Where is the Leadership: Part I

Part I:  This post will be the first in a two part series.

What does ...

Having your CPM credential revoked by NARM + Multiple dead babies + Larceny & Misrepresentation = for a MI midwife??  

It equals...still practicing without real consequences.  Yep, you read that right, still delivering babies for MI families.  How can this happen?  

The bottom line is that MI has no laws or regulations in place to stop the reckless midwives like this from practicing.  NARM can hold their peer review sessions, make polite suggestions for change, and midwives can stop referring clients to someone they know to be dangerous, but nothing is in place to prevent that person from continuing to practice. Heck, these midwives can even move to another state, and still practice, if the laws in that state don't prevent them from doing so.  (i.e. Michigan = hotbed for midwives who don't like to play by the rules.) 

Case in Point:
Bridgett Ciupka's (former CPM) NARM credential was revoked in 2004.  Yet, four years later, she was the midwife for Ms. Mushin and her baby, Alia Mushin, who died in-utero, while still under Ms. Ciupka's care, after her mother was 4 weeks post-dates. Further concerning events were charges of Larceny and Misrepresentation in 2009, for which she is still on probation, according to current court records According to Metro Midwives and Birth Partners, Bridgett is still practicing in MI.

The scary truth is that this is just one example.  In MI, we currently have OOH midwives who have served probation for wrongful death, who are in the midst of a criminal trial in other states, who have filed bankruptcy repeatedly to avoid civil accountability, and who have numerous deaths and injuries on their invisible records.  We have midwives who have faced criminal charges for the death of mothers and babies, and those who have dodged charges that should have been pressed.  Ironically, these are precisely the midwives leading Michigan's professional organizations for midwives, and the drive for legislation.

What could these particular midwives have to say about all of this?  Well, they say home birth is still safer than hospital birth, that babies die in hospitals too...in fact some babies just aren't meant to live. They say that peer review through NARM is working, despite the fact that it does nothing to prevent dangerous midwives from continuing to practice.   They continue to offer home birth to women who have had three prior cesareans, and brag about their success on FB, despite having lost a mom and baby after a HBAC2 (Home birth after 2 cesareans).  They continue to offer home birth for breech babies and twins, insisting that it's "just a variation of normal".  They tell mothers who have pre-eclamspsia that it is safe to have a home birth, but when she strokes as a result, it's all about the choices she (the mother) made, and nothing about the professional responsibility of the midwife.  

These midwives tell women to trust birth and their bodies, but don't tell them that sometimes women really do need medical help, or when to get it.  They pretend the system is working like a well oiled machine, when in fact they are covering up the truth about what is really happening out there so they can continue selling an ideal that doesn't exist.  It's an ideal that can't exist while the dangerous midwives continue to represent the leadership.  

Don't just take my word for it.  Here are the thoughts from an anonymous midwife who shares the same concerns: 
 
      "My greatest frustration in all of this is that so many of the midwives have become 
      defensive in this state when it comes to discussing regulations and clinical 
      judgement.  When a well-liked midwife acts erroneously, in terms of poor clinical 
      judgement, the first concern seems to be about her as a midwife." 

     "I know midwives who gave up midwifery because of frustration with MMA not 
     wanting to admit that another midwife was incompetent or negligent, because that 
     midwife was also internationally known and well liked.  The view is that if we as 
     midwives censure one bad midwife, we are failing to stick together and will 
     provide fuel for the OBs and others who would like to see midwives disappear. 
     Our censure is seen as a crack in the armor of our united front to promote 
     midwifery as a profession. It is also seen as being disloyal to the sisterhood. I 
     suppose the general feeling is that any of us could make a mistake, and no one 
     wants to be criticized for the care that they provide. Feels to me like insecurity 
     about the perception we would like families and other professionals to have of us." 

