My Current Thoughts on Midwifery

I no longer blindly support homebirth midwives. I have to get that out there. I used to, but now I don’t. I used to put them up on a pedestal and revere them — doing WOMENS WORK, helping other women — but I know now that is not entirely true. Because I’ve seen some midwives who have harmed women.

I saw it years ago, when a homebirth midwife, a CPM who is still licensed and had two apprentices with her, left a pregnant woman whose labor had arrested. In retrospect, the midwife should have transferred her to the hospital for hydration and probably some pitocin. But instead she abandoned her. The mom ended up going to the hospital by ambulance.

My own first homebirth with a CPM did not go very smoothly. First of all, I wasn’t a great candidate for a homebirth, having had absolutely no prenatal care and being morbidly obese. I was probably anemic as well. Still, a CPM took me on and then after My Masterpiece was born I had a retained placenta and a postpartum hemorrhage. I also went to the hospital by ambulance.

20120725-084106.jpgmy two homebirth babies

Cousin It’s homebirth was excellent — but I had a lot of medical intervention during my pregnancy. I saw a homebirth-friendly obstetrician. Because I’d had weight loss surgery between My Masterpiece and Cousin It, she kept an eye on Cousin It’s growth via several ultrasounds. I also had my labs drawn regularly, and I received iron infusions when my ferritin and hematocrit were dangerously low. (My awesome hematologist was supportive of homebirth.)

I reminded my midwife about my history of having a retained placenta and postpartum hemorrhage and I asked her to be very conservative about blood loss — and liberal with anti-hemorrhagic medications. With her during the birth was another CPM and a nurse. I was in good hands. It was a beautiful homebirth.

20120725-092300.jpgCousin It was safe.

Meanwhile, I hear and read a lot of homebirth horror stories. I saw some scary stuff (to me) during my brief tenure as a CPM apprentice — one of the reasons I stopped was because it felt like too much pressure, having two lives in my hands. I’m not sure I would have ever felt qualified.

That brings me to a second issue: the lack of standards among CPMs. Because they are regulated by state, what’s allowed in one state isn’t allowed in another. What education and experience is necessary in one state isn’t necessary in another.

A great example is Oregon — a midwife in Oregon need not even complete an education in midwifery! And in Texas, midwives can attend breeches, multiples and VBACs; South Carolina midwives cannot attend any of those. What I’m saying is, there probably ARE some good, experienced, well-qualified CPM out there — but you can’t tell that just by the initials behind their names.

And I do not see women encouraged to ask a lot of questions of their homebirth providers, specifically about their experience (or lack of), their education, the circumstances in which they transfer, the back-up plans, or how much experience their apprentices have. It’s almost like questioning a midwife is some sort of red-light that the woman doesn’t TRUST BIRTH implicitly. And not just TRUSTING BIRTH is bad, according to many midwives and homebirthers.

I mean, I trust my driving but that doesn’t mean I don’t wear a seatbelt. I trust Whole Foods Market but that doesn’t mean I don’t cook a chicken thoroughly. Trusting birth blindly is not a point of view with which I agree.

20120725-090910.jpgBorn at the hospital.

Right now I stand for more strict standards across the board for CPMs. More education and experience requirements, and apprenticeships with multiple midwives, if possible. A national standard so that the term CPM can actually mean something. And more transparency! MANA — the Midwives Alliance of North America — won’t even publicly release their death rates. That is shady.

Would I discourage my daughters — or daughters-in-law — from having a homebirth? No. But I would insist that they understand their midwives limits and experience and education. I do not want them to just TRUST BIRTH.

20120725-092022.jpgStay skeptical, girls!

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8 Responses

  1. I did not have a homebirth and having one in my future is unlikely (in large part because 1) i am obese; 2) my FIL is an OB but I do support the right of woman to birth they way they feel is right under their particular circumstances.

    Births seem to come in two fashions: birth is a medical process that needs to be managed with tests and interventions OR birth is a natural process and women need to embrace and have no interventions.

    I think that birth is a collaborative process where a provider educates the woman about her body and the processes involved with birth. Irrespective of whether a woman desires a homebirth or an elective c-section, her options should be well presented along with possible consequences.

    Midwives and doctors that attend homebirths should know when a patient deserves or needs to be transferred to a hospital setting because of complications. A woman and her birth team should be educated to look for signs that indicate a transfer before a homebirth occurs.

    • “A woman and her birth team should be educated to look for signs that indicate a transfer before a homebirth occurs.”

      ^^^ I think that is where a lot of midwives go wrong. A woman really WANTS a homebirth (like I did with my fourth kid) and if she sees a midwife for her entire pregnancy, there begins a sense of entrapment, where they become friendly and the midwife wants her to homebirth as well.

      Also, a non-legal midwife has an impetus to keep the woman at home — transferring or transporting are legal issues.

      Whereas with an Ob it’s the opposite. They seem never to form relationships that influence their treatment plan. He or she usually doesn’t care about your hopes and dreams.

  2. You’ve raised some great points! On the continuum of maternity care, we don’t have to be at the extremes: blindly trusting physicians or blindly trusting midwives. I agree that we need to ask questions and become informed. I’m all about informed choice and decision making! Thanks for this great post.

    • Thank you! I think the most important point is not to be afraid to question your provider’s skills. That does not mean you don’t trust them; it means you’re an informed consumer.

  3. I hate the “trust birth” motto. But don’t tell anyone. They might send Carla to come get me.

  4. I really appreciate your perspective here. I’ve been fortunate in living in Washington state, where there’s a rigorous midwifery school and licensing requirements. The Washington midwives I’ve talked to tend to be conservative about transferring care, which is how I ended up having a homebirth-turned-hospital birth with my first. I do believe direct-entry midwifery needs to be standardized nationally and midwives held accountable if they make mistakes.

    It’s a hard topic to think about, because for me personally, I had a pretty terrible hospital-birthing experience, and then a beautiful homebirth. I really, really don’t want to give birth in the hospital again, but I do want to be safe. Knowing you can trust your care provider with your life and that of your baby — it’s huge, as you said.

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