I have just over 24 hours to my midwife certification exam. In my midwifery path, certification by exam is a requirement for licensing. But when I get that certification, I will be able to be licensed to practice in any state and it will make my international work a little easier.
Certification and licensing are frequent topics of discussion among my midwifery friends. I have some on both sides of the licensing fence, and on both sides of the certification fence. Due to the crazy nature of this world, not all my friends who think licensing is good are licensed (some are in states without licensing opportunities). Similarly, not all my friends who think licensing is not a good idea are not licensed (some states require licensing to work as a direct entry midwife).
So what about me, where do I land in the debate?
I personally have no problem with certification for midwifery or any profession. Education alone would be nicer (and cheaper), but certification does provide a protection for the midwife consumer and me as the midwifery school consumer. Why? Because I believe knowing your graduates must pass an exam on the basic competencies of a midwife improves the didactic quality of the school. I can’t imagine spending thousands of dollars on a program only to find out it didn’t really give me the information I needed to work independently as a midwife.
I know there are some who feel the certification exam is no proof you are a good midwife, and I agree. Honestly, the only way to be a good midwife is to be a midwife for a few years. I will still be a new midwife, with or without the exam. But the certification exam shows I have a minimum competence with the tools and materials I will be using . It shows I understand the basics of evidence based practice — even if the process of test writing means it will be two to three years behind.
As for licensing, I am a fan. Again, I don’t think licensing makes you a good midwife. It is simply a way for the profession to be regulated — to ensure that all those who are practicing have met the minimum standards. But from the public health side, it does some amazing things. First and foremost, it gets midwives counted. Midwives, especially direct entry, tend to be invisible in research. As long as they are invisible, they will not be taken seriously and their practice will suffer from “evidence” problems. I want to change that.
I also have friends who are against licensing because they feel it restricts their practice. I disagree on two counts.
The first is that every state has a midwifery practice act, and if your practice doesn’t meet the definition your practice is already restricted. If your state’s laws don’t mention midwifery beyond nurse-midwifery it is too easy for your practice to be labeled as illegal. Licensing prevents that.
The second is that I believe midwifery practice (as with any health care practice) should have restrictions. A midwife should be expected to provide evidence based care, even if that means some mothers will be told home birth is not a safe option for them. I believe this as much as I believe physicians should be expected to provide evidence based care, even if that means some mothers will give birth vaginally in the middle of the night on a weekend. I don’t want midwives making their own estimations about which woman is or is not safe birthing at home any more than I want physicians making their own estimations about what is or is not an indication for cesarean. It is too easy to keep moving your own line in the sand.
The current problem is the lack of universally accepted evidence based guidelines – but this I see as a temporary problem. If the system is broken, you fix the system. When you ignore the system completely you lose opportunities to make change (like the problem I have with my research where direct entry midwives cannot really be counted and therefore their impact cannot be estimated).
Change is a slow process, and some of my friends have been waiting too many years (some whole lifetimes) for change. Some have been so burned by past “change” that they have learned to distrust the system. Some gave up fighting years ago, and now just want to do their midwifery without interference from governments or certification organizations. I know this. The sad truth is I don’t personally see a way to move midwifery forward — to extend the rights and protections for direct entry midwives — without causing their practices to be interfered with.
For me, the importance of licensing goes beyond my direct entry friends here in the US. For me, it is also an international thing. Midwives everywhere should have access to good quality training, good and useful tools to do their work, and be paid by the health system for the work they do. For this to happen, midwives need to be a real part of a countries health system rather than an invisible “problem” the health system sometimes ignores and sometimes attacks. Midwives need to be taken seriously. Licensing is one step to being taken seriously.
I was talking with another nurse practitioner (yes, I am actually a nurse practitioner now!!!) about what I would do with my midwifery training. I’ve decided to pursue a PhD, which means I am pretty sure I’ll never work as a baby catcher. I knew this, and accepted the possibility when I applied for the PhD program. But, as I explained to her, midwifery isn’t just about catching babies because women are more than a uterus.
But I also trained in family practice, which means I can help identify an illness or treat a chronic condition. In the real world, these two disciplines overlap. Pregnant women get sick, and women with chronic conditions get pregnant. Having the combined background puts me in a sweet spot to help women in these in between spaces.
