I’ve been catching up with blogs of late, and wandered back to a post on Fogelson MD’s blog about a DEM in OR who thinks (as I do) that breech at home without someone with lots of experience (more than a handful) is a bad idea. I liked the tone of his post, I like that he has a DEM in his family and gets to chat with a homebirth provider about these issues.

If you have the stomach for it though, read through the comments and see how he takes a first year midwifery school apart, before being an ass to her preceptor, and then again to the student. It made me think about a couple of things which have dismayed me of late. I recently heard that a local training hospital is all-of-a-sudden doing ultrasounds at the labor bedside to confirm presentation, often after a VE where the fetal skull was palpable. Why? A few curious doula’s asked. My suspicion is that there is a new crop of residents about, and their hand skills aren’t terrific. Perhaps it’s a box they must check on their charts. I don’t know. Made me think of the med students I worked with overseas who had never seen a fetoscope, let alone understood how handy they are for you know, assessing fetal position.

The other incident involved a trip to the hospital with a friend who suffered some outta-the-blue abdominal pain. After an xray and an ultrasound while waiting for a CT, I asked for permission and gently pounded on her CVA. Predictably, she yelped on pain. Turned out she had a kidney stone (it was confirmed by the CT). She hadn’t had a physical examination though. The ER physicians literally hadn’t laid a hand on her. Ok, I know, those tests probably didn’t do any harm, aside from the hours of waiting, and the expense, the discomfort of the ultrasound and what ended up being a waste of resources, but I don’t understand is why a simple examination was omitted. Bottom line it wouldn’t have HURT to put your doctor hands on my friend’s body and actually assess what may have been causing her pain.

So anyway, Mr Fogelson railed against the evidence supporting moxibustion as a decent effort to try to turn a breech baby, I got a really unpleasant taste in my mouth. It’s not that I think that moxa is a particularly good or a bad thing to try if you have a babe who’s breech, or acupuncture, or any of the other things folks try to vert babies which *are* really, totally unsupported by randomized controlled studies. I DO think that if the end point is a cesarean section, why the hell NOT throw everything AND the kitchen sink at it. The fact remains that those things give scared moms and dad’s something to DO with their upside-down baby while they contemplate a surgical birth the idea of which they’re probably not wild about. I don’t see the NIH rushing off to begin a RCT of Pelvic tilts or inversions or flashlights and dad’s voices in the crotch! Why not try it?! It certainly ain’t gonna hurt!

Why does a doctor feel like encouraging a dad to lovingly talk his baby into moving head down is “woo-ism”. Why would it matter if it was the dad, or if it was the baby simply deciding it was time to turn head down? There is simply NOTHING BAD about that. Again, while no-one is doing RCT’s of this method, I’m sure there are midwives and parents who have enjoyed the giant roll of a baby late in pregnancy and the solid thunk of a cranium engaging in a pelvis shortly after a session of dad-chat.

Why is it that physicians come so far from actually touching patients/clients? Why can’t we wrap our head around the thought that families and babies sometimes actually interact meaningfully in-utero and the ramifications of those moments ripple onward into extra-uterine ways in ways which we actually can’t scientifically quantify. Why is the un-quantifiable automatically discarded by the medical as irrelevant? Why does it seem like some of these docs default all too often to the tests, and the technology and the almighty “science” at the expense of human interaction and compassion, and occasionally yes, leaving the door cracked just a little for the inexplicable. Worse, that seems increasingly to be the way they are taught!

This becomes evident even in our interactions with each other (docs and midwives) on the vast, impersonal informational dumping ground that is the internet. Mr Fogelson speaks a pretty game of “how nice it is to have a conversation with a ‘sensible’ homebirth midwife”, but the disrespect and tone of his later comments to the student midwife and her preceptor who had been quite clear in their transfer and referral process for breech were uncalled for. She, like me and many other midwives, doesn’t plan breeches at home because she’s not adequately trained to attend them. They showed up in essence to support his initial post, and the midwife whose letter he posted, and instead he was a jerk, while trying to school a green midwifery student. I’m still not sure why.

This in the face of that recent study talking about how a great chunk of ACOG recommendations are based simply on opinion, it’d strike me as more respectful if he’d perhaps actually acknowledge that. Midwives expert opinions are often grounded in a different philosophy and expert opinion, often no great studies, but some awfully good observation from many hundreds of years of practice.

How is that any different?

In the meantime I’ll just pour some more love in my hands. No evidence for that, but guess what. That improves outcomes.

Rant over. That is all.

