I am at the Midwifery Today conference in Harrisburg, PA this week/weekend. If you're here too -- hi!!
My observations (and opinions) are as follows......this is my first time at a MT conference, so I am seeing this entire conference through both a new attendee's eyes, a new midwife's eyes, and through a CNM's eyes.
My first impressions where....awesome, amazing, such wisdom to share between such wise women! Meeting and listening to Angelina, a traditional partera (midwife) from Mexico was just...awesome. She brings four generations of traditional midwifery experience and wisdom with her. Granted, the majority of her clients are indigenous Mexican women, who have different body structure than the clients I see, different cultural beliefs, spiritual beliefs, and who have different diets/nutrition than the women I care for, but much of her wisdom is in a general type of knowledge that applies to all women. Care and pampering of the mother, good nutrition, proper alignment of the baby, nurturing the spirit, and assisting women at their births (mostly upright positions, by the way, which is much different than what I see in the hospital). Listening to Angelina tell her stories, share her wisdom, several of us remarked on how she should publish this in a book to share with midwives all across the world. I genuinely hope that Angelina does this. What an amazing legacy to share with women and midwives across the globe! (By the way, Angelina
Gail Hart - lots of wisdom, intelligence and experience from this wonderful woman. She taught a session on shoulder dystocia and malpresentations. Gail presented evidenced-based material, research studies, and a good discussion on how shoulder dystocias occur, and how they can (hopefully) be prevented, (possibly) predicted, and how to resolve them. A great topic, with a thoroughly researched and well presented session.
I didn't get to attend the Spinning Babies session -- sold out :-(
Now, for some of the downsides to bringing many different midwives and birth attendants together........misinformation and plain old wrong information. Gail at least acknowledged that hospitals and medical providers (MDs, peds, NICU, CNMs) are there for a reason -- when things go in an abnormal direction, it's time to transfer. But other presenters....I will not name names at this point....are sharing/teaching some unsafe and wrong information. Now, if anyone can counter my thoughts/opinions on the following, please do. I am always open to learning --- evidenced based please, not anecdotal! --
Mouth to mouth resuscitation on a baby that is newly born and needs resuscitation. No. Standard precautions!!! If it was my baby, or a very close family member, or a dire emergency, and equipment was not available, that would be different. But seriously.....carry a newborn bag/mask and a tank of oxygen with a blender on it.
Only use air for resuscitation of a newborn. Uh, no. See my comment about a bag/mask with an oxygen tank with a blender on it. You start out with 21% oxygen (room air), and increase it if needed, if baby does not respond appropriately. Then you dial down the % of oxygen, until you gradually wean baby off of oxygen. And if baby still needs oxygen....transport to the hospital.
As the midwife/birth attendant, stimulate the baby's ear to get it to breathe. (Seriously...lick the ear, nuzzle it, even put your tongue in the baby's ear.) Once again, this is fine and instinctual if you are the mother doing this to your baby. But this is being told to birth attendants/midwives, to do to your client's baby.
Don't do tactile stimulation to a baby that needs resuscitation. For real? Sorry, but a little bit of gentle tactile stimulation is really going to work to get a baby to take a good breath, or to encourage a baby to continue to breathe.
In a woman with hyperemesis, an enema with electrolytes will fix her dehydration. Oh now, come on, really? H.G. is a true reason to go for IV hydration, IV medications, and even possibly a longer term PICC line. Take her to the hospital. An enema?!?
An example was given of a woman diagnosed with preeclampsia at 35 wks gestation. Not the best nutritional status. The midwife's advice? "You don't really have it (preeclampsia), and I can fix it with good nutrition." Get the ef out of here!!!!! Preeclampsia can not be cured with good nutrition, especially if she is already 35 weeks pregnant! No evidence given to back this up, just anecdotal experiences.