I have an extensive knowledge of sexual health issues, and can help women as they make decisions regarding contraception or if they need treatment for a sexually transmitted infection or if they want a little help trying to conceive.
I am trained to support lactation, and all breast health issues which means I can as easily help a woman work through a plugged duct or thrush as I can assess a lump she found. I am comfortable enough with my skills to help a woman make evidence based decisions about breastfeeding while using a medication.
I understand the menstrual cycle and can help a women if she is moving through menopause, missing periods or bleeding heavier than she used to.
All of these are skills I have gained while training as a midwife. These are basic healthcare issues I may run into with any woman in primary care. No, I will not be a baby catcher, but I am a midwife and will still provide midwifery care for the other aspects of a woman’s life.
I am studying my least favorite subject tonight – TORCH infections. I have to admit to not learning much about these in class, not because we didn’t cover the information, but because I was not yet thinking about infections like a midwife.
As a childbirth educator, my training in pregnancy infections went something like this. ”Herpes is no big deal. They can cover any spots and prevent spread to the baby.” ”Toxoplasmosis is no big deal. Most women with a cat have already been exposed.” I was then assured that the medical community exaggerated these infections and used them to get women to do what they want.
It is scary to think this type of education felt adequate to me. I have to be honest, the provision of reassurance without adequate information on a subject was something I was told the medical community did to ensure people were compliant. I am not sure how I was oblivious to the same quality of “education” being provided to me.
I’m older and better educated as I pour over research on the subject today – actual research and not a paperback book for expectant mother’s about pregnancy. The reality is, these infections are serious and they do pose dangers to the baby. Fetal death, blindness, mental retardation and seizures are just a few of the possible outcomes. Maybe if I had understood that from the beginning I would have taken the time to really learn them instead of pushing them into my “not going to bother” pile.
Being on this end of it, I also have a better appreciation for how unnerving such a possibility must be for an expectant mother. If it were me, I wouldn’t want to be told not to worry about it. I would want information, real hard facts to help me understand how to reduce the risk to my baby. I can guess most women would react the same.
I may not see many women with these infections, just like I may not see many shoulder dystocias. This is why I now believe it is important for me to take these infections seriously. I need to be able to explain the risks to a woman, and help her understand how she can reduce those risks. I need to be able to tell the difference between being in contact with someone with an infection, and contracting the infection. I need to be able to identify a problem early, because quick identification of the infection may offer a chance for treatment, and that may be able to help a baby.
And as for herpes, I can accept that it isn’t usually going to be a problem. Not because the herpes virus is no big deal, but because I’ll help her prevent an outbreak and reduce the risk of transmission with suppression therapy. Having good information to share means the women I work with can make decisions based on solid research.
People like to say that statistics lie. Actually, the statistics tell the truth, people just are not always educated to understand what they mean. This happens alot in the birth world with the cesarean rate.
The CDC releases statistics about birth in the United States each year. In 2010, the CDC reported that 32.8% of all births in the United States were by cesarean surgery. This data has lead some childbirth professionals to assume a woman giving birth in the US has about a 33% chance of ending up with a cesarean. But this isn’t necessarily true. Why?
Because that number includes two different groups of women with two different rates of cesarean surgery.Childbirth Connection has a graph that may help visual learners get this concept, and statistics nerds may prefer this 2005 report from the CDC.
One group of women in that number is women who either never gave birth or only gave birth vaginally. The other group of women in the number is women who previously gave birth via cesarean. Women with a previous cesarean may give birth vaginally, or via cesarean. Currently the VBAC rate in the United States is pretty low, which means the cesarean rate for women who previously gave birth via cesarean is pretty high.
As you look at the graphic on the Childbirth Connection page, notice how in 1989, the cesarean rate was about 23%. Using this graphic we see that about 18% of women who had a cesarean previously gave birth vaginally, which means about 82% of those women gave birth via cesarean. In the same year about 16% of women who had never had a cesarean before gave birth via cesarean. Although the overall rate was 23%, a woman who had never had a cesarean before only had a 16% chance of having a cesarean.
Fast forward to 2004 on the Childbirth Connection graphic and you see the rate of cesarean increased to about 29%. Rate of VBAC declined to about 9%, meaning about 91% of women with a prior cesarean gave birth via cesarean. Primary cesarean rate also increased, but to about 19%. So although the overall rate of cesarean was 29%, only 19% of women without a prior cesarean gave birth via cesarean.
