Direct Entry Midwives

[1babysmom]

So a DEM is pretty much my only option outside of a birth center or hospital here, and although I hope to UC we've decided not to do a UP. I am going to be meeting with the 2 midwives in my area sometime in the next 2 months (I'll be starting appts wth them after 20 weeks), and I've done some "research" on direct entry midwives, but just wondered if anyone might be able to share their own experiences with a DEM, what they were like, what their "policies and procedures" were as far as complications and/or hospital transfers went, etc.

[alegna]

Not sure exactly what you're looking for, but my midwife is a non-CNM midwife (called licensed midwives here...) and I'm thrilled with her

-Angela

[Adasmommy]

Is a CPM (certified professional midwife) like a DEM? I'm not down with all the terms but our midwife is a CPM and I am very happy. Our last birth was with a CPM too.

Ours have a birth center but also do homebirths. They are very nice, chatty, girly (as opposed to doctor-y) but seem to know everything, which is nice. Our current CPM is very into getting nutrition from food, not supplements and otherwise encourages healthy pregnancies, not interventions!

They do ultrasounds for an extra fee, but absolutely no pressure--just an option (we don't). We requested no doppler and she is happy to use the fetoscope but warned us that most patients use the doppler so we will have to remind her when she reaches for the doppler every visit!

She sounds like she might want to use the doppler some during the labor but I am optimistic about skipping it . . . we'll see.

They do GD tests but claim that we can forgo it upon request. They will also let me skip the Rhogam (I am RH negative). She strongly encourages RH neg mothers to get the post-partum Rhogam if cord blood shows the baby is positive, but doesn't blink an eyelash at skipping the prenatal shot. I am thinking that 'strongly encourages' means that we can still skip them both if we want to. She also gave me exact data on the brand of Rhogam they use so that I can research it and see if there is a better one available.

I know there are laws that govern many of their transfer policies, like how long labor has gone on, what week we're at when we go into labor, etc. I also assume I don't have to do anything I don't want to, whatever policies are. I did not ask them what happens if I refuse I would guess she'd stay to assist the birth but . . . ?

I don't remember their transfer rate, but they go with you to the hospital and stay with you for the birth.

Hmmmm, not sure what else to tell you. I hope this is even relevant to your DEM question!

I would think that meeting with a midwife, and asking her all your questions is the best bet. I don't think they lie about their policies, and you would get a good feel for personality too!

[1babysmom]

Yeah, a DEM isn't licensed or certified, but we don't have any other options. I will be meeting with them and asking as soon as we make an appointment but I'm trying to get an idea of things beforehand.

[Defenestrator]

I have always thought of DEMs as simply being a midwife whose path to midwifery did not necessarily include nursing school -- she "directly ent(ered)" her profession instead of going to nursing school as a prerequisite.

Some DEMs are CPMs, or, more recently CMs (the ACNM credential that is only recognized in a few states) They might be licensed too or might have other credentials that are recognized regionally. In my state, it was common for quite a while for the DEMs to seek our state credential (managed by the state midwifery organization, but not by the state itself) because it was older than the CPM and a model for the CPM. So, there are plenty of midwives in my state who are not CPMs who have been practicing for decades. Because we are a state where licensing is not available, the CPM does not offer us much in the way of legal protection.

I just finished my portfolio for my CPM -- I did it to give me a little geographic flexibility -- we may move in the next 5 years if the economy stays as bad as it is for my dh's work or if he gets an academic position. I also liked the process of going through the work of it -- an affirmation of my training for the last 5 years. But I still consider myself a DEM and will continue to even after I receive that credential next spring.

I think that it is important to recognize that all credentials available to midwives, whether they be the CNM credential or the CPM or another credential, document only the most basic level of training. Being a good midwife is a combination of talent and art and passion and constant study and having someone document that you have attended 20 or 40 births doesn't tell much about skill or ability. Its hard, because we are not really given the tools as consumers to judge midwives.

Every midwife is different in terms of her relationship with others in the community. Even midwives who are more "in the system" like licensed midwives or CNMs might only have good ties with their backup doctors or a few professionals in the community. Others will put a lot of effort into making relationships with professionals for referrals. I don't think you can generalize it as a DEM/CNM/LM thing.

One question that you might ask is what happens if there is an emergency in your prenatal period. Is your midwife going to be on-call for you? Will there be extra fees for coming to help you on an on-call basis? If you have to access medical care, will your midwife be in contact with your care providers or go with you for screening or care in an ER? Will you be encouraged to hide her identity? Would she be willing to reveal her identity if there are issues with CPS, etc.?

Good luck!

[pinksprklybarefoot]

So are you planning on seeing a DEM for just your pregnancy, then UCing? I had a CPM for my pregnancy (transferred at the end due to complications) and I know that she would have had an issue with me getting prenatals from her but UCing. I probably would have been responsible for her entire fee, as well.

I really love the CPM that I had. I wish she could have officially attended the birth (she acted as labor support and was awesome). But I'm sure that they are all different.

[mamallama]

Defenestrator gave a great description of a DEM & raised some important questions.