So where is the leadership?  The midwives we are talking about here, are not representative of every midwife out there.   Clearly there are midwives who are concerned about what they see in the OOH birth community.  The dangerous midwives are blending in with the rest to unsuspecting mothers, protected by professional midwife organizations who would rather defend people like this to protect their cause, than confront reckless practices to ensure safety.  The voices of mothers sharing their stories of negligent loss, the voices of concerned doulas, apprentices, and fellow midwives, all fall on deaf ears.  It is easier to ignore the problems than to acknowledge and address them.  It would make midwifery look bad to admit there are problems.  

My question is, when will the leadership shift?  When will the ethical midwives who are practicing safely, those that care about this profession and the mothers and babies they serve more than themselves, rise up and change the culture of OOH midwifery today?  It is concerning that the current leadership doesn't see, nor do they have any interest in, addressing these matters.  Furthermore, they are corrupting an entirely new generation of aspiring midwives, instead of doing what is right, and pushing for legislation that would serve to protect them further.  When will our legislators do what is right on this issue?  When will women in this great state demand better, more consistently reliable care? 

This blog is not about smearing midwives.  It is a call to action for the good to rise up and make OOH midwifery what it has the potential to be.  Unethical tactics, dangerous practices, cover ups, and denial won't get any of us anywhere.  How can we effectively improve what is broken if the leadership of OOH midwifery pretends that problems simply don't exist, all for the sake of protecting a "sisterhood."  Who is protecting the mothers and babies? We want leadership that is honest, ethical, and can lead OOH midwifery toward safer practices for MI families. 

**OOH means Out of Hospital Birth, referring to home birth and/or freestanding birth centers

Ask an OB: Fear of Unwanted Interventions

"Ask an OB" is our blog series with Dr. Maude "Molly" Gurein, MC, FACOG.  If you have a question you'd like to ask her, please share it with us here.

What do modern OB's really do, as far as all the "unwanted" interventions that the natural childbirth community talks about? ~ Confused Mom

      Q1: Are vulvas really still coated with Betadine? If so, why is this a good practice?

  
A1: Hahaha – that’s funny…no, I haven’t seen that done since 1978

  
Q2. Are women still "forced" (not my experience) to have their feet/legs in stirrups? If so, why? (As a doula, I've seen most dr.s totally ok with different birthing positions but this is not what the ncb community likes to claim).

A2. Stirrups? No, I haven’t seen anyone “forced” into stirrups…not sure how we would manage that. Women tell us how they are most comfortable and we accommodate them. I’ve delivered babies squatting, on their side, sitting, in bed, on the floor, in a Lazy Boy, in the shower, wherever they want to be.

Q3. Is routine separation of infant and mother demanded or only if the infant needs assistance?

A3. Babies are with moms 24/7 at Sparrow Hospital. I’ve actually had complaints from moms who WANTED to send their babies to the nursery and they were told NO, baby stays in your room with you all the time. Sparrow has focused on this for > 10 years, and is now pursuing “Baby Friendly” status, which is a national certification that is quite difficult to achieve.

Q4. What do dr.s think of moms who want low to no interventions, like no IV, no EFM, etc.?

A4. Doctors wonder about the motivation for these requests. Give me your reasons and let’s talk.  Let’s deal with the underlying issues first, then get down to the specific requests.

IV for instance – can we negotiate a heparin lock? That way you can move around freely, and I can have a fighting chance to save your life if you have a post partum hemorrhage. PPH is not uncommon, occurring in up to 5% of deliveries, and when it starts, your blood vessels constrict, making an IV start difficult/impossible. With the blood flow to the placenta at 750 cc per minute, it doesn’t take long to exsanguinate. So when someone refuses a heparin lock, I wonder if she is someone I feel comfortable getting into a possible life and death situation with.  

Monitoring…well if you are low risk and you elect intermittent monitoring instead of continuous monitoring, and are willing to accept Apgars a bit lower, then I can live with that.  For those who worry about being, "Tethered to a bed/not allowed to move around," I'd say you can go anywhere you want to as long as mom and baby are low risk and doing well. 

Q5. Can you address these other NCB claims: shaving the pubic area, routine episiotomies, and routine enemas?  

A5.  

- Shaving the pubic area: hahaha – never have seen that, even in 1975 when I started med school.

