Friday, September 25, 2009

An excerpt from the original Apprentice Academics curriculum: Practice and Practicals

This is a short excerpt from a section on practical preparation.....copyrighted 1981 Apprentice Academics The Midwifery Home Study Course...a lot has changed...
Measure your finger, knuckle to knuckle.  Purchase or make a dilatation chart and practice checking dilation with your eyes closed.  Become familiar with the “feel” of the spread of your fingers at each centimeter. 

Buy or borrow a pelvis and practice pelvimetry.  Keep in mind that the real thing feels very different.

Practice labor mechanisms with a doll and pelvis.  Use a textbook and go through each mechanism fore every imaginable presentation and position.

Exercise your arms and fingers: lift weights; grip rubber balls; etc.  You will be amazed at how important this will be.

Practice good health habits and work on your own nutrition.  Midwifery puts a lot of demands on your body.

Attend every local function concerning birth and babies regardless of who is the sponsor.  Every class and every meeting will bring you in contact with information and contacts.

Become an expert in some related field.  This will benefit your family and your clients and it will make you a valuable resource for other practitioners.  You can never know too many people; the more contacts, the better!  Many of your future opportunities will come from the contacts you are making now!

Put yourself on every mailing list you can even if the topics seem peripheral now.  You may find a connection later. 

Organize public presentations of videos and speakers on birth related topics.  Use the public meeting rooms at your library or civic center. 

Sell birth related books you would endorse at information meetings or health fairs.  Contact the Special Sales office of the publishers for bulk discount information.

Submit book reviews for publication in magazines or newsletters.

Write a column for new parents or expecting parents for your local newspaper.  

Interview home birth couples or midwives for a “future” book! 

Recommended Reading: Empowering Mothers

Recommended Reading
Empowering Mothers
E Dawson, R Gauld and J Ridler say midwives need to abdicate control
Nursing RSA VERR{LEGING Vol 8 No 4 1993}

Ideally, lactation success depends on many factors: 
     A healthy mother with perfect nipples and a hungry eager baby; an informed supportive partner; an experienced, caring midwife with no time limits; clinic sisters and doctors knowledgeable in overcoming lactation problems; supportive, well-informed family and friends; how many of us know of this ideal situation?  What can and does go wrong?   Who can help?  Who has the time?  
     Over the last few years it’s been encouraging to see the increased awareness of the benefits of breast-feeding, but unfortunately breastfeeding practices and protocols have just not been kept up.   At a seminar on breastfeeding in Cape Town last year, 81% of the health professional present felt they did not have adequate know-ledge to help mothers breastfeed.  And a study by Professor Walter Loening and Jane Maasdorp of the University of Natal, found the level of knowledge among doctors and nurses of breastfeeding to be quite appalling!  
     While the need for the extensive education and training is obvious, let’s look at things from a different angle.  Let’s start by looking at these two statements: - 
* Breastfeeding is a confidence trick
* Breastfeeding is 95% psychological.  
95% of a mother’s ability to breastfeed is psychological – she must have confidence in herself. 
     In order to help a mother breastfeed, therefore, our first and major task is to instill confidence in the new mother.   How do we do this? 
     This depends on an understanding of cultural differences, lifestyle and background.  The assumption that all mothers are ill-formed about breastfeeding should not be made.  Some women accumulate a vast store of up-to-date knowledge during their pregnancy and all they need is lots of reassurance and encouragement.  
     She may or may not have planned her pregnancy, but in the majority of cases she has the desire to be a good mother to her child.  Respect her ability to make decisions that will affect herself, her baby and her family.  
     Communication skills are so important here.  Make use of such courses offered to you.  
     Breastfeeding is not usually a medical problem – it is a mothering concern.  A very emotive issue.  Sometimes health workers voice their own strong opinions, not facts.  Of course, we’re all entitled to our own opinions – so is the new mother.  Do her the courtesy of allowing her to make her own decisions and form her own opinions based on sound up-to-date facts.  It will do wonders for her self –esteem and confidence.  A new mother is smothered in other people’s opinions and receives much unsolicited advice from well-meaning friends and relatives.  The very best defense that she has to cope with is this confidence.  Confidence in her ability to nurture and nourish her baby and to meet his ever-changing needs.  
Give information and not advice. 
     This is not an easy thing to do initially.  What’s the difference between information and advice and why do we say this?   
     When we give advice we also send another unspoken message – a lack of confidence and trust in the woman.

