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How do you feel about direct entry midwives? - Page 3

post #41 of 60
I had 2 unassisted homebirths but I we would personally be comfortable being attended by DEM even if she only self studied or apprenticed
post #42 of 60
Quote:
Originally Posted by mwherbs View Post

Everyone keeps saying that the UK midwives or other out of country midwives have superior educationa and they represent college degrees.. And yet for years upon years a foreign midwife moves here and at best she can sit for the RN exam/ licensing. I call BS on all your posturing when it comes down to brass tacks the professional organizations do not accept them as equals or superior education.
Mostly has to do with all those non-midwifery related classes, like English 101 and 102... PE credits...


 Have you compared the educational requirements, the actual classes that UK midwives, Canadian midwives, or those from the Netherlands must pass to become licensed and registered midwives in their respective countries?

post #43 of 60
Yes on core content in midwifery, excellent. But again I ask you why do foreign trained midwives get diverted to RNs status only, when they move here?
Nonmidwifery academic degree componets. The best midwives in the world that have better outcomes than most doctors in this country... Can only work as nurses....
You are asking for reform only on the LM end of things and I think that we need to seperate midwifery from nursing and academic degrees. And go for a very through midwifery education with clinical home birth and hospital training.
I also think that midwives should be the labor monitors in the hosptial, not nurses. Like the UK system.
post #44 of 60

It's the same with doctors who are licensed physicians in other countries. When they come to the US their medical education residency can only be considered acceptable here if they can show that they have completed equivalent courses in their home country. For some that means they need to complete a residency, for others the medical education they received is so poor they might as well complete medical school again.

 

 

Midwives are a different animal. DEMs and CPMs in this country would qualify as traditional birth attendants (TBAs) in other countries, especially w/i the EU. They would not be allowed to obtain a license or to promote themselves as midwives, although they may refer to themselves that way. Many of the developing world countries are moving toward Registered Midwives (CNMs/CMs). This means an education based on ICM standards. Although US MEAC programs say they meet ICM standards there is wide disparity in program quality as most MEAC classes won't transfer to accredited universities.

 

If a foreign educated midwife comes to the US there are several programs that can help her work through becoming a licensed midwife in the US. This link leads to the information packet from ACNM. It does explain the minimum requirements and how difficult the process will be. And this link goes to the Florida pre-licensure packet for foreign educated midwives wishing to practice in that state.  From looking through these 2 documents, I suspect that foreign educated midwives who need to earn a living and have a nursing degree may decide it is simply easier to prove their education as an RN and work in that field, rather than pursue proving their midwifery education. Part of the difficulty with the midwifery route is that the US has 50 states that all set their own scope of practice and regulations. They also have different regulations for the different types of midwives. It would be so much easier if there was a single, university based educational curriculum and standard for midwifery education.

 

I don't think foreign educated midwives are being pushed into working beneath their education as midwives by working as RNs. I think it may be more of an economic decision on their part. I have a friend who works in the local med center as an LC. She is a British educated midwife and an LC, but she is here with her husband who took a US based job. She wanted to work while they lived in the US, but it was much easier to become licensed as an RN and use her IBCLC credentials to get a job, then going through all the hassle of proving her midwifery education and not be sure of a job in the end.

post #45 of 60
Oops this double posted sorry.
post #46 of 60
Oh yes it is an ecnomic decision all the way around. Several midwives that have trained the older DEMs in this country have been foreign trained midwives. And have actually been DEMs in this country. I have had the good fortune to work with a few, one of the gals I started midwifery with moved to Houston and trained with a gal named Mercy, she was British trained, worked in Africa, and came here and worked at Jeff Davis hosptial as a nurse, as well as did home births and trained midwives at a school she had in the 80s
Mabel was in Oregon and after many years became a CNM, but she basically had to do the whole stint... I saw her at a midwives of color conference several years ago and she was talking about how frustrating the nurses are to work with, she was teaching a shoulder dystocia class...
, there was another gal in eastern Washington in Walla Walla, try as she might no CNM or LM on her horizon--- she worked at the hospital as an RN but could run circles around the local docs... The Seattle school would only give her at best 2 years credit of a 3 year requirement....
I worked here in AZ with a Brazilian mw that went to midwifery school in England... No credentials. There was a British midwife who did home births in AZ, and was part of the AZ midwifery school here in Tucson i dont know if she even had her RN in the US, she did have good doctor backup...