A helpful distinction that I've recently heard is that the CNM is a midwife who specializes in hospital birth. A DEM (or a CM or a CPM) is a midwife who specializes in out of hospital birth. Not only have the two types (CNM & DEM) taken different paths, their paths have led them to different areas of expertise.

As far as policies and procedures, from what I've seen, they're as individual as the midwives themselves. Where I live, a rare few will be ok with supporting your plans to UC. I had one of them as support for my planned UC. I was very happy with the care, the relationship and with my birth. I wish there were more midwives like her.

[alegna]

Originally Posted by mamallama

A helpful distinction that I've recently heard is that the CNM is a midwife who specializes in hospital birth. A DEM (or a CM or a CPM) is a midwife who specializes in out of hospital birth.

This is not always true. We have several CNMs here who specialize in homebirth.

-Angela

[mamallama]

Where I live, CNMs are under such tight restriction that they can't attend out of hospital births.

That was not the case 6 years ago when my middle child was born, but those days are gone and it is most certainly the case now.

At any rate, the CNM training does not specify out of hospital. In my state, there were only a couple of opportunities for out of hospital clinicals per year (I had one of those CNM students at my birth. Mine was one of four OOH births she attended.) The training for DEMs is strictly OOH.

[AlexisT]

This depends very much on the area. Where I'm from (New York) only CNMs and CMs are recognised, and CNMs do home birth and birth centre births as well as hospital.

The important factor for a CNM is that they are trained in both nursing and midwifery, and can do well woman care as well as care for pregnant women.

LM (Licensed Midwife) is really a regulatory thing, rather than a training issue.

[1babysmom]

Originally Posted by pinksprklybarefoot

So are you planning on seeing a DEM for just your pregnancy, then UCing? I had a CPM for my pregnancy (transferred at the end due to complications) and I know that she would have had an issue with me getting prenatals from her but UCing. I probably would have been responsible for her entire fee, as well.

Both are okay with it if it works out that way. That was the first question I asked them and wouldn't have considered them if not. They're actually both really interested in it and very supportive. And they will adjust their fees accordingly if they don't attend the birth.

Both of these DEM's are not licensed or certified, they've both told me.

CNM's around here (or at least on the OR side) can rarely practice out of hospital either.

[SublimeBirthGirl]

I had a UC and there were two local midwives willing to come if I needed them (I UP'd as well). I have attended 2 homebirths with DEMs and they were great. Just like with any kind of practioner, they vary from person to person so interview. And I recommend trying to find someone who will actually support you in your UC, rather than trying to keep it a secret. It really depends on who's available in your area though.

[Romana]

Originally Posted by mamallama

A helpful distinction that I've recently heard is that the CNM is a midwife who specializes in hospital birth. A DEM (or a CM or a CPM) is a midwife who specializes in out of hospital birth. Not only have the two types (CNM & DEM) taken different paths, their paths have led them to different areas of expertise.

This is really not true. In my state, all CPMs/CMs/DEMs are illegal (cannot legally attend birth, do prenatal appts, etc.). Only CNMs may legally attend homebirths, and while there are some underground midwives, the only legal attended homebirth options in the state are the 3 practicing CNMs who do homebirths.

Free-standing birth centers were also illegal in my state until just this past spring, so we don't have any of those yet, either. While many (probably most) CNMs practice in hospitals, I'm not sure this is a helpful distinction. I see the biggest distinction in how they're trained - CNMs have to have a nursing degree (hence "Certified Nurse Midwife") and receive more training, and probably more medicalized and hospital-based training, to receive their degree.

[pigpokey]

Since this can have regional tones, and varies midwife to midwife, maybe you could also post this in your tribe with your general or specific location.

[staceyshoe]

I have a DEM who is amazing! She delivered ds also. She has a relationship with an OB who serves as back-up for her. I chose this midwife because she was far less likely to tranport for reasons that I would not want to transport for. (Case in point when my water broke with meconium and I was still able to deliver at home.) I was looking for someone to serve as a consultant during our birth--to present our options and make suggestions--so that we as parents could make the necessary decisions. Her philosophy was very much that the parents are the ultimate decision-makers. It turned out to be a really good fit for us. I'm not sure if it's because she was a DEM or just her personality.

[Arwyn]

Originally Posted by alegna

This is not always true. We have several CNMs here who specialize in homebirth.

-Angela

What is true is that one can become a CNM without ever attending a birth out of hospital (there are a few CNM paths that will entail some out of hospital births, but all require in hospital experience), while all DEMs are trained exclusively in the out of hospital setting. To complicate the matter, CNMs can also be CPMs - the CPM certification is open to all midwives, DEM or CNM.

Confused yet?

Personally, I think licensing and certifications mean almost diddly - I'd want to know how much experience the midwife had, and almost more importantly, what her philosophies were. Does she really trust birth? Is she secretly fatphobic? What are her transfer rates? What are her protocols? How often do clients "risk out"? What does she consider an absolute contraindication for homebirth? Etc. Tell me all that, and I'll know what I'll need to know about that midwife - tell me CNM or CPM or DEM and I might have a few guesses, but I'd still basically be in the dark.