We need to take a good 
look at our own attitudes.  
It is often painful to abdicate control.

Advice begins with phrases such as: - 
“You should…” 
“You ought to…” 
“You must…” 
“You should have…” 
     Even if the mother is open to receiving advice, the outcome is rarely positive.  The possible consequences are: 
~ If the mother follows the advice and is successful.  
   Result: She’s likely to become more dependent on the midwife rather than learning to trust herself and her baby. 
~ The mother follows the advice and fails.  
   Result: She has to face the consequences and the midwife loses credibility. 
~ The mother rejects the advice and is successful.  
   Result: She may also reject the midwife. 
~ The mother rejects the advice and fails. 
   Result: She may resent the midwife or elevate her, but feel diminished herself.  
     Giving information, on the other hand, implies trust.  The underlying assumption is that the other mother is capable of making her own choices.  Giving information, making suggestions, and presenting options conveys trust which is the basis of any helping situation.  Even though the midwife may have a greater wealth of knowledge and experience about breastfeeding, she needs to respect the mother’s ability to make her own decisions.  
Eg.  “How would you feel about…” 
“You might find that…” 
“Some babies seem to need…” 
“Recent research indicates…” 
     Discuss options and don’t forget to give positive strokes.  She is the expert on her baby as nobody will get to know her baby better than she will.  Tell her this.  The goal here is to empower the mother.  Give her facts she needs to make an informed decision and support her decision.  
     Explain to the mother how the breasts work - she will then be able to work many things out for herself. 
     Make the explanation simple without talking down to her.  Eg. You could explain that he breast is not like a bottle - it is not a container that is filled up and emptied.   
    Explain that what collects in the breast between feeds in the foremilk which is watery and quenches the baby’s thirst. Only once the milk ejection reflex has occurred in response to the baby’s suckling, does calorie-rich hind milk become available.  The breast is like a production site with the milk being made almost continuously – the quicker the product (i.e. the milk) is taken off the production line the quicker and more plentiful will be the production.  
     The majority of mothers today are breastfeeding when they leave the maternity unit, however, within a few weeks or sometimes even days, most of them switch to the bottle.  Why?  Insufficient milk supply, breast infections, embarrassment, fear of criticism from friends and relatives, and general confusion are some of the reasons given.  
     Women need to be prepared for the first few weeks.  With an understanding of what to expect during the first crucial weeks of adjustment it will be easier for her and many more women and their babies will enjoy the benefits of breastfeeding. 
     On leaving the hospital, new mother’s need to know a few important facts:  
     The golden rule of breastfeeding – the more the baby sucks, the more milk will be produced – a brief explanation of supply and demand.  
     Newborns need to be fed at least 10 to 12 times in 24 hours.  The stomach of a newborn is the size of a walnut and breast milk is digested in about an hour and a half.  
     A fussy time of day is normal for many babies – it’s not necessarily a sign that something is wrong.  
     At about 10 days many babies go through a growth spurt (and again at about 6 weeks and 3 months).  They appear to be hungry all the time and mothers begin to doubt their milk supply.  A day or so of feeding the baby more frequently will increase the milk supply very well. 

     An explanation of what to expect as regards to the baby’s stools is important – what they look like and the frequency – loose and frequent in the beginning, may change to only once a week later, etc.  
     Water and dummies are best avoided in the early weeks – they may cause nipple confusion and interference with the initiation and maintenance of the adequate milk supply.  
     Adjustment – The new mother should be encouraged to think of the first 6 to 12 weeks as an adjustment period – baby needs to be held close and fed often as he adapts to extra-uterine life and mom needs frequent breast stimulation to initiate and maintain a good milk supply.  The frequent close contact helps with bonding.  
     The mother needs to be cautioned about trying to be supermom. 
     Wet nappies – what goes in must come out!  In the exclusively breastfed baby, after the first 36 hours, 6 to 8 really wet nappies a day is a good and pretty reliable indication that the baby is getting enough.  
     Where to go for help - Remember that problems often arise after “clinic hours”.  Mothers need telephone numbers of  24-hour breastfeeding counselors.  
     This may sound all very nice and ideal – fine for a well-run, and well-staffed maternity unit.  But does it really take so much time?  A lot of patience is needed to help a mother breastfeed.  A lot of time is spent helping and encouraging her – it really doesn’t take too long to impart these few important points.  Or put them on a simple hand-out for each mother to take home with her.   

