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Location: Allentown, PA

I'm a Christian wife and a mom to three daughters and two sons. I'm a member of the board of directors of EmPoWeReD Birth. In my "spare time" I'm a doula, and a certified childbirth instructor.

Thursday, January 27, 2005

Certified Midwives in Utah

Apparently there is some legislation pending in Utah to regulate what are known as "direct entry midwives." These are midwives who did not become nurses first as "Certified Nurse Midwives" do, but rather follow a variety of paths to learn their midwifery skills--typically involving some formal schooling and significant "apprenticship." By choosing not to become nurses first they do not have to learn about topics that are irrellevant to midwifery, like geriatrics, but instead focus on just midwifery--the care of low risk women during pregnancy, and for gynecological needs. In my state many serve the needs of the Amish and Mennonite communities. Many follow their training up by pursuing "Certified Professional Midwife" status by passing a certification exam offered by the North American Registry of Midwives, and then maintaining stringent certification renewal requirements on a regular basis.

When this topic enters the public arena, it never fails that someone who hasn't really bothered to be educated about birth beyond what can be learned from the TV drama "ER" (birth is dangerous! A pregnant woman should rush to the hospital at the first inkling that birth might occur in the next week so that she can be properly surrounded by machines that go "beep" to detect any possible problem.) has to sound off about the topic. In this case it was the editorial staff at The Daily Herald in Provo, Utah. I've given birth to two babies in a hospital (Jessica, and Katie), and two at home (Jason and Sean), as well as attending many births as a doula, and I'm also a Bradley Method of Childbirth instructor; so I think I know a bit about it. Let's look at just a few of the things they have wrong, shall we?

The article calls direct entry midwives (DEM) "low end" and states that they have a "light" training program. I disagree. The midwifery knowledge they have is on par with Certified Nurse Midwives (CNM). In some ways I'd say they learn *more* about how to promote healthy birth than CNM's. But as I said above, they just don't learn about topics not relevant to the care they choose to give.

The editorial states that the proposed legislation would require DEM's to inform patients of their credentials and back up plans in case of emergencies. The author seems to assume that this is not already done, but typically the woman who seeks out care from a DEM would either know her as a member of the community, or would have much more vigorously interviewed her than the average American mother who picks her OB/GYN out of the listing provided by her HMO, and asks very few questions.

Here's a winner of a quote:

As we've said before, it is foolhardy to forsake a hospital with its personnel who are trained to respond to emergencies and who have modern technology close at hand. But some people do it nonetheless. Home delivery seems warm and fuzzy to them -- as if a newborn baby really cares. We venture to guess that what matters most to a newborn is a warm blanket and a mother's breast, in that order.

It's foolhardy to forsake a hospital? Why? Countries with much better maternal/infant mortality and morbidity statistics than ours have higher rates of homebirth. Birth has occurred at home through the vast bulk of time, and we have still managed to survive as a specises. Ironically I would agree that to the newborn what matters most is "a warm blanket and a mother's breast," but I'd venture a guess that the baby is MUCH more likely to get those things at a homebirth than in a hospital birth. All too often in my work as a doula I see babies taken away from their mothers when there is no good need to do it.

The hospital rooms may look "cozy and comfortable" on a tour...but obviously the writer has never actually tried to lay in one of those wonderful labor beds for any period of time. They AREN'T comfortable. As much as I respect and reccommend the OB team that attended my first two births, and think the world of the two OB's, I doubt either of them would give me the coat off their back--literally--as my Certified Professional Midwife did when it was necessary to help facilitate the progress of my labor with my son Sean. And when a 3000 watt light starts shining at your private parts, there is no more "as welcoming as home" about it--its cold and clinical. As far as "actual doctors nearby"--typically when a woman is laboring in a teaching hospital, which many do, the closest she is going to get to a "Dr" being around for the bulk of her labor is a resident who may have attended 15 or 20 births so far--in comparison with my midwife who has attended over 600. I've been in the hospital when the nurses caught a baby--I myself was caught by a nurse. I've been at a birth where the on-call OB (who had never met the mother, he was not from her practice and couldn't be bothered to stop by the hospital early in her labor to at least introduce himself) didn't show up until an hour and 50 minutes after the mom started pushing--but she gave birth about an hour and 40 minutes after she started pushing--the resident caught.

