What We're Seeking: Standards for Education

"What We're Seeking" is a bi-weekly series that expands upon Safer Midwifery for Michigan's statement of purpose.  This week's post examines the need for consistent, high standards in the education of all midwives.   

Think about your profession. Are you a plumber? A teacher? A lawyer? Consider the range of qualities among your colleagues.

If you are going to hire a lawyer, do you want to hire a mediocre lawyer who was trained at a questionable school?  A teacher who earned her degree online, but has little experience with children?  Do you want the least qualified economist to make policy for the country? No . . . you want the best person you can find.

That is why there has to be a bar, a high bar by which all members of a given profession must be measured as a minimum standard of education.  In the case of emergency/specialized care, there has to be a significant amount of intensive clinical training and consistently current educational standards to ensure these professionals are adequately prepared when lives are at stake. 

With no standards for education, the danger is that there is no bar.  This is precisely the case for midwives in MI today.  There is a vast spectrum in the training of midwives that spans those that have no formal education whatsoever (literally learning through mail order and watching you tube videos) to those who have advance practice nursing degrees...and everything in between.  Not only is it nearly impossible to sort the mediocre from the highly qualified, it's down right dangerous to consider that the person calling herself "midwife" could lack the essential skills necessary to keep women and babies safe during birth.  Hiring a competent midwife is confounding to the consumer when there is no minimum standard for the education, training, and skills she possesses.   

When we hired a midwife we made too many dangerous assumptions, one being that anyone who called herself a midwife was educated and competent, a trained expert in birth.  While this might be true for some Michigan midwives, it certainly is NOT true for all of them.  How can consumers know with certainty that who they are hiring has at least had sound educational training behind them when there are no standards for how midwives earn their title or even standards for how they practice?  

Further complicating things is the fact that the qualities that seem so important to those hiring midwives actually end up being those that matter the least.  Many women want their midwife to be warm, friendly, personable, compassionate - and most are.  Well, those things matter if you are a Kindergarten teacher, or if you work at a coffee shop. But when you board your plane, do you peek into the cockpit and think, "Wow, I hope he is friendly!" No. You look at the pilot and think to yourself, "I hope he knows how to fly this plane and keep all of us safe."  

Do pregnant women deserve nurturing and compassion?  Sure, but not at the sacrifice of safety and the utmost competence.  These are women and babies we're talking about here, life and potentially deadly events.  How can MI allow anyone to call herself a midwife with no standards for education or training?    

Safer Midwifery for Michigan is advocating for clearly defined, higher standards for the education of ALL midwives. 

Portrait of Michigan Midwives

Hiring a "midwife" who practices outside a hospital can mean many things in Michigan:

She may or may not be licensed

She may or may not have clinical training

She may or may not have a high school diploma or college degree

She may or may not be certified in neonatal resuscitation

She may or may not carry malpractice insurance

She may or may not report her outcomes to the state of Michigan, or anyone else

She may or may not have had previous, preventable infant deaths or birth injuries

She may or may not have strict "risk out" criteria and truly take on only low-risk clients

She may or may not carry and use prescription medications illegally

She may or may not effectively evaluate and appreciate risks

She may or may not believe in "high risk" as being more than a variation of normal 

She may or may not transfer your care before it's too late

She will not have all of the tools, medications, resources, and skills at her finger tips to resuscitate your baby if he or she needs it.    

Furthermore, given a bad outcome, poor decisions, inadequate skills, mistakes made, red flags missed or flat out ignored, you may or may not be able to hold your midwife accountable...most likely not when there are not standards or regulations by which to do so.  

Midwifery can be done responsibly and ethically.  Collaborative care is happening in many parts of our country, even some cities in MI.  The problem is, that without a defined scope of practice, you don't know what you're getting when you step outside a hospital and into the hands of a midwife.  

Links:

Lansing State Journal Article: "Home birth movement raises questions of acceptable risk..." 

Freestanding Birth Centers: Common myths revealed

Ask A Midwife:  How do I pick a good midwife? 

The importance of defining risk

Considering out of hospital birth?  Questions to ask your midwife

Lansing State Journal: "Homebirth movement raises questions of acceptable risk..."

The Lansing State Journal has spent 3 months researching birth in Michigan.  Reporter Louise Knott Ahern did countless hours of research and interviews to compile a comprehensive piece about midwifery in the state of Michigan.  The article considers everything from philosophy, to birth options, and safety.  

You can pick up a print copy of the Lansing State Journal today, Sunday, June 3rd, or you can find all the articles, videos, and more at:

"Lawsuit brings home birth movement into the spotlight"

"Home birth movement raises questions of acceptable risk" 

"Who cares how the baby gets here?" 

"How far is too far in a birth emergency?"  

"Where do hospitals fit in with 'normal and natural' birth?"

"Birth Center's practices under scrutiny since March lawsuit"  

"Read local birth stories and share your own" 

(Notes: Be sure to check out the links on the left and right of the article too for extensive resources, interviews, birth stories, and more.  If you start getting pop up boxes asking you for a subscription, just clear your browser's cache.)  

Dr. Amy weighs in on the subject too on the Skeptical OB Blog: 

"Brilliant series on the dangers of home birth"

A full article review by Safer Midwifery for Michigan will be posted tomorrow. 

What We're Seeking: Informed Consent & "Choice"

"What We're Seeking" is a bi-weekly series that expands upon Safer Midwifery for Michigan's statement of purpose.  This week's post examines the issue of informed consent as a means for making an informed choice.

Midwives and their clients are proponents of "educating" themselves and making "informed" decisions about the care they receive.  Women often feel "empowered" by making choices for themselves instead of inviting a physician to do so for them.  This brings me to the question, what does it mean to truly make an informed choice?  In order for someone to make an informed choice, giving their consent, they must first have some body of information on which to base their decision.  The word choice indicates that they are choosing between at least two options.