As you can tell, I started out very enamored and excited to be at MT this week, but I am clearly becoming less and less excited about it. NONE of the speakers are CNMs. None are medical/nursing researchers. Yes, there are some very wise LMs/CPMs as speakers, but there are also some that I thought would be good to learn from. No. Giving wrong information to other aspiring midwives is just WRONG.
And now, I am even more firm in my belief that there needs to be a very basic entry level testing/certification/licensure process for ALL midwives in this country. While things are definitely different in poorer countries, third world countries.......we are in the United States. We are NOT a third world country. We are rich with educators, researchers, physicians, certified nurse-midwives, evidence-based practice. This needs to be throughout our country. Yes, there are midwives who serve women in poor communities, in different cultural communities (Old Order Amish, Faith Tabernacle, etc), but we all need to be well educated. We all need to know when we are in over our heads (or heck, let's acknowledge it before we get in over our heads!), and we ALL need to work towards the common goal of good midwifery/medical care for all women and babies.
In the end, I am so glad that I chose Frontier for my education. I could NOT have chosen a better path for becoming a midwife.
26 comments:
Sounds like a rich learning time on many levels! What obstacles do you see in standardizing education and standards for midwives in this country? Any solutions for those obstacles?
AMEN!
Yes, thank you for speaking out. Prepare for the backlash from the CPMs and DEMs though..stay strong.
Thank you for your honesty. Truly. I can't say I'm shocked by this..... misinformation and non-evidence based care is rife in the home birth community here in our country. Unfortunately.
How long does it take to set up oxygen for a neonatal resuscitation? Probably takes a couple of minutes, where breath resuscitation is instantly available. Those minutes can make a difference, and you can start breath resuscitation while your assistant gets the oxygen together if that ends up being needed. This is standard procedure in home births. Midwives have been sued over a lot of things, but mouth-to-mouth is not one of them.
Electrolyte enema _may_ help a mother avoid a hospital admission for dehydration. It should not be considered a cure and the mother should be continued to be monitored for dehydration and sent to hospital if necessary.
I've never heard of a midwife advocating against tactile stimulation for helping a baby breathe. Did you ask for a rationale?
I don't know what your concern would be about licking an infant's ear. It's a little non-conventional, but I don't see much chance of germ transfer. But you also seem to find mouth-to-mouth to be objectionable, so I'm not sure if that's because of your training or just your own feelings about such things.
Agreed, the whole "pre-e can be fixed with diet thing" is without any proof. Good nutrition may help prevent it, but the diet usually recommend is Brewer's diet, which has about twice as much protein as a normal pregnancy diet, and I don't understand how that makes sense since protein in the urine is a sign of pre-e.
Speaking of education needed, you learned about the rebozo, and you probably learned other things from non-CNM midwives that you didn't get from your training program, and might not have ever learned working in a hospital. Some of them can be applied there, and some not, but I guarantee there ares some things you are also miseducated about that other types of midwives know better.
Anonymous, re. what you were saying about pre-eclampsia: The protein in the urine in pre-eclampsia has nothing to do with the amount of dietary protein. It's a sign of kidney problems starting to develop - the filters in the kidney, which are meant to keep out large molecules such as protein molecules, are becoming leakier and letting more protein through. (This in itself is normally fairly harmless and reversible, but it's a danger sign that increasing problems are developing.)
Not saying this to defend the Brewer diet - I'm very leary of claims that a potentially serious medical condition can be universally fixed just with the right diet to the point where no further action would be needed - just wanted to clarify that point.
AtYourCervix - thanks for your post, and I'm so glad to see midwives making the case for better education/universal credentials, which I agree is extremely important!
It isn't so much about the Frontier Nursing School as that you went the full CNM route. And, of course, it didn't hurt that you have had all those years in L&D as well.
The MAJOR problem with US midwifery today is the need to make non-CNM midwifery illegal. CPMs and other direct-entry midwives are simply dangerous to women and babies, end of statement.