To me, as I planned my first home birth, there was some aspect of "warm and fuzzy" to it. But there was more. I really do feel that being in the hospital slowed my first two labors because I could not relax as well. It resulted in more pain for me, which means more stress hormones getting transferred to my baby. But even beyond that, as a low risk mother I found that nothing happened in my first two births that could not have been dealt with during a homebirth. In my first there was thick meconium in the water (but I do question if that would have occurred with a homebirth--I had a LONG labor, which is associated with meconium--perhaps my labor would have been quicker at home, and thus no meconium?), so I would have needed to transport to the hospital. But it would not have been an "emergency transport." My water broke and revealed the meconium more than 6 hours prior to the birth, and it is really only at the point of birth that meconium becomes an issue. With my second, quite frankly, I did not need all the bells and whistles that the hospital provided. The birth cost $10,000 in a hospital, but could have been handled for less than $3,000 as a homebirth. In a country where we bemoan rising medical care costs, why do we not embrace safe and low cost options for childbirth?

Here's another one:

The most important question is safety. Childbirth is not without medical risks, and in fact can be highly risky. And it's not just a risk to the baby: There are two lives at stake -- mother and child. If things go wrong (and they can, no matter how thoroughly the mother's been screened), you need trained medical personnel to be right there, not waiting for you at the emergency room door 30 minutes after a midwife figures out things aren't working as planned.

What is so wrong with showing up at the ER door 30 minutes after the midwife has detected a problem? Generally since the midwife is offering one on one care to the mom, not distracted by other patients, she is going to pick up on problems very quickly. In most cases it isn't going to take that long (its about a 10 minute drive from my house to 2 different hospitals--most moms who choose to "homebirth" will find some place to birth near a hospital for possible transport if their home is not suitably close). The midwife will have called ahead, so the OR team is getting ready without the distraction of having to care for the mom.

On the flip side, I recently attended an attempted VBAC. This is "the birth to be most feared" for most care providers. Her water broke at 4 a.m., so we were concerned that she was laboring against a clock. She entered the hospital slightly after noon, and in the early evening her cervix wasn't changing much, so she consented to some Pitocin. That brought a constant fetal monitor. But the dang thing would not keep track of the baby's heart beat. It kept loosing it. The nurse would readjust it and the baby was just fine, so we really didn't worry. She commented a couple of times that it was picking up the mom's heartbeat when it wasn't picking up the baby's. At 4 a.m. the next morning the OB walked in with scrubs on. NOT a good sign. He took one look at the fetal monitor and seemed concerned. He did a vaginal exam. Mom was progressing. But he proceeded to give her extreme pressure about how the baby had been showing distress for 2 HOURS, and so he needed to do a c-section because the uterus might be rupturing. We managed to get him out of the room for the parents to talk alone, and during that time the monitor slipped again--picking up the mom's heartbeat. The mom, wanting the best for her baby and fearing that the Dr. might be right about possible rupture, agreed to the c-section. I went out to tell the Dr. of their choice, and he practically yelled at me "of course she is having a c-section! Her baby has just had a 4 minute deceleration!" Exasperated I said "that isn't the baby, it's the mom's heartbeat!" "NO it ISN'T! It's 95, how in the world can it be the mom's?"

I didn't argue--I had said too much already. But stop for a minute. Take your pulse. Mine is 80. When I'm standing and just walked downstairs to get a timer. Mom was laying down and relaxing really well through contractions, which would slow the pulse, but doing hard physical work and was emotionally stressed by the Dr., which would increase the pulse. Is 95 really that unlikely a pulse for the mom? No one bothered to take her pulse directly to compare.

But even after this it was a full 30 minutes before the first incision was made. 30 minutes. After 2 hours of supposed troubling fetal heart rate tracings on a VBAC, a supposed 4 minute decelaration.

BTW, mom's scar looked very healthy and pink, no sign of rupture. Baby was very healthy and had high APGARs.

Now let's look at some numbers. I love numbers.

One need only look at infant mortality rates in the past two centuries to see the benefits of medical technology. Far fewer children die at birth today. In 1910, 190 infants per 1,000 died at birth. By 1940, the number dropped to 47. In 2001 it was only 6.8 per 1,000.

Does the writer not understand that antibiotics and understanding of the need for cleanliness in medical practice lead to the vast majority of this decline in infant mortality? I suppose he doesn't realize that "childbed fever" was actually CAUSED by Dr's who would go from autopsies to births without washing their hands.

Beyond that, the author seems to think that "infant deaths" refers only to deaths at births. This is not true. These deaths are all deaths to live born children in the first year of life. Many have no connection what so ever to mode of birth.

And the author also misses the point made by the CIA...our current infant mortality rate ROSE in 2003, and currently is 42nd in the world. Babies born in Havana have a better chance of surviving the first year of life than babies born in Washington D.C. Obviously all our bells and whistles of technology aren't cutting it.

