Intervention is a tricky little word that seems to divide midwives.  Most midwives agree that midwives in general use less “intervention” then physicians. But that seems to be where the agreement ends.  What makes some midwives feel a woman can be successful at an intervention free birth in a hospital, while others believe even women giving birth with a home birth midwife receive regular interventions?

The problem arises when using different meanings for the term intervention. Some midwives use the term to mean surgical or pharmaceutical techniques (cesarean, pitocin, epidural). Some midwives use the term to mean anything done to alter the natural course of labor (castor oil, cytotec, tocolysis). I remember being taught that intervention was a all the things a woman didn’t want to have happen when I was training as a childbirth educator.  So, what does this term really mean?

To understand what counts as an “intervention” for health, I rely on my understanding of prevention. Why prevention?  Because as a nurse this is how I order my thinking about the interventions I use to help a woman achieve the healthiest birth possible. Honestly, every contact I have with a woman is an intervention.

There are three levels of prevention, each with it’s own set of interventions based on whatever risks the woman may be facing.

The highest level of prevention is tertiary.  This is when a serious problem has been identified, perhaps a woman has had an eclamptic seizure or the fetal heart tones reveal a prolonged bradycardia. In this case, intervention is focused on stopping whatever is causing harm and minimizing the effects of the problem to help the woman and her child achieve the highest level of health possible.  So, with an eclamptic seizure the interventions include safely moving the woman to a recovery position, injecting the appropriate doses of medication to prevent additional seizures, close monitoring of the woman and baby to identify any residual problems.

The middle level of prevention is secondary.  This is defined as early identification and treatment of problems to prevent escalation. In this case, interventions include screening to identify woman and babies at risk as well as all the things done to help minimize any risks identified.  An example would be identifying a mother’s blood type.  If the mother is Rh- blood and the father is Rh+, Rhogam can be used to help minimize the risks for the next baby. Taking a history during a prenatal appointment and screening tests are interventions for secondary prevention because they help identify health issues for the mother or baby.  Taking blood pressure, monitoring the fetal heart tones by any method and monitoring the progress of labor are all interventions for secondary prevention.

The first level of prevention is primary. These are the things that are done to prevent a problem from starting in the first place. This includes most education I would give a woman, such as educating a woman about her nutritional needs so she can improve her diet as necessary.  Another example could be offering an influenza vaccination.  During labor, ensuring a woman stays adequately hydrated is a primary intervention because it helps prevent problems.

To help you get these concepts, here are a few more examples:

During labor, I recommend a woman change positions regularly as a primary intervention because I know it will help labor progress normally.  If, during labor, the mother begins to have a backache, I may recommend certain positions as secondary prevention because I know she may have a baby in a posterior position and these positions will help relieve some of her pain and help the baby move.

During pregnancy (and as she is planning her pregnancy) I recommend a woman maintain optimal intake of folic acid (perhaps through a prenatal vitamin supplement) to help prevent neural tube defects – and this is primary prevention.  If, during pregnancy, screening reveals a woman is anemic I may recommend an iron supplement as secondary prevention to help rebuild her iron stores and avoid the problems anemia can cause during the post-partum.

Is everything really an intervention?

Yes, everything I do as a midwife is an intervention on one of these three levels.  This is because everything I do has a specific purpose – to help a woman make any necessary changes to have the healthiest pregnancy and birth possible.  Providing education so she can make lifestyle changes is an intervention. Screening to give her information about the state of her health is an intervention. Responding quickly if there is a problem in labor is an intervention. This is true whether I do this work in her home, at a birth center or at a hospital.  This is true whether I provide the education as a midwife, nurse, doula, or childbirth educator.

I hope you see “intervention” is not a word to be afraid of, and in the purest terms, an “intervention-free” birth is only possible for women who choose to give birth alone. Even women who hope to achieve a natural birth do not generally mean they want to avoid the interventions of the midwife listening to the baby’s heart tones or recommending things they can do to be the most comfortable. A birth does not need to be intervention-free to be natural.

I meet a lot of wannabe midwives, and a lot of midwives.  The wannabe midwife I meet most frequently is the one who is angry with the “birth system” and plans to become a midwife to fight that system.  Usually, the plan is to become a homebirth midwife to provide for births, “the way they should be.”  I like to ask wannabe midwives two questions before I agree that is their path.  Why?  Because usually they do not realize all the ways to bring change to the system.

Question #1:  What is it about the “birth system” that bothers you?

While your first response may be, “everything,” think deeper.  Are you concerned about the treatment of women?  Are you frustrated with the current protocols? Do you feel research is lacking? Is is restrictive legislation that irks you? It is important to understand what part of the system you feel is broken, and which part you want to fix because the fix for each part is different.