If we want to make each mother feel good about her mothering, and to feel in control, we need to take a good look at our own attitudes.
It is often painful to ab-dicate control.
So often a new mother is treated like a child herself and feels she has lost 
control of the situation.

Maureen Minchen, at her outspoken best, says, “If we don’t know what we are doing and why, then we shouldn’t be doing it.”  The sad fact is that some cases of lactation failure are iatrogenic.  Perhaps as important as all the technical information is the shaping of attitudes which give mothers their rightful place in child health strategies.  Protocols that truly support breastfeeding usually require breaking from tradition.  Such protocols include early first feeding at the breast, demand feeding at frequent intervals (at least 10 to 12 times in 24 hours), night feeding, rooming-in, and a knowledgeable, and supportive nursing staff.  Optimal newborn care is increasingly recognized as that in which the parents provide all the care for their newborn with minimal supervision.  This move to a patient-directed experience requires often painful abdication of control and is hindered by the subtle competition among adults for the care of an attractive newborn.  
     We are in a helping profession.  We want to help.  But sometimes we hinder.  Mother nature can manage with very little help most of the time.  Research by a Swedish pediatrician, Dr. Lennard Righard, showed that healthy newborn babies left with their mother for more than an hour before any procedures were undertaken, found their way to the breast and started nursing correctly for 20 minutes after birth.  The key to the matter lies in our attitudes to the newborn and his mother.  
     Now that sound, research-based information is readily available, the professional ignorance which may have been acceptable in the past is no longer acceptable.  
     We need to have extensive education and training in the art of breastfeeding, knowledge and skills in the techniques of breastfeeding, and an understanding of the psychological growth essential to a woman’s gaining confidence in her ability to mother her own infant.  

(References on file) 

This  is required reading for Ancient Art Midiwfery Institute’s Advanced Midwifery Studies.
There is so much food for thought here when preparing to be an authentic “with woman” midwife.

Wednesday, September 23, 2009

FOLKS DO GET BORN by Marie Campbell

This Post Test is Copyrighted Ancient Art Midwifery Institute 1995.  
 Part of the AMS curriculum options.
  If you complete it and send it to us we will send you an issue of Historically Significant free.

by Marie Campbell
Folks Do Get Born, copyright 1946.  It is hard to find, but worth it!  I found mine on Ebay for around $50 but may be much higher at times.

1. What is a “gift child” mentioned in this book and who had them?
2. What did Martha mean when she said she germinated someone?
3. What did midwives mean by saying, “I caught babies by the Old Law”?
4. What effect would it appear to have had on the number of granny midwives practicing in Georgia after the State Board of Heath assumed responsibility for supervising and licensing midwives in 1925?
5. Mam Bob said grannies will some day be:
a) respected as they should have been   
b) written up in the history books 
c) a nigh gone thing
6. Why did Liddie Ruth Duffy want Roger Dell’s hat?
7. A midwife without a “Lison Blank” is without:
a. a blank birth certificate   
b. an application to practice midwifery in Georgia   
c. a midwife certificate
8. How did Aunt Lovetta come to have a story she referred to as a Wild West Show?
9.  “Maybe you calls it bleeding at the cord…, We calls it umbilical hemorrhage.”  Who said it and to whom?
10. Tea of black haw roots was believed to prevent miscarriage.  Who talks about tricking women by telling women to take it thinking that it will do the opposite?
11. In her prayer, what did Aunt Jennie ask the Lord not to forget in his hurry?
12. The warmer was the source of some righteous indignation from Molly Baker, whose mother had been a granny midwife before the warmer came on the scene.  Who did she specifically mention as having been saved by her mother in this circumstance without the modern convenience of the warmer?
13. When Mary Belle performed her play of her attending a homebirth, what did she say should be done to the cord and was that Old Law or New?
14. What were her last words to her patient?
15. Sister Mandy was also known as:
a. The Bringer
b. Ma Mandy
c. both 
©Copyright Ancient Art Midwifery Institute 1995

High Tech Midwifery I wrote for Midwifery Today I think in their first year

For you youngsters:  This contains some "dated" terminology.  We started in 1981 as Apprentice Academics.  This opinion piece was written several years after we started but long before we became Ancient Art Midwifery Institute.  You can see I have been concerned about ultrasound for a long time.  I have become even MORE hands-off in my philosophy since then.

