credential is superior. They see more complications due to required clinical experience.
I have to say that, although it is not a popular view around these parts, I tend to agree. That's not to say that there aren't some CPMs who are capable of handling most births. That's not to say that midwives absolutely need to be nurses first - but I do think there should be a standard of education, credentialing, and licensure. And even if they are not trained as "nurses" first, I do think they should receive medical training. Because while normal birth is not necessarily a "medical" event, many of the more serious complications of childbirth do require medical knowledge, training, and equipment.
As for the issue of insurance, I think it's an interesting topic. It certainly seems plausible that the rates of medical malpractice insurance may have an impact on care. I know that one of the former midwives at my practice, a hospital practicing CNM, left the practice because she was unable to pay her insurance premiums without attending more births than she was comfortable attending per month. But it's just unacceptable that family's like Liz's end up holding a 10K bill, with nothing left over for counseling for the parents and siblings. Totally, totally unacceptable.
Someone correct me if I'm wrong, but I believe it was Marsden Wagner who proposed that there be a public fund for parents and families affected by birth injuries/stillbirths, so the burden of care (or in the case of stillbirth, funeral expenses and counseling) is not totally upon the family. I'm not sure that this is the answer, but it's certainly an interesting idea. Of course, there would then have to be a separate process for professional review and discipline in the event of negligence, rather than relying on the fear of monetary damages to police behavior.
Liz, as ever, I respect your bravery and determination to share your story. This is absolutely a discussion worth having.
I think the CNM credential is superior. They see more complications due to required clinical experience. And transport is terrible in this country, especially in states where homebirth with a CPM is illegal or alegal. I have felt these pressures first-hand. Moms reluctant to call, midwives reluctant to transfer. It is terrible.
In Canada, the UK, the Netherlands - the system is so different. Midwives are well-educated and trained, and follow their patients to the hospital and have hospital privileges. The system here is broken.
This is not a criticism of very well-meaning CPMs. But the ones I truly respect admit that the minimum requirements for the credential are more than insufficient. And there is a terrible, erroneous group-think phenomenon among many NCB/homebirth advocates.
I say this as a woman who has had two homebirths and believes in the right of women to choose that option and know what they're choosing and have it be as safe as possible. There is no doubt whatsoever in my mind that homebirth is, in this country, more dangerous than hospital birth, in terms of neonatal/perinatal death. Unfortunately. And every woman has the right to know that. Otherwise, we are liars when we say it is about informed choice.
I think your post is an excellent summary of the issues here and I completely agree with everything in it.
Many good points made by other posters above. I have a couple of things to add:
1. I think the number one thing that needs to change is integration of midwifery into the medical system in the event of transfers -- collegiality, respect, etc., at the very least not treating HB transfers like crap. I've heard nasty stories of retaliation against HB transfer mamas that about turned my hair white (unnecessary episiotomies to "punish" the woman for attempting a HB, manual placenta removals on unmedicated moms, etc.). The midwife I used for my second son's homebirth shared with me recently that the hospital closest to my home has treated her worse than any other hospital she has transferred to in this area. That was pretty much enough to take homebirth off the table this time. If I would not feel safe transferring to that hospital, I might hesitate; if she knew it would be unpleasant to go there, she might hesitate (even if it was subconscious, not willful). That possibility was not something I was comfortable with.
2. On malpractice insurance, I can see both sides, but I think that if malpractice insurance is as expensive as I think it is, homebirth midwives being required to carry it would ultimately limit women's choices, in one (or more) of several ways: (1) midwives would have to pass on some of the cost of the insurance to their clients, making fewer women able to afford HB; (2) the insurance company might force them to limit their scope of practice as a condition of getting the insurance, e.g. no VBAC, breech, twins, perhaps other conditions as well; (3) midwives might have to take on more births per month than they could comfortably handle and that would be safe for their clients to afford the insurance; (4) in some areas, midwives might not be able to afford the insurance at all and thus might not be able to practice. All of these things would arguably have a negative impact on women's ability to access the maternity care they feel is right for them.
3. On training, I'm not familiar enough with the requirements of CNM v. CPM, but I will say that I have seen some attitudes in the traditional midwifery community, loosely defined, both online and locally, that strike me as too cavalier about medical risk factors. In part because midwifery has such a loaded history and present of being in conflict with the obstetrical community, there are extremes on *both* sides that I'm uncomfortable with. On the midwifery side, there is a little too much trusting birth sometimes and not enough acknowledgment of real risks. I don't want to be too harsh, because reasonable minds can disagree about such issues, but I know that there are definitely CPMs in my area whose practice styles would not be a good fit for me at all for precisely this reason.