- Routine Episiotomies: went out 10 - 15 years ago

- Routine Enemas: last saw one of these about 1979

Sounds like the NCB people you are referring to haven’t been in a hospital since the 1970s!

Part of the Problem: Peer Review

This post is written by an anonymous guest writer, a former CPM apprentice who has a unique perspective regarding peer review sessions among midwives:  

Part of the problem with CPMs self-regulating, is that the peer review process does not correct poor practice. Peer review is a process where a CPM cherry picks some friendly home birth midwives, to review a case where there was a complication or bad outcome. Often, there is nothing that comes of it: “Oopsie-daisy, we had a bad outcome, too bad for the parents, and too bad for the baby.  Birth is a safe as life gets.” The CPM who had the bad outcome can document that she had a peer review and all is good.  Back to catching babies.

But another way that peer review fails to ensure safe midwifery is when peer review results in a midwife receiving inappropriate and reckless feedback for her actions at a birth.

 
An example:

Let's say a midwife has a client who is having a normal, low-risk pregnancy. Nothing special about this mom. Everything in the course of her pregnancy has gone uneventfully and right around 40 weeks, she goes into labor. When the midwife checks the client in active labor in her home, she discovers that the baby is breech and informs the mother that she will need to go to the hospital for a c-section delivery. This midwife (rightfully!) made this decision based on:
 
     1) the undiagnosed breech position discovered in labor,
     2) her lack of training in handling breech deliveries,
     3) her license does not allow for attending breech deliveries at home.

She called the back-up hospital and provided information to the OB staff with the information regarding the client. Then she and the client went to the hospital together. This was not an urgent transport. But a necessary one.

She was present and cooperative with the OB staff, provided background information on the client and stayed with the family during the delivery and immediate postpartum recovery. In my mind, she did everything right.

Now midwives don’t like surprises. They don’t like missing a breech presentation. And they don’t like it when a family planning a home birth ends up with a hospital surgical birth. Families have some adjustment as well. And sometimes I think the adjustment to the change-of-birth-plan is harder when the baby is not in any acute distress. An unplanned c-section, even if it was not a true emergency c-section - requires some emotional and mental (not to mention physical) adjustment.

So after this birth, the midwife requested a peer review with another midwife in the area regarding this birth.

And here is the part of the problem:

Upon hearing about this less than ‘homebirth-perfect’ hospital birth, the consulting midwife may criticize the first midwife’s actions:

“You didn’t need to transport that mom for a c-section.” 
“Breech is just a variation of normal.”
“She was still in early labor, you could have called one of us who will attend breech births to come and attend the birth.”
“That mother is probably traumatized by her c-section and the hospital care she received.”
“Your client would have had a much less risky vaginal birth than the c-section.”

And the midwife who’d acted appropriately, within her professional scope of practice, within her personal skill level, and by the rules that govern her license, was now second guessing herself.

And let's say the memory of this ‘peer review’ follows her to her next birth, and her next birth and her next birth. And the next time she has a labor complication - maybe a breech, maybe something else - she may NOT transport her client in labor. She may remember what her peer told her about protecting her client from harm. About hurting women with unnecessary interventions. About not being ‘midwife-enough’ to stick it out at home with women who have complications.

This. Happens. All. The. Time.

Too many midwives see themselves as not only appropriate for low-risk, healthy women, but for women with increased risk, women with breech babies, twin babies, women who have labor complications and prolonged labor, women who have history of surgical deliveries and women with complex health conditions. They minimize complications (low-lying placenta, elevated blood glucose levels, hypertension, gestation beyond 42 weeks), and encourage each other to treat these complications as “variations of normal.” A midwife who appropriately refers women to medical care is often derided by her peers as being a “medwife” or as being “too jumpy” - or told that her actions caused unnecessary harm. 

And they convey this reckless message in peer review. 

This is part of the problem. Peer review is held up by NARM as assuring competence and safety in midwifery care. But unfortunately it allows for unscientific, non-evidence-based recommendations to be perpetuated among midwives.  And this is harmful not only to midwives, but most importantly, to midwifery clients. 