When I was a student midwife, I asked one of my preceptors what her favorite bit about midwifing was. I fully thought and expected that she would reply that catching slippery wet new human life was her favorite, so enamored was I of that at the time. She thought for a long minute and replied simply “When I leave”. I think I stood there gaping not quite understanding. She then explained that, for her, leaving a new family tucked up in their own bed, warm, fed, new babe at the breast, house tidied and quiet was the best bit about her job. I totally understand this now after a few years of practice. Those moments are absolutely golden.

This week though as I did prenatal and postpartum visits in clients homes, surrounded by a gaggle of breathlessly excited and curious older siblings and neighbor children and even another homebirth mom who’s last baby I had the privilege of touching first, I found new joy in my work. For a moment I wished that I could do all my prenatal visits in my clients homes, surrounded by their things, their loves. It felt a bit like I was in that beautiful children’s book Welcome With Love. Of course I can’t do every visit in my client’s homes, there aren’t enough minutes in the day. Its nevertheless something I adore about my work, the quiet, personal time I get to spend in my client’s homes. Really getting to know them, and they me in the gentle sharing of tea before blood pressure and measuring and leopolds on their own bed or couch. In showing little fingers how to squeeze the bulb of the blood pressure cuff, or hold the tape measure, or listen to heart tones with a fetoscope. In those moments I feel the generations of midwives and physicians before me who also had the honor and privilege and responsibility of being invited to care for families in their homes.

Welcome with Love

***

Then this week as well, spurred by yet another evil third party insurance contract requirement (and yes, I DO think that the fact midwives are required to jump through these hoops is at best obnoxious and at worst offensive but anyway), I plucked up the courage to ask a local physician who I’ve had the pleasure of working with occasionally these past three years, if they would be willing to act as a reference for me. This is a giant hurdle for midwives, as professional liability carriers prevent physicians from entering into formal consulting agreements with individual midwives. So for years, midwives have had to rely on the assurance of local training hospitals who will document that they will consult with and accept transfers of care from any provider. Sometimes this suffices, and sometimes it doesn’t. Regardless I have worked hard since I’ve been in practice to show up and prove to my physician colleagues that I’m actually committed to the same endeavor they are (healthy moms and babies) and that I am sensible, careful and transfer care appropriately. I learned a long time ago that where the baby comes out isn’t the be-all and end-all. I don’t actually care where the baby comes out. Its lovely when it’s at home, or at a birth center but it IS possible to have a divine birth in the hospital either because a change of venue becomes a good idea OR because the mom simply wants to have her baby there. From a practical perspective it’s challenging for a homebirth midwife as I don’t get paid when this is where we end up but that’s food for another post. Midwifery care is about more than where the baby is born. We’ve all proved that over, and over. In any event, I really needed a physician to be willing to answer a phone call from an insurance wonk and say “Yes, I’ve worked with her, she’s good people”.

This doc was graciously quick to tell me that they were. This is a lovely gesture of professional goodwill on their part, and it will make the lives of my clients easier as we will no longer have to pursue separate authorizations for my care every. single. time. It tells me that I’m seen (and I’ve felt invisible a LOT as a homebirth midwife on hospital turf). It’s just one midwife, and just one doc but it also makes me hope quietly that we might actually be getting somewhere. Three years working in this community, and I feel like I’ve found a little spot where I’m seen and vouched for as a colleague. It feels really, really good.

Facebook, I’ve decided, is the devil. I’m a super social human, so their platform sucked me into the vortex about three years ago and I started thinking in pithy (and not so pithy) status updates. My three year old recently started telling me to “get off Facebook”. I went on vacation for a week, and dramatically curtailed my FB use. Godhelpme my return to blogging is my methodone.

And so I find my way back  to my poor neglected blog. Unlike my living room which is now cluttered with FOUR children, instead of three and their assorted gear, it takes no time at all to straighten things out and throw up a new coat of paint, er, theme (thank you WordPress). I’m still here, coming up on three years of practice, almost 100 courses of care under my supervision, loads of lovely babies, and strong mothers and fathers. Mainly homebirths. Loads of transfers in the first year or so, almost all for first time mom’s having long, difficult labors, but a few for hairier stuff. Have forged some decent relationships with local hospitals. OB hospitalist physicians at our local hospital are usually excellent, and occasionally completely crap. On balance though I’d say that we’re pretty well off here, as far as reception goes.

I have taken on some new bits and pieces, I now sit on the state midwifery association board and chair the board of the state Underwriters Association which administers professional liability insurance to midwives here. I had another baby last year. Finally a girl. Her birth was excruciating. I found the answer to the question of “am I done yet” therein.  She is my last. I am happy for this. I am still married to my husband as he is a most patient dude. Cranky and bad-tempered at times, like me that way, but patient. And he seems to love me still. We celebrated 10 years of marriage last year too.