Wow! Fascinating perspective. I am new to L&D but we have great midwives. A few who still have some odd practices but mostly all certified who deliver in hospital on consult ob when they need to. Canada does not allow people to call themselves midwives and practice as same if they are not fully qualified and licensed.
I have a pretty good idea of what lay midwives will be in an uproar. The ones who don't carry oxygen at all because they think it's dangerous and believe that hats on babies cause bonding problems and hemorrhaging.
Thank you for your perspective, sister! As a CNM, I too believe that all midwives should receive, at minimum, a basic education that will prepare them for delivering the standard level of care. We owe this to our mothers, babies, and our profession. As another poster wrote: Prepare for the DEM/TM backlash...
There are very few midwives who would advocate against using oxygen. Many are restricted from using it, however, even if they're fully licensed/certified in their state. They have varying degrees of education, depending on their program. You'd probably be surprised several CPM states require several college classes in A&P, biology, etc.--and most have way more hands-on experience before practicing on their own than any CNM.
To try to claim all TM/DEMs are dangerous to their patients shows a marked lack of understanding about midwifery. Remember that Ina May Gaskin practiced for years as a lay midwife.
Anon, ideally you would set up O2 BEFORE the need for resus, like you'd have all your resuscitation equipment ready to go before the birth. Any midwife worth their salt doing home births should have oxygen and a resucitation bag and set it up the same way every single time, at every single birth (assuming there's enough time to do so). Mouth to mouth could save a life in a pinch, but it should not be relied upon. That's insane.
I'm fascinated to read your take on the MT conference, and also the responding comments. I'm a huge fan of LM/CPMs, but it's always nice to see the other side.
I have heard of the "enema for HG" idea several times - I don't know how well that works or not. But I do want to thank you for taking hyperemesis super-seriously. One of the main problems HG mamas have is getting pregnancy care providers to take them seriously rather than writing them off as hysterical ("just eat some crackers and stop complaining"). I love seeing your passion for caring for women's needs. If there is one weakness I have seen in the natural-living community, it is a tendency to write off the need for serious medical intervention in cases such as hyperemesis. I've actually seen advice like "suck a lemon or go for a brisk walk" given to hyperemetic mothers. And one of America's most well-known midwives gave absolutely horrid advice about HG in one of her publications - something along the lines of "tell the mother to shape up and stop feeling sorry for herself." Oh, dear.
Again, I love licensed midwives. We have had all of our babies at home with an LM and are currently planning our fourth homebirth with our beloved LM. But it's great to see others from the CNM community pointing out weaknesses. The CPM v. CNM conversation is a good one, and I think both sides have excellent points.
Anyhow, looking forward to seeing the conversation continued in the comments!
Thank you for posting this. I am a nursing student, on the road to CNM, who was also at the MT conference. I had the same thoughts and feelings. At first the opening message was great, lovely, emotional, and I was excited to be there! Then as I continued to sit in classes that so clearly lacked evidence-based information, classes that did not even align with the description of the class and seemed only as a means to voice their agenda... I became quickly un-enamored. I also picked up on a large "elephant-in-the-room" feeling against modern medicine and technology, and any professional who went that route. Like you, by the end, if nothing else, it attributes more to the reasons why I'm going through nursing school and getting a solid educational background. I also feel all midwives should be regulated to get scientific education. The spread of blatant misinformation that can potentially bring harm to mothers and babies, really hurts me, and I left the conference feeling more sad, instead of excited. It was nice to see I was not the only one.
Jenifer doula -- you are not the only one. I spoke with several others at the conference who felt the same way as you and I. And no, they were not all CNMs either (just for the record).