For more about NARM's review process, click here.  

Baby After Loss

While the central focus of this blog is advocating for safer practices in midwifery, we also recognize the importance of supporting families who have endured loss and injury along the way.  This post in particular, begins to document the personal journey of life inevitably moving forward after loss, and the complexities that come along with it.   

The journey for us started with a feeling that something about Magnus's death wasn't right.  We started asking questions, and quickly learned there were many obviously negligent practices that took place in our care.  Much of the past, nearly two years now, has been spent seeking accountability and reaching out to help others.  Those two efforts have been enormously healing in and of themselves, and will continue to be a part of what we must do.  I have found the way in which we perceive Magnus's love to be present with us every day, leading us forward, and the way we can talk about him as a family to be a great comfort. 

It hasn't been an easy journey by anyone's standards.  The most difficult moments seemed to come when they were least expected.  Last week for example, we went as a family to a 20 week ultrasound for a baby we're eagerly, yet anxiously, expecting to arrive this summer.  This is our third pregnancy since Magnus's birth and death.  We have hoped to have another baby for many reasons, but fully knowing that nothing could replace Magnus.  This entire pregnancy has seemed surreal.  It seems as though my husband and I are bracing ourselves for the moment when someone pulls the rug out from underneath us yet again.   I think it's much like self defense, like preparing yourself for the worst, in case things don't work out.  

We went to the ultrasound last week full of nervousness, and hoping everything would be okay.  We took our 4 year old son, who wanted to also see his brother or sister on the screen.  Everything turned out great, in fact we're expecting a girl.  What surprised me was the flood of emotions that came afterward.  We are excited to be having a girl, and in a way glad that it will be a different experience than any we've had before.  At the same time, I found myself struggling with such a definitive move forward in our lives.  I don't want to ever forget Magnus, and I know that we won't, but things felt more real after seeing our baby on that screen.   We also were mentally prepared for raising two boys.  We had hoped for a girl so things would be different, but when it turned out to be the case, we found ourselves emotional about shifting away from the idea of having two boys to raise.  Before this baby, I always felt like we had two children, one who couldn't physically be here with us.  Now that has suddenly shifted to feeling like we have three children, still one who can't be here.

We feel so grateful for this baby on the way.  It's difficult though when I know we likely wouldn't have attempted another pregnancy had things turned out differently with Magnus.  It's an awkward sort of blessing and tragedy all rolled into one.  I had heard other people refer to their "Rainbow Babies", and never quite knew what it meant.  In the middle of my emotional roller coaster last week, I came across this beautiful description of what the term means:

       A "Rainbow Baby" is a baby conceived after the loss of another child.

      "Rainbow babies are the understanding that the beauty of a rainbow does not negate 
      the ravages of the storm. When a rainbow appears, it does not mean that the storm     
      never happened or that the family is not still dealing with its aftermath. What it 
      means is that something beautiful and full of light has appeared in the midst of the   
      darkness and the clouds.  Storm clouds may still loom over but the rainbow 
      provides a counterbalance of color, energy, and much needed hope."  
     (Author unknown)

Her words so eloquently summed up exactly what I had been wrestling with.  And so we will celebrate this rainbow baby, the light that brings us much hope.  We will try to trust that things will go the way we hope they will, and try to push out the fear, the harsh reality that too many times it does not.   We will never forget what happened to Magnus, and will be dealing with the aftermath for a lifetime to come.  The most challenging part is finding security in life, trusting, and enjoying the good, instead of bracing for the next big blow.  We work hard on that daily.  We refuse to submit to sadness, (even though it still often creeps in), and instead look for ways to "grab the good" from every situation we face.   

My favorite good moments from the ultrasound experience were the sigh of relief I heard from my husband when we could see and hear the heartbeat.  It was when Jonah's baby sister lifted her arm and "waved" at him, and the smile of pure love that spread across his little face.  It was learning that it is okay to be happy, without one bit of lost love for Mangus.  

