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Saturday, March 30, 2013

to license or not to license. is there a question? or what is an empowering birth? who decides?

OK this is an opinion piece and i imagine it'll piss a few people off. 

but i've been in tears this last week and i don't want to keep quiet about it. i was ready to quit being a midwife. 

recently i found myself in the midst of a discussion on midwifery licensure. i don't know why i bated myself into this trap. i was premenstrual. we have a client who is going through a difficult time and a midwife who is reaching out to any and all resources that she can find to help this momma. reaching out in a way that would not be possible if she were working outside the system.

i'm back to believing i'm not a feminist because i'm not hating on the system which i guess is being equated to the "man" and therefore in order to be a good feminist, i'm supposed to hate. sigh. sorry i know that is filled with sarcasm and passive aggressiveness, but i'm still pretty upset about this. 

as most of us have heard there is a midwife in north carolina who is being charged with murder as a result of a fetal demise. tragic. for everyone. 

i've read some backlash that this case supports the flaws of seeking licensure. i'm not quite sure the logic, but i guess it is because in north carolina homebirth with a midwife is illegal. the state does have CNM's, but from my knowledge they work on the base and i'm not sure civillians have access to them, and they sure aren't doing homebirths. and this is where lets hate on the man comes in, why, because the obstetric community does not support OOH birth, CPM's much less "community midwives". 

*tangent* i've heard this word community midwife tossed around in this case. i prefer it over traditional midwife. and from now on will try and use this term, particularly speaking of unlicensed midwives.* though really, aren't we all community midwives if we are attending births out of hospital? so maybe i'll use it for all midwives that don't work in hospital, licensed or not. i don't know. i just hate traditional midwife and medwife. makes my skin crawl to have such division between us. 

there was a discussion that you can listen to here on progressive parenting. there is also a post which is allegedly the mothers side of the story. *the mothers story appears to have been taken down. sorry*

i said that this is an opinion piece and so here is my opinion. 

if the midwife were licensed she would not be charged with murder. this case would have gone through a review by her peers to deem whether she acted appropriately or not. she would have had a trial and held accountable by her peers. she may or may not have lost her license based on their findings. and the family would likely have recourse in a civil suit to recover any financial damages, though that will never bring their baby back. if it is a state in which midwives carry malpractice, well then there also would have been a system in place to provide the family with compensation, not force them to seek it on their own.

and the midwife, well she would be on board with any health care professional and would not be charged with murder. this is the case in hospitals right. the unfortunate nature of what we do will be the eventual bad outcome. it happens in hospitals and there is no media coverage about it. it is silently swept under the rug and dealt with in back rooms. when this happens at home with a midwife, particularly an unlicensed midwife, and in a state where midwifery is illegal. it devastates the community.

i'm not here to judge the midwife. i'm here to talk about how it would have looked if midwifery were legal and if she were licensed.

back to the discussion i was bated into earlier this week. the discussion that had me in tears. the discussion that caused me to pause and fear being a midwife. 

i'm not naming names. there is no point. but there definitely were some heavy hitters involved. and actually most of these people are friends with midwives i've worked with.

the slogan "midwives for families, not midwives for midwives" comes to mind. 

so in this discussion, these women were critical of licensure because of the restrictions that it puts on birthing mothers - namely, breech, twin and VBAC. in many states once midwives become licensed these criteria are out of their scope and midwives cannot serve these women out of hospital. the argument - they are higher risk. the unfortunate reality is that the obstetric community has seen these women as a obstetric emergency and will advocate for early elective c/s. so the mothers are really not in a good place. 

there is a positive side however, ACOG recently put out recommendations saying that vaginal twin birth was a safe as a c/s; in many countries such as canada breech birth is coming back and more practitioners are being trained in how to help manage them, and VBAC? well in WA state midwives can choose to care for women who are attempting VBAC's using a community standard protocol that is evidence based. so things are improving. options for birthing women are improving. it's not perfect. 

i don't completely get the argument that these restrictions say that women are not smart enough to make decisions regarding their own bodies. i think if that is the case then these women should birth unassisted, at least don't hire me. when you hire me, you are hiring me because i sought education in how to help mothers prenatally and throughout their birth and postpartum. you are hiring me because of my knowledge. 