The aforementioned definition would imply that midwives offer clients balanced research, information that supports multiple perspectives, and then the client decides what is best for her without influence of fear or mantra.  In order to achieve the goal of making an informed choice a client also assumes that the research being presented by her midwife is credible, evidence-based, and in tact (meaning it hasn't been manipulated to influence her in a particular direction).    

After establishing a clear understanding of what informed decision making entails, lets look at the opposite end of the spectrum, indoctrination and brainwashing behavior. 

A) Indoctrination: 

1. To instruct in a body of doctrine or principles.

2. To imbue with a partisan or ideological point of view.

(Synonyms: brainwashing, schooling, training, inculcation, ingraining, instilling)

B) Brainwashing:

1. Intensive, forcible indoctrination, usually political or religious, aimed at destroying a person's basic convictions and attitudes and replacing them with an alternative set of fixed beliefs.

2. The application of a concentrated means of persuasion, such as an advertising campaign or repeated suggestion, in order to develop a specific belief or motivation.

(Synonyms: indoctrination, conditioning, persuasion, re-education, manipulation)

Now it's time for you to decide.  Below are a few scenarios for your consideration.  Each is based on real life experiences with out-of-hospital midwives in MI.  Read each one and determine in your own opinion if you think it represents informed choice or indoctrination.

Scenario I:  

The biggest decision a mother makes is where to have her baby.  When considering the options, every mother looking at out-of hospital birth asks the question, "Is it safe to have my baby outside the hospital?"  When touring a freestanding birth center early in pregnancy, here's how the conversation went for one MI mom ~

Client: Is it safe to have our baby here?

MW: Birth is as safe as life gets.  Your body was made to do this and women have been giving birth for centuries.  Birth centers aren't for everyone.  We screen our clients carefully and only take on low risk women with normal pregnancies.  In addition, we have attended hundreds of births.  We know how to spot trouble and get you the help you need in plenty of time.

Client: What if something goes wrong? 

MW:  The hospital is only 12 minutes away should you need to transfer care.  We transfer moms often and for a variety of reasons.    

Client: Have you had adverse outcomes before? 

MW: We did deliver one baby who we knew wasn't fit for life outside the womb.  There are no guarantees and babies do die in hospitals too.  Having your baby at our birth center is safer than the hospital, who has a cesarean rate of 32%.

Client: What does the birth center model offer in comparison to the hospital?  How do the two differ?

MW: The hospital staff does not know how to support natural childbirth because they don't often see it anymore.  They are bound in practice by limitations that insurance companies require of them, like not letting you eat during labor, tying you to a bed with an electronic fetal heart monitor, and giving you IV medications.  In a hospital, you are subject to the doctor's protocols and decision making, and much more likely to receive unnecessary interventions.  At the birth center, babies are born gently, in comfortable rooms, and in birthing tubs.  Your instincts guide you, no one is telling you when to push or how to move.  You can eat and move freely and let labor progress naturally.  

Comments:  What evidence-based information was given to inform the client from Scenario I?  The only fact I can find is the cesarean rate for the local hospital.  Were there any risks discussed for either option? How can this client have made an informed choice when she was only told about all the wonders Natural Child Birth & what the birth center has to offer, but none of the specific risks?  To say that, "There are no guarantees, they only take low risk clients, they transfer to the hospital and that the hospital is only 12 minutes away," is not an explanation of risk, they are marketing statements.  There is no talk whatsoever about those risks that come up in an instant during birth that can't be avoided, the potential for harm when those situations arise outside a hospital, or the benefits that modern obstetrics can offer in certain situations.  There is no discussion about what would constitute high-risk.  There is however a lot of implicit philosophy already starting to be suggested as superior.  With NO discussion of risks involved, how can this client make an "informed" choice about where to have her baby safely?

Scenario II: Approaching 20 weeks, a midwife asks her client if she'd like to have a 20 week ultrasound.

Client:  Is there a reason to have an ultrasound other than finding out the gender? 

MW: It's really up to you.  There's no reason to have to do an ultrasound.  In fact there aren't really enough studies to know if ultrasound technology is 100% safe for babies in utero. 

Client: Well we don't want to know the gender and I guess if there's no reason to do one, why take the risk? 

MW: Here's our waiver form to decline an ultrasound if it isn't something you want to do.  The choice is yours.

Comments: Again, influence of opinion or sharing evidence-based data?  Does this conversation show balanced information that would lead a mother to make and "informed" choice? Does signing a waiver mean she's been "informed"?

Scenario III:  A birth center client is asked if she would like to do the typical Gestational Diabetes Screening, after all the choice is hers to make.  The midwife gives her client a piece of paper to read over that explains what Gestational Diabetes is, who is at risk, and how to avoid/treat it.

Client: Is this testing necessary? 

MW: Considering your nutritional habits, I don't see any reason to be concerned.  You can have the testing done if you want to. (Note: this particular client of average weight and height, has gained 40 pounds already, by 24 weeks gestation)

Client: What would happen if the test came back as concerning? 

MW: You would have to monitor your diet more closely and with appropriate effort your baby will be fine.   
Client: What are the concerns about having a baby with gestational diabetes?  

MW: The babies are generally larger, but you body won't grow a baby too big for you to birth.  Being labeled as having Gestational Diabetes increases your chances of having lots of interventions and a c-section.  Here is our waiver form if you decide to decline testing. The choice is yours.

Comments:  Influenced or Informed?

