what make a hb midwife "not safe" to you? - Page 2

[sharita]

I think in some people's opinion, my midwife would be considered "unsafe" but only based on things her experience level allows her to be comfortable with doing such as twins, VBACS, and breech births.  These things are a matter of opinion though.  I think as long as the midwife is 100% honest at all times about her birth philosophy, routine care, how she handles emergencies, etc.  Now certain things I don't believe are a matter of opinion such as having a birth assistant.  One midwife alone just wont cut it in the rare instance things go south.  REsponsible midwives know you need an extra set of hands such as when I had a PPH and my midwife couldn't leave me long enough to run to her back in the other room to get her pit and had to bark orders to the assistant while she did uterine compressions. 

I have heard stories of midwives misrepresenting themselves and upon interview until contracted or paid, sell one birth philosophy, then offering less than the standard of care.  These you can't foresee unfortunately.   Or the ones who seem to agree with your birth philosophy only to do things "their way" as it comes up. 

Go with your gut.  Things like whether she attends breech deliveries, VBACS, twins, believes in delayed cord clamping, herbals and supplements instead of prenatal vitamins, or what her birth philosophhy, Id say just make sure it reflects yours, you feel comfortable with her from the first meeting, she doesn't try to talk you into beliefs she has that you don't share.  As long as she offers regular prenatals, offers testing when symptoms suggest it be nessesary such as UTI's and such, seems proactive such as suggesting iron building foods and herbs if you even start to show signs of anemia (as not all test but just take precautions) for example, is honest about transfer rates, ...

Speaking of transfers, ask midwives about theirs and the what-if's and when they transfer.  If they act like they dont transfer except in last resort as if they are against it, or even give the slightest hint they may keep you at home too long if signs show you need to be elsewhere to protect their transfer rate or reputation or pride, then bail.

When talking to my midwife, I was asking her about unforeseen emergencies and she gave me a very detailed step by step explaination on what we would do in the case of each one but said very calmly that if those things didn't work, we transfer as a healthy baby is the ultimate goal and most important and though it very very rare, the need doesn't arise from time to time and she would still be with me if I have to go but only as my "doula" as she is only a CPM and not legal in my state, and would do her best to advocate for me so that we could still stick to my original wishes as much as possible without compromising mine or baby's health.

It made me feel very comfortable with it.  She was very comfortable in telling me specific examples of instances that required transfer and the events that led up to that decision and how it played out and the outcome.  If a midwife is uncomfortable in telling about when things didn't go as planned Id take it as a red flag somewhat that they felt they did something wrong.

4 years ago, my first meeting with my midwife, my gut told me we were a perfect match.  She was only a DEM at the time and was working under another more experienced midwife who I loved but after meeting with only once I knew we had slightly different philosophies.  I was still comfortable with her but you have to find one that "fits" you.  My midwife for example may be a bit too hands off, comfortable with things other midwives aren't.  She has delivered babies all over the world, worked with Ina May Gaskin on "The Farm" and has seen "almost" everything.  She is confident in her abilities but not overly so that she would throw caution to the wind as she recognized even before I did that I needed intervention last time. (I should have felt odd but she noted my skin color and flush and sensed it before it happened and is really in tune with her instincts as a baby catcher.

Some women though are more comfortable with a more medicalized midwife.  I think its all about finding the right fit, a likeminded birthing woman.  Other than that, go with gut, look for red flags and never compromise what you are comfortable with because it's someone elses way of doing things and they arent willing to bend to give you the experience you want.

[jengacnm]

Originally Posted by Mama Metis 

Finally, *for me* I would consider a midwife unsafe if she could not commit to my uninterrupted care in the event of a transfer. Meaning, if transfer becomes necessary or desireable at any time, I would want her to be responsible for my care in the hospital (jointly with her backup OB, as needed). Of course, in the US, only a CNM can offer this, which is why I chose a homebirth CNM. I realize others may not have this option. 

If this is available in your area, consider yourself fortunate. I am a home birth CNM who wants to be on staff at a hospital and can't, in a major urban center. I contacted ACNM (my professional association), and there are 60 home and hospital CNM practices in the US.

