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Birth Professionals (Archive) > Loose lips - sink nothing?
Everywoman's Avatar Everywoman 12:14 AM 11-24-2005
HIPAA is only one document that guides ethics. I am interested in hearing from midwives about what, in addition to HIPAA, informs or guides your ethics.

I look forward to responses.

It is not a "twist" that a hired practitioner does not want to be identified. It shows the profound lack of understanding of the role of the midwife. It is self-serving, potentially abusive to the client, and patriarchal.

The midwife is present for the family. This is a basic concept that appears not to be understood.

The lines are clear. Perhaps the insult to me was my catalyst, but is not at present the driving force, seeing this monumental opportunity to educate midwives.

Again, if the purpose of a thing is not known, abuse is inevitable.

pamamidwife's Avatar pamamidwife 04:57 AM 11-24-2005
it might be a monumental opportunity to educate ALL care providers - LMTs, chiropractors, acupuncturists, etc. however, if you're discussing cases without giving specific personal information (including information that pertains to a woman's emotional history and state), is this not sharing and educating and learning? is it not relating similar cases to other women who are in similar situations ("I once had a first time mom whose baby was breech at 38 weeks....")

who will police this? I'm interested because, as a midwife, most of what I have learned has come from reading other midwives stories and case questions on midwife email lists and online.

I think that there are two sides - and I'm not speaking about the mw that is ridiculing or condescending or not having integrity about the birth stories she retells.

In essence, by my own presence at a birth, that story is also mine. It's how it is told, why it is told, that makes it feel smarmy or not.

But, alas, I can see I just don't agree. It somewhat reminds me of endless talks about racism, feminism, etc. There are valid points, but where does it start and where does it end? who is really holding the power? To me, it's about WHY it's being told that matters...is it to offer insight to an attitude of life that people generally don't see or is it to elevate the storyteller to a powerful, egocentric position?
pamamidwife's Avatar pamamidwife 05:10 AM 11-24-2005
Originally Posted by Everywoman
Notyourusual, praise, you ask? Yep. midwives have knowledge that is lost on much of the rest of the chilbirth community. . .and their knowledge is wonderful for outcomes. People listen to their midwives, they praise them heartily, midwives bask in the glow of it all. I remember attending a breech birth. The family called me heroic. They said I saved the day! I was in the midst of reading a book at the time that outlined different approaches to medicine. I felt like I was being pushed into the mold of heroic (or patriarchal) thinking.
oh, yes, that's why I do it. i want praise. i'm an attention whore. yes.

(sarcasm end)

seriously, i do it because i not only discuss births and beautiful things i see, but it's been a revolution for me as a midwife learning from families. i've changed so much, still question my skills, my knowledge, why i do this work. it's a way to process in a light that also allows people to see that midwives are NOT heroes or gods. we don't have all the answers - nor should we. that is precisely what should set us apart from the medical model.

as a student, i really wanted to know what a life of a midwife was like. not like babycatcher (though her success and the popularity of the book wasn't based that she was a smooth, non-interventive midwife that never had fear, but because birth stories are juicy and amazing), but REAL stories of conflict and family and your own business and juggling all of that. i wanted to read about THAT. not hippie birth stories with lsd-type references. i wanted to know what it was really like. i still remember that eagerness to know and want to know. most mws wouldn't do more than give me a few sentences ("it's a struggle, but we manage"; "divorce is high for midwives") in real life.

with that in my recent memory, and my ability to process memories and feelings better in writing than any other medium, I chose to have a private journal and then also realized that perhaps one day I'd want to compile more of a book-type account of my life as a midwife. this blog is one step towards that. in the end, authors like peggy vincent retold stories with various little things changed so that families could not be identified. she changed names. with 'babycatcher', more people were exposed to just what a midwife is - people who never even knew that midwives still existed.