The graphic stops at 2005 because of implementation of a new birth certificate system which prevents accurate counting, but we can estimate as long as we accept the numbers we have are only estimates. In 2010, 33 states were using a birth certificate that allows us to count primary cesareans. So we have a count, but it will miss about 25% of the births in the country (because they happened in one of the 17 other states).
From the data we have, we can estimate that in 2010, 23.6% of women without a prior cesarean gave birth by cesarean while about 91% of women who previously gave birth via cesarean did so again. This means, that although the overall rate of cesarean in 2010 was 32.8%, a woman giving birth for the first time had a 23.6% chance of having a cesarean. Instead of 1 in 3, her chances are more like 1 in 4.5. On the flip side, 9 in 10 women with previous cesarean are likely to give birth via cesarean.
I heard it again today, “They won’t let me….” Whenever I hear someone talking about “they” or “them,” my ears begin to perk up because I know there is more to the story than I am being told. Here are the things that go through my mind.
1. Does this woman understand what she was told and why? I don’t ask that to be smug, but out of real concern about miscommunication. It can be easy to believe everything you hear, even if what you heard was not what was said. It is also easy to believe things you hear from individuals who are not in a position to be decision makers. If a friend tells you the hospital doesn’t do water birth, you are much less likely to ask about the option on a tour. If you don’t ask, you won’t find out that they only have two water birth rooms so if you are interested in a water birth you need to tell someone on admission.
2. Is this woman making assumptions due to misinformation? If you were to believe everything you read, every doctor, nurse and midwife is out to make sure you have a terrible birth experience that hinders your breastfeeding and bonding. The good news is that most health care providers are NOT like the stories you hear. In fact, each health care provider is a unique individual, just like every mother. Individuals have strengths and weaknesses, good days and bad days, get tired and will even have opinions. Sometimes the opinions of other individuals will be different from yours. But you cannot know this unless you ask. Making sweeping generalizations about everyone within a profession is stereotyping. Not only is it unfair, accepting your assumptions based on stereotypes means you are less likely to ask the questions you need to ask to prepare for the kind of birth you want.
3. Is this woman feeling judged about choices she made and just trying to get out of the conversation? For those with a passion for helping mothers have natural births, it can sometimes be difficult to understand why a woman wouldn’t choose a natural birth – and this can come across as judgmental in conversation. Some women politely smile and nod as you continue explaining the perils of epidural, some will get angry and tell you it is none of your business, and some will blame the decision on someone else so you will leave them alone.
How do I handle these situations? First, I never assume the mother and I are “on the same side.” I don’t make assumptions about who she is or what she wanted from birth or how she feels about not having an option. I don’t argue against the medical establishment, medical techniques or individual caregivers. Instead, I listen. I let her talk, sharing what she feels is important. If she needs to know I am listening and not judging I might ask if she can “Tell me more about that?” Instead of deciding for myself how she is feeling, I ask her, “how do you feel about that decision?” Then, I listen. Because she might be angry the option is gone, but she might be relieved.
This week I have been sharing some of the harder lessons I had to learn to become a midwife. The value of humility is perhaps the hardest one I faced.
I thought I did approach birth with humility. I believed I understood the process and knew that the best course of action was to let the labor take it’s course. Yet, at the same time I failed to see how I approached birth with arrogance.
- When I would hear labor stories, I would decide for myself what doctors, midwives, doulas and mothers had done wrong despite not being present for the labor.
- I had answers for every problem a woman might face because natural birth was always possible.
- I assumed what I knew about birth was not only all there really was to know about birth, but also the most important things to know about birth.
I now approach birth with a different type of humility.
- I accept that there are things about the human body I do not know or understand. I accept the ability of others to know and understand those things even if I currently do not.
- I accept that problems can arise in labor without anyone being at fault. Babies and placentas can have problems despite the best health of the mother and care of the midwife.
- I accept that the hands and knees position and a doula cannot possibly be the answer to every problem.
- I accept that there are multiple ways to respond to a problem and most of them will give a good outcome most of the time.
If you don’t have a way to access full research articles, you need to get one. Check with your local libraries and state college system to find out what programs they offer for the local community.