I have much new craziness on the radar. in a few short weeks I shall enter into a partnership with four friends and colleagues and together we will open the county’s only freestanding, midwife-run birth center. This will devour whatever brainspace I have left and radically shift the population of women my practice cares for. I am thrusting myself deliberately into a very uncomfortable space in order to shift my practices status quo. Its time that midwifery was accessible and ABLE to serve ALL women in my community, not just the white women. Our efforts are intended to provide a place for African American, Native and non-English speaking women to have excellent, culturally appropriate and accessible midwifery care AND provide a beautiful and lovely middle ground where folks who don’t want to have a hospital OR  a home birth can come and birth their babies. Come back over the next few months and you’ll get to read allll about it, and laugh at me as I lose my mind in the process.

Wendy Hands

In the meantime, here’s my divine Miss W. Wish her luck, she has three mental big brothers, and her mama’s a midwife!

For those of you who want a primer on my more prolific blogging days you can find it all at http://www.mamamidwifemadness.blogspot.com and the grittier tales of my Vanuatu training at http://somewheresouthoftheequator.blogspot.com/

Up here on one of the more northern points on my NEAR BLOODY VERTICAL learning curve.

All is well. Though I feel like I’m playing a semi permanent game of daily whack-a-mole.  Turns out that actually figuring out the inner workings of a midwifery practice is nothing short of crazy-making. With that said I’m achieving a lot, in the few almost childless hours I have in a day which amounts to about two hours in the morning when H (5yrs) is at preschool, and A (9mo) is cheerfully gnawing on whatever detritus remains on the floor after the dog’s done his morning sweep, and then a couple more hours (if I’m lucky) when both boys are ‘resting’ of an afternoon before O (7yrs) gets off the bus. The rest of the time I make lists compulsively in several different places which, while not terribly helpful, assuages slightly my more manic “must work, dammit” energy.

This week I have:

  • Applied for a DSHS provider number and a spot on the coveted Homebirth Provider list maintained by the State. Yes, here in progressive Washington Licensed Midwives are medicaid providers, and as such serve large numbers of low income women. This is the first of about 12 hurdles which I must navigate before the state will reimburse me (at the standard shockingly low rate) for my services. Not complaining though, as DSHS clients I expect, will comprise a hearty chunk of my clientele. The DSHS chronicles will henceforth be tagged, as those aformentioned 12 hurdles will no doubt be noteworthy.
  • I managed to figure out how to secure a copy of the letter formerly known as Easterling, now bearing the signature of another highranking MFM doc at Large University Hospital which outlines that as a Large University Hospital that they offer 24/7 OB consulting and referral services to all Obstetric providers, not just me. Except it actually says my name. The things a License number will do!  It was actually not a huge deal to get (Oh, how I love my internet fax machine) but it will be a vital part of my next steps of applying for health insurance contracts, as individual physicians are actually prohibited by their malpractice carriers to have any written consultation or referral agreements with individual midwives. Stupid, yes. But there you have it.
  • I signed up for a provider number to administer Newborn Screening tests (I only half-jokingly call them Newborn Screamings) , and birth certificate filing (which I’ll mercifully be able to do on-line!)
  • I requested privilege packets from the two Seattle area birth centers. Not such a huge deal, though I must obtain a TB test as I’m sure the one I had when I emigrated 10 years ago (!) is null and void.
  • I signed lab contracts, and as of next week will be cheerfully drawing labs of all sorts at my clinic. I have calls in to the local radiology outfits as well. I’m also expecting a contract in the mail from a midwifery biller who I will happily pay to reduce my personal contact with the insurance industry. She cheerfully calls herself a “layer of administrative waste”. I don’t mind, if it means I don’t have to turn myself inside out trying to get paid. God only knows if this week is any indication I’m liable to be spending stupid amounts of time on the phone already.
  • Sat in on a marathon phone conference training for a big state OB outcomes data collection.
  • Attended the birth of a lovely baby boy.
  • I have enjoyed my first few visits with my new clients!  I love that I can spend as much time as they need. The upside of hiring a new midwife!

I should also mention that in the last two weeks I’ve had my offspring home sick for 5 days, and then another public holiday bookended with public school non-contract days. This make for a nice 5 day vaycay for the teachers which I don’t begrudge them, but seriously, sometimes it feels like my children are never actually in school. Oh, and I completed H’s kindergarten application. Is it August yet??

In other, completely off-topic news the sun came out in a big way up this way, melting all the snow at the Olympics (whoops), and tricked my cherry and plum trees to burst into flower (unheard of in mid-February). My garden bed was warm and ready, so I now have Peas rockin’ it early.

Oh yeah, and A, freak baby, decided to walk across the garden on Sunday. At 9 months.