in essence, if ya got something to say to me, by all means, please email me. if someone takes issue with me or my blog, you can address me personally. if you'd like to rail on me, by all means, go to it, girl! i'm not afraid of criticism and i'm always willing to admit when i'm wrong. but, i'm not fond of the talking around aspect that many online dramas bring. i also adore the fake name stuff when we get critical. makes it easy to say whatever negative things you have to say with a smilie.

truthfully, i feel like i've just about exhausted my ideas here and will just have to agree to disagree on various points. but, if you'd like to address me personally, ya know where to get my email address, right? "just something to think about "
Zoo Loo Naturals's Avatar Zoo Loo Naturals 06:21 AM 11-24-2005
I know some of these ladies here locally, I know who some of the midwives and clients are, I know the stories, I share stories, I ask questions, I'm learning from the sharing we do here.

I DON"T get in a wringer about any of it. I just don't feel there is a negative vibe happening about any of it. That's the point, right? The positive ju-ju is what keeps midwifery alive and well in this meat-market world.
mwherbs's Avatar mwherbs 02:46 PM 11-24-2005
so I have been doing this like I said before over 20 years but have been told birth stories all my life-- my grandmothers' stories their friend's stories, my mother's stories and her friend's stories, aunts and uncles as well. When I became pregnant the first time stories of complete strangers... and sometimes I share these stories because I know about them and it might fit a situation-- there is no way I could get permission to tell most of these stories and the same would hold true of most of the early births we were at---people would give us pictures of their births to share but we had no permission slips and I knew I was not going to publish them. And yes we told the upsetting stories the transports and the mistreatment women received at the hospital-- I am present at these things and the hard stuff as well as the good stuff needs to be known-- partly because we are not of one culture, mostly because of a misuse you are looking to define and asking us to think about/define--
do you think that the stories I told about youngdoula/mw I had permission to tell? why would I have permission to tell about someone's abuses, most of the time these folks all the way around hold that stuff close to their chests or what if I get permission - from a signed paper but then when a person hears what I am telling they do not like what I say or the way I say it... this is more like what we are getting at there can be misuse in any direction -- so with that youngdoula/midwife story there are other parts probably important and strange and things that don't always fit in contextually- maybe I only want to tell certain parts of a story to be illustrative... another part of that story was when youngdoula/mw (and you don't even know how close or not close of a relationship they had- could have been lovers for all you know, that would put a different light on it now wouldn't it?) in any case when the yelling was going on -- not just youngdoula/mw yes she started it but laboring woman started yelling and fighting back- she got out of bed, managed her contractions on her own, her contractions became harder, stronger, lasted longer, as soon as she could even before the contraction was over she would start in fighting back , loud, angry, resolved, how dare someone challenge her choices, her right to do what she wanted, who else would she have felt this much freedom to really yell at, certainly not the nurse that was in the room who had been rude and sharp to everyone in the room except the laboring woman. The nurse was slowly undermining the whole time, kind but subtle things and in some way a strange attachment way trying to push all of laboring woman's support away, telling about her own natural birth story and how laboring woman was so much more in pain and not handling it , I think that youngdoula/mw was responding to this as much as the laboring mom's choices that were prompted, initiated by the nurse, she felt that change of trust that giving in and pushing away and reacted -- this is not any way I would want to treat a laboring woman and yet this is probably what helped her, this state of mind she is a young warrior woman, fighting for all sorts of causes and even listening to hard core protest songs during labor. I had one aunt who had an urge to ride a roller-coaster in labor and went to a park and did so 2-3 times what do I know , we are told and most people do respond to low lights and.... but not everyone these are intense and important stories for someone who may need to feel released to do what they need, I do not want to personally get into a fight/argument with a laboring woman but if she want to yell at me ok. -- I have several supermarket stories told to me by women who out of nowhere because I was pregnant or my children reminded them of some lost child or because I said hello they share