This is where I have gotten my impressions that midweifery is a vocational education, in foreign schools... They start off with the basics of microbiology, and health sciences and then branch off into didactics and clinicals specific to midwifery.


There are many books on the professionalization of midwifery, one where they interview older midwives in the UK as well as doing some research around the subject... There was a big shift that moved more women to the hospitals- and you can see that hinted at in the pbs show CALL THE MIDWIFE, the upper class young women were came to work with the poor. The social disconnect /disparity between the women they served and themselves shifted where women felt comfortable to give birth...
If clients dont feel comfortable with you in their homes it is an aspect of what can cause them to decide they want a different midwife, even if of lesser education or expertise , it is not simple as educate everyone to a set medical bar, because what happens is other women will be called to help....

As far as MEAC accreditation or foreign accreditation has to do with economics, and politics...
post #47 of 60
Quote:
Originally Posted by Buzzbuzz View Post

"There are lots of problems with the UK and their health system, but I think their approach is much more dignified and respectful of mothers. Unless I'm mis-informed, there are no limits on where a woman may choose to birth. If a woman chooses home, she can either be attended by a NHS midwife or an independent MW. Elegant."

 

This comparison is not really applicable to the situation we're working with here in the states.  NHS midwives and independent midwives are all colleged educated and are trained and licensed (registered) in the same way (unlike CNMs and DEMs). The key difference between NHS and independent midwives is who pays the bill at the end (the NHS or the family).  People hire independent midwives when their local healthcare trust does not have the budget/staffing to provide homebirths.  Perhaps someone on the ground in the UK can correct me if I am wrong but that is my understanding of the issue.

 

I gave birth in the UK. i was a high risk hospital birth, but I'm familiar with the system. All midwives in the UK, regardless of their employer (independent, NHS primary care trust, NHS hospital trust) are trained identically. NEW midwives are all trained to BSc level (this is the same standard as nurses, physiotherapists, etc). Older midwives, however, were not trained in a university based system--much as US nursing transitioned from hospital based schools of nursing to college based, so did the UK, and they did it later. 

 

If you choose an independent midwife, you pay the full costs. The reasons for doing so include continuity of care (NHS midwifery works on a team based system, and you may see different midwives for antenatal and delivery depending on setup), willingness to perform higher risk births, and lack of support for home birth in a given area. (this varies tremendously from place to place). 

 

THe existence of independent midwifery in England is threatened by a proposed government requirement for liability insurance, which they currently do not carry. 

 

The official criteria for midwifery led care are very strict. Here are the criteria for where I gave birth: http://www.bcf.nhs.uk/our_services/maternity_services/ridgeway_mlu/midwifery_led_acceptance_criteria?display=original&revision=1&_ts=2151

 

There is some variation on VBAC being accepted for midwifery care. Breeches and twins are rare.

However, you will sometimes hear of breech and twins being delivered as NHS home births as if you refuse to attend hospital they MUST send a midwife. Frankly, given the average experience of NHS midwives with these births, I regard it as foolhardy to try--I rejected breech vaginal birth out of hand after doing some investigation--but you can. 

 

Gena, your argument amounts to, "my right to choose outweighs other women's need to be assured that their providers are well trained and safe." It places the onus on patients to investigate their providers. It is essentially selfish as it argues that no one should be asked to restrain their choices for the common good. 

post #48 of 60
A BSc is how these midwives who move here still only can become RNs.
Thanks for sharing that info,
I think that it would be reasonalbe to have a direct entry midwfe have equavalent to a BS.
But the laws would need to reflect the level of professionalism and support competent level of care. Re access to tools and meds.... And be legal in every state

The push in this country for advanced practice nurses to have PhDs is over board.