The author feels that the proposed bill would offer no protection to patients. I argue that it would! The licensing board is likely to be MUCH more stringent in investigating complaints against midwives than they typically are in investigating complaints about Dr's. So if a midwife is practicing irresponsibly, she will likely loose her liscense--unlike an irresponsible OB, who will simply settle a closed malpractice case, and continue practing with patients none the wiser.

The alleged psychological benefits of home birth seem overstated. While the idea is quaint and heart-warming at one level, it should be viewed as the emergency option -- little better than a birth in a taxi cab. The physical safety of mother and child should be the paramount concern. They'll soon get over whatever coldness comes with a hospital.

Uuuggghhh. What about the PHYSIOLOGICAL benefits? Faster labors, less painful labors, less problems for the baby. "Developed" countries with higher rates of homebirth than the US--like the Netherlands and England--have lower rates of complications than we do. Homebirth is little better than birth in a taxi cab? Well I may not be the best housekeeper in the world, but I think my house is a bit cleaner than the average taxi! And I'd really be shocked to find out that a cabbie carries medical oxygen, a doppler to monitor the baby, a blood pressure cuff to watch mom's BP, drugs to help the uterus contract in the case of excessive bleeding after the birth, sterile scissors to cut an episiotomy if the baby is in distress, cord clamps, nasal aspirator and De Lee suction equipment to clear baby's nasal passages as needed, and warm blankets to wrap the baby; not to mention the years of experience to recognize an impending complication, the knowledge to know how to deal with them (including yes, transferring to a hospital)--all things that my Certified Professional Midwife brings with her to births.


Blogger Sarah said...

Oh, my goodness! I REALLY wanted to post a comment and I HAD to really want it because I had to set up a blogger account to do it!

Anyway, I'm finally here. Whew.

I wanted to say how much I enjoyed your article on Certified Midwives. It really is making me consider doing a homebirth for our next baby. My husband and I took Bradley classes when I was pregnant with our son, but we only got through a couple of them before my water broke and I had to go to the hospital. I was in the hospital for about five days before my son was born.

What would I need to know in order to begin investigating homebirth as an option for our next baby? I'm not yet pregnant, so obviously there's no rush on this information. I just like to be prepared.

And thanks for the great writing!

9:51 AM, January 28, 2005  
Blogger Sarah said...

I should mention that despite the five day wait, my son was born at 32 weeks. Very early. They didn't just let me hang around in the waiting room or anything like that! :)

9:53 AM, January 28, 2005  
Blogger Jenn said...

You should be able to sign in anonymously without making an account...hmmm...never actually tried that myself though.

Anyway...I had a client whose water broke at 32 weeks, and she gave birth at 35 weeks. She stayed in the hospital for a week, then went home until she went into labor. Obviously though, neither her situation nor yours is a candidate for homebirth because of the possible prematurity issues (though in my client's case her baby was very vigorous and healthy at birth--cried on the perineum and needed no special care)--you would get "transferred."

But for a future birth...it is never to early to look into the options in your area. Contact your Bradley instructor to find out who she knows who does homebirths. Start interviewing, and learn if you feel comfortable with the options you have. Also talk to her about what your options would be to finish up a class series with her when you become pregnant again.

There are lots of resources about homebirth on the internet--I used to participate regularly in the Parents Place Homebirth discussion board (http://messageboards.ivillage.com/iv-pphomebirth), but only go there occassionally anymore. That is a good place to start learning.

12:33 PM, January 28, 2005  
Blogger TulipGirl said...

Sarah, I had premature rupture of membranes with my first, and even though he was born full term, it did concern me when I was expecting the second.

The midwife I had with my second recommended various supplements to strengthen the uterine sac. Whether they worked or whether it was something else, they were strong and she had to manually break them right before #2 was born (at 11 days after my due date!)

Just posting this to let you know that sometimes the things that happened during one pregnancy lead to fears about the next. But a skilled midwife can often make suggestions that will help your body prevent the same problems. *grin* And every pregnancy/birth is different--even though we hear that, it's hard to remember.

Personally, I'd love to see a list of books Jenn recommends about birth. I know I read a ton before my kids were born.

(two hospital births, two homebirths, all with great midwives!)

6:17 AM, January 30, 2005  
Blogger TulipGirl said...

I saw this and immediately thought of Knitted in the Womb.

1:24 PM, January 31, 2005  
Anonymous Anonymous said...

If this bill were to pass it would effectivly eliminate 96% of homebirths in Utah. This bill will not only effect Licensed Midwives, But unlicensed midwives as well. SB243 is clearly a restraint of trade and is a very poor attempt to stop midwives from practicing.

Tara Tulley CPM,LDEM


9:55 PM, February 06, 2007  

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