The Delicate Relationship Between Assessment and Safety

If you've ever taken the time to read loss stories from families across the country, you'll start to notice alarming similarities.  One of the most rank, is a severe lack in proper assessment before, during, and after labor.  Our blog often brings to light dangerous practices taking place in out of hospital birth, in an effort to identify core issues that need to be addressed if midwifery is going to safely offer women options in childbirth.  Proper assessment during all parts of pregnancy, childbirth, and afterward is a vital component to improving safety and overall outcomes.  Much work is to be done.  The question that lingers in the meantime is how does a mother know when her care is not appropriate when assessments have fallen by the wayside?  We aim to share some of that insight here.  

There are a million and one assessments that can be done for various reasons.  No two women are alike, and we all have different journeys in pregnancy.  There are however, a few key prenatal assessments that are often ignored, downplayed, or mistreated in the out of hospital birth community, that have lead to several unnecessary infant losses across the country.  In many cases, had these assessments been done, interpreted correctly, and treated appropriately the babies would be alive today. 

Key Prenatal Assessments
Rh Factor
Gestational Diabetes
Group B Strep
Ultrasound       (Video of an ultrasound)
(**Ultrasounds are not always considered a necessity.  They can however, offer your care provider a wealth of information about factors that directly impact you and your baby's safety.  ~ blog post about ultrasounds, and why they matter coming soon ~ There are times when ultrasound can give your care giver vital information that should not be skipped, for example when you're expecting a breech baby.  Check out the link to learn more.) 

Important Issues with Assessment
There are three primary issues with assessment as it pertains to out of hospital birth.  

1) The first issue is the way in which assessments are downplayed, ignored altogether, or presented as "options" by some midwives.

There is a critical difference between choice and subtle persuasion.  If an ultrasound, for example, is offered at 20 weeks, but then followed up with statements about how there really isn't any reason to do one, or that research doesn't necessarily prove its safety, or how they aren't very accurate anyway...a mother isn't likely to feel that the assessment is very valuable.  

Another common example is Gestational Diabetes Screening.  Many midwives will consider your nutritional habits good enough.  They will tell mothers, "your body can't grow a baby too big."  In our case, despite having gained 60 pounds with a 10 + baby, our midwives told us that the test often is wrong, and that the solution would be a dietary change anyway if the test proved positive.  We were led to believe the test was a waste of time, and hence "declined" doing it at all.  Our care providers certainly didn't think it was necessary.  The truth about Gestational Diabetes?  It can be very dangerous for your baby if uncontrolled and undetected.  Yes, your body can grow a baby too big to for a safe vaginal delivery. 

Midwives will "offer" or claim they offer comprehensive prenatal care and testing, when in fact they do not.  They usually keep a checklist of routine labs/tests and have the client initial that they've "declined."  If your midwife, or her webpage vaguely states that they "counsel" on prenatal testing, you'll want to be sure to ask specific questions about what assessments they value, and how they will be done.  Please visit this link about Informed Consent to learn more about how to be truly informed.  If you haven't been told about the benefits of a given assessment, and clearly understand the value behind them, you aren't getting all of the information you need to make a decision.  There is a reason why the assessments on this page are considered "routine" in the medical world, and it isn't so doctors can make millions of dollars on unsuspecting pregnant women.  

Assessments are even more important if you're considering an out of hospital birth to ensure your pregnancy is meeting important safety criteria to be a good candidate.  Home birth is not safe for everyone or every pregnancy, and without proper assessments, your midwife cannot appropriately monitor your pregnancy within boundaries.  The unfortunate truth is that many out of hospital midwives don't have boundaries at all, which makes it even more dangerous than it has to be. 

2) The second issue is a severe lack in knowledge and accessibility when it comes to how to reliably perform, and interpret assessments.

What a midwife claims to offer versus what they are actually able to offer are too often two very different things.  In Michigan, there is only one place a CPM can get lab work done without a physician back up, and that's at U of M.  Many do not have a relationship with an OB, and therefore end up sending clients to an expensive, vanity ultrasound facility as their only option.  Even then the baby's, size and position might be checked, but none of the other important assessments and measurements.   