Next week I will secure my first quarter of professional liability insurance (malpractice coverage) and then the first wave of insurance paperwork will go out. I will buy the remaining bits of furniture for my clinic and (this is the fun bit!) my birth bag. I have set a date for my clinic open-house/warming party (March 20th) and look forward to filling the place up with lovely people, and then lovely clients. It’s this that I have waited and worked so hard for.

So it goes in Leafy Corner. I may have changed my name, but there’s definitely still a bunch of mamamidwifemadness going on.

Time for a fresh start, a new look!

I continued to feel that I needed to jettison MamaMidwifeMadness. Here I am. Still a mama. Now a brand new midwife, and yes, still managing a good deal of miscellaneous madness. But now, I get to cast off my student cocoon, and figure out how to dry my wings in this soggy corner of the world…

I kicked around some names for this wee blog, but found that what I do seemed to suit it best. I am a homebirth midwife. In truth, I would be happy to attend women in whatever site they chose, but at the moment our options are home or one of Seattle’s lovely freestanding birth centers. So Homebirth Midwife it is.

I am a Certified Professional Midwife, and, when the State gets around to sending me confirmation (the glacial pace of bureaucracy!), I’ll also be a Licensed Midwife. I have a new practice. It is little, but growing. The name is a little homage to my Australian roots. And yes, they are gumnut blossoms up there in the header thingy. You can expect me to be writing about the challenges and delights of establishing a new midwifery practice. You can be sure that there is no manual for this. It’s an interesting if sometimes exhausting ride.

Our climate of progressive, professional, out-of- hospital midwifery here in Washington is one I’m proud of.  I am grateful and humbled to stand upon the shoulders of the midwives here who work so tirelessly to bring our special brand of midwifery care to many, many more women here than in many places in this country. In addition, there are Washington State trained direct entry midwives who are registered and practicing in Canada, Australia and New Zealand and the UK as well as all over the United States.

I have less time for my blog now that I am no longer a student and now that the small boys in my house number 3, rather than 2. I am about though, and watching closely as some great (and not so great) discussions roil about the blogosphere.  I think that this medium is a powerful one, and one which midwives and their clients are using to great advantage.

Change as they say is incremental. And it takes time. As midwives though, we understand patience. Right?

Thanks for joining me in my new corner of the blogosphere!

So yes, months and months have gone by it seems and I have been unable to drag words out of myself sufficient to deposit them here…

  • I have instead made much milk and grown a fat, lovely baby. He has two shiny, sharp new bottom teeth, much stronger opinions about things, and threatens to crawl.
  • Attended an extra 6 births pursuant to stupid school requirement, took baby with. He lolled about as mother after mother pushed their babies into the world. Invariably he watched as if to find out what ‘kind’ of baby it was, then sighed deeply and promptly slept through the busy-ness of postpartum, newborn exam and cleanup. Without exception those births were lovely.
  • Officially graduated from SMS (for real, this time, even have the transcripts and diploma now)
  • Studied, traveled to California to sit the NARM exam, before attending the 2009 MANA conference where I finally got to meet Ina May. Briefly contemplated racing around snapping pictures to make a “Midwife All-Stars” trading card pack… Lots of cool people there, Ina May of course, but also Anne Frye, Saraswathi Vedam, Carol Leonard among others. MANAmania is indeed, just that. Much singing, and dancing, and telling of stories. I thoroughly enjoyed and was moved to tears hearing from Florida midwife Jennie Joseph. Want to eliminate racial disparity in preterm birth and associated morbidity/mortality? Check her method out. It’s fantastically simple, and yet our mainstream maternity care system seems to be incapable of replicating it. Also caught up again with lovely Sherry of the Labor Payne Epistles.
  • The MANA/ACNM Bridge Club was an epiphany. Many hurt CNM’s and CM’s (not to mention the CPM’s) who had a LOT to say to the ACNM’s reps who seemed to show up to stand in the fire. The ACNM is facing real challenges with nurse-midwives losing their jobs all over, their fickle physician allies are rumored to be training PA’s to do births to “solve the midwife problem”, while the MAMA campaign is forging ahead, making some pretty significant strides in furthering the CPM credential federally. Homebirth numbers nationally are still small, but homebirth is usually the domain of the CPM, with fewer and fewer nurse midwives practicing at home. My feeling is still that we must be midwives together, and if not, then the ACNM needs to step aside and get out of the way. Homebirth and CPM’s will eventually overcome, and the option will inevitably be preserved. Midwives are perhaps the most stubborn people in the world.
  • Passed the NARM (can call myself CPM now!!)
  • Reaquainted myself with my family who had been without me (for all intents and purposes) for about 18 months
  • Wrote and built phase one of my practice website (Well. I tortured Husband until he did that)
  • Much practice start-up planning, negotiations and discussions with collaborating midwife.
  • On a family level we’ve implemented brutally ascetic new financial regime in preparation for evil student loans coming due in January. It’s not been terrible.