And i do think despite the obsticals placed in their way, over all direct entry midwifery is a valid and safe choice for most moms.
It is a hard profession for a young poor woman to enter into and years of unpaid or little pay during training. So can place a great deal of hardship or even exclusion on populations that would be better served by midwives from their community working in the community.


There is alot said about diverstiy of training and possible gaps and yet this does exist in medicine and CNM midwifery as well, the college of medicine near me is pass fail in its grading.


When ever choosing a provider, do not go and be examined, do not do anything that would make you feel obligated to hire them, go with a list of questions and take a friend, you could use an internet generated list but mostly use that as a guideline- get a feel for how the provider addresses your concerns or views, what is their education and experience, interview many before you decide... And be aware of someone who trys to assume care oh call me if you want an ultrasound no obligation....stuff like that if you are bleeding or something it is useful and may be expedient but other than that it also sets up an obligation loop... Sort of like all the free samples that drug companies do... They spend more money on free samples than they do on research and development that is because they know it is where the money is...
Edited by mwherbs - 5/14/13 at 6:05am
post #49 of 60
Quote:
Gena, your argument amounts to, "my right to choose outweighs other women's need to be assured that their providers are well trained and safe." It places the onus on patients to investigate their providers. It is essentially selfish as it argues that no one should be asked to restrain their choices for the common good. 

 

"It places the onus on patients to investigate their providers"

 

That is absolutely right.  True skill level among medical professionals in this country varies breathtakingly.  I consider it reckless in the extreme for any person in a non-emergency situation not to investigate their providers - look for news stories, talk to other patients, nurses, ideally colleagues, etc.  Their life and quality of life depend on it.

 

The common good is better birth outcomes.  DEMs can be a part of this, and like any providers there are good and less good DEMs.  I will be the first to speak out about good and bad care, and I ask others to.  I do so freely, and particularly I've spoken out against a local DEM I know to provide bad care.

 

A mother choosing a DEM knows what they are getting.  They know their MW doesn't carry liability insurance and in many cases isn't licensed.  If a MW claims to be one thing - a CMN but isn't, prosecute to the full extent of the law.  But for women who want a certain type of care that a DEM offers, they should have that choice.  We don't need to protect them from it if they make an reasoned choice.  That choice can, and often does lead to ... the common good.

post #50 of 60
That is an extraordinarily privileged point of view. Many people in this country have a limited choice of providers or lack the resources to investigate.

Everyone should be able to trust that their providers have met a minimum standard of competence. I am entirely unconvinced that everyone hiring a DEM is aware of their lack of training and oversight. In fact, I know this is untrue because women have said so.

Maybe people in this country want doctors who don't have MDs. Maybe people want to become doctors without paying for medical school. We don't have that and it's not just because the AMA wants to restrict entry to the profession. Midwives should be held to the same standards as any other health profession. In the aggregate, more lives will be saved by fully trained and regulated midwives than by allowing unlimited freedom of choice. You are asking other women to give up their safety for your own, and legislatures to prioritize your freedom over their safety.
post #51 of 60

"A mother choosing a DEM knows what they are getting.  They know their MW doesn't carry liability insurance and in many cases isn't licensed.  If a MW claims to be one thing - a CMN but isn't, prosecute to the full extent of the law.  But for women who want a certain type of care that a DEM offers, they should have that choice.  We don't need to protect them from it if they make an reasoned choice.  That choice can, and often does lead to ... the common good."

 

I would agree with AlexisT that there seems to be a fair bit of confusion amongst consumers as to the qualifications, licensing, etc. of DEMs.  In part, this is due to the general difficulty a non-expert has in determining the actual skill level of a hired "expert".  As a legal professional, you surely have seen clients who have had no real sense of the true skill level/proficiency of their lawyer as they lack the knowledge base to measure it. 