Beyond accessing necessary tests, appropriate interpretation of results are also a vital part of sound care. Even if a midwife is able to arrange her lab work at U of M, or a client to pay for an ultrasound out of pocket, they are then left to interpret the results themselves, often without any training to do so.  It's difficult to detect risk factors if you don't have access to proper assessments, or the knowledge base to interpret them properly.  One of the biggest differences between home birth and hospitals is that the medical practices have mechanisms for providing further follow-up testing and care, where midwives do not.

3) The third issue is the way midwives go about treating abnormalities with home remedies instead of referring clients for proper medical care.  
  
The third challenge regarding assessment for out of hospital midwives (beyond philosophy, accessibility, detection, and interpretation) is the appropriate treatment of those issues that are detected along the way.  A common example is the way many midwives go about "treating" Group B Strep.  Most do not do IVs, which is the research-based, and most effective Group B Strep treatment, because they don't want to get caught practicing medicine.   Instead, midwives are presenting women with research supporting Hibiclens or suggesting they put garlic in their vaginas, rather than referring them for medical care.  Proper assessment of babies born to mothers with Group B Strep is also vital, and can be life saving.

Language to Worry About (aka Red Flags) 

• If your midwife "offers" the above-mentioned tests/screenings but subtly encourages "declining" of those tests 
•  If your midwife "offers" tests, but tells you that all/most of the other clients refuse that test/treatment
• If your midwife suggests home remedies to treat an issue (ex: putting garlic in your vagina instead of getting IV antibiotics for Group B Strep)  
• If your midwife doesn't have any mechanism to provide follow-up tests/procedures for abnormal tests/screenings (scheduling, collaboration)
• If your midwife does not directly facilitate referral for appropriate follow-up care when tests/screenings are abnormal or requiring further evaluation (ex: if parents are left to do this themselves)
•  If your midwife "offers" a test and simultaneously gives you an article from Midwifery Today (or any other heavily biased "resource") on that test 
• If your midwife "offers" a test/treatment and when you accept it, they don't have the material/equipment on hand to perform it. (glucola, pap smear, chlamydia/gonorrhea culture, RhoGam, Vit K) so they reschedule it for another visit. Often, these tests don't happen at the follow up visit, either.
• If your midwife drags her feet (this can be subtle) when you accept a course of care/treatment -multiple marker screening, glucose screening, RhoGam @28weeks, IV abx - until you change your mind, forget about it, or it's conveniently too late to do the test

In Conclusion:
This post was meant to do three things: 

1) Offer mothers up to date information and resources about routine assessments for prenatal care.  

2) Help mothers understand the necessity and importance of key assessments as it relates to safety.  

3) Offer a sense of what abnormal, or unsafe care might look & sound like so that any mother can readily identify when a red flag should be raised.  

Many of you have read Magnus's Story, so I won't recap here.  What I will say is that the issues we are discussing in this post are vitally important to safety.  A midwife who a) does not have the skills or access to appropriate assessment  or b) does not value assessment in her philosophical approach to birth, pose a very real breach of safety for any mother and baby.  Every loss or injury story I know, (which is far too many) could have been prevented with appropriate assessments.  Here is my personal example:

• If our midwives had appropriately screened during the prenatal period, they would have seen that we were considered high risk for many reasons.  Instead, they pretended that our 10+ pound breech presenting baby was a "variation of normal", downplaying the severity and dangers involved, and failing to acknowledge any risk at all.  
• If they had known what to look for when the ultrasound results came back at 38 weeks for a frank breech baby, they would have seen his size and nuchal cord wouldn't make us candidates for a safe vaginal breech delivery outside a hospital.  
• If our midwives would have assessed my cervix dilation progress, they would have noticed I wasn't fully dilated before I had pushed for 4 hours against myself.  
• If they had assessed time passing, they would have noted that 6 hours of pushing for a breech delivery was a "prolonged labor".  
• If they had appropriately monitored during labor, they would have found a baby in great distress who stopped breathing, but instead didn't know until he was born without a heartbeat.  