so back to this discussion that i was in. i can see for the most part what these women want is for optional licensure, like what oregon and minnesota have (though oregon is possibly transitioning into mandatory licensure). they disagree with the CPM being the standard. which i can agree with, i think midwives could do with more rigorous training, but i also think that the CPM is an adequate baseline and that these are good midwives. and to streamline a system of licensure. it's a starting place.

what shocked me out of this discussion was the alleged belief that licensure impacted the care we give to mothers. that it put licensed midwives on par with OB's. and what got me to my core was a comment that licensed midwives were intervening in women's birth causing them to have postpartum depression and breastfeeding issues. that women were hiring a midwife expecting one thing and then not getting the birth experience they wanted because it was "managed" by the midwife rather than just allowing the mother to birth the way that she wanted. 

oh my, i could break down this in so many ways, but it got to me. so not only do i have the responsibility of two lives in my hands, i also have the responsibility of how my actions may impact the mother and baby (and negatively at that). one of the reasons that i became a midwife was to protect that postpartum period, now i'm being told that if i'm "managing" a birth and that if it isn't what the mother wants (but if in my educated opinion needs to happen) that i'm causing mothers to have negative birth experiences and postpartums. pressure. ok. i tap out. i don't want to be a midwife then. i can't handle that. seriously. it's too much. 

thankfully i was surrounded my amazing women who took me in their arms while i cried and replenished my strength to move forward. 

what this all makes me wonder is what are we as women putting on other women. all these expectations. we set each other up for failure, that you are never good enough. oh a midwife helped direct your pushing or reduced an anterior lip. you didn't birth on  your own. your body didn't do it itself. seriously? do we think that women who were attending other women in pictographs just sat back and let a mother birth on her own and didn't do anything to facilitate the process? that's pretty nieve. 

a doula at a birth the other night talked about her births. her second baby she had an anterior lip that the midwife eventually reduced after the mother recognised that her pushing efforts were being held up by something. in her next birth that sensation returned. she knew within herself that the lip was there and asked to have it reduced, and then the baby came. does this mean that the mothers body failed her? what right do we have to judge women and their birth experiences? 

if i'm "managing" a birth by protecting a mothers perineum, telling her to slow down as the head is crowning so she doesn't blow her bottom out, is that her body not working? if she is happy, but you are not because someone else had hands on her body as she pushed. who needs to take a step back? birth isn't just going to look one way. i've only attended 130+ births. they have all been different. i've watched mothers birth their own babies without anyone's hands on them, i've also helped a mother direct her pushing. one wasn't more empowering than the other. and if you judge a woman because she had help, who is the one disempowering her experience? who is the one causing her postpartum depression when she's been told her body failed her? that she could have had it better? 

why do we as women sabotage each other?


  1. *hugs*
    The reason I chose a midwife is to have a woman who CAN put hands on my body during my labor and birth. I WANTED someone to guide me through my birth process. I needed, for the health and safety of myself and my baby, to have someone with the knowledge of all of the what ifs, so that in the moment something became evident that would or could endanger myself or my child, this wise woman could love me enough to talk me through the situation and preserve my birth experience. This is what I got. Did it stop PPD with my first? NO. That was my journey and there was nothing to do but take it. Did it save my life with my second birth? Quite possibly, yes. I had no idea I was hemorrhaging. My husband doesn't know what a hemorrhage looks like compared to normal bleeding. I would have had no capacity to assess my own injuries and to find and stop the bleeding before passing out. Because this was managed expertly and I missed out on those moments of quiet reflection on my birth and coming to the realization on my own of what my body had just done does not mean that my birth was adulterated, it means that I was cared for. I am so sorry that you went through that. Know that midwives like you are loved, sought after, appreciated, and valued.

    1. thank you Angela. for your words, reassurance and the hug.

  2. What an interesting take on the licensure/not debate. I have followed (not closely enough) many of these conversations at the international, national, and state levels and find them fascinating. The perspective of dis-empowering women through involvement in the birthing process did not seem to be a pervasive theme through these dialogues but I see how it might fit.

    I am currently seeing a midwife in KY where midwife attended homebirths occupy a very strange place of alegality that can easily slip into illegality. My midwife is anti-licensure due to the regulation of midwives' ability to attend the women who want their services (breech, vbac, twins, age, etc.). To play a little bit of devil's advocate here, I will also add that in my search for a midwife, I interviewed many women, and perhaps there is some truth to the link between midwives who are pro-licensure being more involved and prone to managing a birth. Whether these practices dis-empower women, hmmm... I'm not too sure I groove with that argument...