Too, I perceive an attitude of pity toward moms who need to transfer/transport and need interventions, and a simultaneous desire to distance from them because they had to cross over to "the other side," a feeling that it is in some sense a failure, either of the mom's body or of her preparation or commitment or whatever. I don't even think it's always necessarily a conscious feeling, just a sense of "you're not one of us anymore." I felt it from my Bradley instructor, who is now training to become a midwife, and to a lesser extent from my HB midwives, and I've seen tons of it online. Lovely women all, and I don't think they meant it in any way maliciously, but it was still there. I find this really regrettable and think it perpetuates the chasm between midwifery and obstetrics that IMO needs to be bridged. There should be no judgment at all of necessary interventions -- just gratitude that we have them and were able to avail ourselves of them when they are needed. Not every birth is meant to be natural. S**t happens and it doesn't have to be anyone's fault. I have been fortunate to have two lovely intervention-free births, but I would hate to feel that anyone would have thought I was inferior in some way if things had gone down differently, kwim?
i am in austin. your link dosn't work? what is it?
Liz-What part of TX are you in? Have you seen this? http://www.ipetitions.com/petition/texasmidwives/ I agree, all insurance should cover MW regardless of place of birth. But I don't think that was the original question.
1-I think that MWs should in no way be afraid of transfer. It's hard to get this question honestly answered when interviewing MWs. I would interview a few, and get their response, and if they all end up saying they transfer to the same location with the same OBs during a HB, I'd say that's a good start. We had a HBAC that turned into a transfer due to bleeding, and being 30+hours and me being exhausted, and turns out we had a partial abruption. It was an 'emergency', but it was handled smoothly and the hospital we transferred to and the OBs on call all have a high respect for the MWs in our area, and that respect is mutual. That's important.
2-I agree that if a MW doesn't feel comfortable taking on that mama, she needs to refer her away. It would be very very silly and flat out dangerous to take her. IMO if a MW is uncomfortable taking me on, due to my specific situation, she doesn't have the training needed to be my MW (for that situation that is). For EX, I was a HBAC. I interviewed 9 MWs before choosing one and a few of them seemed very uneasy with me HBACing. A few even said if your baby is breech I don't know if I'm comfortable with that. I didn't choose them. I chose a MW who was comfortable with VBAC because she had worked with so many and it also helped that she flat out believed in my body to birth (even though I didn't get a vaginal birth)
3-Malpractice. I think this is totally a different subject. Not about safety, more about compensation, but I do see how they go hand-in-hand. I think that, yes, some MWs will become fearful and have more transfers, and more interventions, and I think that a mom should consider that carefully when picking a MW. Some won't be swayed and really just have insurance to cover those 'fluke' instances. It IS very expensive, and hard for MWs to have. BUT I know some do, and some must, so therefore it IS possible, and if a MW wanted it, she would get it. If it was required, she'd have to have it. I don't know how much having malpractice ins. will improve birth outcomes, except for maybe that fear that drives more transfers will put those crazy 'fluke' births in obstetric care where an OR is right down the hall when needed. So, I see both sides.
I think in the southern area of the US (excluding NM), mainly TX and Eastward, MW if tough. They don't have as good support, and they don't have good reputations, and they are still looked at poorly in general in that society. I think that's something that will change with time, more OBs seeing how safe MW is, etc. It's a shift that won't be done easily.
I completely agree if there are health concerns, but sometimes it is simply because they don't like doing homebirths (just wanted to add that i don't think this happens very often by any means).
I actually think that is very professional of them. If a midwife is not comfortable treating a patient with a set of circumstances, then it would be unethical for her to take that patient. Making referrals to other HB midwives would be great, but I would have a big problem with midwives taking patients that they were not comfortable treating for whatever reason (as long as it was due to health concerns that the midwife maybe didn't have enough experience with or something, and not something discriminatory).
Because I am a Doula and getting pretty involved in the birth community would you mind PMing me the name of your MW. Not to rat her out, but because I am curious, and feel it important to know.
http://www.ipetitions.com/petition/texasmidwives/
Try it again, don't know why it's not working.
