MoonDragon's Pregnancy Information
BIRTH METHOD CHOICES
BIRTH METHOD CHOICES INDEX
Description of Choices Types of Practitioners Types of Practices Types of Locations
DESCRIPTION OF CHOICES
The options in childbirth involve selecting a practitioner, type of birthing practice the practitioner works in, the type of birthing or delivery facility and birthing choices involving natural, non-medicated birthing using relaxation & visualization techniques to anesthetic choices to full surgical medical management.
Expectant parents should explore their choices and select those that match their preferences and requirements. There are limitations in many cases due to complications of a pregnancy, lack of options in smaller communities, economic constraints, prepaid health plans or insurance restrictions, and laws in some states that "attempt" to control who can attend births and perform deliveries in various settings which include home births, birthing centers, and hospital facilities.
WHEN CHOOSING A PRACTITIONER
Keep in mind... Licensure or certification does not necessarily guarantee competence or quality of care. It means the practitioner has completed basic class coursework and passed required tests (regurgitation of information, regardless of the actual ability to problem solve), and that they pay their fees to keep their licensure. But it does not mean that this practitioner knows what he is doing, knows how to handle unexpected or stressful situations or how to find solutions and solve problems. Nor does it mean that he cares about his patients and their health outcomes. A license or certification can lead to a false sense of security for people seeking health care. This has been proven over and over again with incompetent licensed doctors practicing, maiming and killing their patients through neglect and malpractice, poor patient care, poor communications skills with patients and staff, inability to properly diagnose and treat their patients, poor surgical skills with poor outcomes, drug and/or alcohol dependency interfering with their ability to provide proper patient care, their inability to learn and change and update established old practice protocols, psychological problems and impairments from a minor personality flaw to full-blown "whackadoodles" (unofficial term for someone totally off the edge), and a lack of personal and professional ethics... just to give a few major issues.
When you decide on choosing a practitioner, find one that you are comfortable with and can work with. Credentials should only be part of the evaluating process for a good choice. Finding someone you can afford is important too, especially if you are financially strapped with limited health insurance coverage that will still provide the care needed. Beware of those with little time to work with you, large egos, inflexible attitudes, poor communication skills and have a poor standard of care (you may have to ask around the community, but not necessarily coworkers, partners or affilated persons with false recommendations). Do not be afraid to fire the practitioner if they do not live up to your needs, expectations, and standards. Take charge of your health care and your body. Take responsibility for your own care and consider the practitioner only as a consultant to your care.
TYPES OF PRACTITIONERS
| DEM - Direct-Entry Midwife | CNM - Certified Nurse Midwife | Physician |
| Other Options - Unattended Birth | Choosing the Type of Practitioner |
DOMICILIARY DIRECT-ENTRY MIDWIFE
A Direct-Entry Midwife (DEM) is a domiciliary maternity and woman care practitioner who primarily assists expectant parents with home births. She may also be found in some free-standing birthing centers (non-associated with any particular hospital or medical group). She may also provide well-woman care, dietary & birth control counseling, and childbirth preparation instruction.
This type of practitioner may or may not be certified (CM, CPM), licensed (LM) or legally regulated in her particular community / state / country of practice. She is called a direct entry midwife because she has chosen to proceed directly into midwifery without pursuing a nursing degree.
She tends to approach pregnancy and birth from a view point of being a natural, healthy function of the female body and not an illness, a pathology that needs to be cured, or something that needs to be "medically managed".
She may have entered the art of midwifery from a variety of routes, depending upon the options and training available to her. These routes may include, but are not limited to, apprenticeship, formal midwifery schools & informal educational routes, on-the-job experience, workshops, training seminars, and many more options.
She is fully capable of handling healthy, low risk pregnancies and births and has been trained to handle emergencies should they arise, and know when to do medical referrals and/or emergency transports to a medical facility when they are needed.
She has established practice protocols and follows evidence-based methods of health care, preventive methods and dietary guidance to promote health and well-being of the mother and baby. She uses alternative relaxation & visualization techniques, empowerment, support & other natural methods of assisting the birthing woman in place of potentially dangerous and harmful drugs and techniques used in a more medically managed institution.
Certification or No Certification: The Traditional Midwife
There are many excellent, qualified DEM midwife practitioners who are unable to obtain or choose not to pursue "regulatory" certifications and licensure in their practices due to personal ethical reasons, regional, legal and/or medical constraints in their communities of practice or possibly for financial reasons. This does not necessarily make them less qualified than their certified/licenced counterparts. It is quite expensive to become "certified" and/or "licensed" and to keep it current (it has to be renewed every year to every 3 years, depending on state and certification requirements). Some midwives do not have a large enough midwifery practice with sufficient number of clients (paying and non-paying) yearly to be able to qualify for certification and/or they may be unable to afford the extra financial burden of obtaining and maintaining their certification status. This can be a very limiting factor for midwives having less than 3 births per month and may be offering sliding scale services for low-income clients or using other means of compensation.