High Tech Midwifery 
by Carla Hartley

My work with Apprentice Academics brings me in touch with hundreds of midwives every year.  I am in a unique position to notice trends among midwives.  Over the past year I have observed a trend that is scaring me – more and more midwives are becoming “HIGH TECH”.  In the last few months I have talked with three beginning midwives who had never used a fetoscope in their training – only Dopplers.  I  know midwives who are “ordering” sonograms on a somewhat regular basis.  
Are midwives embracing technology out of a lack of knowledge of intrinsic dangers and potential risks?  Maybe it is a desire to do more in less time (which we can all identify with) but it should set off a warning bell somewhere in our subconscious that we have gotten off track.  There  is also the possibility that midwives lack confidence in their own diagnostic ability.  I am afraid, however, that the underlying reason could have a great deal to do with our desire to work with, and to be accepted by, the medical community.  In our attempts to seem less radical, less judgmental, and more cooperative, are midwives being seduced by technology?  It is not a desire to learn technical and medical information, or a wide variety of skills and services offered that makes a midwife a “Jr. OB” – it is a reliance on technology.  

I asked a large number of parents why they had chosen home birth with a midwife rather than a physician attended hospital birth.  The most frequent answers were: level of caring, amount of time spent together, lack of gadgets and machines.  I like those distinctions.  Rather than three unrelated comments, I see a definite relationship between them  I would like to see all three distinction preserved; compromising one may eventually compromise all.  Any unwarranted use of technology carries with it the risk of detachment from the client… and ultimately from the art.  The French doctor who invented the first stethoscope, Rene Laennec, is credited by the authors of Medicine on Trial, with the simultaneous creation of a separation of doctor and client – a symbolic act of distancing one’s self from the client that has become woven into medicine.  Midwives, on the other hand, have practiced in the opposite manner.  We attempt to draw closer to our clients during the relationship because we know it enhances the safety and because it is our way.  My fear is that as we use our hands and ears less, we will also use our hearts and minds less.  We will create a separation and will be at risk of losing something that is uniquely ours… that which defines a midwife as    
“with woman”.

Living what you believe! (From old ACCESS)

One's philosophy is not best  expressed in words;                                        
it is expressed in the choices one makes.                                                                          
In the long run, we shape our lives and we shape ourselves.  
The process never ends until we die.                                                                             
And, the choices we make  are ultimately                                                 
our own  responsibility.
Eleanor Roosevelt

In other words: LIVING WHAT WE BELIEVE!  My stand on midwifery and midwifery education and birth in general has cost me a lot. Being different has meant far less income than I could have had if I had just gone along with the majority.  But since I BELIEVE different things, I have to DO things differently. The way I see it, NOT STANDING on principle and not living what I believe would cost something far more valuable.

Study Assist: Communication

We are constantly trying to influence someone about something. When we are attempting to influence, we need to be careful about the words we choose. Our listeners are only going to give us a short amount of time for us to make our point, so each word, each phrase, needs to bring our listener closer to our point of view.  Make a list of the words you normally when you talk about birth .  Are you choosing the BEST words out of those to make your point with the fewest words in the shortest amount of time?

Be sure your message is clear and easily understood. Some words give conflicting messages. The two I am thinking of now are “but” and “however”  They cause the listener to do a mental “double take.”  We immediately start to feel defensive and can’t help but stop listening long enough to wonder what’s next?  “But” and “however” immediately negate whatever preceded them. “I love you but…..”  “You did a good job but……” You probably did the best you could, however…”

I am immediately apprehensive when I hear a “but” or a “however.”  Those words cause a negative gut reaction and set the emotional stage for defense.  They also fail to accomplish the goal.  Feedback, correction, or suggestions are better dealt with after an “and” than a “but” or “however”.  You know it is true with your children; it is equally true for adult conversation.

To be effective communicators we need to ask ourselves, “what does the first part have to do with the second?”   While we correct our children because we love them,  that should be a given.  There is no reason to  remind the child we love them before we address behavior that needs changed.   We should never give our children the idea that our love for them is conditional.
When critiquing a student’s academic effort or an employee’s performance, there is no need to add a personal component to the issue.  Address the feedback as the separate issue that it is, and in a way that needs no attempt at or need for buffering.  

Try to eliminate “but” and “however” from your conversation altogether for just one day.  It is harder than you might think.  I have had to erase both of those words two or three times from this little post.

Tuesday, September 22, 2009

The Aim of Authentic Education

The aim of (*authentic) education
is the knowledge not of facts
but of values.
William Ralph Inge
* with addendum by Carla Hartley

Something to think about on the Licensing Issue.

We must be careful not to let our current appetites steal away
any chance we might have for a future feast. Jim Rohn
"The establishment of medicine as a profession, requiring university
training, made it easy to bar women legally from practice. With few
exceptions, the universities were closed to women (even to upper class
women who could afford them) and licensing laws were established to
prohibit all but university-trained doctors from practice. It was
impossible to enforce licensing laws consistently since there was only a
handful of university-trained doctors compared to a mass of lay healers.
But the laws could be used selectively. Their first target was not the
peasant healer, but the better off, literate woman healer who competed
for the same urban clientele as that of the university-trained doctors.
...In the witch-hunts, the Church explicitly legitimized the doctors'
professionalism, denouncing non-professional healing as equivalent to
heresy: "If a woman dare to cure without having studied she is a witch
and must die." (Of course, there wasn't any way for a woman to study.)
Finally, the witch craze provided a handy excuse for the doctor's
failings in everyday practice: Anything he couldn't cure was obviously
the result of sorcery."
-Witches, Midwives and Nurses: A History of Women Healers
by Barbara Eherenreich and Deidre English


"It is your work in life that is the ultimate seduction."—Pablo Picasso
Be careful......I know this to be especially true about what we do.....It is so easy to become so passionate about birth and helping families that we often put our own families on the back burner....... Carla

Monday, September 21, 2009

AAMI is Fundamentally Dedicated to....

Ancient Art Midwifery Institute is fundamentally dedicated to the promotion of midwifery as more than a contemporary profession.  Midwifery really is an ancient art and we can't forget that there were smart, caring women who came before us.  Our generation did not invent this profession and if we don't mess it up,  it will continue to exist long after we are gone.
When my days are done, I want to be known as someone who did what she could to hold the door open for the next generation of smart caring women who practice the ancient art of touching the future. 

We could learn a thing or two from geese!

When flying in a "V" formation, the geese in front create an updraft for the ones behind them. This increases an individual bird's range by 71%.  When the lead goose tires, he drops back in the formation and another goose fills in.  While flying in formation, the geese in the rear honk encouragement to those leading the flock.  When a goose gets sick or tired, two geese stay behind with the sick one to protect it. They don't leave until it can fly again or dies.  
(Source: "40 Tools for Cross-Functional Teams" by Walter J. Michalski)

I decided not to supply my original "editorial" for this one.  By now, you probably know what I took away from this little blurb!  Carla

Class Notes, an AMS publication/Think you CAN!

Whether you think you can or think you can't, you're right. 

-Henry Ford, 1863-1947, American Industrialist, Founder of Ford Motor

I just want to get this into every fiber of your being.... You will not accomplish much if you are constantly telling yourself that you can’t....I throw a lot of this stuff at you repeatedly because if you ever make it a part of your “picture” of yourself it will work.  I promise.  I am not asking you to be delusional and imagine yourself in a perfect world with superhuman abilities.....picture yourself as busy, too busy even......but also picture yourself doing an incredible amount of stuff toward your goals in little bits and pieces.....if there are excuses in your picture....take them out.....if there is frustration....look for some ways to reduce it....just keep plugging away little pieces here and there and make a plan to get bigger hunks of time for your projects....don’t just think it will drop out of the sky....

My suggestion for this week is that you write this on every mirror and put it on your fridge and your calendar and your bulletin board....embroider it on your pillowcases if you have to. Consider it a GOLDEN rule!

Do not let what you CANNOT do interfere with what you CAN do. 