Why is this so important when you can read the abstract free on Pub Med? Because an abstract is only a teaser of what is included in the study – think of it as the advertising content created to help researchers find the articles that are most likely to pertain to their topic. The abstract will list some results and conclusions, but due to space limitations they won’t really be explained.
The full article will also have a good amount of information that is necessary for understanding the generalizability of a study. It will have complete information about who the subjects were and how they were recruited for the study. It will give the limitations and delimitations – which means the things that limited what the researchers could study and the limits the researchers set for themselves. Think of the difference in recording length of labor in a group of women if recruitment is done at hospital admission, or if recruitment is done at the first birth center visit. How might these populations differ?
The full article explains the methods used, which is key to understanding how to interpret the results. Think of the possible differences in findings between a study that asks women to rate the pain they feel in labor at two hour intervals during the process and a study that asks women to rate the pain the felt in labor when they gave birth 1- 5 years earlier. Which method will you assume has better quality data?
Abstracts generally have a one sentence conclusion, but the full article will give you a better discussion of the way the current paper adds to past research and the next steps research should take. Think of a paper that finds an association between obesity and cesarean surgery – if you only read the abstract you might believe the researchers think obese women are more likely to need a cesarean. But if you read the discussion you could quickly find what the researchers were able to control for, and what additional factors (perhaps higher rates of failed elective inductions) are potentially causing the association.
The full paper can also lead you to additional research on the topic to help you form a good base of knowledge – because one of the most useful parts of a paper for a person who wants to fully understand an subject is the references. Any paper will only list a small proportion of the research reviewed by the authors before completing their study, but the ones listed are most likely the most relevant. The references are not going to be listed in the abstract.
Bottom Line: Find a way to get the full paper. Don’t make assumptions based on the abstract.
Yesterday I shared how my training has caused me to relearn how I think about the term “intervention.” Today I want to share another word that needed to be reframed in my mind – “normal.”
When I first began in the natural childbirth movement, when I heard the word normal I always interpreted it to mean “OK” or “Safe” or “Ideal.” I’m not sure if I had thought of the word that way before my first training, or if I somehow picked up on that meaning through my readings. It was, perhaps, a combination of both. I was too young and inexperienced to ever see something bad or dangerous as normal, and the training encouraged me to continue this line of thought.
The most specific example I can recall would be my thinking about newborns. Perhaps you’ve also had the same mindset about some of these. ”Physiologic Jaundice is so common, it’s just normal for babies to be jaundiced. I don’t know why doctors get so hung up about it.” or “It is normal for the newborn to have really low vitamin K levels at birth. They increase by the 7th or 8th day, this is no big deal.” or “They get so hung up on blood glucose levels. It’s normal for glucose levels to be low when you need to eat. Just give the baby the breast and she’ll be fine.”
Today, I look at the things I used to say and wonder how I could be so confident in my statements when I didn’t have a full understanding of all the issues. I also wonder how I always assumed “normal” meant good or safe.
You see, a Type 1 diabetic is going to have high blood sugar levels if they don’t take their insulin – this is the normal functioning of their body because a diabetic does not make insulin so the glucose cannot be metabolized. Yes, this is the normal functioning of the diabetic body, but it is not safe.
“But wait!” you say, “The ‘normal’ newborn is not sick, their body is functioning as it should be.” That is true. But neither is the ‘normal’ newborn body functioning like a one or two week old, an older child, nor an adult. Their body is in a state of transition, and it is this existence in a state of transition that makes these “normals” something worth watching a little more closely.
Before a baby is born, most of the work of the liver is done by the placenta. When the baby is born and separated from the placenta, the liver is just a little behind. It isn’t producing as many of the things needed to help blood coagulate when necessary. It’s ability to form glucose and store glucose are very immature, as are its production of hormones to regulate carbohydrates. It’s ability to conjugate bilirubin is limited, as is its ability to break down any medications.
Closely linked to the function of the liver is the function of the kidneys. Their job of regulating fluids and electrolytes is also done by the placenta before birth. At birth, blood flow to the kidneys does increase, but the filtration abilities are limited – salt stays in while glucose and amino acids leak out. The newborn isn’t very good yet at concentrating or diluting urine to regulate body fluids.
The newborn does a poor job of maintaining body temperature.
At the same time the digestive system is starting to gear up for use. Mucus is being eliminated and the necessary bacteria for vitamin K production are beginning to grow.