The rains and chilliness have come again to leafy corner. The fire is invariably in the grate. The pace of my life has diminished measurably aided in part by the hefty doses of oxytocin flowing as freely as the milk. I am discovering, as my train of thought is oft derailed, that milk coma is a shared motherbaby phenomenon.

I have between 3 and 6 births a month on the books for the next 6 to 8 months or so. Most of these as a birth assistant, but some will inevitably see me on first call and assuming the mantle of primary midwife for real. I’m really enjoying watching the growth of the new student in the practice as she gains confidence and skill. It’s not my turn to teach, as I have so much yet to learn, but I am really looking forward to it when the time comes.

I continue working towards a series of meetings with our local hospitals with the mission of improving home-hospital transports. At the brilliant suggestion of a super cool OB from Canada who is using this technique in his mission to enhance communications betwixt midwife and physician in Canada, I’m contemplating pursuing some training in Compassionate Listening. Figure it can’t hurt, might help.

Originally posted elsewhere April ’09. Thought it was worth putting up here too.

Of late, I’ve heard several senior midwives in my community voice concern that media attention is being focused too closely on home birth, and too little on midwifery care, which indeed is probably the key factor to all the excellent outcomes which midwifery clients enjoy. I’ve sat and mulled over this for a couple of weeks now, about what place homebirth should take in campaigns to further access to midwifery care. Is it ALL about midwifery care? SHOULD we shift the focus away from homebirth?

It’s true, we DO need more midwives providing midwifery care to improve this horribly broken system women are fed into routinely, and fed out of with more than their fair share of iatrogenic morbidity (unnecessary cesareans anyone?). But we also need to take a deep breath and look closely at where we’re at and what it is we are really asking for.

When compared with the hundreds of thousands of babies born in hospitals annually in the US, homebirthed babies are rare and precious creatures. Homebirth is still considered ‘fringe’ in many quarters in this country, though homebirth advocates (usually those who’ve actually experienced the difference!) are vocal and impassioned. I think it’s easier for all of us to focus on the stunning, life-altering shift of a baby born into a mother’s or father’s trembling hands than it is to dissect the much less awe-inspiring (and certainly less sexy, media-wise) impact of good, thorough, woman-centered care during the childbearing year.

Direct entry midwives/Licensed Midwives/Certified Professional Midwives provide midwifery care in out of hospital settings. We achieve excellent outcomes for both mothers and babies at HOME and in FREESTANDING BIRTH CENTERS. We do this in deceptively simple but extraordinarily cost effective ways. We spend TIME with our clients. Hospital OB practices are occasionally (dare we hope increasingly?) taking a leaf out of the midwives’ playbook, making that same commitment and guess what? They’re lowering their CS rates (and I’d bet their client satisfaction rates are climbing too). If it were possible for physicians broadly to set aside the focus on pathology of pregnancy and birth, and apply the very basic tenets of midwifery, I think we’d see a shift away from the 32% cesarean rates, probably see a shift away from the low birth weight and premature birth rates, increases in breastfeeding rates and associated life-long health benefits to both mother and babe, to say nothing of the profound impact a shift like that could have on women’s lived experience of their care, and entry to motherhood. We need only look to physicians like Marsen Wagner, Sarah Buckley, Michel Odent and hundreds of other less well-known physicians worldwide who we laud as being revolutionary. They might be within their circles, but they’re just talking about midwifery care, are they not?!

As I write this, independent (homebirth) midwifery in Australia is being sold down the river by none other than the Australian College of Midwives. In a schism which I find oddly reminiscent of the divisions which keep midwives in the US divided and effectively conquered: So called “independent” homebirth midwives will be de-registered and find themselves practicing illegally if they practice without professional indemnity (malpractice) insurance. Midwives working within hospital birthing units however will receive limited prescriptive authority, increased autonomy and the indemnity insurance. The College appears to be effectively trading independent midwives livelihoods, not to mention Australian women’s birthing choices so that they can increase their hospital purchase. Their logic I’m sure is that this will increase women’s access to midwifery care. Perhaps it will, but at what cost? My bet is that it will marginalize further those women who seek to birth at home, further limit access to VBAC (a whole other note), and force midwives to practice illegally – to no-ones benefit whatsoever.

Last year the American Medical Association at its annual meeting it adopted a policy written by the American College of Obstetricians and Gynecologists against “home deliveries” and in support of legislation “that helps ensure safe deliveries and healthy babies by acknowledging that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital” or accredited birth center. When powerful physician trade union interests are threatened sufficiently that they call for legislation to restrict women’s choices in birth, or intervene successfully to lobby to have pro-midwife legislation voted down in state houses (as happened this week in Michigan), midwives need to recognize that this is a basic threat to our livelihoods, to women’s choices in maternity care, and her right to birth wherever she chooses. In this way it IS about homebirth.