with me, I tell these stories at times too. perhaps instead of a release I should issue a warning... and even at a party, most likely a party that is peopled with doula's and midwives a doctor or 2, a few nurses I would tell a birth story and depending on what I was trying to get across-- maybe that I can be totally useless or the wholeness that a birth can be without much extra drama, yes I am lying under the birthing woman and she has me pinned to the floor where she just threw me down- and on falling trying to not get hurt or let her get hurt her baby crowns-- and she is gripping my shoulders- digging into them with her hands and she is not going to let me go, we are belly to belly no one else is in the house, she is roaring into my face, and breathing she weighs no more than 100 lbs but I cannot move her, and dare not disturb her I turn my head and yell to the gals who are getting the cars ready to transfer her.... one gal peaks in and sees us- baby is coming, she pulls a robe over that has been dropped on the floor- and slides mom's underwear down- yes there is a head, and mom roars and pushes and out the baby comes in the bag completely and unruptured I can see the baby by looking straight across my body between mom an me- her eyes are open and she is in that red jellybean of a bag, other gal did not have time to catch just guide luckily she had pull the robe over it made for a soft landing--
telling a story like this reminds them, clues them in that it is not all about liability or IV doses or checking to be sure someone can push or that anyone need be there doing something, even in a long labor, even with a long stall, even with a tired out mom-- despite all the pathology that can be brought up. The first telling of this story starts with filling in the gals who were there but missed it both mom and I tell the story-- but we have no permission slip.... by telling the story instead of just hitting them over the head with dry info-- I love science studies and yet I almost want the whole all the stories that go with the studies-- If you are talking about unique occurrences- that may be enough of an identifier but it is of use not only to birth workers in a private meeting but to their spouses- remember the stat about doctor's wives having the highest intervention rates, and to us as a culture in general-- who has permission to inform us about birth in our culture-- and what are they showing us-- what about those horrible birth shows- they probably have permission up the kazoo.. not only from the clients but the docs and nurses as well-- but do we really think that everyone in those shows when they get down to it after it is all over with that they wanted to be seen or for it to be edited in that way or.......
I think that having a paper is just small what is bigger than a piece of paper is respect and intent. How do the cable shows serve us as a population? I have watched them and if I still got those channels I would still on occasion, but my family changes the channel quickly as soon as I start yelling. there are ways that what they show a disservice because they are angling for drama and portray things not necessarily with an intent to help others, it normalizes certain choices and there are no critical eyes commenting on differences and ways things could be done differently... maybe I want something like the doula squad or midwife on the job- someway that you have the typical birth show with the gal intending to go natural- everyone standing around and she is pinned to the bed- trying to hide from the bright lights of the film crew - hand over her face and you stop action right at that point when they escalate into intervention and interrupt by giving alternatives- get mom out of bed up to the bathroom-- suggest something..... anyway I am moving from the point but the thing is yes stories are how we learn all of us and shows can trick us and give us more info but it may not be better info--- and permission a just a piece and may not be a complete answer-- I think you are still talking about an attitude and some respect and that even with a permission slip may not be had
Everywoman's Avatar Everywoman 10:45 PM 11-24-2005
Pam, where do you think I was addressing you specifically, unless I was addressing what you said directly within this forum?

I will not reveal my name. I have been involved in midwifery for quite some time, and I am well-known in several states by legislators, midwives, other perinatal professionals, and clients. I work with pregnant women in varied capacities, many of whom frequent these boards. Many would doubtlessly know who I am and about whom I am speaking. I want to award this woman the privacy she took from me, deserving or not. Please honor my decision.

I do have more to say about this; are you willing to discuss it with me in such a way that we both may share a learning experience?

For now, the new Beaujolait wine is staring me in the face, begging me to open it and join my family and friends. I look forward to reading MWHerbs post and replying to all within the next few days.

