Sunday, April 22, 2012

Considering Out-of-Hospital Birth? Questions to Ask Your Midwife

Note: "Out of Hospital" birth is defined as home birth or birth at a freestanding birth center, one that is not within the walls of a hospital.)  

A note about pointed questions: If you are embarrassed to ask the questions lest you offend the midwife, don’t be. Any midwife who bristles about these questions needs to be left in the dust. She should have complete composure, no defensiveness and be clear and truthful in her answers. If she can’t act professional with you, how will she act with a doctor in front of her if you transport? It’s a midwife’s job to answer these questions; it’s your right to know the answers.

Are you licensed?  What are your credentials and experience?
Being licensed, regardless of state is critical.  Do not hire a midwife practicing without a license.  Know the laws in your state.  In all states CNMs have a license, but CPMs are licensed in some states, not in others, and illegal completely to practice in yet others.  Even if you find a CPM who is licensed, please thoroughly understand their credential because it is far less education, clinical practice, and experience than a CNM.  The philosophy of their credential is also something to be concerned about. 

How long have you been practicing as a primary midwife for out of hospital birth?  How many births have you attended as a doula? As an apprentice? A midwifery assistant? How many births have you been the primary midwife with supervision and then without supervision at a homebirth for? How many births did you experience in the hospital setting?  
I can’t stress this enough, asking the midwife more pointed questions will give the woman more information than just, “How many births have you been to?”  But, what should the answers be? Because there is no standardization in midwifery education or skills training, the answer depends a lot on the woman.  It’s difficult to evaluate philosophy and character, indicators for how this person would handle your care in the event of impending danger or crisis.  The more specific questions you ask, the more information you have.  At a minimum, you’re looking for someone who has experienced hospital births, complications, transfers as the primary caregiver, and doesn’t hesitate to describe circumstances that were out of her scope of practice whereby care was transferred.  

Do you carry malpractice/liability insurance? 
If your midwife does not carry malpractice insurance, find another care provider.  This is an enormous red flag as it says a great deal about the philosophy under which that midwife is practicing.  Malpractice insurance protects them as much as it protects you.  It establishes a consistent set of guidelines for scope of practice, safety measures, and professional development for the caregiver you are hiring.  Without this is place, they can function in whatever way they please…and if they do act negligently you have NO recourse.  Insurance is a mechanism to ensure your safety and to help families who suffer negligent circumstances like preventable birth injuries and preventable deaths.  Don’t hire a midwife who isn’t responsible enough to carry insurance.  

How do you evaluate risk? 
This is another critical aspect of your conversation.  How much is too much risk and how will it be determined?  I don’t know precisely the exact answer, but your potential midwife should be able to explain exactly what she monitors, looks for, when she might be concerned, when she would transfer your care. 

What defines your scope of practice?
In other words, what types of births do you take on and which would you consider too risky?  Who regulates or determines your scope of practice?  If a midwife is running the show by her own rules, there is a problem.  Ask for a copy of her scope of practice from whomever has issued her credentials…it could be a state board via public health code or ACNM, a national credentialing body for Nurse Midwives.  What are they permitted to take on in an out of hospital setting? 

How do you define “high-risk”? 
Some midwives don’t think anything is too high risk for them to handle.  Many claim to take on only low risk, normal pregnancies, but somehow end up delivering breech babies, twins, women with gestational diabetes, women with high blood pressure…and on and on.  Even low risk, normal pregnancies can go wrong in seconds, but at the very least, establish a boundary of low and high risk in your own mind and with your midwife.  Consult an OB and ask this question too. 

Do you think a hospital is ever necessary and under what circumstances?
Your midwife should be specific about this.   A general “of course they are” isn’t going to cut it.  This question will help you get a sense for her attitude toward hospitals.  Does it sound like a working relationship?  Her answer shouldn’t be about mothers who aren’t strong enough or who fatigue, they should be about specific concerns for the labor and delivery of your baby…prolonged labor (more than 3 hours of pushing with little to no progress), too much pain, meconium present, size of the baby as determined with ultrasound before labor, baby’s position, multiples, high blood pressure, VBAC, gestational diabetes, group B strep...etc.    

What is your relationship with the local hospital?  What privileges or practicing rights do you have at the local hospital?  Does the nearest hospital have a Neonatal Intensive Care Team/Unit? 
Only hire a midwife who has a good standing with your local hospital.  Don’t just take her word for it, ask the manager of the Neonatal Care Unit, Nurses, Doctors, local paramedics.  Ideally, hire a midwife who has practicing rights or privileges to work and transfer along side you as part of your continued care in the event of transfer.  If your nearest hospital doesn’t have a Neonatal Intensive Care Unit or staff, out of hospital birth is not for you. 

What hospital do you transfer to?  What records & personnel transfer with me?  What would happen in the event of transfer?
You need to know where the nearest hospital is that includes a neonatal unit.  It doesn’t really matter how many minutes away the hospital is if your midwife doesn’t catch danger signs soon enough or her fear/ego gets in the way of transferring you in the first place.  A hospital 10 minutes away won’t matter once the crisis has hit.  The key is someone skilled, equipped, and responsible enough to catch it before it gets to that point. 

Midwives are also notorious for taking less than detailed records or sending no records at all during transfer.  You need to know what they note during labor, how that compares to an OB or L&D nurse, and what a transfer would be like.  (See post about what transferring is like.) 