And so, if it’s the impassioned, satisfied home birth clients and the “ooh” factor of homebirth which keeps midwifery care at the forefront of the momentum to reform our broken mainstream system, then so be it. I’ve become a homebirth midwife because I didn’t want to be a CNM, or an OB. I’m not ashamed or reluctant to talk about the fact that I will care for women inside their homes, and handle transports to higher level care when and if women need it. I feel that the midwifery care I provide to healthy, low risk women is far superior to medical or high-volume CNM midwifery care women and their babies experience in hospitals. Every opportunity I get to talk about homebirth is a springboard to larger, more important discussions about thorough informed consent, the wider benefits of midwifery care, about how mothers and babies DESERVE better than they’re getting.

I personally look forward to a day when I can attend my clients in the birth site of their choice: home, birth center or hospital, but that’s a ways off for most LM/CPM’s (though it IS happening people!!). I would note also though, that I wouldn’t ever give up homebirth practice. CPM/LM’s are, I think at heart, home birth midwives. Without birth at home as a legitimate, well-championed choice, we all lose. Not least of all the midwives.

Direct entry midwifery in the United States IS proudly, unashamedly, wonderfully ABOUT homebirth. I would suggest we forget that at our peril.

So, the more I think about the way the survey was worded, the more I realize that they’re framing the discussion in terms of “we’re gonna get sued for care we weren’t a part of until things went bad.” I’m not sure that that’s happening, midwifery clients are less likely to sue because of the relationships they build with their midwives, but perhaps after a bad outcome after a transport they may be more inclined to lay blame at the feet of the hospital staff? Most of the OB related law suits I’ve heard of have resulted in everyone in the vicinity being named, physicians, nurses, midwives, everyone. So ACOG is perhaps misplacing their concern. I confess to getting a little irritated at their constant fretting over potential litigation. Perhaps if they spent more time with their clients and addressing some of the systemic flaws in a system which drives a significant chunk of homebirthing women our way fewer suits would follow. But I digress…

ACOG seems increasingly threatened by the groundswell of support for midwifery care, and appear clueless about just how tech-savvy the movement has become. I’ve been chuckling a little imagining their surprise when they realized that so many midwives and homebirth clients hijacked their silly survey!

Another thought which I have percolating is that the county call physicians who are called in to ‘manage’ transports (which are invariably for non-urgent scenarios: pain meds, needed augmentation and the like) can and I’m sure DO face exactly the same set of dramatic rare complications coming through the doors (things like cord prolapse, abruption and the like) from their own patients, and women who walk in off the street as well as the very occasional unlucky homebirth client. This being the case I’m inclined to ask: what is the difference?? I’d also point out that some of the other issues postpartum hemorrhage etc. are perhaps more likely to occur iatrogenically inside hospitals under their own protocols due to the widespread, routine application of pitocin for just about every laboring woman. What we use as a first-line treatment for bleeding doesn’t work as well in a uterus which has been soaking in it for hours.

And then, amongst all of this is the feeling that I have, that has been expressed much more eloquently in the wonderful huge Dutch study and several good UK studies, that none of this has to be this way. If Docs would work with midwives (and yes, some do!) to provide excellent care throughout the course, we’d probably be happier transporting in. The clients would feel safer doing so, and if we midwives actually had a cats hope in hell of developing a working, consulting relationship with a physician willing to take transports, the docs would know and trust that the midwives were transporting prudently, in a timely fashion (which most midwives DO!). There’s ample evidence that this OPTIMIZES outcomes.

I just wish we could all get to the table in some meaningful way because there is SO much bullshit flying around!!

My goal for my practice is to make sure that all of the OB’s and family practice docs in my community know I’m here, know that I’ll do my level best to ensure that my clients are thoroughly taken care of, that I’ll consult and transport in a timely fashion and use my state midwifery organizations Guidelines for Transport. I want them to come to understand that while we don’t have to always agree with each other’s ways of doing things, we do have to agree that professional respect is in order and, when we transport into the hospital into the care of whichever county doc is on call, we’re on the same team. It’s a phrase used too often used, but midwives DO care deeply about healthy mom, healthy babe, as much as I know doc’s do. The difference may be that midwives value the birth process more, have had the benefit of a lengthy prenatal course to understand thoroughly a woman’s hopes and fears, and understand that in many ways there’s more to healthy than two heartbeats. I can be completely sure though that there isn’t a midwife or mother who would willfully compromise the health of a client or a baby for a vaginal birth at all costs. It is antithetical to midwifery care.

