Friday, July 27, 2012

What We're Seeking: Defined Scope of Practice

I've written before about the number of midwife apprentices who seem to be speaking out about the dangerous practices they have witnessed in home birth.  What concerns me more are those who are too afraid to tell the truth for fear of being ostracized by their own community.  This speaks volumes about the tumultuous dynamic that exists within midwifery.  

Instead of really working to improve practices and keep mothers an babies as safe as possible, a strong undercurrent is working to adhere to misguided practices with purposefully vague guidelines.  What does it mean to "define scope of practice"? It means defining exactly what kinds of births are simply too risky to be taken on outside a hospital, and defining when/how a midwife should recognize that the situation at hand requires the expertise of an obstetrician.  Defined scope of practice helps a midwife assess precisely what is "low-risk" and what is not.  It helps her determine when to take action (ach-em, transfer of care) to ensure the safest circumstances.  Defined scope of practice sets boundaries, not restrictive boundaries, boundaries with a purpose.  Having a defined scope of practice leaves no question marks for the midwife and works to protect the mothers and babies she serves. 

We recently received the following email from a former apprentice regarding informed consent and lacking scope of practice guidelines.  Her words perfectly illustrate the dire need for defining a scope of practice for out of hospital midwives.

"Regarding informed consent...Do I think midwives are incapable of providing evidence-based information?  No.  They are perfectly capable.  But there is no incentive or requirement for them to do so.  Nor are there any professional practice guidelines or professional practice bulletins for CPMs or other out-of-hospital midwives to work from.

  • The Royal College of Midwives writes practice guidelines and cites evidence for these practices.
  • Canadian midwives have guidelines for out-hospital-birth and informed consent. And even outline steps to take when mothers refuse a standard of care.

"But I have seen nothing even close to this coming from the professional organization(s) that represent CPMs and home birth midwives. 

"Most of the informed consent given by individual midwives are highly skewed toward the midwife's own personal biases and opinions.  They don't have specific professional guidelines to assist them.

"What is (and was) so frustrating to me is no one in OOH midwifery seems to be asking: 'What is the best/safest course of care in certain situations?'

"My first choice would be that midwives would put their heads together, scrutinize the research and evidence, make an HONEST assessment of what types of cases are being attended at home births (high-risk), and come up with (safe!) guidelines supportive of the midwifery model of care.  I don't see this happening."  

So I have to interject here an example in Michigan, of midwives "putting their heads together" for midwives, and regulating midwives with House Bill 5070.  Come on ladies, she said "honest assessment of what would be safe guidelines"!  You're not fooling anyone who really is looking for safer practices in midwifery.  You're just asking the state to hand you a license for your unsafe practices, without really considering what criteria would actually make things safer in home birth.  There are no practice guidelines, in this bill or anywhere else, that have anything to do with evidence-based research for a CPM or out-of-hospital midwives.  Just lots of magical intuition and trust in birth coming from NARM, plus the perks of writing prescriptions for pain control and a board of all midwives to keep your practices hidden.     

"I think the profession (NACPM) should write their own specific guidelines.  And I know I'm asking for moving mountains when I say this.  I think forcing CPMs to act like professionals will either force them to better themselves and their practices - or cause them to become completely fractured. But I think either option is preferable to what exists right now."

For more on this topic:
Home Birth Story: Why women shouldn't have to be their own midwives (coming soon)


  1. To be fair, most of these practice standards should be part of professional practice guidelines - not encoded into state law. Especially those that would change over time when practices are re-evaluated for safety and efficacy (*ahem* breech at home & garlic in hoo-haas *cough cough*).

    But CPMs have done this to themselves by not creating their own professional evidence-based practice guidelines specific to OOH practice - so it becomes up to the state to babysit these people. Not ideal.

  2. The shortage of caregivers contributes to this problem. Also, Michigan is a long state geographically. Why should women need to travel over an hour to get to a Level 3 hospital for births? Why aren't you educating women about the various levels of hospitals as well as the various levels of midwives who practice in Michigan? RNs and LPNs who have 1, 2, 3, or maybe 4 year degrees are the attendants for women in hospitals 24/7/365. Why aren't these professionals under your scrutiny? A student can work in OB dept via a teaching hospital after how many months of college instruction?

    1. They are not under my scrutiny because my baby didn't die in the hands of an LPN nurse. This blog is not about nursing. It's not even about maternity care. It's about midwifery in our state, and the problems that are taking innocent lives. There are so many issues to address with midwifery alone, we chose to focus on that area of improving maternity care. If you, or someone else would like to start a blog about hospital based maternity care and the issues you'd like to see change, I'm sure many would benefit. It's simply not the focus here. I agree, there is a shortage of caregivers. That doesn't mean offering substandard care is an appropriate solution. Why wouldn't midwives strive to be the gold standard, strive to be as safe and educated as they could be? It's simply not the case. Instead they are taking unnecessary risks in the name of choice, and telling women to trust birth, to trust themselves. Well, that's all terrific until trusting your body fails. There is no risking out, there are no standards, and there is no accountability. If midwifery and out of hospital birth are to be a reliable option, the practices and profession must improve. I'm sure there are many issues and inconsistencies in a hospital, but those aren't the issues our advocacy group is addressing.