From Class Notes, An AMS publication/The $550 Paper Jam

The $550 Paper Jam

I was on a very tight deadline.  I had to get on a plane in less than 48 hours and had 5 System Works, curriculum binders to print and collate.  My printer had a bad habit of jamming if I didn’t load the paper in a certain way but it was so time-consuming to do that.  I was multi-tasking like a tornado getting ready for this trip.  I was working so hard that I was in a cold sweat.  I had just loaded the printer with $50 in ink cartridges and a fresh stack of paper and pushed print,  when I heard the undeniable sound of disaster.  My printer was grinding paper up like a garbage disposal.  “I don’t have time for this!” I screamed at the moaning, screeching  hunk of junk. I hate gadgets.  If it has a cord, chances are I have issues with it.  (Anyone who has seen Office Space can guess what my favorite scene is!)  I worked for more than two hours trying to extricate the wad of paper that the printer had basically shredded but even with tweezers I could not get it all out.

So on to plan B.  Ray rushed to Comp USA and bought a new printer.  We wanted the exact same printer so we could use all these ink cartridges on the shelf and not have to load new software.  However since it had been purchased more than 10 minutes (well a year ago) that printer was obsolete. We had to buy the next latest and greatest but the same brand thinking that would help us in some way.  I cheered up a bit when Ray called to tell me he was rushing home with the new printer.  I figured if I did not go to bed at all before my trip, I could still finish.  I was bitter about the loss of time trying to do surgery on that cranky printer, but there was still hope. 

Ray got home with the new printer.  We installed the software and the printer wouldn’t work.  We could not figure out why.  We spent more than two hours trying to make it work. I believe that if I had money for a live in maid I would opt for a live in computer geek instead!  Ray and I together don’t possess one brain when it comes to computers.

My dutiful, but not easily defeated, husband packed the printer and rushed it back to the store.  There he learned that the problem was that our system did not have enough memory for the new printer.  They could add memory and I could pick the computer up in the morning. But time was short.  

My instructions were to unplug the computer and meet Ray with it at the street and he just might have time to get it back to the store before they closed at 9 pm.  Just a few minutes before nine Ray sped our ailing computer to the computer hospital, otherwise known as Comp USA, as if his life depended on it.  

His instructions were to offer double the normal fee if they could have it ready by 10 am the next morning.

He did. They did.  I paid.  I rushed the computer back home, installed the software, plugged in the printer and literally finished the last System Works twenty minutes before I had to leave for the airport.  After I had boarded my flight I  did the math.  That paper jam had cost more than $550 for the new printer and new cartridges and  installing  more memory.

So there is my story about the most expensive paper jam in history.  It is not all that interesting, really....but it was oh, so frustrating.  And all because I did not take the time to load the paper the time-consuming, but nevertheless, correct way.

If you are skipping steps, not following directions, and not taking the time to do this job right, your time is coming.  You may not experience a $550 paper jam,  but the course will not go as smoothly as it would if you took your time and did it right in the first place.  L cph

From Class Notes, an AMS publication/Carla, the Groupie

Carla,the Groupie

I am always thinking about how I can help aspiring midwives on their journey.  The more steps you take away from the starting gate the less you remember what it felt like I try to remember what I told my students in the early days because that was what I valued in my own journey.  

One of the hardest but most valuable lessons I learned was that the midwives I idolized could be wrong and I had to think for myself.  I will give you some examples of how flawed my thinking was.

1)  When I started  training to become a CCE I attended some midwifery meetings and workshops.  Even tho at that point I did not want to BE a midwife,  I saw that I did not own the proper midwife  uniform and ran out and bought twirly skirts and bandanas for my hair. 
I am NOT a twirly skirt person, but I thought I had to become one.  And me in a there is a picture! Some people look great in a bandana but unfortunately I am not one of them.  I looked like I 
was having a bad hair day, every day... or a cold onion.
2) While I was training to become a CCE I came to know a 
California midwife very well.  If she said it, I believed it.  didn't look it up.  That was good enough for me............even when in my own studies I ran across proof that she was saying things that 
were just not true, I did not want to accept it.  I loved her and it seemed disloyal to disagree with her on any level, much less admit that she didn't know as much as she tried to make people think.  Later, one of my preceptors would ask me a question and then ask why I believed in my answer.  If I gave the midwife's in "that is what _______thinks." she would ask, but what do YOU think?