MEAC accredited midwifery schools can run $20,000 to $35,000 [2013-2014] for their midwifery-degree programs, depending upon the school. Midwifery schools are scattered and few, a limiting factor for potential students (not all students can pick up their families and move to a school location). Not all schools offer financial aid. Some require that the students obtain their own preceptorship to oversee their training. This can be a problem for some midwives wanting certification if there are few or no other preceptor-accredited, certified midwives in their geographical region to work with. For more information about education and certification through MEAC and NARM, see the following links.
MEAC Accredited Midwifery Schools & Non-Accredited Midwifery Courses NARM (North American Registry of Midwives) Certification Information
Equvalency Applicants - NARM - Choose Your Route To Certification
Experienced Midwife - NARM
Entry-Level Applicants Midwifery School & Clinical Sites - NARM Preparing For The NARM Exam
Registering For The NARM Exam (Exam Cost $900 )
Recertification - NARM (Every 3 Years - Minimum $150 to $216 )
THE TRADITIONAL MIDWIFE
A traditional birth attendant (TBA), also known as a traditional midwife, community midwife or lay midwife, is a pregnancy and childbirth care provider. Traditional birth attendants provide the majority of primary maternity care in many developing countries, and may function within specific communities in developed countries.
Traditional midwives provide basic health care, support and advice during and after pregnancy and childbirth, based primarily on experience and knowledge acquired informally through the traditions and practices of the communities where they originated. They usually work in rural, remote and other medically underserved areas. TBAs may not receive formal education and training in health care provision, and there are no specific professional requisites such as certification or licensure. A traditional birth attendant may have been formally educated and has chosen to not register. They often learn their trade through apprenticeship or are self-taught; in many communities one of the criteria for being accepted as a TBA by clients is experience as a mother. Many traditional midwives are also herbalists, or other traditional healers. They may or may not be integrated in the formal health care system. They sometimes serve as a bridge between the community and the formal health system, and may accompany women to health facilities for delivery.
TRAINING & FOCUS OF WORK
Traditional birth attendants are often older women, respected in their communities. They consider themselves as private health care practitioners who respond to requests for service. The focus of their work is to assist women during delivery and immediately post-partum. Frequently their assistance includes helping with household chores. TBAs may not have any formal training on how to attend pregnant women. Many are highly experienced in well woman care including how to recognize and respond appropriately to complications of pregnancy.
It is being increasingly recognized that TBAs may have a role to play in improving health outcomes in developing countries because of their access to communities and the relationships they share with women in local communities, especially if women are unable to access skilled care. Some countries, training institutes and non-governmental agencies are initiating efforts to train TBAs in basic and emergency obstetric care, family planning, and other maternal health topics, in order to enhance the links between modern health care services and the community, and to improve the chances for better health outcomes among mothers and babies. There are some findings that targeted interventions for training TBAs can lead to reduced perinatal mortality. However, there is little evidence of large-scale effectiveness of such programs, as they are rarely integrated within a general strategy for improving maternal and child care.
In developed countries, some traditional or lay midwives are becoming increasingly vocal in support of their right to practice without formal regulation, advocating for a woman's right to choose her place of birth and birth attendants. They see their role to include promoting change in societal attitudes towards birth, and favoring the "art" of midwifery founded on maternal or compassionate instincts, rather than over-medicalization of this natural event.
For full article and references, see Wikipedia: Traditional Birth Attendant
TRADITIONAL MIDWIVES ARE MIDWIVES
© 2007 Midwifery Today, Inc. All rights reserved.
This article first appeared in Midwifery Today Issue 82, Summer 2007.]
This article was adapted from the Latin American & Caribbean Network for Humanization of Childbirth's proposal to the International Confederation of Midwives, World Health Organization, UNFPA and the World Bank requesting that they use the more accurate term "traditional midwife" rather than "Traditional Birth Attendant." It was originally entitled "The Traditional Midwife in our Region."
Traditional midwives have proven to be a sustainable and unique labor force at the service of many mothers and their children in isolated and poor communities. This document was created in consultation with traditional midwives, midwives and other health providers from Latin America and the Caribbean.
As a people, we appeal to you to find the balance between development and culture, based on the importance of equity, justice, safety and human rights. As a result we submit this document as a necessary first step in working out conflicting interests between your organizations and ours.
Centuries ago European traditional midwives began to educate themselves in order to acquire new abilities. As a result they have been able to maintain a generally successful practice to this day. Traditional midwives in Latin America and the Caribbean today have the same rights and abilities for self-improvement.