    When I was interviewing midwives I asked directly their opinions on the license/not license debate. I am only speaking from anecdotal experience here, but many of the midwives that I interviewed who were pro-licensure were also very structured in their behaviors while attending the birth (bad word choice, but I'm trying to articulate a very complicated discussion here) and their perspectives on the role of the midwife. More specifically, when I asked what their typical approach to a birth (from the phone call on) they were all very similar in trajectory, rituals, and procedures, most/all of which were very hands on approaches. The midwives that I interviewed that were anti-licensure responded (nearly unanimously) that they would behave at the birth in any way that I wanted them to. They would be as hands on or hands off as I wished (based on both the birth-day and long continuous conversations throughout prenatal period) unless there were complications. This meant that I could decide that my midwife simply watch while my husband catches the baby.

    All of these experiences are anecdotal, and to be honest, I met many midwives (on both sides of the debate) in my search who I thought would be exceptional birth attendants for me. I chose the midwife that I chose, not because of her perspective on licensure, but due to many factors, including that 'gut' feeling I had when we sat down for our 2 hour interview.

    I don't intend to stir the pot, and to be honest, I had not even put the two traits together until reading this blog and putting a little more thought into my interview experiences. Whatever the various opinions on the matter, i would personally, like to see more cohesion between midwives. I wish to see a greater degree of cohesion and support for all of the different perspectives whether they vary or not.

    1. Thanks Alissa. I don't think you are really being devils advocate or stirring the pot. i think that you summed it up beautifully that you chose your midwife because you trusted your instincts and you didn't need her to be licensed, you didn't need someone else to tell you she was OK.

      but i would like to know if she is/has ever been a CPM. I wonder how your decision would have been influenced if you lived in a state where midwives were licensed. and that practicing unlicensed was illegal. I wonder what your options would be.

      midwives can work in illegal states and still be CPM's. midwives can be midwives without this designation, but they are choosing to or not succeeding in meeting a nationally agreed upon and regulated standard. for whatever that designation is worth.

      i'm also interested in what constitutes a "hands-on" approach.

      does that mean taking vitals and heart tones at regular intervals or does it mean the midwife has to catch the baby? i've been to quite a few births (in licensed states) where no one touched the baby for up to 20-30min after the birth. as a new midwife i'm not sure i'd be comfortable with making the assessment that a baby was OK just by pure observation, though a healthy baby is pretty obvious. i've been to numerous births where no VE's were done, because it was clearly unnecessary, but i've also worked with midwives who like to do at least one VE to confirm that baby is head down. i've also been at births where there was a surprise breech that wasn't identified until we saw babies bum at the mothers introitus (the family was given the choice of transferring to the hospital which meant a c/s as it was her first baby or staying home - they chose to go to the hospital).

      so the idea of hands-off, i really wonder what that means. in practice most midwives will be as hands-off as they can if that is what the mother wants, but they are not going to compromise on basic standard of care - i.e. taking FHT's every 30 min (more when mother is pushing). we've been asked to use a fetoscope during labor instead of doppler and midwives are willing to as long as obtaining HT's is possible, but the mother has to understand she has to cooperate for that to be possible, and that in practice using a doppler really is less intrusive to the labour process as we can get HT's much more quickly. But that is her choice.

      even in a highly regulated state like WA midwives will do what families ask as long as it is not compromising a basic standard of care to which they will be held accountable by their peers. Emi's comment below illustrates this.

      i don't really know what to say about women who don't want that standard of care. i know women who don't want FHT's monitored at regular intervals and have opted to birth unassisted. it is their choice and to be honest i think the wisest. they are taking control and responsibility for their decisions without making another individual accountable. if a baby died at a birth that i chose to respect the mothers request not to monitor FHTs, i would be held accountable both by my peers and by the law. i would lose my license and potentially go to jail. i don't think that is fair to ask of me. and i don't think that it is fair to then say that i am not being with woman, and that i am serving the medical system and not women's rights. some midwives may be comfortable with that. and maybe this is why optional licensure has some validity. i don't know the answer to that. but i don't think that it is a reality we live in. in order to live in society we have to follow the rules that exist, for better or worse. if you don't like a law than as a community we have to work to change them.

      thank you for sharing your experience.

      it’s been way too long lady, we need a reunion!