NavelgazingMidwife's Avatar NavelgazingMidwife 03:30 PM 11-26-2005
writing from the Contemporary Resort at Walt Disney World - Thanksgiving vacation with family (extended and immediate) - 2005

I have been struggling with this issue hard and recently the entire thing came to an explosion about some of my writings on-line (and I REALLY do not want to discuss that specific issue here because it is not the topic of discussion and is being worked through privately). I do want and need to lob ideas back and forth with other writer/midwives & doulas to get a feel for respect for confidentiality, heart, feelings, and, at the same time, sharing incredibly valuable "inside" information that benefits all of us in our introspection and movement through life.

I know that reading other women's stories, through a midwife's or mother's perspective, has benefitted my own practice/style. If it weren't for reading about birthrape on-line, I'd still be a midwife thinking vaginal exams were vital to a baby's entrance into the world! If I hadn't read other midwives speak about their own introspection and inner questioning of what they learned, saw, or did, I don't know if I would have come as quickly to the realization that what I learned, saw, and did wasn't quite so great after all.

I do understand that a woman's birth story is incredibly valuable in her re-telling it. I also know that a midwife's re-telling is incredibly valuable in a different way. Women in birth have altered senses of time (and should!), altered perceptions (and should! [such as who was in the room when, if the back massage was helpful before the saline injections or after*, etc.]), and because a midwife charts, she writes HER view - slanted as it is - of the birth.

I also know that NONE of us sees ourselves as others see us. Listening to other midwives share about a woman's reactions to her husband's marijuana smoking during labor* or a husband's withdrawal from the birth room at every opportunity* just isn't going to be said in the woman's own birth story, eloquent as she is.

I am reminded (a LOT) of the old adage: There are three sides to every story - yours, mine, and the truth.

Easily, my favorite birth story scenario is layering a mom's story either on top of or under my own re-telling of her story. It adds diminsions and layers to the complete story not "gotten" otherwise. For every person who tells the story, they also add to the whole. It's a mosaic, a prism, a never-ending and always-transforming fluid even though it happened in a moment in time.

Most women do not write their birth stories (and I am speaking of writing since this is a blog/list/group/Net discussion) for a long time simply because of time (understandable!) and I know that I write birth stories as quickly as I can so the details remain fresh and sharp. In my Outlook list of Things to Do are no less than 15 birth stories yet to be written, some from as long as 5 years ago. While the blunt edges will remain (transfer, suturing, giggly toddler, etc.), nuances are certainly lost - the halo of the sun's rays as she tilted her head to kiss her husband's hand*, the look on her face as she learned her baby might need further genetic testing*... aspects such as these - seemingly dramatic at the time, fade slowly as more and more moms, families, babies, situations, life experiences shade the memories.

I've debated this writing a composite woman idea - making up a woman (Kate)* and putting aspects from several women together to make Kate experience many of the situations two, three, or more women experience during their pregnancies, labors, and births. To me, that is fiction and I suck at writing fiction. I am a storyteller - an essayist - a blogger and must find a way to continue writing what I know yet protecting my client's privacy and dignity (even if what I share is how she orgasmed during birth - a delightful aspect to me, but for a Moslem woman [or anywoman], might not be something she'd want shared).

I also know that I like real stories! I don't read much fiction at all. It's just who I am. I can't be alone or there wouldn't be the plethora of non-fiction tell-all's available about every conceivable topic, including birth. I want the stories I read to TELL ALL! Real stories grab me... I can "see" them much more clearly, can "watch" the action of a shoulder dystocia's recovery or an extensive suturing job's relief when it is not fiction.

While looking into blogging ethics for my own hoopla, I am discovering how other people are attending to this really, really, really new course we are traversing. I have gotten at least 2 ideas from this thread alone that I am considering incorporating.

First, I am working on a Blogging Informed Consent (BIC) for my client's charts. I hope to have it complete within a week or so (I'm having a lawyer and several extremely trusted Net-savvy birth community friends/peers review it before I publish it or incorporate it into my practice. [Until then, there is a moratorium on my writing present-time client anything.]).