 

Sometimes, the midwives themselves don't appear to be clear on their status.  I have seen discussions on this very board where some midwives have taken the position that there is no such thing as "alegal" practice (which is the position of the Big Push for Midwives campaign) while others claim that alegal status exists and that they are not practicing illegally even though state statute does not specifically permit their midwifery practice.

post #52 of 60
For me the women that interview me have known the difference. When i talk about my scope and training and experience and define the differences they know CNMs may have worked with them or are even refered to me by a CNM .
Who I meet that doesnt seem to know the difference, the general population.
Home birth is 1 % of the population or less in my state , there are cnm practices, in particular a CNM run birth center and so clients have midwives to choose from , and frankly I dont want clients that are confused or dont know the difference.
post #53 of 60
Quote:
Originally Posted by AlexisT View Post

Everyone should be able to trust that their providers have met a minimum standard of competence. I am entirely unconvinced that everyone hiring a DEM is aware of their lack of training and oversight. In fact, I know this is untrue because women have said so.

Agree.

My friends who hired the DEMs... the ones that had bad outcomes, did not do the research that hubby and I did. They hired a DEM that a friend or acquaintance had used and didn't bother to look/ask/investigate further.

I'm going to stir the pot here again...

It's not just your birth experience that you, the mom, are messing around with here... its your child's life and your possible future fertility.... we need to make sure that our "choices" are safe. That won't be possible until all practicing midwives meet a minimum of licensing/education and experience criteria.
post #54 of 60
Quote:
Originally Posted by philomom View Post
It's not just your birth experience that you, the mom, are messing around with here...

 

Phew, I have to take a deep breath here.  Not sure this thread has much of a purpose at this point.  None of us are changing each other's minds, nor are we having a positive discussion. 

 

Not sure why some of these posts are on the "Homebirth" board.  The effect of many posters suggestions would be to limit MW attended HB to near non-existence.  Several PP'ers have suggested that we need to protect mothers from their own choices, because women can't be trusted to make thoughtful decisions.  Besides being condescending, this doesn't make sense since homebirthing and DEMs are a non-mainstream choice.  A family has to make the affirmative decision to do so, and it's never an easy one.  Homebirthers are a thoughtful crowd, to the extent they are any one thing.

 

Now we're got "it's all about the birth experience" argument quoted above.  No.  Homebirth is not "just the birth experience" and I would have thought that position had been thoroughly debunked.  It's about limited experience and options available through the licensed channels.  I certainly didn't stay home for the experience.  I stayed home, like most homebirthers do, because a hospital would have meant medications and surgery I didn't want or need, and I was more concerned for the health of my babes than for myself.   

 

If licensing means educational and competence requirements alone they might be appropriate.  But in this country they would mean a MW would lose her license by attending certain mothers - twins, perhaps, breeches, VBACs, etc.  That's what it means for CNMs. So, licensing would mean more limited birth choices, and a loss of a body of knowledge relating to OOH births - ie the physiologically normal ones.

 

Licensing does not equal competence.  The question is whether licensing equals a greater chance of competence.  I doubt that, and certainly haven't seen it in my experience.

post #55 of 60

"But in this country they would mean a MW would lose her license by attending certain mothers - twins, perhaps, breeches, VBACs, etc.  That's what it means for CNMs. So, licensing would mean more limited birth choices, and a loss of a body of knowledge relating to OOH births - ie the physiologically normal ones."

 

Setting aside the licensing question -- isn't there a larger ethical one?  If, for example, as the study I linked to in another thread shows, independent midwives in Britain have both a higher death rate than NHS midwives, and 28% of the deaths in question occurred during twin births -- can an ethical independent midwife ignore that fact and continue to practice twin homebirth?

 

Where the tipping point on safety for a particular practice in which it becomes ethically inappropriate for a provider to engage in it?  Or is it your argument that the duty of a health care provider is to give unrestricted freedom to patient choice (for example, why not offer bariatric surgery to people 10 pounds overweight if they want it?)

post #56 of 60
Quote:
Originally Posted by Buzzbuzz View Post

"But in this country they would mean a MW would lose her license by attending certain mothers - twins, perhaps, breeches, VBACs, etc.  That's what it means for CNMs. So, licensing would mean more limited birth choices, and a loss of a body of knowledge relating to OOH births - ie the physiologically normal ones."