So I'm moving to Canada, where home and hospital midwifery practice is the norm.

[Mama Metis]

Wow - I had no idea how rare this was! I had often wondered why more people don't take the option to have a CNM with hospital privelages attend them at home, especially since the international literature on homebirth safety shows that the "smoothness" of the transfer is really the key to the safety of homebirth. Now I know! My CNM is not at all a "med-wife" either, which is the stereotype I read a lot on these boards.  Anyway, I do feel fortunate! (But how unfortunate that the system is not set up to better facilitate this set-up.)
 

Originally Posted by jengacnm 

If this is available in your area, consider yourself fortunate. I am a home birth CNM who wants to be on staff at a hospital and can't, in a major urban center. I contacted ACNM (my professional association), and there are 60 home and hospital CNM practices in the US.

So I'm moving to Canada, where home and hospital midwifery practice is the norm.

[mammamo]

Originally Posted by jengacnm 

If this is available in your area, consider yourself fortunate. I am a home birth CNM who wants to be on staff at a hospital and can't, in a major urban center. I contacted ACNM (my professional association), and there are 60 home and hospital CNM practices in the US.

So I'm moving to Canada, where home and hospital midwifery practice is the norm.

If I became a CNM, that's what I'd want to do too! It's too bad that the US is going to lose a midwife tho :(

[Millicent]

Being a CNM doesnt afford you much advantage in transferring care where we live.  We have CNMs that have a birthing center and hospital privs.  Apart from someone needing pit, when if there is any kind of serious complication the doctors take over anyway.  The hospital nurses are territorial with them and treat them like crap and ignore their orders. I was working with the senior midwife from the practice in the hospital once and watched a charge nurse chew her a new one for letting mother stay in the shower while pushing.  (Oh, so that's what a masters degree gets ya?) 

They have to transfer to the hospital for every little thing because of their back up doc agreement.  For instance, a mother can only stay at the bc for 12 hours postpartum or she'll have to transfer to the hospital.  Doesn't matter if she needs rest, has a long drive ahead, etc.  The CPMs don't have near the micromanagement to worry about and can transfer pretty flawlessly to the hospital.  They have access to the same labor drugs out of hospital.  Anything the CPMs can't use, the CNMs have to check into the hospital to use anyway (cervidil, cytotec, etc.), where to docs rule the roost and the CNMs scurry around and try to stay out of the way.

[mwherbs]

You could have been talking about our birth center. The only difference is they dont have admiting prevliges, their back-up docs do, and the mw who is with a mom at the birth center dont continue care in the hospital another mw in that practice does.
And the nursing staff is just as bad including challenging the more liberal doc's orders...

[Mama Metis]

I don't know, if there is a serious complication, you want the docs to care for you. That's their purpose - to work on cases where complications come up. But women transfer for lots of reasons, and it's nice to know that you can transfer without complete discontinuity of care. It seems like the benefit/draw-back of hospital privileges would depend largely on the back-up doctor.  Unfortunately not all CPMs can transfer flawlessly to the hospital - that is one of the major things that makes homebirth less safe in the US than elsewhere. It's moot for me anyway, because CPMs aren't licensed in my state, and I feel that decreases the safety substantially because they are not recognized or respected. 
 

Originally Posted by HBACtivist 

Being a CNM doesnt afford you much advantage in transferring care where we live.  We have CNMs that have a birthing center and hospital privs.  Apart from someone needing pit, when if there is any kind of serious complication the doctors take over anyway.  The hospital nurses are territorial with them and treat them like crap and ignore their orders. I was working with the senior midwife from the practice in the hospital once and watched a charge nurse chew her a new one for letting mother stay in the shower while pushing.  (Oh, so that's what a masters degree gets ya?) 

They have to transfer to the hospital for every little thing because of their back up doc agreement.  For instance, a mother can only stay at the bc for 12 hours postpartum or she'll have to transfer to the hospital.  Doesn't matter if she needs rest, has a long drive ahead, etc.  The CPMs don't have near the micromanagement to worry about and can transfer pretty flawlessly to the hospital.  They have access to the same labor drugs out of hospital.  Anything the CPMs can't use, the CNMs have to check into the hospital to use anyway (cervidil, cytotec, etc.), where to docs rule the roost and the CNMs scurry around and try to stay out of the way.