I will ask any of my former clients I can find to sign the BIC - and by sign, I mean either yay or nay - and will adjust my movements appropriately.

(I'm tweaking with "you can share this, but not that" sorts of permission... like what I do with photographic releases.)

I'm in a lost place about the clients I cannot find or had a blink of a moment with (many of the migrant women, for example - or the women in the military). I await an answer from inside as well as listening with an open heart to those whose stories might be being told by someone else far, far away - how does that feel?

I think I have also decided to write the birth stories as always and then put them in a Birth Story Folder and periodically pull one out to share as if it had been "last night." Even if the mom gave informed consent, I wonder if sitting on it - waiting for awhile to give her pause to choose again - shaking head - (am I going to call her weekly and say, "is it still okay to write about you? probably not - this is the issue in the BIC I am coming up against).... Dr. Jen's situation is what brought this part about because of the small town aspect and finding birth records and cocktail party discussions, etc. While I don't have that very small community to contend with, there are only a couple handfuls of midwives where I am and it's easy peasy to figure out who had the 14 pound quadruplets at home.*

My family of origin (and it's a big one at the moment!) has asked several perceptive questions.

1. Why does anyone even care that you write their birth stories? Why would you need an informed consent at all?

Several family members who have had children stated they were extremely private in all aspects of their lives, yet would be honored to have someone tell their story. When I explained that it isn't always happy or pleasant, they began to understand.

2. Why would you write birth stories? Who reads them?

Women read them voraciously when pregnant to try and see what's coming around the corner, to assimilate into their community, to familiarize themselves with the lingo, the options, the mishaps others have taste-tested for them. Of course, there are a million other reasons, but I suspect voyeurism is also high on the list despite protestations to the contrary.

(And yes, I am hyper-aware of writing's exhibitionistic intent.)

I believe voyeurism is also present when it comes to midwives or doulas (or docs), but I think it's a different flavor than a mom's. New birth "workers" might not see a umbilical cord break off (without pulling on it) for 20 years, yet by reading, she can learn it isn't an hysterical 911 emergency and can feel reassured that she does, indeed, know what to do. New doulas might find information about how to best serve an extremely conservative Christian family by reading about another doula's red-faced suggestion to the mom to "take your shirt off."*

(As I write these fake people and scenarios, they easily fit someone - or many-ones - I have had contact with over 23 years. This makes this entire topic even more challenging! What happens if a woman who signed a NO on the BIC thinks a story is about her, but it really, really isn't? What if I decide to be stupidly daring and write fiction, yet it turns out that my composites are spitting images of birth stories of women I've never met or even heard of? Lawyer stuff, I know.)

Reading over this before sending, I sigh about the amount of asterisks in my piece. I wonder if I will learn to know the SHIFT 8 as much for disclaiming as for emphasizing (*like this*). Should I put a disclaimer at the beginning or end of anything I write? What would it say?

I.e. My entire world knows that there is a parenthetical disclaimer on any appointment made. "Would you like to go to the picnic Saturday?" "Absolutely! (unless there's a baby)" "Mom, can you take me to the ballgame on Tuesday night?" "Sure! (unless there's a baby)" They learned this looooonnnnggggg ago and when meeting new non-birth people for things, the parentheses are removed for awhile, re-placed in time.

Am I going to go overboard with asterisks and make my papers look as if snow flakes are falling down, down, down the essay?

This is long and I find some resolution in its production, but still see the gaping holes (I picture those lace thingies my Nana used to make for the arms of chairs) I don't yet know how to fill. Once again, I'm watching, listening, learning, trying hard to grow and change where the situation requires it, and want more than anything to preserve a woman's heart, spirit, and dignity.