    2. I agree on all points, and I often wonder how I would feel if my midwife had ever been (or is) a CPM or if I was in a state where there were both certified and licensed midwifes and (as a result) more midwives. My own opinion on licensure sits somewhere along the lines with my midwife's (remember, I'm not a MW, just an anthropologist) on most points, but I am also a very strong proponent of standards of care including checking heart tones, monitoring basic physiological markers (BP, Temp, FHR, etc) while at the same time allowing for some flexibility in terms of other criteria (length of labor, breech and twin births, VE).

      There is so much misinformation about midwifery in North America and contested perspectives in the practice itself. If we could all get on the same page perhaps we could make some really meaningful changes for both women and practitioners.

    3. And YES!! We need a reunion!

  3. I appreciate your thinking on licensure and what happened in NC. I have to say that I am thankful all the time that I live in WA where there is a strong and supportive professional community of licensed midwives, nurse-midwives and ob's. Not that it's all sunshine and roses, but as a newbie midwife, I feel really supported. And we have practice guidelines to follow - they are not legally binding, but it helps when a labor wanders into a grey area. And I think that's a good thing. I guess I'm just trying to say that had the NC midwife been in such an environment, she may have felt peer pressure (in a good way!!) to follow a practice guideline that would suggest when a transfer to the hospital should be considered (e.g. too many hours in labor) or "mandatory" (e.g. maternal fever).

    As far as being hands on or not, I'm sure you've been with enough laboring women to know who needs that and who doesn't. And sometimes as a midwife-in-training/new midwife, I may have been too hands on when I didn't need to be, but that discernment will become more refined as I gain even more experience. You can only do so much for your client, right? You're not her social worker, just her midwife. You're role/responsibility has to end somewhere so that you don't stretch yourself too thin.

    Don't give up. You've come so far!

  4. looks like the link to the mothers story no longer exists. sorry.

  5. so interesting reading this
    especially because here in ireland- a midwife cannot practice without insurance. the laws around homebirth are hard here... and they are very quickly trying to take it away altogether. i have had such negative feelings about the insurance- the way it pinholes pregnant women and midwives-- wondering IF it is best, or if it is business- government interference with women's bodies and educated women who know more about birth than a suit.

    but this side of it also makes so much sense..

    regarding a midwife altering the woman's birthing experience
    we know that anything can alter her experience. in a different world while we are birthing- anything that she chooses, or doesn't choose- can impact how she felt about her birth. so there is no real way to 'protect' her from what your judgement might do to her birthing experience. it is for her to work out herself.. it is her birth journey and process.

    i adore. ADORE my midwife... oh. she is wild and incredible and so wise.
    and i had to really work through a few things in my pregnancy with her- having scans that i didn't want, but she asked for me to have. having internal exams- having so many sweeps - like a necessary evil. choosing her care and loving hand over a hospital induction, over a hospital midwife i don't know- or one that doesn't care for me, or love me like she did- with her hands up my vagina. writing in my birth notes about how she had to force a finger into my cervix. (ugh)

    but that was my own thing to work through. i accepted it. i made my decisions and i had to ask myself what was my issue, what would i rather, what would i decide- especially given the other options, legally as well.

    and then the birth- i think you have already read my birth story. holy fucking divine the birth was incredible.
    and then a transfer immediately post partum to hospital- traumatic stitches, but my hand held by my midwife, and held in her eyes, and loved fully. made it a non issue. made it not part of my BIRTH story

    so.. you know..
    just. you are not responsible for the way a woman views her birth. she birthed, and you were there.. and she will forever hold her birth with you there- as part of it- so you could be the reason she says that she had an orgasmic birth, or a traumatic birth. it isn't ON you- it is her birth, and she works through it, with herself, and who was present.

    i blame the midwife in the hospital for my shitty first birth. i blame her for everything. she didn't give me respect- i felt she hated me. she was probably really just fine, and clinical, and whatever.. she probably just wasn't MY woman. and not everything is her fault- but i blame her, because she is my scapegoat. she will never know.. and i have had to work through forgiving myself for my decisions, or undecisions- and forgive her.... in my own time.