[Millicent]

Don't kid yourself into thinking licensure will get you respect.  We have had licensure for over 20 years and we still get treated like idiots, especially by the nurses.  Transfers are really bad right now in the area with the most midwives.  The county has a 24% out of hospital birth rate.  Yes, 1/4 are born at home or birthing centers by CDMs (no CNMs) and transfers are rotten if you get any doc but one.  And that one doc gets heavy heat from the hospital and his collegues for "working with the midwives".  They have threatened  to yank his priviledges.  

[Mama Metis]

Wow - it sounds like a really hostile environment. But 24% out of hospital births? That's huge! Good for you for providing this vital service. 
 

Originally Posted by Millicent 

Don't kid yourself into thinking licensure will get you respect.  We have had licensure for over 20 years and we still get treated like idiots, especially by the nurses.  Transfers are really bad right now in the area with the most midwives.  The county has a 24% out of hospital birth rate.  Yes, 1/4 are born at home or birthing centers by CDMs (no CNMs) and transfers are rotten if you get any doc but one.  And that one doc gets heavy heat from the hospital and his collegues for "working with the midwives".  They have threatened  to yank his priviledges.  

[Millicent]

The Mat-Su Valley (Palmer/Wasilla-Sarah Palin's hometown) has 3 birthing centers and a half dozen homebirth midwives that serve less than 90,000 people.  There are more OOH midwives than O.B.s by far.   The O.B.s are pretty pissy about it because of the money.  The one doc that supports midwives has a two year old practice that is bursting at the seams.  It's only hostile because of competition.  So it's bitter sweet.  Lots of happy moms and babies, good money for the midwives and the occasional crappy transport.  If you  have to transfer before onset of labor (risk out), they can go to the uber cool doc and it's all good.  Overall, they have it pretty cushy.  (Although the majority of pediatricians in the area refuse to see babies that were "born underwater", even if their siblings are under their care....no joke.)

In Anchorage we have a tiny homebirth contingent, one CDM birth center that limps along, and a booming CNM owned birth center.  We have about 1/5 the OOH births here that they do out there, but our homebirth transports tend to be decent.   There are 4 hospitals competing with one another, and they try to be civil to everyone.  I know a mom who transported from an UBAC attempt, no prenatal care, non-vax, etc. and the big hospital treated her great.  She goes back to that doc for care now.  Some understand it's not only good for moms and babies, it's good for business!   I have observed that the towns with only one hospital are the ones that have the worst transports, worst support for scans/labs, lack of VBAC, etc.  Competition keeps em on their toes.

[Youngfrankenstein]

I have met an un-safe midwife (IMO)  Here are the highlights:

Me: How many births have you attended?

Her: So many I lost count.

Me: Do you carry pitocin in case of PPH?

Her: No, herbs are better. (that's all she said)

Me:  Do you carry oxygen if needed?

Her: Some studies have shown that too much oxygen can actually damage the baby. (again, all she said)

Me: Who is your back up mw?

Her: I have never missed a birth.

Me: Who is your back up mw?

Her: I have a doula who is almost off maternity leave.

I could go on and on.  It was bizarre.  This was the first mw interview we had while I was trying to convince DH to have a homebirth.  I was annoyed and upset.  We smiled and left.  Then we met our mw and were so blown away all of her "perfect" responses to all of our questions. 

Another thing is that my mw and I talked and talked at each pre-natal appointment.  It let me get to know her as a person and she expounded on many things in the local birthing community that showed me she was very involved and kept her fingers on the pulse of the birthing community.  And even though HB isn't legal in Ohio, she was fully ready to come to the hospital in case of transfer.  I know that's not always in the mw's control so it was more of a blessing.