Question #2: How can you have the biggest impact on that part of the “birth system?”

I find wannabe midwives default to the goal of homebirth midwife because it feels like the best way to change what is happening in births. Some wannabe midwives feel it is the ultimate rebellion against a system they dislike.  But rebellion can take many forms, and can happen within the system as well as outside the system. Let me share with you a few of my birth heroes who are not midwives to show you what I mean.

Joy Lawn is a pediatrician who was dis-satisfied with the lack of information about neonatal deaths around the world.  She fought back with epidemiology by devising systems to estimate the number of deaths and to identify the causes so the public health community could begin to tackle the problem and measure their success.

Barbara Harper is a nurse who uses her skills to help hospitals around the world create safe and gentle birth protocols by collecting and sharing research. She teaches midwives, nurses and physicians the importance of gentle birth and ways they can achieve a gentle birth in their hospital.

Penny Simkin is a physical therapist who uses her understanding of the mechanisms of the physical body to help birth workers improve  outcomes through positioning and non-medical interventions when possible. She participates in research to build the knowledge base. Her writings are required reading for many doula and childbirth education programs.

Citizens for Midwifery is a group of parents that advocate for good legislation for midwifery practice. Their work includes collecting and distributing research to local and national legislators while also educating and recruiting other parents to join the work.

EuGene Declercq uses his research skills and knowledge of political science to challenge current beliefs about the American maternity system.  His papers point out hidden problems and highlight the importance of midwifery.

I addition to these “big” names, there are many unknown men and women  changing the face of birth in the United States and around the world.

I think of the nurses who put in extra hours to participate in quality improvement and protocol committees at their hospitals to succeed in implementing policies prohibiting inductions before 39 weeks.

I think of the peer breastfeeding counselors with WIC programs who are  improving breastfeeding success among low income women.

There are many more unknown individuals who need more help to achieve change.

I think of brave souls in insurance companies who are willing to champion the use of doulas, birth centers and homebirth midwives to ensure these services are covered by their programs.

I think of administrators at small hospitals who feel they need to close their birth services due to financial instability, forcing women to travel greater distances when they need care.

There is a great need for change in birth, in the United States and around the world.  Where you fit within this change may be practicing as a homebirth midwife, but it might not.  We definitely need good midwives.  But remember that when you practice as a midwife, you limit the time available to do non-midwifery work and may limit the impact you can have in these other ways. Think of your passions, your skills and what is available around you to determine how to maximize your impact.

I wanted to share something I learned about myself recently.  I love caring for HIV+ patients.  Actually, the patients I have been seeing have AIDS.  What is the difference?  A person is HIV+ when they are infected with the virus; a person is said to have AIDS when the virus has done enough damage to their immune system that they have less than 200 CD4 cells or have an opportunistic infection.

This semester, I’ve been doing clinical hours at an HIV center caring for women living with AIDS.  I truly mean living.  The women I met had all been extremely sick at one point, but with good treatment were able to overcome the challenges and now lead basically normal lives with a chronic illness.  I even met a few women who gave birth to HIV- children because the treatments are able to prevent transmission from mother to baby.

As an FNP and a CNM I will be in the rare position that I can provide HIV care and midwifery care to my patients – minimizing the visits and the confusion — improving outcomes by making it easier to access care. I live in a city with one of the highest per capita rates of HIV in the country – one of the highest in the world. I live in the midst of the south, where HIV is spreading the fastest — and it is spreading fastest among young women. I will be graduating with degrees in nursing and public health, so I can work one on one or at the system or population level.  It is almost as if the universe was leading me down this path the whole time, it just took me this long to find it.

Yep, I want to be an HIV specialist midwife when I grow up.

I wanted to take a minute to share a frustration I have.  When my direct entry sisters criticize nurse midwifery because it does not follow the apprenticeship model, I’m not sure they understand how nurse-midwives are trained.

Nursing education is not like medical education.  There is classroom content, and there is clinical content, but these are not separated. You learn new things through reading and class, and then you go out and do them with your preceptor.  Sometimes things line up beautifully, and other times it doesn’t. When it doesn’t line up you may end up spending hours researching things you are doing in clinical before you get to them in class.

This is very similar to the apprenticeship system used by my CPM friends. Both systems provide the learner with opportunities for a new midwife to be trained by one midwife, or multiple midwives.  Both systems provide the learner with hands on learning.  Both systems expect the learner to be providing care long before they are proficient. Both systems provide the learner opportunities to learn about the interaction with families and how the presence of a midwife. Both systems usually expect the learner to be completing book learning at the same time.  The systems just use different titles.  Nursing calls the midwives who train you “preceptors,” but it doesn’t change the similarities to the direct entry apprenticeship.