In any of these scenarios, was evidence based information given from multiple perspectives?  Was information given without biased influence?  You can't make a choice about something with only partial information and NO explanation of risks involved.  You also can't make a clear choice about something when you're being subtly indoctrinated to think a certain way about birth.  Bear in mind too, that this subtle indoctrination is coming from the very people you have come to trust, when you come through the door each week for you hour long appointment, greeted with a long hug from a supposed friend, and offered a glass of pregnancy tea.  

The goal of all those caring for pregnant women should be to teach them about birth so that they can fully engage in the journey, rather than to indoctrinate them in a narrow set of beliefs. The key to making an informed choice is first having all the information necessary to consider and decide upon. It's being informed of all of the risks on both sides of an issue.  To be "educated" is to have information from multiple perspectives, not just one point of view.  Indoctrination and brainwashing are not synonymous with education.  Ladies you are not making "educated choices", the choices are being instilled in you, made for you, with carefully presented statements of untruth and a side dish of fear about how awful the hospital will be.     

Establishing standards for the practice of midwifery in Michigan is exactly what women deserve in order to have the opportunity to make an actual, informed choice.  In our current state of severely lacking regulation in MI, how can anyone make a choice about even selecting a midwife to attend a birth, when there is no way to know her number of infant deaths, injuries, complaints filed against her, desertions, transfers, etc.?  If there is no standard for education and scope of practice choosing a midwife is like trying to pick a needle out of a haystack, a haystack loaded with needles, and hoping you don't get pricked in the process.  Making an educated, informed choice about your care is nearly impossible within the current midwife model in Michigan. Time for change.   

For further reading on this topic, visit:  Deconstructing Informed Consent

The Roots of Dogma: Ina May's Religion & the Midwives Who Follow

dog·ma  n. 

1. A doctrine or a corpus of doctrines relating to matters such as morality and faith, set forth in an authoritative manner by a church.

2. An authoritative principle, belief, or statement of ideas or opinion, especially one considered to be absolutely true.

dog·mat·ic  adj.

1. Relating to, characteristic of, or resulting from dogma.

2. Characterized by an authoritative, arrogant assertion of unproved or unprovable principles

After reading the recent article in the New York Times about Ina May Gaskin and her battle for home birth, it all makes sense.  Now I know exactly where the dogma started.  

As I read the article, I learned more about who Ina May Gaskin is on a human level.  It seems to me that her perception of birth is much like a religion.  Her followers even reference her as a "saint" and feverishly distribute copies of "Spiritual Midwifery" to expectant mothers.  Apparently, being a saint these days means that you were involved in a four-person marriage, are proud of doing LSD and attending workshops to process your acid trip, and that you preach to the masses about just how safe birth really is without having any real education, medical training, or reported data to back it up.  The roots of Gaskin's movement are most clearly articulated with this sentence: "The participants in the caravan settled in Summertown, Tenn., in 1971. They took a vow of poverty and veganism and lived communally. Birth was a revered 'sacrament.'"  

Do women have a right to choose any religion they please?  Sure they do.  Do they also have a right to know whom they are following?  Absolutely. But (and this is a big "but") when a mom hires a CPM or a lay midwife to attend her birth, does she fully understand the dogma at the root of that woman's practice?  I don't think so. And this is the big problem that I see.

When a woman seeks the care of a midwife, someone who is posing as a professional caregiver, the expectation is that they operate under certain professional parameters, religion aside.  I have to believe that most women do not understand the dynamics of who it is they are hiring or how the the extremist nature of the "root" philosophy will impact the care she receives.  I know I didn't.  I was looking for a more personal model of care and thought birth to be an intimate experience.  I liked knowing exactly who would attend our birth and that our midwife would be present for the duration.  I thought midwives to be a safe, reliable, professional option...part of our health care system (as some are).  Surely it must be safe if they are running freestanding birth centers in the middle of reputable suburbs.

So what went wrong?  How did we end up in the hands of midwives who were so far from the professionals, the people we thought them to be?  What I didn't understand is the vast spectrum in philosophy that resides within the practice called "midwifery."  I wasn't looking for religion and I didn't knowingly volunteer my baby for sacrifice at the altar to advance anyone's cause, yet somehow that's exactly what happened.  Blind religious faith masked as natural childbirth and sold on a communal platter.  Some might call it a cult as in this post from 10 cm, The Cult of Natural Childbirth.  I must admit, in retrospect, much of this parallel seems eerily familiar.  Especially after reading about where the dogma started and after personally experiencing the backlash from the NCB community after speaking out about our experiences.           

What bothers me most is that the "Big Push" for midwives is aimed at the general population. Women are brought into the care of extremist midwives with specific selling points and marketing tactics that make birth sound alluring and empowering. There is no honest discussion of the real risks involved.  Ina May is a good saleswoman - she has already successfully marketed her cause across the country, with 27 states now licensing CPMs (who are directly trained and credentialed from Ina May's organizations, MANA and NARM).

How is this happening when most don't fully realize just how extreme the founder's roots really are?  How can someone earn a license to attend life and potentially deadly events without an education?   How are these women earning the privilege of attending our births with no oversight or accountability whatsoever?  Dogma cannot be allowed to influence maternity care.  Best practices must be defined, standards of care established, reporting outcomes required.  I hope we can reach women in MI and help them understand the complexity of this issue before Michigan makes the same detrimental mistake. Please visit:  Top 10 Reasons Why HB5070 Would do More Harm Than Good.

Every woman has the right to know exactly where this movement is coming from and what it's all about. They also have the right to know how many families it has adversely affected through infant loss and injury, BUT unfortunately, without regulation to require reporting outcomes, we don't have that data. We just have small voices fighting to be heard.  To read more about some of those small voices, visit: Hurt by Homebirth

Click here for Another reader's review of the NYT article .

To read more about dogma in midwifery visit: 

N.A.R.M ~ No Accountability, Renegade Midwifery

The "Whistleblower Midwife" & More

Midwife Masquerade: What Does Your Midwife Believe? 

