Wednesday, August 1, 2012

Home Birth Story: Women deserve not to be their own midwives

I feel compelled to share the perspective of an Ex-CPM student and her experience(s) with home birth.  Please note the inconsistency in practice or standards of care among CPMs.  

"I had two home births attended by certified professional midwives (CPMs). I gave birth to my children amidst my own training to become a CPM. I apprenticed with a number of CPMs and was enrolled in a MEAC accredited midwifery program. I add these details because I was not the average pregnant and laboring mother – I had experience witnessing and participating in home births, and I had knowledge of midwifery and standards of care for pregnancy and birth.

I value and cherish that I’ve given birth my babies at home. I had no unusual reason for birthing at home: I wanted woman-centered, family-centered care,  I wanted to avoid drugs or procedures in absence of complications, I believed my body knew how to give birth, and I wasn’t afraid of the pain. I appreciate the midwifery model of care – I personally selected and knew my midwife, and knew she specifically would attend me during labor and follow up with me postpartum.

I have a lot of conflicting thoughts on home birth due to my experience with it in many different roles. As having been a doula, an apprentice, a home birth assistant and a midwifery client I am intimately aware of the many shortfalls of home birth and “professional” midwifery.

Recently I learned the term “black hole” used to describe what is lacking in midwives’ training. It is so perfect to describe what is missing – it is a black hole – and because no light escapes a black hole – no one is really aware of the lack in knowledge or skill. It’s just missing. Absent.

I had knowledge and experience with many area midwives, but choosing my midwife was quite hard. Because as much as they provided “woman-centered” care, they also provided care that was based on their own personal fears and biases and superstitions. Maybe these weren’t black holes, per se, but there were voids in my care that I knew I would have to fill somewhere else.

For instance one of my midwives did not use the Doppler during prenatal care. (I believe she had one for waterbirths, I’m not certain). Because I knew many midwives in my community, I could ask a friend to meet me in a parking lot and get heart tones in the first trimester of my pregnancy. Which is what I did. 
One of my midwives sort of eschewed routine prenatal blood work. So I found a friend (a midwife) who would do my prenatal blood panel and 28 week blood work.  I was filling in the holes in my care – to create the care I wanted.

Neither of my midwives made any recommendation about finding a back-up hospital provider during my pregnancy. I did this. Twice. With two different area physicians. Both physicians were willing to come in to take over my care during labor if a transport to the hospital was necessary. Both physicians were agreeable to backing up my home birth plans and ordering any tests (BPP or U/S) if there became reason  to do so during my pregnancy. I would not have given birth at home without this arrangement – though neither CPM during either pregnancy ever mildly suggested that I do this.

The CPMs I hired for my care had very different postpartum follow up care than the care that was provided in one of my apprenticeships. There was virtually no postpartum instruction regarding how to care for my baby, myself, or warning signs that would necessitate immediate medical attention. I couldn’t tell if these things were being omitted because they assumed I knew them already as a student midwife, or if it wasn’t a part of their routine care at all. I knew postpartum instructions and things to look for because the midwife I apprenticed under did this quite thoroughly. But again, this created another hole I had to fill.

I go back to how much I appreciate that home birth was an option for me – but I don’t know that I can recommend home birth with either of these midwives to anyone – and for various reasons.

And after working with many midwives, and being attended by two different CPMs for my own births, it has really struck me how there is NO STANDARD of care by these “professionals.”

If anyone were to ask me to recommend midwife “A” or midwife “B” as their maternity care provider, I would feel obligated to give a list of things that they don’t do: “You’ll have to find someone to do your prenatal lab work.” “They’re superstitious about vaccines/GBS screening/hospital back-up. “ “She won’t use a Doppler during prenatal appointments, so you might not hear the heartbeat.” “She doesn’t work with trained assistants.” “She won’t recommend any physician to provide back up, but Dr Y and Dr Z are two who will back up home births.”

It is hard for me to think that this type of care was OK for me, but not for anyone else. The only reason why it was OK for me is because I knew how to fill the holes. Maybe I’m just justifying it in hindsight. But in both circumstances – and for different reasons – I felt I had to midwife myself at some point during each pregnancy and labor and postpartum. This was substandard care. And, it was the best I could get.