I also want more than anything to make my writing mean something - not just be white noise in the world of essays and blogging. The balance is there - and I pray not always so precarious. I'm visualizing clear, thick lines of right and wrong - ethical and unethical - appropriate and inappropriate. Foggy worries float around my head, but I hold tight to the belief that it won't always be so confusing and my (and others') learning won't always be so difficult and painful.

Blindly, I move forward.

Barbara E. Herrera, LM, CPM
San Diego

* not a real scenario or person
doctorjen's Avatar doctorjen 01:29 AM 11-27-2005
I think I'm seeing this issue with a little more clarity - at least as far as formulating my own ideas about what I feel is acceptable.

I think it is okay to share anything you have express permission to share, including pictures and stories, especially if the client has had a chance to review it first.

I think it is okay for those of us who are care providers to share stories and ask for advice/ideas/sympathy or whatever in an anonymous or private way. I know that I personally often need a chance to debrief or think over things away from the situation. I also benefit a lot from peer review and the chance to learn from others. And, let's face it, some clients are harder on us personally than others and it's nice to be able to get some support for this from others who understand. My best friend is also a practicing hcp, and it's sometimes a great relief to call and say "you won't believe this situation" and then get some advice. No ID is shared and my friend lives far away, but gives me someone to bounce things off when I need to. I don't think we have to get express permission for this sort of thing, since no identification is attached, and the client is not directly affected. I also think that speaking in general terms is acceptable and doesn't require specific permission. Such as "I have a client with red hair, what is your experience with red heads?" type of thing - but not "I have this lady with red hair, who is a radio personality in Denver and has 2 other kids and is married to the governor, what is your experience with red heads?" kind of thing.

Where I feel it's problematic is when private details are shared in a way that is potentially traceable or recognizable, and the client has not given permission to share. Those of us who blog, and have our locations and names linked, or who link in a public forum have to deal with this. I know that I've read stories in blogs where I know if I were the client I'd be really uncomfortable with what was said, and I think it's important to be sensitive to this. Also, in my small town practice, this means I have to be careful not to make comments that listeners could trace back, unless the client has said "feel free to talk about my birth with so and so." I don't think it's generally okay to say in a public forum "this client I attended last week was so hard to deal with" and go on to describe things negatively when it is easy for someone to recognize themselves or an acquaintance. The potential to be hurtful is just too high, and people have the right to have their privacy respected. I don't think this applies to just negative comments, either, because some people may not want their private info shared in a potentially public way even if it is positive.

What do you guys think? Do these differences make sense, or am I just naive to think I can see a line between what is acceptable and what isn't?
cathicog's Avatar cathicog 03:18 AM 11-27-2005
: this is along the lines *I* was thinking. I am still learning, and have absorbed tons from the stories I have read-especially the blogs! I use them to visualize what I would do in a given situation, that I have yet to encounter. Breech birth. Shoulder Distocia. Hemmorhage. Multiple births. It is very important to me as a student, to read how different midwives approach these items.. And the preparation is vital. I don't want to know every jot and tittle, although there are some details that sure come in handy, like the one I was told about to guage amount of too much blood: If you put 2 maternity pads under mom and she bleeds thru the one into the other, then it is too much, things like this...I suppose there are going to be people who will be recognised, just by thier due times and size of baby, let's say, but I don't think we do ourselves a service by completely clamming up. (I am becoming paranoid to speak in public, now! ) but anyway, I just wanted to encourage sharing, because it is how we all learn, whether by intent, or not...FWIW, there was a lesson we learned in nursing school; "be careful what you say, because EVERYONE here is related!" and it was so true! People 3 hrs away from each other were knowing who had the heart attack, the premature baby, etc, and you would be surprised who really *was* related to whom! So it paid to be careful, but didn't mean we didn't talk about stuff... May the learning continue...
mwherbs's Avatar mwherbs 02:45 PM 12-06-2005
I wanted to mention something else on this topic and that is really look over your hospital- admittance/release form-- in the last one I looked at it included a release for publication - records, pictures and or movies.
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