Midwife Masquerade: Denial

Should my midwife be my friend?

When Our Baby Died

Freestanding Birth Centers ~ Common Myths Revealed 
The Hypocrisy of Midwifery

The Hypocrisy of Midwifery

I'm growing weary of the hypocrisy that permeates much of midwifery and the accompanying NCB (Natural Child Birth) advocates that can't see the forest through the trees, despite their own great experiences. Those who "sell" natural childbirth say that it is safe and put it on a pedestal. But when a baby dies, they quickly change their tune and say that it was the parents "choice."  Never mind that the risks were never part of the conversation from the start, at least not in an honest way.

How is it that midwives can claim that home birth is safe - as safe as life gets, safer than the hospital - BUT the minute a baby dies the mantra shifts dramatically to place responsibility on the parents as having made the "choice?"  

Dear midwife, ...Wait a minute, I thought you said it was safe?  Isn't that the "choice" I made, choosing something safe, the educated choice that was better for me, for my baby?  I don't remember making a choice to put my baby's life at greater risk?  Did we talk about risks?  I don't remember talking about them, but I do remember talking about how close the hospital was, how sure you were that you could spot trouble with plenty of time, how we are born to do this and babies know how to be born, how you've been delivering babies for 30 years with a spotless record.  I remember choosing you because you told me this was safer for me and for my baby.  I remember all the awful things you taught me about what the hospital and doctors would do to me if we went there.  

I remember you telling me that a breech baby is just a variation of normal, that they tend to fall out.  I remember you telling me that you were confident in delivering him, that we didn't need another, more experienced midwife to be here.  I remember you telling me that recent research supports vaginal breech delivery and that we were good candidates for said delivery.  I remember you telling me you watched a video once on breech birth, was it Ina May's from 1980?  I remember you teaching me to trust birth, and building a relationship in which I would trust you, and I did.  Turns out that trust is exactly what blurred my rational thought.  Our baby never came home.   I trusted you to know what you were doing and to tell me the truth about risks involved so I could make a "choice".  

Instead, the choice people speak of was taken from me, by intentionally manipulating information and conveniently avoiding conversations about real risks involved.  Perhaps I should coin the phrase "choice rape" here. 

Things get even uglier when NCB advocates start defending negligent midwives by saying, "Don't take my choice away just because things went wrong for you.  Maybe you should  have done more research and picked a better midwife."  Why is it that in the Natural Child Birth movement, women are continually exhorted to "educate yourself, mama!" and "take responsibility" for your birth? We don't do that with any other aspect of medical care -- we don't tell women take responsibility for their own breast cancer treatment! Plus, to what degree can a person truly educate themselves when their main tool is the trust they have with their care provider (one who claims to be a professional), and frankly, Google?  I am not a researcher, nor am I a physician.  I am a mother who trusted her care givers to be professionally competent & honest in an area that they posed as an expert.

Dear midwife, . . . Why is sharing the truth about adverse care so viciously attacked?  Why does your good experience with a midwife mean you were smarter than me or did better research?  Why does your good experience mean we should excuse situations that weren't handled properly?  Do you not care about the fact that negligence is happening and being brushed under the rug?  Why should we not hold midwives professionally accountable?  Why should they fly under the radar without reporting outcomes, getting a degree, or carrying insurance?  Why is this about hoping you get lucky in whom you choose to attend your birth and not about consistently reliable standards of care & ethical practice? Why does asking for midwifery to improve its practice, be accountable, and function in a way that is professionally safe, somehow threatening to a woman's choice?  Holding midwives accountable is about doing the right thing, about making negligence known, and ensuring bad things don't happen to other families, not about taking away anyone's choice!   Why wouldn't we aim to improve midwifery if it really has something to offer?   

The hypocrisy has to stop.  Either out-of-hospital birth is safe, or it's not.   
A midwife is either ethical and responsible 100% of the time, or she's not.  Women are being educated about real risks or they are not.  
We're either making a truly informed "choice" or we're not.  
Midwifery is a profession of highly educated professionals, functioning on behalf of the safety and a well-being of mothers and babies...or it's not.     

Related Posts:

Ask an OB: "Risk Out" Criteria

Midwife Masquerade: Denial

The Importance of Defining Risk

Considering Out-Of-Hospital Birth?  Questions to ask your midwife.

Ask an OB: Red Flags

"Ask an OB" is a weekly series with Dr. Maude "Molly" Guerin, MC, FACOG. If you have a question for her, please share it with us here.

What signs should midwives be looking for in labor that signal the mother and/or baby need additional help? It seem that other birth attendants (like dads!) would also like to know these signs and help look out for them. -- Lansing area family 

“Needing additional help” falls in to four categories:
1) Baby not tolerating labor
2) Mom exhausted/too painful to continue without medication
3) Labor not progressing as it should, especially if membranes are ruptured
4) Mom's status is concerning  

1.) Baby not tolerating labor
To know this you have to listen to the baby’s heartbeat FREQUENTLY. American College of Obstetrics and Gynecology recommends listening before, during, and after a contraction every 15 minutes in active labor, and every 5 minutes during pushing (which will be almost every push most likely).  Adhering to this standard will find most cases of severe fetal compromise. Subtle, earlier changes that are marked by loss of “variability” without changes in the “rate” of the baby’s heart will not be picked up by this method.   
You can read this article for details. 