I’ve had some phenomenal transports to a local hospital in my area in which nursing staff and docs have acknowledged in a very heartfelt way: “We understand that you didn’t want to be here, but we’ll do everything we can to help you achieve as many of your birth wishes as we can.” These have been the transports which give me hope that LM’s can work beautifully alongside physicians. I’ve also had other, less-than-stellar experiences which were notable not for overtly poor care of the client, but for outright disrespect and awful treatment of the midwife. Even when the transport was handled superbly from the moment trouble was discovered, to the EMS call, to the hospital doors. From there things went downhill. There’s no excuse for this. None.

What ACOG seems not to understand is that midwives are not going anywhere. Women are going to chose to birth out of hospital in greater numbers as they realize that they have a much better shot at continuous, thorough, woman-centered care with midwives in OOH practices. Midwives have always been here, with woman, and we will always be. We do this knowing that sometimes we need the docs and all the hospital bells and whistles, and we transfer knowing that it’s often a crap-shoot as to what sort of reception we get. For midwives (and their clients) who strive for consistency and excellent care, being tarred with the “crazy homebirthing folk” brush, and the occasional glaring ignorance of hospital staff (“Oh, you’ve brought prenatal care records with you??”), it’s anxiety provoking to say the least.

As a newbie midwife I know that it will take me a long time to build physician trust in my clinical decision making. Hell, I understand that it will serve me well to practice VERY conservatively until I get my feet well under me as an OOH midwife. The piece I can work on though is the getting to know you bit. I can offer to come talk to the EMS crews, and the OB nursing staff. I can show them our transport forms and my practice guidelines. I can be very open and available with the physicians in my community, and I will be ready to call and ask questions when I have them. I’m a part of their community, and some of my clients will inevitably wind up being their patients. Just as it’s my responsibility to care for my clients to the best of my abilities, according to the established standards in my community, it’s also their responsibility to care for patients who need their skills and expertise, no matter where they come from: another doc, a midwife or just walking off the street.

Don’t we share the common goal of caring for women and their babies throughout their childbearing cycle? Sure we do things differently sometimes, and yes, I’ve only attended a fraction of my births training in a hospital. With that said I can guarantee that even as a brand, spankin’ new, just-outta-school midwife I’ve managed more births at home (and the occasional deviation from normal) than any single physician in a three county area. It ain’t a pissing contest, but we need to move past the whispers of terrible homebirth catastrophe stories (which are invariably patently false) and back turning, and refusal to have anything to do with each other and get on the same page (or as close to it as we possibly can). Women, their babies and our shared community health-care resources depend on it.

One birth away from completing the contested requirement for school, then miscellaneous paperwork, a couple of remaining visits on a continuity of care and then, folks, I can divorce myself from my alma mater. Our parting is not 100% amicable, but whatever. I’m a midwife and that was the goal.

Am scheduled to sit the NARM in October at MANA (anyone want to catch up?!) and enjoy the goodness and recharging that comes with sitting in a room of women who get it, and the swirl of white hot politics which surround the profession at the moment. Midwifery and politics is kinda like margarita and roasted marrow bones to me. Favorite things and all that.

Some interesting things have been floating by of late which I’m hoping bloggers with more time on their hands than I do can take up and beat to death. Most notably this evening I’ve become aware of a mindblowing ACOG survey which I suspect will dissappear shortly (it’s sooo ridiculous I have to hope they’ll see how idiotic it is and pull it). In the face of yet more recent compelling international research supporting the safety of midwifery care at home, and the powerful momentum behind the MAMA campaign, the Big Push ACOG is hunting desperately for anonymous anecdotes of poor transport outcomes.

“The American College of Obstetricians and Gynecologists is concerned that recent increases in elective home delivery will result in an increased complication and morbidity rate. Recent reports to the office indicate our members are being called in to handle these emergencies and in some instances have been named in legal proceedings. To attempt to determine the extent of the problem, a registry of these cases will be maintained at ACOG on a year-by-year basis.”

I’ll restrain my comments to simply observing that, for an organization who is so fond of brandishing the “gold standard” of the randomized controlled trial, negating the fact that birth cannot be randomized, and tarring the best studies available with the judgment that they are of “poor methodological quality”: Pot calling kettle black, much?

Independent midwifery in Australia is under pretty dire threat. See Lisa’s blog and the many fine videos on the subject which are all over YouTube at the moment. If you’re in Canberra go to the rally on Sept 7. Numbers will count. There is a way you can attend virtually Homebirth Australia will have more info if you’re so inclined.

Have enjoyed these last few weeks on call. Four lovely births, three babies caught by their mothers (dad’s assisting) in the water. Three births which Alec attended with me, watching quietly in the corner, or dozing. He’s a doll.