I am not against or saying that ALL LMs/DEMs/CPMs are dangerous. Nor am I saying that these midwives should be outlawed or made illegal, or whatever. There is so much knowledge that we ALL share -- no matter what our background, or where we practice. What I do want to see is several things: stop the spread of misinformation, all midwives have some basic entry level of competency into practice, that we follow evidenced-based care (even the words "evidenced-based care" was bashed at the conference), that we all have some of the same basic education before practicing (math, biology, chemistry, anatomy and physiology, english, psychology, sociology), and yes, that there is some way to regulate all midwifery --- not just this crap of state by state regulation. What is legal in one state, is illegal in the next state. Or LMs/CPMs are legal and recognized in one state, but not in another. That's a bunch of crap. That leads to renegade behaviors, and yes -- bad outcomes.
We all need to find a way to join together, and find common ground, as well as work together on a cooperative manner. Medicine, nursing, midwifery, traditional midwives, native american midwives, homebirth midwives, birth center midwives, hospital midwives. We all have the same goal, do we not? Safe, healthy passage of mother and baby in the childbearing years. We cannot lose sight of our shared vision.
I am a CPM who absolutely hated the MT conference I attended a few years ago. As a new midwife, I was hungry for meaty discussions about things that were (and continue to be) at the heart of my practice: risk assessment, relationships with physicians and hospitals, transfers, protocols, practice bulletins based on new (any) evidence for issues relevant to midwifery care (GBS, GDM, etc.). I was very disappointed.
Instead what I found was a smallish group of friends, mainly retired midwives, who seemed like they hadn't cracked a book or read an article that wasn't written by each other in decades. The MT conference is where I finally lost all my respect for the “trust birth” culture. A culture where preposterously low transfer rates are valorized and people spend more time worrying about hats on babies than they do about (fairly common!) life threatening emergencies. I attended “workshops” led by big-wig midwives who knew next to nothing about what they were talking about. The midwife who led the workshop on hemorrhage (she runs a MEAC accredited school for gods sake), for example, had never heard of using cytotec for hemorrhage and had never, ever seen a situation where bleeding was exacerbated by clots. In the case of the mythical clots she recommended, and I quote, “tickling out the clots” from the uterus with your fingers because, I guess, massaging the uterus is always The Worst Thing Ever. After hats on babies and glucola, of course.
I spent most of the time wondering if these midwives lived in a different universe than I did. It seemed like mostly what they wanted to pass along to the attendees (who were mostly students and doulas) was that “everything in obstetrics is false. It is all a lie.” Women don't actually ever hemorrhage, shoulder dystocias never happen and, above all, crazy, high-risk shit is a “variation of normal”. Twins, diabetes, PIH, breech, 72hour labors, preterm labor, post-dates, VBAMC = normal. If you don't think its normal then you aren't in the club and don't care about MamaBaby.
I am disgusted by the lack of accountability and absence of meaningful standards in my community. I am in the slow process of closing down my busy practice and plan to go back to nursing school. I feel like a sane and competent midwife and I have had good outcomes - I risk people out a lot and transfer to the hospital in labor almost 25% of the time - but I have come to acknowledge that the black holes in my training and knowledge are just indefensible. I think this is why you see so much bizarre defensiveness in the CPM community – once folks start admitting that there needs to be better training and accountability, it takes a lot of mental gymnastics not to apply that to yourself/your midwife.
What I would really like to see (because I am just going to dream in your comments section!) would be a nation-wide expansion of university based non-nurse and nurse midwifery. The laws need to be the same for midwives to practice in all states (in my state, for example, it is WAY easier to practice as a CPM than a CNM because of insane collaborative practice laws). I think we really missed the boat with the CM and that ultimately, CNMs and CM s are the only sustainable, safer future for midwifery in the united states. I would love to see a bridge program and for organizations like MANA and/or federal programs set up to support CPMs transitioning back to school and toward a more universal, evidence-based, medically integrated form of midwifery.
End of my rant :)
Wow! So interesting. I would be so bummed to have spent money on a conference where I was expecting and hoping for evidence-based discussions and education only to hear misinformation spreading like wildfire. I actually spent some time with a well known CPM in my town a few months back and she actually told me to go the CNM route. She had over 30 years of midwifery under her belt and 7 years prior in L&D and I thought it was so humble of her to say so. Even she knows that there needs to be higher education in midwifery care. I'm also really happy to hear how happy you are with Frontier. I can't wait to attend!