2) Mom exhausted/too painful to continue without medication

3) Labor not progressing as it should, especially if membranes are rupture
In a “normal” labor, first-time moms will progress about a centimeter an hour during the “active phase” between 4 and 10 cm. The “latent phase”, from 0 to 4 cm can take a lon ger time, up to 24 or even 48 hours. Pushing can take up to 2 hours and be considered normal.  So anything outside this time frame (24 hrs latent phase, 6 hrs active phase, and 2 hrs pushing phase) should be cause for concern. Previous vaginal delivery shortens all these numbers dramatically! Pushing more than 1 hour would be abnormal in someone with a previous vaginal delivery. Many many women will not fit this time frame and be perfectly fine, and we do NOT put women on a timetable in labor! But an alert accoucheur will prick up her ears when these thresholds are crossed and begin to discuss the situation, try to figure out why (baby too big? Labor poor quality? Baby in unusual position?), have Plan B in mind, and do the simple things that can help (hydrate, position change etc). As time goes by and no progress is made, despite best efforts, transfer is a good idea. Frequently pain relief, rest, and augmentation to make contractions better will result in a vaginal delivery. 

4) Mom’s status concerning 
Fever, high pulse rate, excessive pain, high blood pressure, severe headache, blurred
vision can be signs of preeclampsia or infection. Transfer is mandatory if these are suspected. 

You can read more about Dr. Maude "Molly" Guerin, MD, FACOG, right here. 

Should my midwife be my friend?

There is an interesting dynamic between an expectant mother and her midwife.  Those of us who have experienced this relationship know how binding and powerful it can be. Of all the aspects of this relationship, there are two that stand out to me as being problematic. One is the false sense of empowerment and control that is cultivated in the mother as she prepares for birth. And the second is, quite simply, the the highly intimate nature of the midwife/client relationship. These things can complicate the relationship to the point of compromising care, leaving women vulnerable and targeted for unbalanced influence that could put them and their babies in harm's way.

First, let's consider the issue of empowerment and control. If I had to paint a portrait of the kind of women who seek the care of midwives, one of the defining characteristics would be their tendency to carefully analyze every decision they make.  Mothers interested in midwifery care are reflective, educated, well read, and thoughtful. They don't make any choice without asking questions and they don't do things just because it is considered the norm.  They search long and hard until they feel completely reassured that they're making the best choices for their baby. Ironically, this is the type of woman who seems particularly vulnerable to being swept up in the arms of midwifery.  

In fact, these women who think they are "educating" themselves about birth (doing all their homework, so to speak), are the same mothers being seduced by imagery and manipulated data from the NCB community. They are assured that home birth is safe - safer than hospital birth.  They are told that hospitals use too many unnecessary interventions.  They are told that what would normally be considered a high risk factor is "just a variation of normal".  They are told that our culture has lost the ability to birth naturally, robbing us of the opportunity to "experience" birth and keeping us from being the women we were born to be. But the midwife's sales pitch for natural birth is often one-sided, with a stark and deliberate absence of information offered about the inherent risks of out-of-hospital birth. As the midwife builds up the appealing (and false) image of the gentle and safe nature of birth, the mother develops a sense of pseudo-empowerment and a false sense of understanding. The image of a perfect natural birth starts to take shape and the mother's determination to achieve it settles in.   

Essentially, through very carefully crafted and presented propaganda, women are offered an important motivator in deciding to birth outside a hospital - the illusion of control.  In out-of-hospital birth, the woman is taught to control her thoughts, to "trust birth" and to listen to her intuition to guide her through labor.  Her cervix isn’t checked unless requested. She isn’t told when to push. She relies only on her own instincts.  These mothers feel as though they are making a conscious decision about everything from environment to having the freedom to birth the way they choose . . . as if it's as simple as picking out what to wear for the day.  Midwives cultivate this notion by assuring moms that, simply by being women, they are experts on labor and birth and will therefore be able to make the best choices for their babies. As the big day approaches, women develop a false sense of control and unrealistic expectations for their birth experience, including the charming idea that they will somehow be "empowered" if they are able to accomplish this feat "naturally". 

In reality, we must all admit that birth is not something that can be controlled - not by mothers, not by babies, not by doctors, and certainly not by midwives. At best, a doctor or midwife can attempt to guide us through the experience, watching to keep us safe and taking action when things aren't going right.  We cannot control birth and being led to believe that we should is deceiving. 

Another element of the dynamic between the expectant mother and the midwife that proves problematic is the idea that your midwife should not only be your caregiver, but also one of your closest friends.  Midwives sell themselves on the fact that they spend hours of personal time getting to know you and your family intimately. But consider for a moment how creating that kind of close, personal relationship with your care provider can backfire. Establishing an intimate relationship with your care provider can establish a false sense of security and build unfounded trust. Personal relationships involve emotion and those emotions directly affect your ability to make clear and balanced decisions.  This is where the “midwife spell” comes into play.  When a midwife has taken the time to get to know you and bond with you, their influence upon your decisions becomes quite powerful.  “But with great power (and friendship!) comes great responsibility” and, sadly, in some cases the nature of this power becomes unbalanced and potentially manipulative.  This is why we hear stories of women trusting their midwives far beyond what a rationally thinking woman would do.  (Examples: extremely prolonged labor, using garlic to treat Strep B, attempting high risk births outside a hospital such as breech babies, multiples, and VBACs, etc).  In these cases, trust and personal relationships become a liability and can prove detrimental to overall care.

These dynamics between mother and midwife are key components to "advancing the cause" and many women don't realize they are buying right into it.  As she seeks control over her experience and a competent friend/midwife to guide her through it, a woman leaves herself vulnerable to manipulation and influence. She is lulled into a false sense of control and subject to making poor decisions based upon emotional ties.  Then, when things go wrong, the responsibility immediately falls upon the woman and family for having made the choice of out-of-hospital birth.  Never mind that a true “choice” cannot be made if all facets of risks and benefits aren’t presented for evaluation. For many women who believe in making educated choices, and even those who defend their right to have a choice in where/how they give birth, they don't realize that choices are being made for them all along the way. 