According to research, trained traditional midwives have helped to significantly diminish maternal-infant mortality and morbidity. However, we know that in our region of the Americas we are far from: one, eliminating poverty from marginalized communities—a recognized contributor to risks for mother and infants, and two, establishing adequate health services for mothers. Before attitudes against traditional midwives in this part of the world become too entrenched, we propose the initiation of a constructive dialogue with all concerned parties.
DEFINITIION OF TRADITIONAL MIDWIFE
She is an independent essential and primary care provider during pregnancy, birth and postpartum and is recognized as such by her community and jurisdiction. She offers domiciliary services. She works in isolated communities in developing countries and sometimes she practices in developed countries. She is a neighbor of the mothers she assists, and may be aboriginal in her country. Her talents vary according to the region of residence. Her gift as a midwife and her intuition help create an intimate, unique relationship with each mother and infant under her care. The use of diets, plants, various infusions, immersion baths, sweat baths, incense, enemas and massages integrate her knowledge. She understands and uses minimal intervention and special maneuvers to work with the most difficult births. She practices hygiene, promotes breastfeeding, and protects the mother with her presence, advice and prayers. The traditional midwife considers birthing a natural event; for many it is a ceremony.
The traditional midwife works and collaborates in the health of the newborn baby and takes care of her/him as long as it deems necessary. She also takes care of the mothers’ health, offers education with regard to family planning and is accessible to help the women with her needs throughout her life. She gets her knowledge from traditional and informal methods ancient to the profession. This includes learning through her own experience as a mother, assisting other women - from her ancestors, colleagues, healers, other health providers - and by means of self-learning. Dreams, examples from nature, spirits, her spirituality and God may guide her work. When her education comes from a non-governmental organization she is known as a trained traditional midwife. Occasionally she works in collaboration with other health providers. At times she may work in clinics and often she is the bridge between the health system and her community.
- The traditional midwife must be acknowledged as a true midwife, on equal terms as that of the midwife with a formal education.
- All organizations that provide health care to this region need to accept the concept of the traditional midwife as a midwife, as it affects health politics in the Americas.
- We firmly believe that the use of the term "midwife" as applied to the traditional midwife will strengthen the image of all midwives. In addition it will help to maintain an orderly and transparent succession of the profession within our social, linguistic and historical context.
- Using the term "midwife" for traditional midwives is in concordance with the feeling of solidarity claimed by many midwives of our region.
Women' s empowerment and their full participation on the basis of equality in all spheres of society, including participation in the decision-making process and access to power, are fundamental for the achievement of equality, development and peace. (Beijing Declaration, 1995)
A comprehensive explanation offers a more complete perspective. Accordingly, we want to create respect for traditional medicine - a practice that started when human beings first appeared on earth - and a balance with the politics of academic medicine, which evolved from tradition we also share. Both paradigms can relate and together we can continue to offer a complete service, according to the mothers' selection, in such a way that each health care provider can coexist comfortably in this world.
The following points were identified in the document Making Pregnancy Safer: The Critical Role of the Skilled Attendant. We believe that these are areas that need to be addressed and for which we can clearly reach a compromise. (We are using the term TBA for traditional midwife here, because that is the language used in the document.)
- Traditional midwives could perform the role of the skilled attendant, where required, with some training.
- Research indicates that training of TBAs has not contributed to reduction of maternal mortality.
- Experts believe that the best role for the TBA in the skilled attendant strategy is to serve as an advocate for skilled care, encouraging women to seek care from skilled attendants.
- Investing in strategies based solely on TBAs has historically caused governments to delay the development and implementation of strategies for ensuring that skilled attendants are available to all women and newborns. To avoid falling into this trap, the decision to incorporate TBAs into the strategy for the provision of skilled care should be an interim step in a longer-term plan for training and providing sufficient skilled attendants.
- The younger and the most able TBAs, with educational backing and access to appropriate adult education programs, may be able to enter a midwifery program.
"Traditional midwives could perform the role of the skilled attendant, where required, with some training."
We must be careful how statements like "traditional midwives could perform - with some training" may influence governments. Due to circumstances beyond their control, many traditional midwives do not have opportunities to further develop their skills. At the same time they are the only real resource for the poorest and most isolated mothers in developing countries. This perception that they are unable to provide midwifery care is detrimental to their profession and credibility. It can lead to conflict and indifference from other health care providers in health care facilities.
Traditional midwives can be included safely in health care programs. Not all goals for the millennium are attainable in our region. A backlash against traditional midwives in the political arena will increase risks to mothers and babies and will increase underground activities. In the past as well as the present, in our region, governments have been known to identify traditional midwives, attract them to courses, and then oppress them to reduce their numbers and ultimately attempt to eliminate them.
"Research indicates that training of TBAs has not contributed to reduction of maternal mortality."
This statement is a selective reading of the research. A number of research studies have shown the opposite. Sibley's meta-analysis of 60 studies showed that training traditional birth attendants was associated with significant improvements in performance and mortality. There were 8% fewer deaths among women cared for or living in areas served by trained traditional midwives (TBAs). These results appear to confirm that their training could be a useful component of a safe motherhood program. Training programs of the Puerto Rico Health Department revealed that between the years 1931 to 1953, maternal death caused by puerperal sepsis was reduced from 24-percent for every 10,000 births to 0.9-percent/10,000. Bangladesh, which achieved great success in expanding family planning uptake and reducing fertility rates, reduced maternal mortality from 850/100,000 in 1990 to 380/100,000 in 2000, even though, in 2002, only 12-percent of deliveries had a skilled attendant. More referrals (from traditional midwives) were reported in countries where data were gathered: When reliable maternal mortality data are lacking, process indicators, such as increased rates of appropriate traditional midwife (TBA) referrals are important markers of progress in reducing maternal mortality.
Experts believe that the best role for the TBA in the skilled attendant strategy is to serve as an advocate for skilled care, encouraging women to seek care from skilled attendants.
Programs in developing countries have used funds either for training traditional midwives or for establishing facilities with new health care providers. Most have not planned to use funds for each, equally. On the other hand, excellent results are attained when both aspects are developed at the same time (as shown in the examples below), where interactions among health care providers do not pretend to change the role of the traditional midwife or the election of younger ones, it only pretends to add knowledge to the practice of the existing ones.
Other "experts," besides those referred to above, have examined a variety of factors and come to differing conclusions. These include voices of the communities, daily lives within those communities, insular policies, reports, studies, financial budgets, government documents, human rights and interviews with people and agencies involved. Usually the opinions of most experts do not take into consideration all social and economic variables, which historically had severe consequences: delayed struggles for the abolition of slavery and women's right to vote; sterilization of women without their consent in poor countries; groups against vaginal birth after caesarean; and routine episiotomies, among others. When experts are able to integrate many elements and unite people’s voices, programs provide efficient and socially comprehensive solutions. Examples include:
In Honduras, national maternal mortality was decreased by 40-percent between 1990 and 1997—one of the most drastic and important reductions in the region. Traditional midwives kept their role and trade/profession. They were trained on prevalent risk factors, clinics were created and other health care providers were integrated into the communities.
In Puerto Rico from 1950 to 1951 (years of extreme poverty) reports revealed that 60-percent of the births were attended by midwives at home. A reported 46.5% of the maternal deaths occurred in births attended by medical doctors and 28.2-percent in those attended by midwives. Midwives were trained on the prevailing causes of maternal/infant mortality and morbidity in groups within their communities and by collaborators. Health facilities did not exist in many areas of the island. In poor areas and extreme situations midwives were shown to handle difficulties with superior dexterity.
The experience of the Peruvian Quechua is based on the mothers’ wish to give birth at home with a traditional midwife. Their reproductive rights and their free selection of where and how they want to give birth were not denied. Health centers and traditional midwives worked together. Mothers chose. Fifty percent of them kept the traditional midwife or relatives and the other 50-percent used other health care providers like hospitals and birthing centers. Workshops were carefully developed so academics and traditional workers could share their knowledge. Traditional midwives obtained support from other health care providers and access to clinics. The traditional midwives felt respected and validated.
Research on the value of the knowledge base of traditional midwifery is absent. Physicians and obstetricians participating in learning experiences in the community with midwives have stated that when they are in difficult situations they recognized their limited knowledge while midwives always knew what to do. In workshops, these doctors were able to articulate that the process of working together was initiated.
These actions are in accordance with the human rights of all the people involved: consolidating friendship and solidarity among peoples; promoting respect for the rights of others; cherishing cultural pluralism and diversity and encouraging the flourishing of the national cultures of all groups and peoples; enriching the culture of dialogue, mutual tolerance and renouncing violence; promoting non-violence, fighting bigotry, and immunizing the people against the discourse of hatred. (Cairo Declaration of Human Rights)
"Investing in strategies based solely on TBAs has historically caused governments to delay the development and implementation of strategies for ensuring that skilled attendants are available to all women and newborns. To avoid falling into this trap, the decision to incorporate TBAs into the strategy for the provision of skilled care should be an interim step of a longer-term plan for training and providing sufficient skilled attendants."
Investing in strategies based solely on trained staff and hospitals is also destined to fail. Speculations about the cost and effectiveness of programs to train TBAs has led to their widespread abandonment, despite an absence of trial evidence. Absence of evidence of effect is not evidence of absence of effect.
Existing research in other Latin American countries suggests that a lack of respect for traditional practices, valuing the biomedical service system as the only appropriate form of health delivery and programs that encourage training and uncompensated involvement of traditional health providers in the biomedical system, all contribute to a decrease in the number of providers in remote areas.
However, barriers to the establishment of Essential Obstetrical Care centers (EOCs) in areas currently without such services include lack of available or foreseeable funding, as well as the challenge of staffing EOCs in relatively remote and economically impoverished areas - suggesting nothing to do with the training of traditional midwives.
"The younger and the most able TBAs, with educational backing and access to appropriate adult education programs, may be able to enter a midwifery program."
The capacity to learn is different for each person and it can happen at any age. The claim that only young people can learn does not take into account the reality of traditional midwifery practice and values academic knowledge over all else.
As measured at two years post-training, a four-day curriculum (using interactive learning techniques, practical applications and an on-site orientation to referral facilities) and follow-up monthly feedback meetings for training traditional midwives (TBAs) in rural Honduras resulted in improved and retained knowledge as well as marked improvement in referral practice when compared with control traditional midwives (TBAs). Traditional midwives have demonstrated an ability to learn identification of high-risk pregnancies and new methods of managing obstetrical emergencies.
A surprising yet prominent theme expressed by the midwives throughout the focus groups was "the desire for additional training to better help the women of their communities." The States Parties to the present Covenant recognize the right to work, which includes everybody's right to make a living working in what they freely choose or accept, and will take appropriate steps to safeguard this right. (International Covenant on Economics, Social and Cultural Rights, UN).
ADVANTAGES OF TRADITIONAL MIDWIVES
- They have the courage to work with the birthing process in isolated communities, and often without the necessary resources. They do not leave the mother alone.
- With the existence of many marginal communities in Latin America, midwives are the people with special skills and with connections or knowledge to other health services.
- Their socioeconomic level is compatible with that of the women they serve.
- Traditional midwives are usually permanent residents and their constant presence in the community makes them a real alternative for mothers in marginalized communities.
- In many countries the government is not formally opposed to them.
- They have demonstrated their ability to learn.
- Data show that in some places where health clinics were established, some mothers still prefer to be assisted by a traditional midwife during birth. This constitutes their right and is reason enough to simply maintain the existence and value of the traditional midwife and to help cultivate homebirths, which is a real social advantage in the short and long term.
RECOMMENDATIONS FOR FUTURE LAWS & REGULATIONS
It is in our interest that any document of legislative proposal or action for the regulation of midwifery, whether by the WHO or others, provides a law or regulation that is appropriate for the region and defines clearly the role of the traditional midwife. Any legislative proposal that will influence this region (The Americas) should include:
- Written mention of the recognized name in our region - Traditional Midwife.
- Declaration of the right of the traditional midwife to maintain her profession respected, preserved, promoted and developed.
- Establishment in writing of her right to be respected and recognized as primary-care provider for mother and babies in her region by other health care personnel.
- Establishment of a mechanism for close collaboration with other health professionals and provision of equipment for prevention and management of emergencies.
- Recognition of her natural autonomy. In any written document the word "collaboration" should be used and not the word "supervision." The interdependence should be reflected with this term.
- Regulation for the protection of providers of homebirths and for the right of mothers to be attended at home as well as the recognition that homebirth sometimes is a woman's only option.
- Establishment in writing of the principle that gifts or social benefits not be given to mothers as a means to encourage a choice of another health provider over that of the traditional midwife.
- Protection in favor of the traditional midwife. Not to be offended, demoralized, or to be discriminated against because of age, illiteracy or other reasons nor to be used in disguised or open mechanisms of elimination; she should not be oppressed or forced to stop or change her role nor should her profession be targeted for a reduction in numbers.
One of the objectives of human rights education is enhancing men and women's awareness of their rights so as to help enable them to transform human rights principles into social, economic and political reality. It would also enhance their ability to defend, maintain and advance human rights on all levels. (The Cairo Declaration on Human Rights).
- Personal correspondence from Lauren Showe regarding her experience with traditional midwives in Ecuador and Argentina (2007). Personal correspondence from Alina Bishop. México experience with traditional midwives (2007). Díaz, Debbie A. "Historia de la Parteras de Puerto Rico." Thesis. Universidad de Puerto Rico. Recinto de Ciencias Médicas. 1999.
- Sibley, L.M, Sipe, T.A. 2003. Review of: Traditional birth attendant training effectiveness: a meta-analysis. Int J Gynaecol Obstet 83(1): 121–22.
- Puerto Rico. Departamento de Salud de Puerto Rico. Material informativo sobre el Programa de Comadronas, 5 de mayo del 1955.
- Costello, A., D. Osrin and D. Manandhar. 2004. Reducing maternal and neonatal mortality in the poorest communities. BMJ 329(7475): 1166–68. http://bmj.com/cgi/content/full/329/7475/1166. Accessed 18 April 2007.
- Rodgers, K.A., M. Little and S. Nelson. 2004. Outcomes of Training Traditional Birth Attendants in Rural Honduras: Comparison with A Control Group. World Health & Population.
- Santos Febres, Mayra. "Perdónenme la insistencia" El Nuevo Día, 18 de febrero, 2007. Cultura p. 118.
- Shiffman, J. 2003. "Generating Political Will for Safe Motherhood in Honduras." Paper presented at symposium. Population Association of America.
- Puerto Rico. Departamento de Sanidad. Informe anual del Director de Sanidad al Honorable Gobernador de Puerto Rico, 1950–1951.
- Departamento de Salud de Puerto Rico, op. cit.
- Brocker, A., et al. 2001. Promoción de la medicina y prácticas indígenas en la atención primaria de salud: El caso de los Quechua del Perú. www.paho.org/Spanish/AD/THS/OS/indi18_esp.pdf. Accessed 18 April 2007.
- Rodgers, K. See note 5.
- Costello, A., op. cit.
- Low, L., et al. 2006. Challenges for traditional birth attendants in northern rural Honduras. Midwifery 22(1):78–87.
- Rodgers, K., op. cit
- Low, et al., op. cit.
- Brocker, A., op. cit.
- See, for example, a meritorious law to pursue, adopted by the state of Quintana Roo, México: Health institutions working in indigenous communities should promote and foment the use of traditional medicine. This should be done by registration and accreditation of all persons using traditional health methods and giving maternal care. Its application requires the necessary support providing elements so that their work may be accomplished adequately. Estado De Quintana Roo, Legislatura Constitucional. (1998). Ley De Derechos, Cultura y Organización Indígena, Decreto 140. Artículo 34. www.congresoqroo.gob.mx/leyes/cultural/ley019/L0819980731.pdf. Accessed 18 April 2007.
- www.hrea.org/lists/hr-education/markup/msg00421.html Accessed 18 April 2007.
For more information and links about homebirth, midwives, and natural childbirth options.
Benefits to the Midwifery Model of Care
MoonDragon's Articles Index
A Certified Nurse-Midwife (CNM) is a maternity and woman care practitioner that has obtained a nursing degree before proceeding towards a midwifery educational specialty.
Although there are a small minority of CNMs that practice homebirths, most are associated with free-standing or hospital-based birth centers and hospital maternity care. She may be a primary care giver with a physician on call or she may work directly under the physician in his practice.
The CNM is restricted by regulations formed by the nursing board and is required to work under the direction of a physician or medical group. However, many CNMs are attempting to move out from underneath these regulatory confines and become more independent in their scope of practices.
Generally speaking... The CNM-entry midwives may be more medically oriented in their approach to birth and may be more inclined to a standardized "medical management" of the pregnancy than the DEM midwives. They are more likely to prescribe medications, recommend and perform more interventive procedures as dictated by their licensing board, the governing physicians, and the medical protocols that they must work under.
Beware of Obstetric Practices Hiring Token Midwives
These dedicated women (and a few men) are highly needed in the modern, high-tech, institutionalized assembly line and interventive hospital settings. They are often the only liaison between the physician's interventions and the mother's desires to have a non-interventive birth experience for herself and her baby.
Many of the CNMs would love to have the freedom and ability to do homebirths along side of the DEMs but most of these are not wanting the legal and legislative harassments that many of the DEMs endure. While other CNMs are very content with being important caregivers in the institutionalized-clinical setting.
Physician practitioners may be an obstetrician/gynecologist or family physician (MD). Other types of physicians found attending births are Osteopathic (DO), Naturopathic (ND), Chiropractic (DC) and Homeopathic physicians. Although there are a few physicians who practice home births (many of these being alternative medical practitioners such as naturopaths or chiropractors), the majority are hospital-clinical based practices.
If your pregnancy appears to be a healthy, routine pregnancy then your options are open for selection of using midwife care with choices of home, birth-center or hospital settings depending upon your birth desires, or that of choosing a physician that will be able to work with your choices. However, if you are having problems and the pregnancy becomes considered "high-risk", then your options may be likely geared to the obstetrician or fetal medicine specialist.
Physicians, generally speaking, are usually geared to more interventive medical approaches to pregnancy, birth and care afterward. They are trained in pathology and surgery. This is what they know and how they practice. The rates of cesareans have risen to a national average of about 25-percent or higher and up to 60-percent in some teaching-based hospitals. Pregnancy and birth may be viewed as and considered to be a "medical problem" that needs to be "managed" by high-tech & interventive medical protocols (these protocols may not be evidence-based in practice, but might prove to be more ritual-based in their approaches and are extremely resistant to change). Pregnancy may not be viewed as something that is a natural function that women and babies were meant to experience together.
Physicians tend to spend much less time with their patients than midwives do with their clients (terms: "patient" refers to someone who is considered "sick" or "under medical care/supervision" while midwives usage of the term "client" refers to a healthy individual that hires the practitioner for the service of midwifery). Physicians are less likely to sufficiently address patient concerns or worries than midwives and are more likely to be "patronizing" toward their pregnant moms.
OTHER OPTIONS - THE PLANNED UNATTENDED OR UNASSISTED BIRTH
Another option open to birthing couples or mothers is a home or out-of-hospital birth that is "Unattended" or "unassisted" by a health care provider or midwife of any kind. Usually these are considered to be highly controversial and dangerous, but I have also seen many planned unattended births go very well without problems. I still highly recommend prenatal care by a midwife or other health care provider with an "Unattended or Unassisted Birth" choice.
CHOOSING THE TYPE OF PRACTITIONER THAT IS RIGHT FOR YOU
There are many options open to a pregnant woman and her partner. Seek out and meet with those who provide diverse types of care. Discuss your birth plans and what you want with them. See where they stand on certain issues and find out how flexible they are regarding your plans. If you have religious preferences, then seek out those providers that follow your paths of spiritual awareness or complement your beliefs. Birth is a physical, emotional, mental, spiritual, and psychological experience that can ultimately shape and reshape a woman's being and that of her baby.
Personality considerations should be just as important as qualifications when choosing a practitioner... maybe more so, depending upon what you feel is important to you. Find one that meshes with you and your personality as well as your plans. Do not be afraid to ask questions, be informed about what you want before hand and decide what "qualifications" are important to you and your needs.
(***For me, I would rather have someone "less medically qualified and experienced", but more in tune and open to me and my plans. I need to be able to discuss my desires and fears with the person I choose and I need to feel comfortable working with them. I do not want to have to argue or fight to have things my way. I am hiring them for a service. I am able to take full responsibility for my choices and decisions regarding my health care and my body and life... instead of handing these choices over to someone else to make for me. - MoonDragon Midwife, Mother of 5, Two of which were born at home.)
Remember.... You are "hiring" these people to take care of you. You have the perfect right to "fire" them as well. You have the right to choose what or what you do not want... and you can walk out and say "NO!!" to any procedure or situation that may be presented to you. Without a court order... there is nothing they can do to you without your consent and you can revoke your consent at any time, regardless of any waiver they may want or make you sign. If they proceed against your expressed will, than a lawsuit for "assault and battery" can be pursued in a court of law. Empowerment comes from within and is supported by the laws.
TYPE OF PRACTICES
There is only one midwife or physician in the practice or office. The office may be located in a commercial setting or may be located within the living-home-based residence of the midwife or physician. When the midwife or physician is away, a covering midwife or physician may be available to provides care of the clients or patients. There may be an assistant or an apprentice or other "helper" available to assist in record keeping and procedures.
The partnership or group practice has two or more midwives and/or physicians that work in the practice and/or office. They may be of the same specialty or a combination of two or more specialties. This latter is often found in an HMO (health maintenance organization).
This type of practitioner works out of a hospital setting with an office located within the institution. They are employees of that facility and must work within the confines of the protocols set up by that institution. As a rule, many of these types of practitioners do not have outside private practices or offices but practice more within the hospital clinical and research settings.
This may combine the services of a midwife and a physician, or a midwife as a primary care giver with a physician on call as needed.
| HomeBirth | Birth Center | Hospital |
HOME BIRTH DELIVERY
A home birth is sometimes the first choice of many women with a normal pregnancy and expecting a normal delivery. A midwife or physician may attend the birth or it may be a planned unattended birth, as chosen by the woman and her partner.
The advantage of a home birth location is that it is usually the most comfortable for the woman giving birth. She can pick and choose who she wants to attend her birth among family, friends, attendants, children and such. Instead of having to "rush off" to a birth center or hospital, she can stay where she is and her attendants come to her. She is able to change positions, move about, eat, sleep, and use comfort-relaxation methods more effectively in the home setting.
There is much less chance of infection within her own environment and more choices open to her in facilitating her birth plans. There are no chances of lost or swapped babies, much less chance of maternal or infant injury or death, and much less chance of unwanted invasive procedures since she is empowered in her own environment. She has the decision making power and she can express it at any time and be listened to by her attendants. The mother and her baby become the focal point of the experience and she has the full attention of all attendants at all times.
If there is a need for emergency assistance, either it is handled on the spot or arrangements are made in advance for emergency transfer to a hospital if it becomes necessary. Either way, the woman and her partner have the final decision-making right.
Disadvantage of a homebirth is that this is usually planned for healthy moms giving birth to healthy babies in a stable, loving and emotionally healthy environment. Sick or high risk pregnancies are highly discouraged from actively seeking a homebirth and are usually referred to "managed care" health care providers with access to high tech equipment and medical care in a hospital setting. This is an attempt to insure that there is the best possible outcome for these high risk situations.