Women seeking midwives deserve to *not* have to be their own midwife. They deserve to have all the holes filled, and all the care provided. Even if that care goes against the midwife’s personal beliefs. (And to be clear, we’re not talking pro-life/pro-choice/religious beliefs – we’re talking about things like routine blood testing , routine lab specimens, hospital back-up arrangements , and auscultation of fetal heart tones with a Doppler.)

If I could have hired a certified nurse-midwife (CNM) to attend my home birth, I think would have. It is legal in my state for CNMs to practice out-of-hospital, it is just very rare. It is also legal in the nearby neighboring state for CNMs to practice out-of-hospital. Again, it is very rare. There was no CNM practice providing home birth services within a hundred of miles of me. There were at least two dozen CPMs or “other” midwives in my area who would attend my home birth.  CPMs are legal in my state. And I was training to become a CPM. Naturally, I chose a CPM to attend each of my homebirths.

Both of my home births went well. And every issue that came up in labor was handled in a sufficient manner.

But I cannot recommend these midwives.  And I have not.

And I have a hard time recommending home birth with a CPM to anyone these days." 

Someone recently described the gaps in a CPM's training and education to be much like Swiss cheese.  Depending on the program of study and your preceptor, skills slip through the cracks.  Safer Midwifery for Michigan is advocating for consistent standards for education and training of midwives.  Clients can be informed, but using the term "midwife" to describe your profession should stand for something we all can count on.  


  1. i could have written this almost word for word. I've been wondering lately if the "educate yourself mama" rally cries help the negligence along. people don't know what they're missing since they educated themselves & cared for themselves.

    1. Thanks for your response, Davi. I think this experience of midwifery is similar to that of a lot of women - but just how much do they know about what they are missing in their care? If they are not actively studying midwifery, they probably know very little - only what is told to them by their midwives. And why wouldn't they trust their midwives to be providing 1) accurate information, 2) the best (evidence-based) care? Especially when spending an hour or more at each prenatal appointment?

      A lot of women in my community ask me for recommendations about midwives to hire - and I am very reluctant to give any recommendation. The disclaimer should be "buyer beware" in lieu "educate yourself."

  2. What helps me in reading and hearing about these very concerning lack of standards and training among midwives is this: what is the overarching goal in having a baby? Is it the experience of the couple as they birth their baby in a comfortable environment? Is it the ability of the couple to choose how they want their birth to go - or at least determine what they want without being harassed by medical professionals? Is it to be consistent with a worldview of "nature knows best" and technology and Western medicine should be minimally used and always treated with suspicion and skepticism? Is it to save money? These may seem like ludicrous questions, but they need to be raised. I think too many women and their partners are too short-sighted in looking at all the issues that surround "we're having a baby." If there are any issues that fall short of the overarching goal to provide the very best care prenatally, during birth and after birth for the LONG TERM GOAL OF HEALTH AND WELL-BEING (including the memories and experience of the birth)FOR BOTH MOM AND BABY then there could be a serious problem in that pregnancy outcome. Perhaps we only need to understand how women deliver in third world countries to have a "reality adjustment" as to how important this issue of health and safety, utilizing standardized protocols, really is.
    I really appreciate this post. Thank you.

    1. LauraT - Thank you for your response and your questions. Do you think is it the responsibility of the parents or the midwife to discover 'all the issues that surround 'we're having a baby''? What role should professional midwives accept in being responsible for providing accurate, fact-based information to the parents? And how much should be left for the parents to discover?

      If a midwife is a CPM or CNM, parents may assume that these midwives adhere to professional practice standards. If they are licensed as well, they may assume that the midwife is working within a collaborative network that assures safety. Is it wrong for the parents to make this assumption? Or should they have to do more homework? Unfortunately in many states in the US, certification and licensing for midwives can fail at providing this assurance.

      Great questions. All these questions need to be addressed if we want to achieve safer midwifery.

  3. This is so much like my own experience! I am NOT a midwife, never trained to be a midwife or doula, but I am well read. I was shocked by my CPM's postpartum care, including the complete lack of instructions on monitoring vitals and which warning signs to look for. I only knew what was missing because I'd delivered with CNMs at a birth center who provided that care, and I understood the reasons for it. It is completely unfair to expect women to become experts, instead of having all healthcare providers be required to provide expert care.