I’m starting to get organized business-wise, I have a phase 1 website up, and am beginning to talk to a few families who have babies due early next year including a couple who I worked with as a student in a prior pregnancy. I’m penning letters of introduction to the local docs, and will shortly begin introducing myself formally to the EMS crews in my neighborhood and the L&D nursing staff at the local hospitals. This piece of the puzzle is important to me and I’m really, really enjoying it. While I don’t expect a mad rush of “Wonderful, there’s a new homebirth midwife about!” sentiment, I’ll be happy knowing that they know I’m here, and that I care about our working relationships. The rest will have to come over time. I am nothing if not persistent.

This next phase promises to be a hard slog, but I’m grateful and happy to be finally beginning.

Oh yeah, and here’s my waterbaby, who keeps me away from the computer so much.

Take THAT, ACOG!

Ok, let me preface this with the fact that I’m only slightly post-coffee, and so my morning hair-trigger persists a little. But HOLY shit, what is it about the reactions to the Pit to Distress discussions?? Mercifully most of the reactions have been ones of disgust and anger (where I think they should be), but increasingly I’m seeing it spun into two camps: the “this wouldn’t be happening if women didn’t all ask to be induced so often because they’re miserable, or their inlaws are coming, or doc is going on vacation” or the nursing camp which is focussing on the nurses responsibility to decline, or argue unsafe physician orders. It’s not even about whether or not the words “pit to distress” or “pit to D or D”, or whatever else are written into the chart or are accepted as a reasonable option in any hospital. While the nursing ramifications of these types of orders are very reasonable discussions to be having, NONE of these angles addresses the issue at hand!

Regardless of whether or not a woman is so rediculously miserable with being pregnant, or whether a nurse can use her hospitals protocols as back up to refuse to administer what she feels is an unsafe dose of medication we’re talking about a system in which physicians are allowed to practice in a manner which is DANGEROUS and LIFE THREATENING. We MUST NOT blame women for presenting for an induction when they have (usually) been given what they -and probably their physicians – truly believe to be good clinical reasons. We MUST NOT blame the nursing staff for having to act as the safeguards for their patients (or not being able to, as the case may be). We HAVE to call the physicians (ACOG?!) on this particularly vile mismanagement and the medical school programs who teach their students that labors can be ‘managed’ this way. Where’s the accountability?!!

I don’t give a rats ass (sorry again, it’s the coffee) if some quarters believe that this isn’t common and therefore not worth getting worked up about. In the last few days I’ve heard first hand report after first hand report, in my state (where incidentally the ACOG chair – who is very pro-midwife and homebirth – when asked about this was shocked and appalled too), in other states. When the words “pit to distress” appear in textbooks the case can be fairly made that this is happening too frequently. Honestly I believe that even once would be too many. If you’re uncertain if a mom/baby needs a cesarean, then to my mind you have two options: 1. You make the decision that the dyad needs a cesarean (hopefully for a sound clinical indication) or 2. You WAIT and WATCH for a true indication that takes them to the OR. Throwing high dose pit into the equation to accelerate this call is simply reckless and also, I think, cowardly. Asking nursing staff to participate in that process is beyond cowardly. I’ve stood up and applauded for the nurses who have made it clear to their physicians that “they want the pit turned up, they can do it themselves”. The nurses shouldn’t have to fight to ‘protect’ their patients.

As ever rising cesarean section rates are debated in this country I think that we have to very closely examine the reasons which are so commonly brandished by the physician camp: “you don’t get sued for doing a c/s, you get sued for not doing one”, “The childbearing demographic has changed” (AKA, too old, to fat, too short, too young etc. etc.), and address more closely the MANAGEMENT of pregnancy and labor in this country. Midwives are working largely with the same demographic, and yet through attentive, comprehensive, holistic prenatal care, excellent childbirth education, one on one labor support, and yes, no routine pharmaceutical augmentation of labor, we manage to facilitate vaginal births for many, many more women just as safely. All that, AND midwives are many times less likely to be sued by clients, even after bad outcomes – even in states where professional indemnity insurance is available to midwives. Why? Probably because midwives take the time and work hard to establish solid, trusting relationships with their patients – something which (respectfully) is tricky to do when you only see your physician for short minutes at a time and who (usually) step into the room as your baby crowns. So the “you don’t get sued for doing a c/s” thing rings hollow. All too often mother/physician relationships are based on blind faith that your doc has your best interests at heart. Clearly though, as we discuss “pit to distress” that faith is terribly misplaced. That this is happening AT ALL, ANYWHERE, is TOO MUCH.

What we need to figure out is what we have to do to stop it and we have to stop blaming the women for what happens to them when they walk into a hospital.

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