When it's all said and done, who would you rather employ? A competent doctor who lacks bedside manner but who keeps your baby safe, even if it means having to make tough decisions that you might not like? Or a midwife who is your friend and encourages you no matter what, but puts you baby's life at risk? I think the answer is obvious.

When Our Baby Died

When our baby died, we thought we were alone and that no one on earth had experienced the devastation we were feeling.  Over time, we learned that there are many families left behind by the dark side of midwifery.  Over time, we learned that our loss experiences were eerily similar. Over time, we came to realize the bizarre spell that midwifery had cast upon us, a spell that took hold of us for months following our baby's death.  

Below is a series of steps that outline how the grieving progression went for us over the first year since our baby's birth and death.  The purpose in sharing this is for other mothers and families to realize they aren't alone.  There are threads we all have in common, not only in loss, but in coming to grips with the experience of negligent care with midwives, and how it affects our lives afterward.   

(Traumatic birth - 3 months)  
1) We experienced Devastation; Shock; Nightmares; Difficulty Breathing

2) We desperately tried to protect the way our baby was remembered, including the fact that he was born at a birth center instead of a hospital. We felt determined to defend our midwives.

3) We tried to make sense of everything by telling ourselves that our midwife did everything she could, that babies die in hospitals too, etc. . . . but that didn’t seem right.

The following link has been copied and pasted from a former Oregon blog about midwifery and provides an analysis of the psychological relationship that takes place between mother and midwife after loss.  Reading this put into words what I have been trying to describe about the "spell" that it seems we were under in the days/months after our baby's death.  This post defines and explains the progression of how women react and why after losing a baby with her midwife.  

Psychological Analysis: “The MidwifeSpell” after Loss

(Around 3 months postpartum) 
4) We started to realize that things didn't feel right. We felt deeply unsettled. Our midwife's explanation that "some babies aren't meant to live" never left me. It kept nagging at me to find out more about what actually happened.

5) We started to ask questions of our own midwives, then of other midwives and obstetricians, too.  We talked to the EMTs and doctors in the RNICU that tried to save our son’s life.  We started to read in detail what recent research said about our kind of birth. We asked for medical records.

6) We understood that our baby's death was preventable, that we were put into harm's way to advance an agenda, that our midwives lied to protect themselves, that our labor and delivery was grossly mismanaged, that we had been severely uninformed, and that what we had experienced was extreme negligence. 

(Around 6 months postpartum) 
7) We slowly started to realize there are other families who had experienced the same thing, both here in our very community (under the care of the same midwives, same birth center) as well as across the country. It began to feel like an epidemic to us.

8)  We learned that loss & injury in home birth is more common that most people think. We learned that most families don’t talk about it and, tragically, that the birth communities they held dear usually blame the parents.  We learned that midwives have contrived responses to loss.

Below is a link to the "10 centimeters" blog about common reasons given by midwives to loss moms.  It is insightful to say the least and helped me understand the dynamic I was personally experiencing as I tried to gain understanding of what had happened. 

 What We Say to Loss Moms (10 centimeters) 

(Ongoing)

9) We experienced other kinds of loss. Yes we lost our baby, but we also lost our faith, our trust in humanity, any feeling we formerly had of being protected in this world, and our confidence in our ability to make decisions.  We felt embarrassed, too - foolish for not having seen who our midwives were and for trusting their guidance.  I still feel like I’ll never be a good enough mother a) for not knowing something was wrong and b) not being able to see this coming.
 

(Around 6 months - present)

10) We learned there are no regulations, no reporting outcomes, no insurance requirements, and no accountability for midwives in Michigan.  We feel compelled to change that in an effort to protect other families. 

I hope that this post reaches other mothers out there who have struggled to understand loss with a midwife or loss under negligent circumstances.  The message intended in sharing our experience is that you are not alone.  I hope this post offers insight that, in some small way, resonates with your experience and further helps you move forward.  Please send us an email using the "contact" tab for further support.

(Another post coming soon that examines the relationship more closely between mother and midwife entitled, "Should my midwife be my friend?")  

Midwife Masquerade: Denial

Yesterday we talked about the wide range of birth philosophies that influence midwifery. This range of beliefs creates an enormous disparity in quality of care that is not always apparent to mothers and families searching for a caregiver. While it might be easy for a family to assess a midwife's credentials, it is more difficult to evaluate her philosophy of practice.

In the past here on the blog, we've also noted the phenomenon of the NCB (Natural Child Birth) community throwing support behind midwives instead of families when "unfortunate outcomes" come to light. Those families who dare come forward to share their horrifying experiences of loss and grief, find themselves against a defensive community of NCB supporters, claiming that the family is on a "witch hunt" instead of seeking accountability. I think there are three reasons why this is happening.

One of the biggest reasons is simply because the majority of these supporters are women who have had only good experiences with a midwife. They instantaneously feel as if something they hold dear is threatened. Some of these women do not yet fully understand the vast differences among midwives, nor do they understand why it matters because they have only had positive interactions.  In essence, they still are living within their bubble of beliefs, in an echo chamber - not understanding how midwifery could stand for anything but the best birth experience imaginable.

The issue of misplaced support and understanding in the NCB community is perhaps further explained by the notion of denial. It is very difficult for people to feel like something they researched, believed in, and trusted could be misguided.  How would that reflect upon our own choices?  It would make us look foolish for believing in it in the first place, let alone recommending it to our friends.  The first instinct then is to defend their choice, to protect their midwives, to tout their good experience, to cry "don't take our choice away just because you had a bad experience."  