    1. Becky - I'm sorry to hear that your CPM provided dismal postpartum care. This lack of standard (competent! expert!) practices among midwives is a serious problem. Thank you for adding your comment and contributing to this important discussion.

      It IS unfair to expect women to become experts. Not that they couldn't, but they shouldn't have to. They should be assured that when they hire a certified, licensed midwife that they are receiving safe, competent, high-quality care.

  4. You should read this, seems to provide a background into what the DEMs and CPMs in Michigan think:

  5. I am so disappointed to read this post and the "ditto" responses.

    As a CPM of 13 years, with 6 yrs of education, training & internship prior to receiving my credential, , I am disturbed to read that this is the type of care women are getting from our "newer" CPMs. I provide ALL these standard of care points the author references: Comprehensive prenatal care including ALL maternity labwork & diagnostics, doppler use to detect & monitor fetal heart tones (prenatal & intrapartum), emergency care plan/physician (both OB/Gyn & Peds) collaboration/transfer care plan, thorough postpartum and mother/baby monitoring guidelines and instructions, postpartum care visits: 24 hrs, 3 days, 2 wks, 4 wks, & 6 wks, etc...

    I have ensured that ALL my apprentices have learned and adhered to these same standards, understanding the importance and the rationale for offering this level of quality care to mothers and their babies.

    Unfortunately, many newer CPMs who came up in the early 2000's went through their training too fast, jumping from preceptor to preceptor, program to program, seeking to "get their numbers" fast. This "fast tract" pursuit of the CPM credential had been finally addressed by NARM, and it is less likely to be an issue in the future. It doesn't correct the current "black hole" in the standard of care which the author speaks about; and consumers of midwifery care should, indeed be careful about the midwife they are considering. Ask about the standard of care you expect and ensure she will provide you with the care YOU are looking for.

    Midwives DO honor YOUR choices and decisions, such as declining certain lab tests, using only a fetoscope instead if a doppler, declining or delaying "routine" newborn procedures, etc.

    Caveat Emptor IS true for ALL healthcare consumers, whether they hire a physician or midwife.

    1. Unfortunately my midwife had been practicing for 20 years, so inexperience and rushing can't account for it. I think the problem is a combination of the "trust birth" philosophy along with no defined standards of practice.

    2. Really Kim? Did you get tired of being called out over at the SOB, and that's why you're commenting here? You really think that NARM has done anything substantive to fix the gaping holes in the CPM credential, or that this is a new problem? It would be laughable if lives weren't at stake. I've gotten a pretty good idea of what you think constitutes evidence-based maternity care, and I'm not impressed. We have the CNM credential. There is no need for the CPM or DEM. The sooner that these imitation credentials disappear, the better.

  6. The midwife I am training with has arrangements to get prenatal lab work, GBS checks, Gestational diabetes, ultrasounds uses a doppler during prenatal appointments and labor, all assistants have taken multiple classes including Neonatal resuscitation, and has a back up physician...

    1. Well 43two, that's just great. The problem is having it done consistently. Our midwives had "arrangements" to do so too, but the way these "options" were presented as unnecessary, leads many women to opt out without understanding the value in having those assessments and determining risk factors. They also had a "back up physician" that was never called and wouldn't have been unless we asked for it ourselves...that is since everything is a variation of normal. These practices have to be consistent in order to mean anything at all. One great, responsible, ethical midwife does not mean they are all doing the same...which is precisely the problem.

    2. Hi 43two - thank you for your response. I didn't mean to insinuate that all CPMs are lacking in their standards of care and follow up. The training I did as an apprentice sounds similar to yours. The midwife had a lab account, the carried medications, was trained in NRP, CPR, and had a very supportive back up OB. And all parents were required to have a consulting appointment with the back up MD of their choice.

      But the problem is - that was slowly revealed to me after working with a half a dozen midwives and giving birth with two others - there is so much inconsistency among midwives (CPMs!) and how they practice. Some call this a variation in 'style.'. I personally do not believe this inconsistency of practice lends itself to safe home birth practices - in fact, quite the opposite.

      I wish there was consistency among CPMs. And some agreement about what increases home birth safety. And adherence to those standards. I haven't seen it. And I am entrenched the home birth community - I keep my opinions pretty guarded. But I feel that it's time to tell the truth. Because midwives - as a group of professionals - are dropping the ball. And the preventable, fatal outcomes due to shoddy practice are simply unacceptable.