What does all this mean? This means the majority of newborns are going to go through these early transitions without a problem. But the newborn is in an delicate position – anything that causes additional stress can overload this immature system quickly. This is one of the reasons the highest rates of death in children under five occur in the first year; and the highest rates of death in the first year are among those less than one week old.
As a midwife, I am trained to watch for these things in all my newborns – not with tests but with my eyes and ears. If something is off, I am trained to investigate quickly to help keep the system in the proper balance during transition. Some of the most common problems look the same or lead to each other in those first hours. For example, if a baby is too cold, the body burns glucose quickly to try to warm the baby which can lead to hypoglycemia. Or a baby who doesn’t feed well may begin to have problems with hypoglycemia, and may also have higher bilirubin levels if they are not stimulating good bowel movements.
While I still accept that this transitional time is normal for a newborn, I no longer pass these first few hours or days off as no big deal. While the baby is transitioning to extra-uterine life, I watch a little closer because this is one time when early detection of a problem makes a big difference in overall health.
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.
Safe Motherhood. It seems like such a simple request. Around the world women and babies still die during pregnancy and childbirth – despite medical advances that could save many of them.
Five years ago, when I began my journey to fight maternal and neonatal mortality, I thought the problem was simple. Today, I see that the health of mothers is affected by more things than the availability of a skilled birth attendant. Like an onion, layers of cultural, socioeconomic and political problems continue to cause problems for women. While we are finding some solutions, we are not there yet.
Layer One: Family
It may be hard to imagine if you are reading this, but there are places in the world where a woman does not have the right to make decisions about her own health. The decision of whether or not she seeks care during pregnancy or birth may lie with her husband, her father, the family as a whole or even the community at large. The decision is based on the cost of care, the perceived need for care and the value of the woman to the society.
Layer Two: Poverty
Being poor in a developed country disadvantages a mother, but being poor in a developing country leaves many women with no options. If the closest health care is hours away, she may feel herself lucky to attend one antenatal clinic, and may simply accept that if something is not right in labor she will have no way to seek help in a timely manner. This is the risk many women take to achieve motherhood.
Layer Three: Cultural Norms
When accessing health care is expensive, accessing health care is the exception rather than the rule. This leads to cultural norms where normal healthy women give birth at home without assistance or with minimal family or community assistance. For many women in the world, this is a sister, mother or another mother from the community who has no training.
This becomes even more difficult in places where women have very little or no value. For example, if her only value is as a worker in the field she may not have the ability to take a day off to attend a local clinic without being considered lazy. Or if a woman is valued most for her ability to bear children, she may not be considered valuable enough for health care until she has proven herself by successfully giving birth the first time.
So women are caught in a cultural trap where the desire for high quality care is weighed against the belief that seeking even basic antenatal care means something is wrong with her.
Layer Four: Social Status
It seems the wealthy and educated look down on the poor and uneducated throughout the globe. This is so ingrained in cultures that we don’t even see it in our own as people laugh at jokes making fun of “country folks” and insult those who have different political ideas from our own because we cannot see why they might feel differently.
In the birth world, I see this through the poor treatment of mother’s within existing medical systems. Doctors and nurses are always educated. The poor women they work with will almost always have less education than them. In societies where status matters (which is basically all of them) there is a feeling that it is OK to treat poor women differently because the poor women deserve to be treated badly.
- You have to yell at them because otherwise they are so proud they won’t do what you say.
- You cannot be nice to them or they will be weak and not labor well.
- She needs to learn how to be tough because she needs to be a good mother.
- She doesn’t know anything and she won’t do what she is supposed to unless I tell her.
Layer Four: Community Resources
Even if her family desires care for her, if the community has no way to provide that care the woman may still have no options. Rural women living in communities without transport to the closest health post may lack antenatal care only because there is no realistic way to get the mother there and back safely. How should the family manage the upcoming birth – send the mother to an area with care before labor begins (paying for her stay of unknown length), or try to create a system that allows for her to access needed care when labor begins (risking not making it to a health post with emergency care in time if it is needed)?
I still wish safe motherhood for all the women of our world, but I no longer think the solutions to these problems are simple. If the solutions were simple, we would have the problems solved already. The truth is, families face difficult decisions when it comes to motherhood. My goal is to help them have more options.