Tuesday, December 4, 2012

The Complicated Task of Choosing a SAFE Midwife

What I didn't know in choosing a midwife to attend the birth of our baby, was how critical it would be to choose a "safe" midwife.  I didn't understand the vast differences in philosophy, education, or practices that exist within one profession.  If nothing else, I want every other mother out there to understand there is a difference, and enormous difference, and that just because someone calls herself a "midwife" does not mean she practices safely. 

It is important to me that our readers understand that there is no standard for the use of the term "midwife".  It means a million and one different things, especially in a state like MI, that has no regulations or defined scope of practice that is consistent among "midwives".  In MI, this spectrum ranges from CNMs, midwives with advanced degrees, most of whom practice in a hospital setting with a license and insurance...to lay midwives who have learned apprentice style, with no formal education whatsoever.  We have many midwives practicing responsibly and safely, most (not all) of whom also happen to be practicing in a hospital.  I have met a few midwives in our state who practice outside the hospital setting, who take risking out and safety very seriously.  Unfortunately, they are hard to find, and even more difficult for a consumer to identify. 

For this reason, I find it necessary to discuss these variances, so that women can better choose a care giver.  This can only be the beginning to this discussion because it is complicated.  It makes sense to start with the questions: How do we identify different types of midwives?  How do their practices differ from other midwives?  What does "certified" mean, and how much weight does it hold?  Who is licensed in MI?  What are the minimum educational requirements?  Why does all of this matter? 

I want to start by first dividing midwives as an entire group, into two groups, those that practice according to scope of practice, and those that live on the "extremist fringe".  The latter refers to those midwives who knowingly take risks for philosophical and religious reasons.  These midwives are the  most difficult to identify because their philosophies in practice take precedence over credentials.   

The philosophical boundary that defines the extremist fringe is blurry.  This news reel from Indiana exemplifies the group I'm referring to.  There are less extremist versions of this kind of midwife, those that still trust birth at all costs, religion or not.  For some, adhering to trusting birth is the religion.  These are the midwives I would define as being on the "extremist fringe" of midwifery.  This is not all midwives, it's not even the majority, but it is a prevalent concern.  Especially if you're shopping for an out-of-hospital midwife. 

Controversy surrounds the trend of home birth 

The article below talks about how those choosing, or encouraging risky births outside the hospital are "chipping away at choice from the other direction".   The author's audience is to the "radical birthers", from the perspective of someone who home birthed herself.

Dangerous home-birthers Spoil it for the rest of us

How do we identify midwives that function on the extremist fringe?  This is difficult.  The most obvious hint comes in the language they use (not in their credential):
  • "Trust birth" 
  • "Your body was made to do this"
  • "You can't grow a baby too big for your body to birth"
  • "...(insert high risk situation here)...is just a variation of normal"
  • Gestational Diabetes Screening, Ultrasounds,  (other important assessments) are not proven to be useful or safe

How do their practices differ from other midwives?  These practices differ greatly from other midwives.  Midwives who are practicing within a defined scope of practice are adequately assessing women for risk factors, treating them appropriately, and risking out.  They appreciate that not every pregnancy or clinical condition is appropriate for out-of-hospital birth.  They value the mother and baby's safety above anything else.  These midwives value natural childbirth, and the beauty of it, but will not sacrifice your safety if a clinical situation arises.  These midwives have the skills, knowledge, and training to monitor risk factors.  They recognize that sometimes women need help, and work to get them the help they need, whether the mother "chooses" it or not.  What is murky, is that some midwives believe they have these skills, or tell mothers that this is how they practice, when in fact they do not.  So what's a mother to do? 

We can start with gaining a better understanding of three components: 1) know the dynamics: that not all midwives are the same, or believe the same about birth and risk, 2) learn about different credentials for midwives, and 3) fully understand the laws in your state (in this case MI) surrounding midwifery, and how that impacts your care...particularly in the event of a bad outcome.  For this reason, I find it necessary to provide a resource that explains the various types of midwives, and their educational background.  Let's look more closely at the various types of midwives.  This can help move our thinking forward in understanding how to find a safe care giver.  (We are also working on a blog post that articulates and explains MI's current laws and their impact, in conjunction with scope of practice.  Will post soon!) 

Types of Midwives doc.

Why do a particular midwife's philosophical position and credentials matter?  The problem is that once a midwife steps outside a regulated situation, such as a hospital, there is little consistency in how midwives practice or adhere to any scope.  Practices are purely individual, making it difficult for mothers to depend upon credentials alone.  Understanding that midwives, within a widely varied profession, differ drastically in philosophical beliefs, and further, that those beliefs directly impact practice and safety, is vital.  Being a "certified midwife" doesn't mean a thing.  It's a term used to sound professional, but when we examine educational training and consider the impact of philosophical differences, we see that the term is meaningless.  

The "Types of Midwives" document presents an ideal, a black and white snapshot based upon credentials alone.  It does not take into account philosophy or beliefs about midwifery and birth.   Filtering those aspects is even more difficult.  It is very possible to hire a CNM or a CM (the most educated type of midwife), who delivers outside the hospital, but resides philosophically in that "extremist fringe".  It is also possible, albeit rare, to hire an out-of-hospital midwife, who functions within a well-defined scope of practice, and risks out appropriately. 

I think the key, from a mother's perspective, is seeking a care provider, and interviewing him/her from the standpoint of safety, credentials, and practices, rather than focusing so heavily on the experience itself.  It means seriously considering the fact that even a normal, low-risk pregnancy can be disastrous in a moment's time, and having access to medical assistance can mean the difference between life and death.  It means accepting that the "experience" matters, but the experience should always be trumped by safety.  If you find yourself interviewing a midwife who tells you birth is inherently safe, that you were made to do it, that you can't grow a baby too big, and that high risk is a variation of normal...well, keep looking, because "safety" is not the priority. 

Women need to understand that hiring a midwife can mean many things, and who you hire, will greatly impact your safety.  When we set out looking for more personal care, I did not fully understand the dynamic within midwifery today.  Nor did I understand the fundamental differences in practice among various midwives in our state and country.  This is vitally important information to grapple with, before considering any midwife for your care. 

1 comment:

  1. It really should not be this complicated. But unfortunately it is. I like how you emphasized going into an interview with a midwife with a level head - and to gather information instead of making your decision to hire a midwife based on the experience - or a feeling.

    Ultimately, I believe that if a midwife is credentialed/licensed/certified, it should provide assurance of quality of the services provided.

    Evidence-based. As safe as possible. Based on current and credible health care practices. And truly collaborative with doctors and the medical facilities where they practice.