Sunday, July 11, 2010

Conversation with my midwife

A few months ago, the midwife I used for Dio’s birth invited me to come to her office and meet a CNM she was thinking of adding to her practice. (Having a solo home birth practice is very demanding. Adding a second midwife would allow her to actually take vacations more than once every few years, to do more well-woman care, and to have more time for breastfeeding support as an IBCLC). Here are some recaps from our conversation.

My midwife Penny and the prospective midwife Holly talked about their backgrounds and how they came to both midwifery and home birth. Both worked as OB nurses for many years before they even thought of midwifery or home birth. Both eventually pursued a CNM degree with the intention of opening a home birth practice. Penny worked for several years in a large university hospital. It was the end-of-the-line for obstetrical cases, where you’d go if a high-risk situation arose in a smaller, less-equipped hospital; if you needed care for a 26-weeker; if you had an extremely complicated obstetrical history. Penny’s time working at Large University Hospital (LUH) taught her the limits of what medicine could do. Sometimes they could save lives and improve women’s and babies’ health. But other times—all too often—all they could do was offer compassion and support, unable to save every life or prevent all bad outcomes. And this was at the most tertiary of tertiary centers.

Penny said that working in such a high-tech, high-intervention setting gave her much more confidence to pursue a second career as a home birth midwife. She knew first-hand what the most advanced medical care could and could not do. There was no mystery or mystique about what a hospital could offer—something she sees as a great advantage, compared to many home birth midwives who have never worked intensely in a hospital environment.

During her years as a nurse at LUH, Penny loved taking care of home birth transfers. She was able to offer excellent care for the specific medical issues that needed addressing, while otherwise supporting and facilitating the woman’s desire for a gentle, unmedicated birth. I remember her telling me the story of catching one woman’s baby in the bathroom and putting the baby immediately on the mother’s chest—something she thought entirely commonsense, but something she got a lot of flack for from her co-workers. It was these experiences that pushed her to become a midwife.

Penny highly values the knowledge and skills she acquired as an OB nurse in a high-risk setting. She is totally fluent in inserting IVs, administering medications, intubating, resuscitating, etc. Now, she hardly ever uses these skills as a home birth midwife, because they are rarely, if ever, needed. (In fact, one skill she says is becoming rustier than she’d like is suturing, because women in her practice hardly tear, and if they do it’s rare that the tears need stitches—something she attribute to her hands-off approach. Dads or moms usually catch their babies; she steps in only if they do not want to catch or if neither parent is in a good position to do so.) But if/when her medical skills are needed, she is really, really good at them.

While we were chatting with Holly, Penny said to me, “you know Rixa, because of your background with unassisted birth, you hired me for different reasons than many women typically hire a home birth midwife. You didn’t need me so much for labor support or guidance. You really hired me for that 5% chance of needing really skilled medical assistance, something that I can do really well.” I thought about that and realized that I agreed with her. I am really independent and pretty much labor and birth all on my own. I don’t rely on my husband or female companions for labor support or encouragement. In fact, I prefer to do things on my own for the most part. So I wanted a midwife not for the 95% of stuff that she does during labor—now, that 95% is quite valuable and many women love the support and guidance their midwife offers during labor—but for the small chance that I’d need some kind of additional intervention or emergency skills.

Which brings me to another point I want to make—the more exposure I have to midwives, the more I realize how credentials and background do NOT translate into a certain style of practice. I have a lot of experience interacting with “lay” midwives, direct-entry midwives (CPMs), and home birth nurse-midwives. A CNM degree does not mean that a midwife will have a more “medicalized” style of practice (although it is true that most nurse-midwifery programs are geared towards preparing midwives to practice in a hospital setting).

Now, I am sure some people reading this are thinking, “Oh, Penny is such a MEDwife!” But nothing could be farther from the truth. She is very professional and very highly skilled. Very respectful of women’s desires at birth. She had such a quiet presence at my birth that I hardly noticed she was there; she honored all of my requests and wishes that we had talked about prenatally. She was especially adamant about not disturbing the immediate postpartum period. She doesn’t care about liability and has deliberately chosen to forego malpractice insurance and go “bare.” She is willing to go beyond the “standard of care,” to borrow a phrase from Dr. Denise Punger. Her attitude is “you need to prove to me why you shouldn’t have a home birth.”


  1. Penny sounds awesome and really similar to my midwife who is also a CNM and former L&D nurse. I also pretty much can labor on my own and with my most recent birth, deliver on my own. I loved how hands off both midwives were at my birth. But i also love having someone who does all the clean up and birth certificate and first baby check up stuff too. And knowing that if I needed it, Rebecca had the training to deal with complications.

  2. I'm really hoping to find this kind of midwife for my second pregnancy (soon :) )

    And how did it end up with Holly? Do they now practice together?

  3. Thanks so much for sharing this conversation.

  4. She sounds similar to the one of the homebirth midwives in my area. I interviewed her for my CCE a couple years ago and she also has a background in nursing (but as a PICU RN). B/c of this, she is also very skilled in some of the same things Penny is, like starting IV's and resuscitation. It's such a shame that the word "medwife" is even used! Stereotypes really don't do much good for anyone.

  5. I reserve the word "medwife" for the CNM that works at one of our local hospitals - the one I personally watched perform over 25 cervical exams in about 8 hours on one of my doula clients.

    Your relationship with your midwife sounds beautiful and wonderful. I, too, recently spent a morning with a midwife who was a perspective add-in to my midwife's practice and I loved her. Yes, she was qualified and kind, and yes, I would just love more midwives in our area.

    So, what did you think of the perspective partner? We're all curious to know!

  6. I would love to have a midwife like that at my next birth- I was happy laboring on my own and catching my baby myself for my first, and it would only have been better if I could have stayed at home and had a capable person there to tell me everything was going great.

  7. I think Penny sounds like a great addition to the practice because she has both a good academic medical background and practical experience.

    Personally, I would never hire a CPM if I was birthing in the US. A CNM has more medical training, which is exactly what you need if you are in that 5% who need help for mother and/or baby and care during a transport to hospital. The US really needs to implement university level midwifery education that includes skills working in both hospital and out of hospital settings.

    A CPM or lay midwife may gain excellent skills over time, but how many women and babies receive sub-optimal care (resulting in death even) while they learn what many other midwives with more rigorous academic studies and practical experience learn already in a 4 year university-level program?

    CPM's who are truly dedicated to their profession would not hesitate to retrain to new standards if the government mandated it.

    CPM's might think what I am saying is unfair, but I'd believe them if MANA released their statistics that would confirm that home birth with CPM's has the same outcomes as home birth with midwives (CNM's) in other countries with more rigorous standards.


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