  3. Hospital guidelines in Michigan effect women far more often than homebirth and midwives. RNs and LPNs with 1,2,3, or maybe 4 year certificates or degrees now work 24/7/365 in OB depts. No offense to anyone but putting a student in the OB dept in a teaching hospital needs to be addressed by practice standards as well as the concerns you folks have voiced. State laws and hospital rules allow students who have never seen a birth to attend birthing mothers. These students rely on other more experienced nurses and other staff in the hospital setting as well as experienced mothers giving birth for subsequent births of their children. How many of these students are trained to ignore the requests of birthing mothers due to protocol of hospital, doctor, or routines? For 30 years I have heard women complain about OBGYNs who argue for episiotomies right in the delivery room. Later these docs make comments about stitching moms up better or tighter than before. This is outdated, not based on research, and in fact is based upon practices dating to doctors who kept slaves for experimental procedures. Women need their health care to be based on facts rather than the inexperience of students and their ignorant OBGYN docs. I am sure that this shows up in other areas besides slashing episiotomies on 60-90% of women in the USA and Michigan too.

    1. Dear Undercover Midwife,
      You can visit our blog as often as you like and complain about the medical field, hospitals, or even episiotomies if you like. While you may not agree with the standards for education, or the practices you speak of, the fact remains that none of your complaints make midwifery or home birth one bit safer. This blog is not about preaching that hospitals are perfect, wonderful, or without room for improvement. This blog is about midwifery, the lack of standards, the false notions that women are being sold, and how to improve it. Why do I not write about hospitals and Obstetricians? That's not what this blog is about. My baby did not die from an episiotomy. He didn't die with a resident without experience. He died with negligent midwives, as did many, many others in recent years. Disproving of hospital care does not mean women should be running home to birth their babies, it means our culture should be fighting to improve the system. The worst hospital in MI doesn't make home birth safer, or midwives more professional. It's a mute point. You're not comparing apples to apples.

  4. Hello Undercover Midwife. Thank you for contributing to the discussion on this blog. I want to say that I understand where you are coming from in your criticism of hospital OB practices. Hospitals are not perfect. Physicians are not perfect. And there are some backwater corners in rural areas that are still doing appalling things to women in labor.

    But I'm going to echo "Safer Midwifery" here and say this blog is not about hospital-based practices. It is about improving midwifery. I try to refrain from criticizing what I know to be true about hospital practices when engaging in this discussion about midwifery. It's not that it's not a factor - it just diverts the topic of discussion.

    In regards to midwifery - I don't know a single midwife who isn't acutely aware of the variation of practice among midwives. It's usually in private that one will say to me "Holy Crap, Midwife X did XYZ." Or they lament the lack of use of anti-hemorrhagic meds, or oxygen, or qualified assistants at births. Or the lack of skills a new CPM has to care for clients. They all talk about this - it would be nice if this discussion was happening on a professional level - to improve the safety of midwifery care - instead of in hushed conversations. The lack of practice standards for midwives is one of the main reasons I'm no longer working on becoming a CPM. This group of professionals was not acting professionally.

    Safe midwifery care is important. This is why I participate in these discussions. Is there anything that can make midwifery safer in your opinion? I'm interested in your perspective and experience regarding midwifery.

    1. Out of hospital or "homebirth" deaths effect change and despair upon women as mothers much deeper than a hospital death with or without negligent caregivers. There may be no transport(s), no ambulance, no sirens, and no need to search for support from counselors, social workers, or other helping professions. The hospital provides all of these. :) Even dialing 911 is part of the cascade of getting help while at home. First responders, EMTs, and paramedics all have varying degrees of experience. Depending on their experiences and location they may get called out once a week or once an hour on other types of calls...but for a homebirth emergency? Mothers and community members and volunteers all need more training in at home emergencies and certainly help in how to hire a caregiver for their birth, their child, and their unborn baby. I think we could begin making birth safer from the bottom up rather than from the top down. How about beginning with Community Midwives who do not offer birthing services yet are willing to come alongside their communities and families and offer consumer education or counseling and referral services? A government, a system, and education for women as mothers BY women as mothers...that would make midwifery safer in my opinion. Mature professionals: (1) can clearly define their role and have a defined scope of practice, (2) offer unique services, (3) have special knowledge, skills, and are specifically trained for a particular profession, (4) have an explicit code of ethics or moral code, (5) have the legal right to offer services, (6) have the ability to monitor the practice of their profession or are able to 'police' themselves, and (7) are able to put the needs of clients of ahead of their own and put the needs of their students or interns in perspective in order to replicate themselves as professionals (Nugent, 1981).