Who determines/decides when to transfer?  What would you say to a mom who asks to transfer during labor?  What complications warrant transfer?  What is your rate of transfer? 
You are hiring a midwife to attend your birth as a professional, a so-called expert on birth.  They need to be clear that they will tell you when you are in danger and be a leader in deciding to transfer.  The decision should never fall on you during labor, nor should you ever be pressured to stay.  If your midwife starts to tell you about how long it will take for transfer to take place, that you’re so close…just a little longer, or if it seems like your midwife is avoiding transfer, indecisive, or stalling, get to the hospital!  .  

The list of transportable reasons is endless and it’s the midwife’s professional responsibility to know what they are. The midwife will surely say something like, “Breeches, twins, high blood pressure, a fever, baby’s heart tones are questionable.” They are hired to know when to transfer (non-emergency) and transport (emergency), but sometimes egos, fear, and mantra get in the way.   

Some states now have an exhaustive list of complications during pregnancy and mandate which of those requires a consultation with an OB and which requires transfer altogether.  If your state does not have these guidelines in place, you are subject to the will of the midwife, making out of hospital birth far more subjective, dangerous, and unregulated.  (Essentially a midwife can do whatever she wants…low risk, high risk…etc.)  If during labor, you or your partner is questioning the situation at all, please be a self advocate and transfer.  

Regarding what the hospital transport rate is, this can be taken any number of ways. Low transfer rate? She only takes very low-risk women, maybe none who’re having their first baby. Or, maybe she stays home hoping complications will resolve or she’s afraid to transport…which directly puts you and your baby in danger.  (See this website if you question whether this happens and how often.) Maybe she has a lot of experience and takes appropriately low-risk women. How are you to know why she has a high or low rate of transfer? You can’t; it’s all in how she sells herself. 

Do you work in conjunction with an OB?  May I have a few visits to get to know him/her?  Under what circumstances might I consult with your OB?
A midwife should always have a working relationship with an OB.  Before hiring any midwife to attend your birth, schedule an appointment to interview the OB as well.  Meet with the OB at the beginning and at the end of your pregnancy (before labor) at minimum.  Talk with them about your plan for out of hospital birth and whether you are a good candidate for this kind of delivery.  Share with them who you have chosen as your midwife.  If there is no relationship with an OB or the two are not mutually agreeing on your plan of care, out of hospital birth should be reconsidered.  

Who is your midwife back-up? 
Some midwives take on more than 3 or 4 clients a month. Be sure to interview the back-up midwives, too, asking these same pointed questions.

How often will I see you during my pregnancy? How long will prenatal visits last?
I’ve never known a midwife to see clients on anything different than the standard monthly until 28 weeks, bi-weekly until 36-37 weeks and weekly until the birth. Plus, appointments are almost always 45-60 minutes long, most of the time being spent on social interaction… getting-to-know-you aspects. The actual medical/technical part lasts less than 15 minutes. When going to an OB, the social aspects are what is often what mothers see as missing. (Please see an important post about emotional attachment and personal relationships, the way they can adversely affect sound decision making and leave you vulnerable to manipulation.) 

What is your philosophy about prenatal testing (Gestational Diabetes, Ultrasound, Group B Strep)?
If your midwife tells you any of the listed tests are dangerous or that they are unnecessary, keep looking.  They do them for good reasons.  If you’re considering more advanced testing, please consult an OB. 

What (emergency) equipment do you use/carry?
The answer should be: Doppler (preferably waterproof) with extra batteries, blood pressure cuff (two sizes), thermometer, glucometer with in-date supplies, lancets, IV equipment with in-date fluids (Lactated Ringers, Sodium Chloride, Dextrose 5% Lactated Ringers are the most common types of fluids needed in birth), in-date Pitocin (which is supposed to be kept cool), Methergine (IM and tabs), Cytotec (for postpartum hemorrhage), in-date lidocaine, in-date sutures of at least two sizes (one smaller one for the labia), in-date Erythromycin eye ointment and Vitamin K for the baby, in-date antibiotics for GBS+ women, scissors, needle holders, forceps (not the kind that pull babies out), oxygen (I always carried two tanks… one for mom, one for baby), a bag and mask with new masks for each baby (they are marketed as disposable; most midwives I knew re-used the masks [after cleaning]), in-date blood draw supplies, in-date catheters, and a Sharps container.

It can be hard to know what answers you’re looking for when you ask a midwife about various complications.  The above list is a minimum and is no guarantee that they will have what they need when an emergency arises.  When emergencies come along they do so quickly, sometimes w/o warning on low-risk, normal pregnancies.  The best place to handle complications is in the hospital.  More important than any equipment is a midwife who appreciates and is skilled enough to spot trouble before it’s too late and has the respect for birth to get  you the help you need.  

If your midwife starts to use fear tactics, telling you the horrors of cesareans, that epidurals will lead your child to be a drug addict, that fetal heart monitoring is only so insurance companies can make a profit, or showing you disturbing videos about circumcision, find another care provider.

Please see our FAQ Page for more information.

Find your state’s public health code and determine what regulations there are for midwives in your state.  If there are none, that is a red flag.  
Nurse Midwives in MI are currently defined under "Nursing".  You will find next to no rules even for nurse midwives in our state.  CPMs, lay midwives, & birth centers are not regulated at all.  There are no safety guidelines for out of hospital birth in the state of Michigan, making standards of education, care, and practice inconsistent and making accountability nearly impossible.  Out of hospital birth in Michigan is an unregulated practice at present. Please see Michigan's Public Health Code  for more information. 

Written by Barbara E. Herrera, LM, CPM (aka Navelgazing Midwife) and augmented by Sara Snyder

1 comment: