Published in the Spring 1995 (Vol. 2., No. 5) issue of The Birthkit
Copyright 1995 Midwifery Today, Inc.

| Honesty | Legal Status | Protocols | On Time | Obligations | Pay | Trust |

Editor's Note: This was written by a certified midwife and contains suggestions and input from midwives across the United States. The Birthkit grants permission to reprint all or portions of this article if you wish to use it as a handout for clients.


One would think that this would go without saying, but unfortunately, it does not. Not only does this quality stand as the first and foremost obligation of a woman to her midwife (and the midwife to her client, of course), but it permeates all the other qualities listed below, as well. Without honesty there can be no trust, and without a trusting bond between midwife and client, there can be no safe working relationship.

There are many reasons why a woman would be untruthful. Perhaps a woman has had several abortions and has not told her husband. If an oral history is taken with the husband present, she may hide the information from her midwife. A woman may be too embarrassed to let her midwife know that she has herpes. Or perhaps she has learned from interviewing other midwives that she has a certain risk factor that would preclude a homebirth. She may think that if she hides the information from the present midwife, she can get the homebirth she wants. But there are dangers inherent in these scenarios.

Each woman has the right to choose her birth place and attendant. Conversely, midwives have the right to choose their clients according to self-imposed limits and protocols. Some midwives do not hesitate to take women who have had multiple abortions or who have herpes; others do not feel comfortable doing so. Most midwives will not assist at the delivery of twins or breeches; while others do not take VBACs. And there are some conditions for which few midwives would agree to be the primary caregiver, such as pre-existing medical/health problems which require the care of an OB. In these cases, the midwife might be able to co-manage your care with a backup health care provider.

Unfortunately, there are some women who so desperately desire a homebirth and/or midwifery care that they are willing to do almost anything to get it. This is unfair and potentially dangerous to everyone involved. If you have any medical condition or significant past OB history, you must tell your midwife, even if other midwives have turned you down. Without thorough knowledge of your history, the midwife cannot make safe decisions regarding your care. Remember, however, that what one midwife may not feel qualified to handle, another may feel perfectly comfortable handling.

If you have special requirements or requests of a midwife, such as religion, lifestyle, philosophy, education/training or legal status, make these clear during the initial phone contact and ask if she can meet them. There is no point in signing up with a midwife only to discover later that there is something about her that you find unacceptable. Most midwives know other midwives in their area, and can refer you to another who might better suit your needs.



Know and respect the legal status of midwives in your community.

In states in which midwifery is illegal, you must do everything in your power to protect your midwife from prosecution. This may mean not giving her name to certain health care practitioners, not putting her name on the birth certificate, not mentioning her name to friends and relatives who do not support your birth choices, and more. If this is not acceptable to you, then choose a CNM who can work legally in your state.



Agree to abide by the midwife's protocols.

The safest midwife is the one who knows her own limitations and does not exceed them. Of course, these limits change as she gains more experience, either becoming stricter or more lax as she sees fit. But they are her limits, and no one has the right to try to get her to change or exceed them.

If she does not feel qualified, comfortable or experienced enough to handle a situation, then it may well be dangerous for her to do so. It is disappointing to be turned down, transferred out or transported from the place and personnel you planned for your baby's birth, but no midwife wants to endanger the health and safety of mother or baby for any reason.

Protocols cover more than just delivery choices, however. They also apply to the ways in which your midwife handles your pregnancy. Most midwives rely on good nutrition as their main ally in preventing complications. But they also have other tools available to them, such as herbs, homeopathics, chiropractic, acupuncture or allopathic medications to treat problems that may arise. She may order certain tests from a lab to screen her clients for potential medical problems. These are all procedures that you may wish to discuss with her before you hire her as your caregiver. Once you are working with her, it is unfair to refuse tests or procedures which she has stated her protocols require.

Keep in mind that not only does the midwife want to provide the best of care for her clients, but she also puts her entire life into the hands of those same clients, especially in states where she may be illegal or alegal (a borderline legality that is legal unless something goes wrong, then it can become a nightmarish legal-medical witch hunt, to say the least). She puts her and her family's financial security and well-being, her freedom to practice and freedom from incarceration and risks of legal prosecution, as well as her reputation and community status and the ability to care for her family on the line for her clients every time she takes on a new client. Most midwives do not carry or are able to obtain medical malpractice insurance to cover legal pitfalls as doctors do. Midwives can lose everything in the event that something goes wrong. It is important that a client does NOT put her midwife at any more risk than necessary, just as it is important for the midwife not to put her client at risk in the event that things do not go right during the pregnancy, labor and/or birth. - Comment added by



Most midwives want to see clients once a month through 28 weeks, once every two weeks from 28 to 36 weeks, then once a week until delivery. Extra visits may be scheduled under certain circumstances. If you must be late for an appointment, give her a courtesy call and let her know your situation. This allows the midwife to either tell you to come in as soon as possible; come in later in the day; or reschedule for another day. Whatever she decides, she will know when to expect you, and she can plan some other way to fill your missed appointment time. This of course, also applies if you must cancel an appointment. And, unless you are experiencing an emergency or personal/family crisis, if you cancel less than 24 hours before your appointment time you may be expected to pay for the missed visit. Even if your midwife does not ask for payment, offer it. It shows her that you acknowledge and appreciate that her time is valuable.

Please honor your midwife's prenatal visit schedule. Most midwives are willing to be flexible when scheduling appointments, but they need uninterrupted family time, too. Many midwives schedule regular or occasional evening or weekend appointments and will do their best to accommodate their clients' work schedules. However, that does not mean a client should ask for an appointment at any time that is convenient. If you had chosen a conventional health care provider for your prenatal care, you would have been seen during regular office hours. Extend the same courtesy to your midwife.

Ask your midwife what her policy is for accepting phone calls at home, and how late you can call her. If your question is not urgent, call during normal business hours (usually 9 a.m. to 5 p.m. weekdays). Of course, your midwife will accept an emergency call from you at any time.



Understand and meet your obligations to your midwife.

Most midwives require their clients to become knowledgeable about pregnancy, labor, delivery, midwifery care, homebirth preparation, parenting, basic childcare/first aid, and other subjects by reading and/or attending classes. This basic information is necessary for you to become a responsible partner in your own health care; you cannot give an informed consent if you are uninformed. If you know what normal is, you will not become frightened unnecessarily. And more important, you will be able to immediately report to your midwife anything outside of normal, so that she can move quickly to take care of it. In addition, if you know ahead of time how your midwife handles various complications, her actions will allay your fears rather than add to your anxiety.

Most midwives also require their clients to meet certain physical requirements regarding the birth site. These may include having running water available and a way to boil it; having a telephone or other communications device; maintaining a certain level of cleanliness; and having certain supplies on hand. If the midwife arrives for your birth and these obligations are not met, it could jeopardize the health of mother or baby. If you are having difficulty meeting any of these requirements, discuss it with your midwife as soon as possible so that other arrangements can be made well ahead of the due date.



There are a few spiritual communities that still provide for their midwives by paying for housing, food, vehicles and other needs. But most midwives charge for their services. Fees may range from a barter of goods, to a sliding scale, to a set fee. Whatever it is, if you engage the midwife's services you need to honor your agreement and obligation to pay her fee. If a client does not pay for services rendered, she is robbing the midwife of money she needs to meet her own family's expenses.

It is best if you and your midwife can agree in advance on a payment schedule. Some midwives ask for a deposit up front; some ask for a minimum amount payable at each visit; others ask that the full fee be paid by a certain date; some practitioners offer a discount if the fee is paid early or require a penalty if it is paid late; still others will accept barter for some or all of their fee.

Of course, we all occasionally have emergencies which stretch our budgets. If such an event occurs, call your midwife and re-negotiate your payment plan. Do not expect her to absorb the cost of your financial emergency by not paying her. And please, do everything in your power to pay the full fee before your baby is born.

While a national study comparing doctor/midwife care has found that midwives spend 10 times as many hours with their clients during the course of pregnancy, labor, delivery and postpartum, you would be hard-pressed to find a midwife who is paid what any physician is paid. Most midwives charge between one-quarter and one-half the fee charged by doctors in the same area. And there is an even greater savings to consumers seeking a homebirth, because unless there is an emergency, they do not have a hospital fee to pay. So, if you can, give your midwife a bonus above her normal fee: if she offers a sliding scale, pay the upper fee for your income bracket; buy her a nice gift; offer her your services, whether it is mending a fence or typing letters for her. This not only helps to compensate her for those who have not paid, but allows her to offer her services at reduced rates to women of more modest means.



If you have been honest with your midwife, a bond of trust will develop during the prenatal visits. She will trust you to accept her advice and information, and you will trust your midwife to help you to make those decisions that are in the best interest of you and your baby. The more you and your midwife honor and respect one other, the more each of you can just relax and allow the birth to unfold naturally. This, of course, means that you need to trust in the birth process as well. If you believe that the birth process can work without medical intervention, then it probably will. But not always.

Dutch midwives have a saying, "Nature is not always mild." Just because you do everything "right," there is no absolute guarantee that you will have a perfect birth and perfect baby. Sometimes birth needs technical assistance. Sometimes a baby is born sick or malformed. Sometimes a baby dies, regardless of what the mother did prenatally to ensure a healthy birth. You must be willing to accept responsibility for your decisions and actions and not assign "blame" to another. No one has all the answers: not any health care provider, scientist, philosopher, nor your midwife and nor you, yourself. Together, you and your caregiver make the decisions that affect your pregnancy, labor, delivery and postpartum. But the final responsibility is yours.

All of the above suggestions apply whether you birth at home, at a birth center or in a hospital. If you act responsibly throughout your pregnancy, labor, delivery and postpartum, then the chances are greatly in your favor for having a positive experience.

Happy birthing and bright blessings!


Copyright 1995, Midwifery Today, Inc.

Permission is granted to reproduce this item in electronic form and distribute it freely, as long as:
  1. This permission and the authorship of the article are retained in any additional publication of the article.
  2. The content of the article is not changed in any way.
  3. You do not charge for the article, other than the cost of download and/or connect time, or photocopying costs, in the case of a printed version.

Midwifery Today, Inc.
PO Box 2672-350
Eugene OR 97402
Fax: 541-344-1422

Last updated Sun, Aug 31, 1997 by
Donna Dolezal Zelzer,

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