It's nice to hear CNMs and CPMs speaking out about the atrocious lack of standards among midwives. It is refreshing. Please note: stating that there are lack of standards does not mean that all midwives are "bad midwives" or that CPMs are "bad midwives" - it means that they don't have agreed upon safety standards to guide their practices. I really hope that those of us who believe midwifery deserves to be held to the same scientific rigor as the rest of modern medicine will keep talking. Because the voices of those who are skeptical of all-things-allopathic are the ones who seem to be defining midwives lately- and painting midwives in a very unfavorable light.
I'd attended a MT conference 10 years ago, and that was enough for me. I thought I was signing up for a doula workshop with practical advice for supporting women in labor, it ended up being an infomercial about "orgasmic birth" and we watched video after of video of women having orgasms during their labors. ??? Huh? This was not what I'd signed up for.
And yes, at these conferences I'd heard NUMEROUS midwives lament having to use an ambu-bag for neonatal resuscitation. The excuse that "it takes time" to set up resuscitation equipment is a ruse - really, many of these midwives are romantically attached to the idea of uber natural birth, they will say thing like they prefer "putting my energy into the baby" by providing mouth-to-mouth resuscitation instead of using a plastic man-made device.
"Energy."
Yes.
OK, then.
I got tired of the rampant superstition around OOH midwifery - specifically. That is where I was, I was practicing with licensed CPMs - they had authority and access to drugs and devices - and would advertise themselves as professionals who used these things - but in private would state their preferences for unfounded treatments that included herbs, aromatherapy, homeopathics, and "energy".
It got old. Midwifery has A LOT to offer women and babies - but we won't be offering anything if we're going to horse around with meaningless, unfounded, superstitious nonsense as the basis of "true midwifery" practice.
It's good to hear that others are seeing this, too. Let's do something about it.
As a NICU nurse and a nurse practitioner student (family health), I can't believe someone would allow someone to be at their birth who wasn't allowed to administer oxygen (as anonymous 5:10 said). NRP guidelines are to start with 40% oxygen and then wean down or up, knowing that a term baby has ten minutes to have oxygen saturations around 95%. Often times if I'm at a delivery of a term baby (and we're called for meconium), we'll start at 21% and then wean up as needed. I've also seen a term kid who needed vigorous stimulation after a traumatic birth/meconium, but because we were aggressive, we were able to leave that baby with mom. Licking the ear just wouldn't have done it (and honestly, that's just gross!).
Melissa, RN BSN
Anonymous CPM from above again - I have done NRP certification 5 times now and have always been taught by the instructors (one a CPM/RN who has attended a couple thousand births) to just use room air. In fact, I have only ever resuscitated with room-air. AFAIK, in our community, *all* the midwives just cut off the O2 reservoirs on the bag and mask to make it easier to do that.
We all have oxygen but use it for moms or blow-by for the baby.
OTOH, this particular RN/CPM instructor has been instrumental in getting our states traditional midwives (including a number of Mennonite midwives) to stop doing mouth to mouth and ineffective "tricks" and to go for the bag and mask sooner rather than later with confidence and not fear. Using room air with a good bag and good technique is effective and, well, 100% more effective than ear licking.
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I'm a level 1 nursing student. I came across your blog while searching for nursing blogs. Thank you for sharing your views. I look forward to reading future posts.
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Thanks very much for this blog post, and thanks to everyone for your comments. I am glad to know that my impressions of the MT Conference were not unique ones. In addition to the anti-obstetrics rhetoric that resounded, I was also struck by the anti-male rhetoric: references to how much men don't know, to men's unreliability, to rape and molestation (by males). It was backward and unsettling. Appropriate references I understand and can support…but the blanket and repetition of it was shocking and unsettling.
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