Assessment is about gathering as much information as you can, so that your care provider can work on a preventive basis to keep you and your baby as safe as possible during this journey called pregnancy and childbirth.  Any responsibly practicing midwife will value assessment, so she can appropriately monitor for low-risk circumstances, and refer you to alternate care should the need arise.  Home birth is not safe for every woman and every birth.  Midwives who claim assessments are not necessary, who do not have the educational knowledge to do the assessments necessary, or who suggest you can be treated with homemade remedies, should be an enormous red flag to the mother.  I hope any mother reading this who is questioning the care she is receiving, never hesitates to get a second opinion.  Doing so could save your baby's life.  It would have saved my baby's life. 

Resources

US National Library of Medicine: Prenatal Testing

American College of Nurse Midwives: Trimester by Trimester

Links
Routine Care During Pregnancy

Routine Care During Pregnancy

Now that the holidays have settled into a nice new year, we're back on track for talking about the serious issues families are facing with the current state of midwifery in MI.  We'll start the year with a series of posts related to assessments, testing, and their relationship to safety.  We hope you find them thoughtful, and useful.   

What do you get when a group of professionals have no practice standards?

A crap-shoot as to what kind of care a client gets. 

A group of us were discussing creating a list of routine prenatal assessments and cares that should be offered by all maternity care providers - specifically CPMs and OOH midwives. There is such a variation of practice, training and skill among these "professional" midwives that it is difficult for a client to know if she is getting appropriate care or not during her the course of her care. Former apprentices have voiced concerns numerous times about the lack of safe care they'd witnessed -and the complicated nature of the problem. A point we keep coming back to is that CPMs have no professional guidelines. There is no document or position statement by an OOH midwifery organization that lays out appropriate care (routine tests, follow up, labor assessments, timing of FHTs in labor, etc). There just are no standards. And that is the root of the problem.

But it sure seems like midwives should be breaking down the issues surrounding what constitutes appropriate care and assessment during pregnancy and birth.  You know, like writing actual professional practice guidelines. Midwives are the ones who keep asserting that they are "professionals." THEY should be sitting down together and writing these standards and disseminating this information to each and every CPM out there saying: "These are our professional standards." "This assures safe and competent care." But instead they know that CPMs do whatever the Hell they want [homeopathic streptococcus, anyone?] and they don't do anything about it except cower behind the tenet of "informed consent."

Our group advocates for professional practice standards. This means each mother who hires a CPM should be assured that she is receiving appropriate, competent and thorough care based on clear and concise professional practice guidelines.

There are a number of places one can look for a list of routine prenatal tests and screenings: 

US National Library of Medicine: Prenatal Testing

American College of Nurse Midwives: Trimester by Trimester
  
But where is the list for OOH midwives? Routine prenatal assessments? And how often is this list reviewed and revised? Which professional organization is doing this? The answer is no professional group of CPMs is doing this. And CPMs do whatever they want. Or don't want to do. 

Peruse this document:

NACPM standards of practice

Does it say anything about routine prenatal care?
Does it say anything about routine labor assessments?
Does it say anything about standard procedures for women planning an out-of-hospital birth? 
Does it say anything about use of unproven, potentially unsafe, ineffective treatment modalities such as herbs or homeopathy?
Does it say anything about safety - and which situations and circumstances enhance the safety of birth in the out-of-hospital setting? 
Does it describe the process of risk-screening?
Is it anything more than a bucket of fluff left for each and every CPM to interpret as she sees fit?

CPMs need clear practice guidelines even more than other health care professionals - because they're working on their own - and not under medical practice guidelines or hospital policies.  NACPM (or MANA) should have regularly-updated, concise, evidence-based practice guidelines for routine prenatal testing in pregnancy, postpartum and for newborns.   
**Every mother reading this should clearly understand that without these guidelines in place for assessments that protect your safety, you are at great risk under a CPM's care.