3) One might assume that would have gotten me off that groupie track, but it didn't. After I started my own practice, I would come home from every birth and call a well-known, actually famous at the time for having been arrested, midwife and ask her point by 
point how I handled things.  She had spent a couple weeks with my family and I completely trusted and adored her.  
I will never forget how after one of those conversations, my husband asked me how long it was going to be before I trusted myself at a birth.  
"You know", he said, "at some point it will hit you that________is not at the birth,  but you are.  So you have to feel like YOU know enough to be there alone or quit." It hit me like a ton of bricks.  
He was right.  There is nothing wrong with getting a second opinion from another practitioner during or after a birth.....but I had to stop trying to get a report card.

Learning to think for myself and believe in my own research  was such a fresh issue for me that it was the motivation for many of the assignments and procedures I wrote into the curriculum. 
That is why a big emphasis for us is to stress that you need to know WHY as well as what!

Friday, September 18, 2009

A sample of what is to come on the topic of licensing, pushing and the future of midwifery

It is NOT about midwifery.  Well, it can be if that is what you really want, but that is just a temporary fix.  PLEASE look further down the road. The real solution is to acknowledge a parent's right to choose to birth with anyone or no one.  That acknowledgement that parents' own their births — and not the state, nor the medical or midwifery community, is inclusive of the fact that birth is SAFE.  In fact, predicated on that truth. We are living proof that surviving birth is not dependent on the credentials of a birth attendant. If we don't tell the truth about birth, who will?  All the objections to midwifery and all the objections to home birth are based on a lie.  That is what we have to correct and licensing midwives does not fix that misconception.  That is why my intention is to keep telling the truth about BIRTH, to one mother at a time, with the confidence that once the mothers know the truth, they will take birth back!
- Carla Hartley

Wanna be a midwife.... but haven't really gotten started?

Shortage of money, family responsibilities, the lack of time etc etc are real concerns but they are only obstacles because we take the path of least resistance and we use them as figure out why you are using excuses not to start.  You can't finish what you don't begin.

maybe you should ask yourself this question...........
If I have not begun, do I really, really want to do this?
Maybe you should join us for a Midwifery Exploration session....

Can't Say you weren't warned: Malpractice Ins for Midwives

This RANT was first written sometime in 2000 and tweaked in 2003...revised a bit recently
© Carla Hartley 2009

I can think of few ideas that pose more potential harm to authentic midwifery and the average family's access to authentic midwifery care than malpractice insurance for midwives.  (I will be writing about some of the other "ideas" soon!)

The implication of midwives needing MAL practice insurance is incompatible with what a midwife does, in my opinion.

When the topic came up, as it did once in a while when I was in practice, I explained it this way:  "I won't be doing anything to be sued for. I won't manage your birth or do anything you don't approve of, instruct me to do, or sign off on.  You own your birth.  You are responsible for everything that is done by me or anyone else at your birth and you should not have anyone at your birth who you feel any reservation about."
Then I gave them my early version of my "server not saver" speech.  I ended by saying  that I would not be comfortable with them as a client if they were even thinking I might "mess something up" with their birth.  Anytime I sensed even the slightest hesitation from any potential client, I would ask them to call me back after they had interviewed two other midwives and asked them the same questions.  If people are asking about malpractice insurance it is a bad sign that they don't have a clear picture of who does what and who owns what in a home birth.

Malpractice Insurance for docs is PROVEN to be bad for mothers and babies. It eliminates choices. The reason that women in many places cannot get a VBAC in the hospital is because the malpractice insurance providers decided that any doc who does VBACs will have their insurance coverage revoked...nice way to decide what choices people have. In my opinion, Malpractice Insurance for midwives is even worse!

Once you have malpractice insurance you have created four monsters....

#1 The insurance company owns you! now the malpractice insurance company determines parameters of practice....not the midwife and for sure not the mothers....Insurance companies are in business for one thing and one thing only....AMASSING WEALTH....  not just money....WEALTH. They are NOT in the business of caring about anyone...They are not in the business of doing what is right.  They are in the business of amassing wealth and they are quite good at it.  They make lots and lots of money and they do not like paying out and if they do pay out they make it up by raising premiums AND eliminating coverage for any practice that has initiated a judgment. As soon as they have a few midwives sued for any one thing....that one thing will no longer be covered and the midwife will no longer be covered unless she pays a fortune....and only then...'til the next suit and then she has to find another insurance company.  So how authentic can midwifery care be if it is determined by insurance companies?
So, what are women going to do who want a vbac but the midwife they have hired is suddenly in jeopardy of losing her malpractice insurance if she assists in the vbac?  Or the mom of 5 who wants a midwife attended homebirth but the malpractice insurance cut off is 3 previous births?  Or the mom with a breech baby and a midwife who is well known for assisting breeches but  now that she has malpractice insurance she can't take breeches anymore.  Do you want to look her in the eye and tell her you made a choice that excluded her from your practice........  To tell her you would like to use your well earned skills to help her have her baby at home safely rather than face the sure verdict of a surgical birth but now you can't?