All this to say, if you were thinking about a university nursing program but were turned off because you wanted an apprenticeship, you might want to look into the program again. You might be pleasantly surprised by what is possible–like apprenticing with midwives at a free-standing birth center or attending homebirths. Just pick a school close enough to midwives who offer these services and make sure it is a school where you can have a part in picking your clinical experiences.

Next week I will be presenting a workshop on menopause. This is to be my very time-consuming project at the end of my midwifery training. Except it isn’t the end, I still have a ways to go (combining degrees and all).

It is interesting to think about how I got to this point.  Ten years ago I would never have guessed I would want to present on menopause, I was still very birth focused.  But as I learned more about women’s health, my interests widened.  I never would have thought I’d like working with women to treat and prevent STIs, but I do.  Dealing with menstrual irregularities, love it. Birth, it is still there.  But it is only a piece of the whole woman, and I’ve always been about the whole woman.

I share this because as you consider your path to midwifery, I think it is important to think about all the aspects of working with women and families that appeal to you.  If I had chosen a path into midwifery with a more narrow scope, I know I would have longed for more and burnt out quickly.  For other women, having such a broad range of practice would only make them wish they could spend more time at births.  Who are you, and in what ways do you want to work with women?

I just received an email update from a woman I almost know–a social networking friend also involved in birth activities in Sub-Saharan Africa.  I had to laugh at the end of her email.  She never thought she would pursue a midwifery registration in her home country, but that is exactly what she is doing. Why laugh?  Because her story mirrors mine. My goal was never to be a midwife by vocation, but to improve the health of women in resource poor areas.  Yet here I am with a BSN and enrolled in a major university midwifery program.

At the same time, I have friends who would love to be midwives.  Women who feel called to be midwives and want to have jobs in their communities as baby-catchers. And these women are not quite there yet.  They continue to hang out, pursuing other avenues until the time is right.

Life is funny like that.

I read an article today that said CNMs can be great, but they have been trained as nurses first so are indoctrinated to the Doctor-Nurse hierarchy, and I had to scratch my head. Hierarchy? As in the doctor is the boss and the nurse follows orders?  This is a very common misunderstanding of the doctor-nurse relationship, and if you believe it you risk not helping your clients  utilize the best services from a nurse.

Each nurse is an independently licensed professional with a scope of practice that determines her role.  Nurses deal with responses to illnesses and conditions while the doctors and advanced practice nurses deal with the illness or condition.  What is a response to illness or condition?  Might be pain, altered nutritional status, emotional distress, educational needs or other similar things. It is the role of the nurse to address each client holistically, assessing risk and addressing these responses. The nurse does this regardless of how the physician chooses to treat the illness or condition.

In a hospital birth system, the nurse is hired by the hospital and is answerable to the hospital for her actions. In the US, physicians are independent practitioners who are credentialed to be able to use the hospital facility.  At no time is the physician in a role of authority over the nurse.  The nurse answers to the nurse manager.  The nurse’s responsibilities are defined by the policies and procedures of the hospital, and most of her clinical decisions will be made following these policies (such as if a patient should be using an oxygen mask or how often a patient will be monitored).

The physician is responsible for managing individual patient illnesses and conditions.  This means it is the physician responsibility to order medications, treatments or surgeries necessary for the health of the patient.  The nursing staff will maintain a record of the patient while in hospital and this information is used by the physician to make clinical decisions. The nursing staff  can also recommend additional management options to the physician based on the risks seen in the patient, but it remains the physician responsibility to order anything.  The nurse, as an agent of the hospital, can provide the treatments or medications ordered by the physician, but cannot order them.

So what does this really mean?

A nurse has great power to influence the care of laboring women.

• A nurse has great power to provide non-pharmacological emotional and physical relief measures.
• A nurse has great power to choose how she presents a patient when updating a physician.
• A nurse has great power advocate for the wishes of her patient.
• A nurse has great power to advocate for policies and procedures that provide natural birth friendly birth spaces.
• A nurse even has the power to refuse to provide a treatment ordered by a physician if the nurse believes it is not in the patient’s best interest or will cause harm.

A nurse will never be in the role of deciding on and ordering medical treatment for a patient, that role is always designated to the physician. But that does not make the physician “in charge of” the nurse. While you may expect this role differentiation to mean the doctor is in control and influences what the nurse does, it is often other way around with nurses at the bedside making decisions about what to share with the physician and influencing how the physician manages the labor.