    1. wonderful erin! thank you. and your birth story brought tears to my eyes.

      i do hope to connect with you more over the next few years as my husband and i do plan on returning to ireland. his folks are in belfast, but i think licensing in the south may be more straight forward. i'm not sure. educating outside of the EU may be a permanent road block for me. when i first started looking at midwifery in ireland in 2007/2008 midwives were already fighting to be able to attend births OOH and to be independent practitioners. i really hope that isn't lost.

  6. I am not as up on the licensure debate as I used to be since I have chosen to continue my midwifery career through nursing but, As someone who has worked for and as an unlicensed midwife, i would like to see licensure remain optional. However, for this to work in the current litigious climate, there would need to be a widespread and committed agreement on the part of families choosing to birth with unlicensed midwives that they would maintain a high standard when it comes to taking personal responsibility for the choice they are making. I know that it isn't a popular view to point back to families and i recognize that they can only take responsibility if they know the whole story. This makes it imperative for midwives to be forthcoming about their experience and their personal boundaries as a birth attendant.
    I do think though that it would behoove midwives to choose to become licensed, and if I was currently practicing as a CPM, I would do so. I see the option to license as a way for hardworking women (who have committed hours of their time and thousands of their dollars to their business and community) to protect their investment. While the mandates that come along with licensure are seen by many as restrictive, they could also be viewed as boundaries that allow a midwife to practice with extreme confidence within a particular scope.
    I know how hard midwives work, so many times stepping away from our own families to nurture another and I think that practicing within specific guidelines allows for a measure of protection for all those who are involved with our practice and who count on us; our partners, our children, our assistants, our friends and the families that we serve. I just hate to see women become martyrs to the trade; I hate to see women persecuted for providing this vital service; I hate the distrust that is so rampant within our community.
    I guess I feel like there is a message that goes along with licensure that says "I am confident enough in my work to know that I can't save everybody; I am not obligated to try and I respect myself enough to set these boundaries."
    I have not always felt this way, in fact this is a bit of a revelation to me but it just makes me so sad to see these midwives being persecuted and to think about the cost to themselves and their families.
    Of course then this begs the argument to go in the direction of: well doesn't licensure (whether mandatory or voluntary) just pave the way for stricter and stricter guidelines leading to midwives being put out of business? I don't know. I sure hope not but I have to say that this thought was one of many motivating factors that caused me to choose to pursue nurse-midwifery. I have little confidence that I will be safe even there but my hope, like the hope of many of my friends and other midwives out there, is to continue to be able to serve women where they are and as individuals. I took full advantage of the availability of midwives when I was having my babies and I hope that it will be there for my children and their children too. Time will tell I guess.

  7. I've been a lurker here for quite some time - peeking in on your experiences with learning midwifery - as I have been a student midwife for a while myself - and have taken some twists and turns on this path to becoming a midwife.

    You seem to have had a full-force encounter with some of the radicalism in midwifery - and it's there. I appreciate you sharing how you've processed this experience - and seeing that you are becoming a midwife because you feel called to be "with women" not with midwives.

    These voices of the heavy hitters, I'm convinced, are in the minority. But they seem to be the loudest. And they use their bully-pulpit to exert their opinions. And tug on your own heartstrings by insinuating that professionalization and licensure will ultimately HURT THE CLIENTS you serve.

    I say poppycock! (Actually, I say something else, but wish to refrain from using profanity on your lovely blog).

    I'm sorry you had this unpleasant experience. I've had my own unpleasant interactions with radical belief systems among midwives. But I hope this experience leads you to a stronger place in yourself - and solidifies your knowledge of yourself as truly a 'with woman' midwife.

  8. I'm a student midwife and I am catching some flack for waiting until it became legal in my area. My own birth experiences were traumatic and I needed support that I didn't get. Hospital care providers did create a mess of my mind and body not by doing their job, but by lying about the necessity of augmenting slow labors and the risks and realities of using drugs to force unnatural contractions.

    I think even a c-section is by no means a failure on a mom's part, but coached pushing and trying to force a cervical lip can both be unnecessary pain and stress if done routinely. I also feel strongly that the routine of monitoring every 20-30 minutes can be broken for a tired mom to nap or rest (seriously the harassment I got over this turned a calm natural labor into a battlefield).

    In general, there is way too much of an attitude that everyone should be fending for themselves. In fact, I'm surprised more moms don't insist on birthing without anyone touching them. We aren't on a planet with 7 billion people to learn to fend for ourselves. We need to learn to give and receive support, and if the birth of a baby isn't a time for support I don't know when is.