The last reason I believe the NBC is quick to shun mothers and families who have experienced loss is deeply personal and has to do with the relationship between a woman and her midwife. When a woman hires a midwife, it's because she believes in birth being natural and she appreciates the personal care a midwife can offer.  Women seeking a midwife often are looking for more.  They want to feel like they are being educated, empowered and valued. They want to feel like they are part of a community (one that can extend past birth and into the child-rearing years) that appreciates birth for all its beauty. The point here is that many women consider midwives to be their friends, sisters, or mothers.  And when the buzz starts to rise about things going wrong, it is nearly impossible to admit that your friend, sister, or mother-midwife would do wrong, even if it is unintentional.   

The truth is that a midwife's beliefs vary widely.  These beliefs significantly impact the care they provide, especially during emergency situations.  If you have a picture perfect birth, without complications, of course your midwife is great.  It is the moments when things aren't going right that you need your midwife to take decisive action to keep you and your baby safe. When the NCB community blindly supports midwives just because they are midwives, they are fostering the downfall of the profession.  If we cannot look at this profession analytically, acknowledging the failures in and effort to improve them, eventually it will fall.  Living in denial and ignoring families who speak out in order to protect something that is false, or at best misunderstood, cannot lead to improved practices.

To "masquerade" is to pretend to be something one is not.  I believe some midwives are pretending to practice safely, claiming they attend low risk births when in reality they are not, claiming that "birth works" for everyone and at all costs, and creating a false image of birth as being inherently safe.  Their followers are creating a space of denial in which these midwives reside, protected by the practices of the midwives acting responsibly and the confounding variability that is implicit in the term "midwife". 

Midwife Masquerade: What does your midwife believe?

We can talk about midwifery credentials and regulations (and those things are important!), but there are other things that are just as influential in a midwife's practice. Let's consider birth philosophy, relationships, & ethical practices. This gets us to the heart of an issue brewing within the profession of midwifery that few realize and even fewer understand until it is already too late: there is a vast array of beliefs and practices all of which fall under the umbrella of "midwifery".

Masquerading behind the title "midwife" causes much confusion for the consumer of midwifery and makes it quite difficult to "know what you're getting" so to speak.  When the mask is removes, we see that some midwives are very responsible, highly educated, collaborate with hospitals when they are truly needed, and value the role of risk in their practice.  They transfer fluently, without hesitation and don't take chances they don't need to take.  In contrast, there are midwives who believe blindly that "birth works" and exercise that philosophy at all costs, without appreciation for the fact that sometimes women in labor need more help than they can offer. These midwives ignore warning signs, teach their clients to fear the hospital, and constantly put mothers and babies at risk to adhere to their own philosophy.  They don't transfer willingly or fluidly (even though they may claim to do so), they take on risks they know they aren't qualified to handle, and take the chance that the outcome will be good.  These are two very different ways of practicing midwifery. (Note: Being a nurse midwife doesn't necessarily mean the former.) 

I don't think these two polarized philosophies are talked about, and they are certainly not clearly understood by the consumers - mothers and families. Every woman wants to believe her midwife is the responsible type, not the kind that would throw you under the bus for the sake of the "trust birth" mantra.   Women who hire midwives are asking questions about credentials (I hope!), but how can we really know about what a midwife believes about birth and how these beliefs will impact us in a time of crisis?  It is nearly impossible.

  

When you've had a terrible experience with a midwife and your baby is injured or dies, you start to question yourself and everything else around you.  Then, and only then do you start to see that some of the fallout within the profession.  You slowly stumble across stories of other mothers, their unfortunate outcomes, and start to talk to other midwives to gain perspective about what happened to you.  Over time you come to understand how vast the gap really is among midwives within the profession and, most likely, you realize that you trusted someone who trusted birth to a fault . . . to the point that they sacrificed the safety of your baby and left you to pick up the pieces.

A close examination of the wide range of practices and beliefs within the profession needs to be considered.  Women who are hiring midwives deserve consistency in caregivers across the profession.  Hiring a midwife should mean something that is clearly defined and consistent in educational standards, scope of practice, and philosophy.  The way it stands now, hiring a "midwife" is a blind game of Russian Roulette and families are paying the price.

The Importance of Defining "Risk"

Risk:

1. The possibility of suffering harm or loss; danger.

2. A factor, thing, element, or course involving uncertain danger; a hazard

As beautiful as birth can be, there is no arguing that it presents an element of danger and with that comes risk.  No matter where a baby is born, there are risks involved.  The greater questions are: How is risk defined?  What is considered "low-risk" and "high risk"?  How is risk assessed?  When do potential or actual risks provoke action?  What resources are immediately available to evaluate risk and take action if needed?  What will those actions be and who will make the decision that action is required?

Both the philosophy of the caregiver attending your birth and the environment in which you are giving birth greatly impact the answers to these questions. For example, a hospital is built on the practice of constantly assessing risk and using the resources immediately at hand to eliminate them.  They take on the patients with the greatest amount of risk and have endless protocols, technology, guidelines, and review processes to continually minimize them. In out-of-hospital birth, the answers to these questions get messy because they depend almost solely on the individual attending your birth and the philosophies that person carries with her.  This is especially true in states like Michigan, where there are no defined practices for what midwives can and cannot attempt in terms of risk.  

We often read or hear that home birth is "safe" for low-risk women or that midwives intend to attend only low-risk births.  Yet somehow, there are hundreds of women across the country sharing stories of babies who didn't survive out-of-hospital delivery for reasons that have more in common than you might think: breech delivery, VBAC (vaginal birth after cesearean)/Uterine Rupture, multiples, post date, macrosomia, etc. Do these situations come about as a result of error in assessing risk or are they an attempt to prove "birth works" by purposefully taking on what most would define as high risk births?  Truth be told, I believe the answer is a little of both.