[MrsWhite]

I just interviewed a midwife and she told me all of her assistants are pregnant or moving and might not be there when I was due.  "But if (I) really wanted one they could make it happen".  Should I be worried if she would be comfortable delivering without an assistant?!  I for sure wouldn't agree to that, but just knowing that she would - is that a red flag?  She's done 230 births.  All of her other answers to my questions were good.  hmmmm  

[Mama Metis]

Personally, I wouldn't trust a midwife who worked without an assistant. Having two qualified attendants is definitely standard of care for a home birth. 

Originally Posted by MrsWhite 

I just interviewed a midwife and she told me all of her assistants are pregnant or moving and might not be there when I was due.  "But if (I) really wanted one they could make it happen".  Should I be worried if she would be comfortable delivering without an assistant?!  I for sure wouldn't agree to that, but just knowing that she would - is that a red flag?  She's done 230 births.  All of her other answers to my questions were good.  hmmmm  

[member234098]

.  

Edited by member234098 - 6/7/12 at 8:25am

[Czarena]

My favorite midwife would fall under unsafe for whomever made that list - she actually did a  twin VBAC breech water birth at 37 weeks. However, she also didn't hesitate to transfer me when I stalled and the baby's heart rate went flat. I actually called her from 5 states away when I was going into labor with my 3rd and wasn't comfy talking to my midwife.

One that I interviewed before falling in love with her was one that answered "whatever you want" when I asked for her opinion on various things. In an emergency - I'd like her to have her own opinion :)

Czarena

[major_mama11]

To me, a midwife is unsafe if she:

-Does not transfer care when appropriate

-Does not collaborate with other providers/ seek input and second opinions when appropriate

-Does not follow protocols

-Falsifies documentation

-Is inadequately trained in identifying the abnormal (like the midwife of someone I know who told the parents that their newborn's grunting was really just mucus and totally normal, resulting in a heartbreakingly preventable death from immature lungs a few hours later).

To me, this does not just apply to homebirth midwives, this applies to people who work in healthcare across the board. I decided I was no longer comfortable with the CNMs I used when I realized (after the fact) that 3 of the 5 things that I listed applied to the way they handled my hemorrhage.

[Amatullah0]

The biggest things that would make a HB MW unsafe to me:

- does not trust mom's instincts (i.e. on when to transfer, where to labor)

- a MW who trusts mom's instincts 100% but mom herself does not trust her instincts

- does not follow mom to hospital in case of transfer(unless there are really scary laws that would put the MW at great risk)

- does not have an assistant (unless, of course, there is some reason for that... like being the only MW in the area, but I would remedy this by having someone else who I trusted at the birth, like DH -- who is, after years of teaching, very competent sounding when it comes to birth. I would trust him to not make like a deer in the headlights if MW told him to do uterine compressions, or grab that vile of pit)

- lies/hides thing/gives short answers(like youngfrankenstein describes, or in a case I recently read about, falsifying medical records) 

and, yeah, many of these examples can apply to different care providers. You don't want an OB who falsifies medical records or doesn't trust mom's instincts(if I tell you I'm having trouble breathing and feel dizzy, or something feels wrong, you had better believe me)

[Turquesa]

A low transfer rate makes a midwife unsafe.  I'd like a MW to chime in on this, but I believe that a transfer rate around 10% is good.  A midwife MUST know when to transfer.  And when you request to transfer, even for a non-medical reason, she should treat the request as jump-how-high.

[mwherbs]

Depends on client base/population. In the past 5-7% was considered normal transfer rate. CPM study puts a higher than 10%transfer rate for primips (dont remember the exact rate of the top of my head) . And some things in stats could just be weird chance, say for 5 years in a row a midwife has no transfers, but then she has 4-5 transfers ... So her stats are skewed but may not mean much at all about how skilled she is.

[Amatullah0]

Originally Posted by Turquesa 

A low transfer rate makes a midwife unsafe.  I'd like a MW to chime in on this, but I believe that a transfer rate around 10% is good.  A midwife MUST know when to transfer.  And when you request to transfer, even for a non-medical reason, she should treat the request as jump-how-high.

I agree that she should transfer upon request, but not that she should have a 10% transfer rate. It could be that she only takes women who are incredibly low risk, or that she has the skills and necessary tools to handle things that other MWs(who have a higher transfer rate) may not.