Transporting Disadvantages of a At-Home Planned Birth:
Transporting during a labor or birth can be disrupting and uncomfortable for the mother and baby to say the least. Although EMS personnel (either basic, advanced or paramedic levels) are highly trained in emergency situations, they are usually much less experienced in emergency childbirth procedures than the average experienced birth attendant, but they are required to follow protocols that are set up by emergency physicians with procedures that may conflict with the birth attendant's procedures. Since they are working under the emergency physician's medical license, they are required to practice emergency care under very specific protocols, which the patient/client can refuse at any time. There may also be some ego conflicts that arise between the EMTs and birth attendants.
Sometimes tough decisions must be made by the birth attendant with the parents, and occasionally these can leave bitter feelings or create blame if decisions were not made in total agreement between involved parties.
Also, the receiving hospital may be less than welcoming in attitude, sometimes even openly hostile toward the birthing parents and their birth attendant(s) that accompany them to the emergency facility. This may actually create more problems with an already serious situation and can open up legal ramifications for the parties involved, depending upon the situations, laws and resulting outcomes. This can be a very real problem in areas where midwives and other birth attendants (physicians and nurse midwives included) are considered alegal or illegal by definition of law and an active pursuit of "harassment" or "witch hunting" exists.
However, the number of pregnancies requiring hospital intervention is only a small fraction (about 5 to 15 percent) of all pregnancies (this includes all the high risk pregnancies). It is estimated that approximately 90 to 95 percent of healthy women having healthy babies are able to have planned out-of-hospital (OOH) births with few, if any, transportable, unmanageable, life-threatening problems for themselves and for their babies after receiving adequate prenatal care and when attended by trained, experienced birth attendants of their choice.
BIRTHING - MATERNITY CENTER
The birthing center or maternity center may be a free-standing facility or located in a hospital. The focus is on a "home-like" environment with family and friends sharing the birth. Often one room is used for labor, delivery and recovery.
Sometimes there is total "rooming-in" with demand breastfeeding of the infant, sometimes not, depending upon the facility. It is important to check out specific institutional protocols. There is usually limited room-space... and sometimes the rooms are fully occupied and choices must be made as to transfer to a regular hospital care facility or to return home and complete the birth there.
There may be fewer choices in birth plan arrangements and stricter protocols regarding potential problems, making transport less of a choice for the parents and more of a responsibility of the institution. In an emergency situation, there are usually standing arrangements for transfer to a hospital setting.
Emergency Transporting For Out-of-Hospital Births (Home Birth and Free-Standing Birth Center):
Keep in mind!!... that even with the best equipped and staffed hospitals, if an emergency arises it still takes approximately 30 minutes to set up and prepare an operating / delivery room for an emergency birth and gather necessary personnel to do the procedures. This is regardless of if you are in the hospital already or in transit to a hospital. Once they have the delivery room set up and the patient in it, they can have the baby out within about 5 minutes. So a wise rule of thumb... if you are planning on transporting an emergency situation, call first and let them know so that they can be prepping for your arrival. Many of us do not live further than 30 minutes from a medical facility.
Also keep in mind that not all medical facilities are equipped to handle all types of emergencies. Small community hospitals may not have 24 hour on-staff people available or have the equipment that may be necessary for the required procedure. In this instance, transport may be necessary to a large urban medical center either by ambulance or med-flight arrangements.
If you need to call for medical transport, here is a listing of Emergency Medical Service (EMS) Protocols for our specific region in Massachusetts. These will explain exactly what the EMS can and cannot do while in transit to a medical facility.
HOSPITAL - MEDICAL CENTER
The hospital may or may not be a full care facility (public or private) that is equipped to handle all aspects of childbirth and any possible emergencies. Check out your hospital before you have to go there for care. Find out what they can and cannot provide. Many of the smaller community hospitals are no more equipped than many office practices or homebirth midwives (we seriously can carry a lot of supplies and equipment to a birth!).
Check to see if they have a 24 hour emergency surgical team on site for those emergencies that come in requiring immediate care. If they do not, they may not be able to put together a surgical team right away if you should need one. Also find out what situations they may "med-flight" out and where they send these cases to and the facility they are flying into.
Also ask about what their policies are before you check into the hospital. Ask about your care and options open to you. Ask about the various care providers that will be assisting you and what you should expect. Ask about what their protocols are for your various concerns, such as time restraints and monitoring devices as well as numerous other things.
It is always wise to have a birth plan set up and discussed with your health care provider or midwife prior to your birth. In emergency situations, your birth plan may not be followed or may have to be changed for the particular situation.
MoonDragon's Pregnancy Information: Birth Plans
MoonDragon's Pregnancy Information: Pregnancy Information & Survival Tips
MoonDragon's Pregnancy Index
MoonDragon's Womens Pregnancy Health Information Index
MoonDragon's Pediatric Information Index
MoonDragon's Parenting Information Index
MoonDragon's Nutrition Information Index
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RELATED MOONDRAGON HEALTH LINKS & INFORMATION
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