And the second monster:

Malpractice insurance
invites litigation.  We are a very litigious society and most people just don't understand who they are hurting when they sue.  I had a job where I had to interview many patients of a doc who was conducting a survey on a bladder repair surgical procedure involving a little plastic anchor that he was trying to get approved by the FDA.  I had to interview all the patients who had that procedure including women who had sued him. Only a couple of the former patients who were disgruntled sincerely believed that the procedure was a failure due to any incompetence, yet several had sued. Most of them LOVED Dr. M and  told me that they did not want to sue, but they needed money to pay the hospital bill and it was only the insurance company they were going after....not Dr. M.  I was not at liberty to tell them otherwise, but boy I wanted to correct that misconception. Some sued him because they felt like he did not care enough about them personally, so it was their revenge. (This will happen to midwives, too, believe me!) 

Some were just disappointed in the results, but knowing Dr. M, I am SURE he told them it was an experimental surgery in addition to all the paper work he had them sign stating that as well.  But regardless of what you outline as your limitations and regardless of what you have people sign, they still  sue.  Most people see no harm in suing someone who has insurance.  Read that again.  They do not think they are hurting YOU...and think that is why you have insurance anyway....wouldn't want you to pay those premiums for nothing, eh?

Eventually this doctor's malpractice insurance was so outrageous he had to leave the country and go practice in Europe where his malpractice was not so high.  He was not a perfect doc but he thought women should see midwives...FIRST.... and only transfer to hospital CNMs if there was a problem...(he thought most women did not need OBs)  He was head of obstetrics at a huge Houston hospital , but his mother was a midwife in Italy and he loved midwives.

I attended several dinner parties at his house. Cooking was his way of unwinding.  Many times there were other OBs there as well.  He often told me that he actually invited them because he thought they could learn a thing or two from me. They did not share his enthusiasm for midwifery but since they wanted to stay in good graces with Dr M because they wanted to be invited back for dinner, there really did not criticize midwives or home birth in my presence.  However, they all felt they had some advice I could use.  What they got fired up about was the admonition that midwives should never ever ever get malpractice insurance or they would find themselves out of a job.  They talked for hours about how malpractice limited their options to really serve patients as individuals and that the spiraling costs meant that they had to work longer hours and make less money and they resented that.  What they resented more than anything was that insurance companies were, in effect, creating medical protocol. More than one of those docs eventually quit medicine.and they have all told me that one thing was to blame.....malpractice insurance.

Which leads to the
3rd monster....not only do you need more money to survive in your business BUT you exclude more people who need you.....since malpractice insurance is pricey, can a midwife hold her fees down to something the average family can afford?  All families don't have insurance....or want insurance....some just want to pay their own way when it comes to home birth....but if the local midwife has to double what she charged last year because this year she has to pay malpractice insurance......where will it end? Midwives are getting in bed with this monster so they can get what?  Usually third party reimbursement....which is a whole 'nother rant. And then there is the common practice of charging insured clients one thing and non-insured another.  This is another rant for another time, too.

There is a
fourth monster which will only be relevant until malpractice insurance is required for ALL midwives.....the inevitable hierarchy that develops and the class war of sorts between those midwives who have it and those who don't....just like credentials....believe it or not, licensed midwives are NOT, on that distinction, BETTER midwives....but, understandably, if they have it, they feature it in their advertising.   Once midwife A carries malpractice insurance and features that in her advertising, the assumption will be made that she is the better midwife, so even more division is likely between the two midwives.  And, the general public will make the assumption that the fact that one carries insurance and another doesn't is a measure of competence, and we all know it is not. 

Let me sum it up this way: Midwifery Malpractice Insurance is just one more way that the wolf wears sheep's clothing.  Midwifery malpractice insurance could deliver a fatal blow to affordable AUTHENTIC midwifery care and that would not be good for midwives, or for the families they serve.
©Carla Hartley 2009