My MW was a CPM, but also had the schooling and training of a CNM. She was also an RN. She's also pretty credentialed as well.
I think YES, too many MWs just 'trust birth' and 'it will happen', etc. I know that things DO go wrong and sometimes a mom doesn't have a typical labor and needs obstetric help. Being one of those moms, I felt EXACTLY what mismiranda said:
"Too, I perceive an attitude of pity toward moms who need to transfer/transport and need interventions, and a simultaneous desire to distance from them because they had to cross over to "the other side," a feeling that it is in some sense a failure, either of the mom's body or of her preparation or commitment or whatever. I don't even think it's always necessarily a conscious feeling, just a sense of "you're not one of us anymore." I felt it from my Bradley instructor, who is now training to become a midwife, and to a lesser extent from my HB midwives, and I've seen tons of it online. Lovely women all, and I don't think they meant it in any way maliciously, but it was still there. I find this really regrettable and think it perpetuates the chasm between midwifery and obstetrics that IMO needs to be bridged. There should be no judgment at all of necessary interventions -- just gratitude that we have them and were able to avail ourselves of them when they are needed. Not every birth is meant to be natural. S**t happens and it doesn't have to be anyone's fault. I have been fortunate to have two lovely intervention-free births, but I would hate to feel that anyone would have thought I was inferior in some way if things had gone down differently, kwim?"
I felt this though, and I'm sure almost every mom does who has to transfer. I know this was just by anxiety and low self esteem talking to me there, and I know my MW didn't think this at all. In fact, she said (and I'm paraphrasing) "I think your birth was a perfect example of how birth should be with midwifery care and obstetric care. You have an uneventful pregnancy, great care through MW, and then when you need to, if something comes up, you transfer and get the help they have there that is out of the MW scope." It was such a smooth transition, and the OB practice respected her, she respected them, they greeted each other respectfully, and we had a cesarean that was needed due to non-reassuring heart tones and some bleeding. After the surgery, the OB talked with my MWs telling them what he found during the operation, and they all shared thoughts. It was great. I think that not every MW has the experience she needs to YES, but in areas where you have options, a mom needs to be informed on what questions are best to ask to find this out. Now, this of course is not throwing blame on you Liz for not 'asking the right questions' NO, your MW should have caught what was wrong and she should have gotten you obstetric help. No excuse. I'm so sorry you had to go through that.
I also like your points on Malpractice. I would add on point 3, that if a MW has to take on 6-7+ births per month, not only would that not be safe, but illogical for me to hire her as my MW because with 7+moms, all the prenatal, continuing education, etc I don't see how she'd be likely to be at my birth, well rested. Not to mention I had a 36+ hour birth, I'd take up too much of her time. :)
Ramona- As a WHOLE I would agree that HB is not as safe in the US than in other countries. Is it safer than hospital birth? Yes, with most moms in most areas. BUT if you have a MW who practices like Dutch MWs, and has relationships with OBs like they do, then I'd say HB is much safer in the US with that MW than in a hospital.
The question is, how, in the geographic areas that need it, do we improve transfer relationships? I don't think it has to do with necessarily getting the MW more skills, if she can't do breech birth, she shouldn't, if she doesn't know how to treat a VBAC mom, she shouldn't. She should refer out, and she should be open and honest with a mom saying that "I am not comfortable with this, adn I don't have the training to make this safe, so I think you should choose ______MW who does, or go to the hospital".
1. I agree the transfer situation is a major problem. My midwife was clearly hostile toward the medical establishment... and with good reason, it seems. The hostility went both ways. While my homebirth had a happy outcome overall, it included some complications, and the hostility was absolutely a factor in the care we received, how involved my midwife was willing to get, and how soon she was willing to involve others when she could not solve a problem herself. It would be very easy to lay the blame at my midwife's feet entirely, but it goes both ways - she was not defensive for no reason.
2. I kind of hesitate on licensure. My stance on it isn't firm, but I just feel that licensing and all the trappings of Western medicine will serve to force midwifery as a practice to conform to medicalized viewpoints. I want choices. And I'm not sure the mainstream legal standards would match mine, or many other women's too.