So this relationship is a balance.  The nurse influences how the physician manages the labor and the physician influences how the nurse works with and advocates for the patient. But even the best nurse may not be able to salvage a patient’s natural birth wishes if they have chosen a physician with a 60% cesarean rate; and even the most natural birth friendly physician cannot prevent a patient from being assigned to a nurse who would rather be at the desk than in the patient’s room.

One of the arguments my teachers gave for the superiority of the BSN over a two year program was the way a liberal arts education gives you a well-rounded perspective of health and life. She explained the exposure to many ideas would allow us to better communicate with the wide variety of individuals who would eventually find themselves under our care.

I’m not a person who would call any education “wasted.” But I am a person who can think of time or money wasted. Which is why I am glad statistics demonstrate that BSN nurses do provide better outcomes.  I doubt it is because BSN’s had a literature requirement.  I think it has more to do with the goal of the program, BSN’s are trained to think through the problem and identify risks.  RNs from two year programs (I am told, but only by those who went through BSN programs) are trained to perform nursing procedures and tasks with less critical thinking.

So here is my question, does this difference have the same effect between CNMs and CPMs?  Is there a difference in the way they approach patients or think about patients that brings about different outcomes?

This is a hard question to ask, because unlike nursing programs, midwifery training leads to two completely different work environments each with challenges the midwife must work around. CNMs may be more influenced by the doctor back-up, nurses at the hospital or hospital protocol. CPMs may be more influenced by restrictions on practice and lack of access to hospital services.  I’m not sure they could ever be compared on a large scale, but it is still worth thinking about.

I took advantage of a wonderful opportunity to dine with three midwifery leaders in my community. The conversation was to be about leadership, and was intended to inspire those of us earlier in the journey.

As a doula I was aware of the problems that occur throughout the birth world.  I did know about enmity between CPMs and CNMs.  I was aware of problems CNMs face as they negotiate a system that often does not want them. But as a doula, most of my time was spent with clients.  When I saw the midwives things were pretty good.  Any background undermining of the midwifery model of care was perfectly hidden.

Last night’s dinner was the most recent in a series of eye openers for me. Perhaps it is because I am training in Georgia, the last state to provide prescriptive privileges for advanced practice nurses. Perhaps it is because I have been hanging around midwives who have practiced for more than 20 years. Whatever the reason, I am learning just how damaging bad policy can be to the maternity care women receive.

The midwives describe working within an environment of constantly being watched. They describe long fought legal battles for the right to practice. They describe having to be satisfied with small gains in rights. They described the frustration of always losing the battles and the wars. Midwives leave the profession because they are burnt out.

This is a different side to midwifery. Yes, midwives get the warm and tender moments laboring with women.  Yes, midwives get to catch babies.  But midwives also get to be taken advantage of by doctors, have their practices limited and be forced into the medical model of care.  I have to ask myself, how much can I take?  As I pursue this path, how long can I work in this environment before my drive to fight for women is sucked out of me?

I’ll probably last longer than most, my goal is research rather than practice.

Today we had our class on the management of the normal labor. We talked about the cardinal movements, the natural progression and stages of labor, how to know when to do cervical checks and how to determine if a woman was actually in labor. We even talked about how to “catch” a baby.

In our case studies I noticed the only hesitation was the case that was obviously not in labor.  I instantly sent the woman home, but some classmates wondered if there were reasons you might keep this hypothetical woman.  There was similar concern about the woman with ruptured membranes and no contractions – could you really send her home? They still had the “but what if” that I had when I began my doula work.  When you first start, you just don’t trust yourself or your assessments – this is normal.

And this is where I got excited.  Because at this point the amount of information I need to learn about the normal labor is pretty slim. In fact, ten years of assisting at midwife attended labors has taught me the essence of midwifery.

We talked about this in my undergrad nursing program.  You see, many people think the essence of being a nurse is about knowing how to give a shot or putting in an IV.  But these tasks are pretty easy to learn, do it once or twice and you’ve got it. What is harder is managing the patient, knowing what to expect and how to best promote health.  This can take years for a new nurse to learn.

Turns out midwifery is similar.  After about 10 minutes of explanation and one or two practice attempts I pretty much get how to put in a scalp electrode.  But to know when to use it, that takes some deep understanding of labor.  That takes being able to assess the labor and anticipate what could happen.  It takes being able to weigh the benefits and risks of using the internal monitor and not using the internal monitor.  To do it well means you understand the recommendations / indications and why it would be indicated.

I still have much to learn. But what a fabulous feeling today to know that I am starting with a body of knowledge that will take some of my cohorts years to build.  And that is why being a doula rocks.