 

Setting aside the licensing question -- isn't there a larger ethical one?  If, for example, as the study I linked to in another thread shows, independent midwives in Britain have both a higher death rate than NHS midwives, and 28% of the deaths in question occurred during twin births -- can an ethical independent midwife ignore that fact and continue to practice twin homebirth?

 

Where the tipping point on safety for a particular practice in which it becomes ethically inappropriate for a provider to engage in it?  Or is it your argument that the duty of a health care provider is to give unrestricted freedom to patient choice (for example, why not offer bariatric surgery to people 10 pounds overweight if they want it?)

I can answer...briefly (I have less time to post these days but have been following along).  

 

I appreciate all sides to this issue and everyone's participation!  What I feel like I'm seeing (though my biased lens) is a trend in our HB community here at MDC to focus more on how we can change midwifery and HB clients but I prefer to think of HB as a continuum of care that includes even unassisted birth but also hospital birth on up to the most significant interventions. So, for me, many of these issues and my opinions are formed no only by what is best at home but also by what alternatives are available. 

 

I'm no expert on hospital birth (or HB either for that matter ;-))  but I think a big part of the issue is that without HB holding some space for things like vaginal twin birth, breech, and VBAC options as well as just general better care for low-risk birth, we have this highly complicated issue that women face. 

 

So, for me, the improvements we're talking about wanting to see with HB are entwined with improvements I'd like to see for hospital birth...starting with transfer care but on up to what options women have when they choose to birth in a hospital setting. 

 

I hope that makes sense... 

post #57 of 60
Twins have a higher death rate in the hospitals with the management that is provided there. what would need to be compared is twin births and deaths in each setting deliberate home births to deliberate hosptial births.

Rather than making an assumption that all outcomes are worse at home,
post #58 of 60
Quote:
Originally Posted by mwherbs View Post

Twins have a higher death rate in the hospitals with the management that is provided there. what would need to be compared is twin births and deaths in each setting deliberate home births to deliberate hosptial births.

Rather than making an assumption that all outcomes are worse at home,

 

 

What is this assumption based on? 

If midwives are doing twins at home, they should be doing the lowest risk, full term, di-di twins, with the first one vertex. The hospitals have to deal with that and everything else, including twin-to-twin transfusion syndrome, advanced cervical dilation, short cervix, higher order multiples like triplets and quads, preterm labor, first twin breech, preeclamptic moms, diabetic moms, and the list goes on.  The hospitals have far more high risk twins, so it would be logical that they might have a higher death rate, but it isn't based on the treatment provided, it is based on the numbers of high risk multiple gestation pregnancies they deal with.

 

If you have a reliable source that shows otherwise please post it.

post #59 of 60
Since i looked at the wonder pages for the years that were compared in the MFM journal to see what range of risk births were recorded and atributed to midwives other than CNMS
They included preterm births as well as term births including twins, and I am sure there were twins that never had an ultrasound- because we know that there are plenty of refusers out there, and to my surprise there were some triplets born OOH.... I am not saying any of this is best practices, and agree with you that di di twins with one vertex would be the lowest risk and is probably what the UK midwives select for, and since the mortality rate is very similar in Oregon this last year they may have done the same selective risk assessment, IDK. As i said before I know a prayer only birth attendant who attended breech twins.... She lived in Oregon at the time...
post #60 of 60

Mod hat for a second...

 

Because we have several threads going with the same members participating, it is easy to mix up threads and topics. Lets keep in mind that we have a safety of HB thread, a general risk  thread, and a thread about the ACOG's statement on HB.  

 

I am in part to blame here because I responded to Buzzbuzz's post which set aside the question of licensing, however, I am now asking that we turn the subject back to the question of DEMs and we steer discussion of twin births and other OT topics to another thread. 

 

Staying reasonably on topic is part of our UA. As members of a community, lets all do our part to be sure that our topics are organized well and on topic!   If posting a spin-off, post a link here to members can find you. 

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