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.
are you in Florida?
because Florida requires all midwives to carry malpractice insurance, but i believe midwives still do home births there-
http://floridamidwives.net/ looks like midwifery is alive and well there... i also know that in Florida all insurances cover home births and even Medicaid covers home birth!
i imagine this helps midwives generate the extra money to cover their insurance, sine they don't only have to take out of pocket payments (like in my state)
I don't know much about the state of midwife licensing or training, but I am in Florida, and my midwife carries malpractice insurance. As someone pointed out, malpractice can make one quicker to jump on the transfer boat, and I believe my midwife is quick to transfer. But I appreciate that. I wanted to birth at home with my first, but it didn't happen. There were no complications, but the midwife takes her licensure very seriously and transferred me for what I believe to be a minor reason. But I would rather have that than a midwife who doesn't recognize true signs of danger and refuses to transfer due to hostility toward the medical community. I am seeing her again with this pregnancy, and while I am hoping for a homebirth, I am confident that she and I will have no issue with recognizing true signs of danger and transferring if necessary.
I also don't know how the malpractice ins. affects costs, but I know that her fees and the other midwives in town's fees are not out of line with what people pay in other parts of the US (according to MDC members anyway). We have 3 or 4 lay midwives in a relatively small town, and I know women who have birthed with each of them. The costs are not prohibitive due to malpractice requirements. I am much happier knowing that my midwife has malpractice insurance and a good relationship with doctors and hospitals in town, and I believe these things make a difference in her quality of care.
Liz, I am so sorry for your loss, and applaud your efforts to fix the system.
Liz, first I want to say that your midwife was completely incompetent and there is no excuse for the substandard care you received! I am terribly sorry for your loss.
The situation in the US is very complex. Because only 1% or so of mothers will choose home birth, we are at a significant disadvantage to impact the overall mindset that the average citizen, much less the medical community has about home birth and midwifery care. I don't believe more regulation is needed. I do believe regulation comes with a price, which will lead to fewer options in the future, and a good probability of the eventual death of home birth if we keep ramping up outside regulation.
I believe the best way to improve midwifery care and home birth safety is in creating very educated home birth consumers. When consumers know what to look for in a quality midwife, and know enough to take equal responsibility for their birth with confidence, safety can only improve. Now, I am not blaming parents who have experienced poor outcomes for not being "educated enough." Hardly! I believe that home birth and midwifery care are not about trusting a midwife to manage the birth for you under her expertise, but about a shared responsibility with the parents, using the midwife's educated opinion as a guide, but also heeding parents' intuition and knowledge. Referring back to Liz's birth, I believe her midwife ignored her feelings about transfer, until the tragedy was too late to be averted. She (Liz) knew, but didn't have the power in the moment to act on that knowledge.
I have had two of my home births with what I, and the local community, consider under-educated midwives, though we came through both relatively unscathed. I know for sure one has retired, and I believe (and hope!) the other is no longer practicing, though she does still have a web page up. I learned a lot of things from these women. One places primary importance on home birth, rather than on the health of mother and baby. She fears hospitals and medical care. Strangely, this devolves into her practicing as a "med-wife" herself, using medical equipment to treat factors that should have been transferred for proper medical care, which places her clients at even more risk. As far as I know, she hasn't had a death, but I do know she has had preemies transferred days later than they should have been in real distress. She calls herself a hands-off midwife, but if you get into a lengthy discussion with her, you will pick up on her anti-hospital, anti-standard-of-care perspective, and I think these should be real red flags. She also did not complete her apprenticeship, but would probably lie if you asked her outright. I didn't find out until I was in early labor, when we'd developed a rapport and we're chatting between contractions. She also has a terrible-to-nonexistant relationship with other midwives in the state.
The other midwife is a lot more subtle. She was a byproduct of the sixties/seventies re-emergence of home birth. She learned to be a midwife while midwifing friends, a la Ina May. Her mantra is that every woman is a midwife. I consider that another red flag, because it is denying the value of education, relying more on intuition and learning by doing. As a movement, we've come beyond this, and it is no longer necessary to wait until you've seen a complication to learn what it takes to manage it. This midwife, like Liz's, denied me transfer for hours when I knew that my baby was not descending at all while pushing. I begged three separate times, over 5-6 hours of pushing at home, to transfer before I finally put my foot down and demanded my husband take me in. Thankfully, there was nothing life-threatening, just my cervix was caught between my pubic bone and little boy's ginormous head. But, I experienced the stigma of the transfer. In other's opinions, I transferred for "pain meds", which is not completely accurate to the situation.