For some midwives, nothing is considered high risk if you "trust birth".  In fact some proclaim that "birth is as safe as life gets".  Every situation to these midwives is "just a variation of normal".   Does anyone stop to think about what that really means?  Isn't anything that deviates from normal, no matter how far the deviation, considered a "variation"?  Maybe it's the use of the word just in this case that makes it sound so causal when the reality is that many of these conditions put mother and baby at much greater risk for birth injury or worse.  

The truth is that evaluating risk out-of-hospital is inherently more difficult and less precise because midwives do not have all the resources and technology available to assess basic statistics, like a baby's position and size. Midwives are only able to offer their best guess based on what they feel with their hands and sometimes this "stab in the dark" assessment is terribly inaccurate and inadequate.  I've heard stories of midwives who thought they were delivering a placenta and ended up delivering twins, as well as surprise breech deliveries . . oops! So, while some people argue that hospitals intervene too much because they over-evaluate risk, we must appreciate that they are often able to provide valuable information and services that are well outside the scope of midwifery.

Because out-of-hospital care is more difficult to manage, it is absolutely critical to engage the services of a competent midwife. This mean many things but, most importantly, she must operate within a clearly defined scope of practice (shared with you in writing in advance) and attend ONLY low-risk births. Within these parameters she must be skilled at evaluating risk, have clear definitions of "low" & "high" risk and be decisive in taking appropriate action (transfer of care) when things go pear shaped.  Incidentally, she must have a working relationship with an OB and hospital to ensure smooth & confident transfer of care.  

Even when a competent midwife attends a low-risk birth, emergencies can still creep up in an instant. Having adequate training and resources immediately available can make the difference between life and death.  The way your care provider defines, assess and acts upon risk factors and the tools she has at her disposal, will greatly impact the outcome of your birth. 

What else can help ensure that adhering to scope of practice and attending only low risk birth actually happen?  State regulation.  Michigan needs to define safety protocols for out-of-hospital birth, define midwives as only taking on low risk birth, and spelling out exactly what circumstances require transfer of care.  The countries that have had great success with midwifery have done just that.  Both the Netherlands and Canada have established absolute and non-absolute criteria for transfer of care and physician consultation.  They consider theses practices a screening mechanism to help consistently identify good candidates for out of hospital birth, a) to minimize risk and b) to ensure the best possible outcomes.  This kind of regulation helps a profession such as midwifery define its scope of practice and institutes a measure by which to hold its practitioners accountable.  Midwives regulating midwives is not responsible, ethical, or effective.  Just ask the families who have lost babies in the hands of midwives operating far outside these parameters.  Time for change. 

"The Whistle Blower Midwife" & More

I recently came across an excellent post called "The Whistle Blower Midwife" over on the blog The Reformed CPM. The author is Mindy Wolfe, a midwife practicing in Indiana. Her blog is fairly new with only a few posts up so far, but it promises to be a great resource for all of us moving forward. Her writing is honest, insightful and extremely poignant as it relates to the training/practice of "certified" midwifery.  Her perspective as a midwife about these issues resonates strongly with my own experience as a client.  

Here is Mindy's introduction: "I chose to become a midwife with the intent of helping women and their families.  I did a majority of my clinical experience at a free maternity clinic in the Philippines and then came back to the States to pass the NARM exam and become licensed in New Mexico.  Shortly after graduation, I moved back to Indiana, where lay midwifery is considered practicing medicine without a license and a felony, so I actually never set up my own practice.  I did, however, have the opportunity to meet other lay midwives in my area.  I was appalled again and again by the lack of education and professional accountability I encountered.  I even had the brief opportunity to work as a birth assistant to a CNM who provides home birth services locally, but learned through that experience that legal care does not always mean safe care.

I have been compelled by my conscience lately that it would be wrong and a violation of my oath to "do no harm" to not speak up.  Women are, in good faith, choosing these practitioners without realizing the risks inherent to this choice.  I firmly believe that almost every single parent chooses the type of care that they do for the birth of their child motivated by a desire to offer the safest and best start in life.  Some practitioners unfairly, and in some cases perhaps unknowingly, twist this natural desire to fit their desire to advance a certain agenda.  This is unacceptable and can result in catastrophic consequences.  

Oversight and regulations need to change, but even more than that, the dangerous mantra of "trust birth" needs to get out of the driver's seat of anyone's health care to make room for care that truly respects women and their children.  Then we'll see real change."

Mindy is not alone in her thinking. There appears to be a new movement among doulas and midwives who trained as CPMs and are now speaking out about how dangerous the philosophy, preparation (or lack thereof), and home birth practices of some midwives really is.

Another example of this trend is a blog post called "Because I Love Her, The Need for Change in Home birth Care."  The author is a practicing doula calling for accountability for negligent midwives and speaking out on behalf of women and babies who have endured preventable loss.  This post makes me feel good - like slowly, some NCB (Natural Child Birth) advocates are hearing our voices.  The first step is recognition, then we can move forward together toward real improvement in maternity care.

Here are three other "reformed midwife" bloggers that are worth a read. They, like us, are advocating for improved practices, higher standards of education, and measures of accountability:

Midwife{ology}

Navel Gazing Midwife

The Sensible Midwife 

What are you reading these days? Is there a great blog, journal, or article about midwifery issues that you think we would enjoy? Let us know in the comments section!

Note: (Certified Professional Midwives are often referred to as CPMs.  CPMs were originally known as "lay midwives", then renamed "Direct Entry Midwives", and even later renamed "Certified Midwives".  Their credentialing body was founded by Ina May Gaskin in establishing first Midwives Alliance of North America: MANA, and later a branch entitled North American Registry of Midwives: NARM.  Both organizations are run privately, politically motivated, and irresponsible in reporting outcomes & holding their members accountable.)