Significant factors both these midwives have in common is that they both would attend a majority of births alone, or only with a student. There was a rather underground or rebellious feeling to their practices, even thought it wasn't necessary in this particular community. There was no collaboration with anyone in the mainstream medical community, and they did not participate in the state midwifery community, or were only peripherally involved.
As part of educating perspective home birth consumers, I believe recognizing and communicating the above red flags would be a key factor in deciding to hire a particular midwife. Other things to look for may be a midwife who requires more from her clients, such as diet logs, required reading, worksheets, or other methods of educating her clients so that they can fully participate with the decision making in their own care. It's not enough for a midwife to give a brief, oral "informed consent" and expect parents to be able to make a considered decision on the spot.
Since using these two midwives, I have found a practice that I think exemplifies a quality, safe midwifery/home birth practice. When we originally met, the midwife would always bring an assistant, preferably another midwife. She had open channels of collaboration with other care providers in her home community, and in most of the various communities she served. She actively sought out relationships with mainstream providers so that her clients could get respectful care, no matter what their needs ended up being. She truly put the health and wellness of her clients above her own comfort in making these strides. I was involved in a number of births with her in which we transferred clients during labor. These varied from simple pain med transfers, to true medical need, though long before they became emergencies. Medical transfers were not hemmed and hawed over, but once the condition was recognized, the decision was made and we packed and left. Transfers were most often made to providers we had a relationship with, but even those we didn't were met with respect, as we entered professionally and provided accurate, professional records of care. Some transfers even resulted in a new care provider relationship to benefit future clients. Clients were never stigmatized for a transfer! Now, she has a full partner midwife. They collaborate care and share births, participate in regular internal chart reviews, and are active in the state midwifery organization and peer-review system. None of this required regulation. This midwife began her practice before regulation in our state, and was one of the first to be licensed by the state when regulation came about. But there was no significant change in the way her practice was run, other than altering a few forms to match the state requirements. Wisdom can't be imposed on someone externally. It is a quality they already possess and use, or they don't.
I am currently expecting twins, so I have been experiencing first hand the collaborative arrangement with one of the area OBs. All notes have been shared (or will be) between care givers. I maintained my prenatals with the midwives, and consented to U/S scans to document the growth and positions of the babies. We originally thought we would have to do a hospital birth, but as things have progressed in such an ideal manner, we are prepared to give birth at home. One stipulation for this home birth has been that I create a document covering my research and decisions regarding the care of this pregnancy and birth. After turning in my first two-page draft, I was asked to add a number of other factors. I recognize and appreciate that I'm being held to a high-degree of responsibility as a parent, and that the midwives know that they are not the only responsible parties. I'm asking a lot of them, to rather venture out of their comfort zone (I'll be the first out-of-hospital twin birth for this practice, though not the first twin pregnancy/birth the one midwife has managed).
I think this paints a very realistic picture of what a healthy, safe midwifery practice should look like. As consumers, we have the ability to hold our care-givers to this standard, by choosing not to use midwives which fall short. We need to be vocal within any group we are involved where we might meet other home birth mothers that there are qualities which show truly superior care, and that we shouldn't settle for less. Not that there won't be some women who prefer other, but they should make that decision after informing themselves not just because they don't know the options.
I would just like to add to the malpractice issue. It is EXTREMELY expensive. And, each year that a midwife practices and each birth she does, her rate goes up. This is because statistically, the more births you do, the more likely it is that you will have a poor outcome and get sued. What this does is makes it too expensive for the most experienced midwives to continue practice. This won't make for better outcomes. The cost of malpractice is why so many CNMs have gone to doing only well-woman care and not births, family practice docs have given up doing births, etc. We lose so many wonderful professionals because they can't cover the costs of their malpractice insurance anymore.
I actually think that universal healthcare coverage would help this whole situation out immensely as families would not have the burden of medical bills for sick or injured babies and therefore lawsuits would not just be done to get those expenses covered.
As far as standards in education go and standards in midwifery.... I really like the Canadian system. I constantly am eying them up and thinking what it would be like to move to Canada, go through their training for internationally trained midwives and get to practice in their system. It seems lovely. If a transport to the hospital is needed, there is still continuity of care. The education there seems great as it is directed at learning midwifery and not general nursing. The only problem seems to be a real shortage in schools there to get enough midwives trained!
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