Sunday, April 10, 2011

What You Didn’t Know About Direct-Entry Midwives

I’ve decided that one of my favorite things is attending the Baby Fair and the Women’s Fair that Mat-Su Regional annually hosts. It gives us the opportunity to see the community, for them to see us, and most importantly, affords us the opportunity to share information about us, our practice, and our beliefs for birth and care. And believe me- I will talk to anyone who will listen! As I stood there this past Saturday, dolling out Sleeping Lady Women’s Health Care totes and water bottles, one of the other doctors (who I had yet to have the opportunity to meet) approached me and very nicely introduced themself. A very nice gesture, yes, but it would inevitably be a very interesting, if not slightly disappointing, conversation. This doctor knew me only as “Tara, Dr. Elrod’s wife.” Not, “Tara, the Childbirth Educator, Doula, and Apprentice Midwife.” They were seemingly completely unaware of the latter.

What was so interesting? We got to talking about the politics of the practice and the issues we have faced regarding call-coverage. It is no secret- Glen has now been on call steadily and alone since January 1st. The other Obstetricians of the valley sent him the now well-known, Facebook-publicized letter, which cited issues with malpractice insurance regarding sharing call with a physician who had a “relationship” with Direct-Entry Midwives. The doctor I was conversing with went on to express their disapproval that those “lay-midwives” could think they could actually have the knowledge to deliver babies- afterall, it took this doctor years of medical school and residency to be able to do this! How could these “lay-midwives” possibly have adequate training, know what they’re doing, and do it safely OUT-OF-HOSPITAL? It seemed to be almost incomprehensible, and nothing short of negligent.

As this conversation carried on, it was reaffirmed to me that the issue with the disapproval, distaste, and fear associated with midwives and Out-Of-Hospital birth is stemmed from the simple unknown, lack of knowledge, lack of understanding, and sheer misunderstanding…all of which lead to complete misperceptions. My mind drifted to Dr. Marsden Wagner in one of my favorite scenes of “The Business of Being Born”- Home birth is like the far-away land that most doctors know nothing about…they have never been and are too afraid to go!

So let’s ask the same question that this physician argued- How CAN a Direct-Entry Midwife provide the same care and carry the same responsibility as a doctor who had to go through years of formal education and training? It is a very valid thought process and question, afterall. How can they have the knowledge and skill and NOT be negligent? The answer is, as my answer was to this doctor- it is not the same.

It is not the same- not the same care, and not the same population being cared for. Perhaps it would benefit many people to know that the reality is, only a small population of women can be legitimately and safely cared for by a Direct-Entry Midwife. Most women risk-out of care before they even walk through the door! Here in Alaska, CDM’s/CPM’s are licensed and governed by the state and there are strict laws as to who a Direct-Entry Midwife can provide care to, along with a risk assessment that pretty much spells it out. These regulations also state what a Direct-Entry Midwife can and cannot do. So who CAN a Direct-Entry Midwife care for here in Alaska (notice I say Direct-Entry Midwife, not ‘Lay-Midwife?’ Ugh.)? Can they take care of someone with a prior C-section (or any uterine surgery for that matter)? No. Can they care for someone with Chronic Hypertension? No. Congenital Heart Defects? No. Seizure disorder? No. Platelets less than 90,000? No. Pregnancy Induced Hypertension? No. Preclampsia? No. Diabetes or Gestational Diabetes? No. What about multiple gestation? No. How about non-vertex (Breech) deliveries- are they permitted to do those? No. In case my point was lost- In the state of Alaska, per the CDM regulations, moms under the care of a Direct-Entry Midwife can have NO serious illnesses, NO serious psychiatric disorders, and NO serious complications. Simply said, they have to be completely ‘normal,’ completely healthy, with a singleton pregnancy, and deliver between 37 and 42 weeks of pregnancy (with baby in the vertex, head down position). If mom was otherwise ‘normal’ and healthy and went into labor at 36 weeks and 6 days pregnant, could she deliver Out-Of-Hospital with a CDM/CPM? Absolutely not. Even one day shy of 37 weeks makes all the difference.

My point to this doctor and my point to anyone who questions the safety of midwifery care and Out-Of-Hospital birth- care provided is so limited and to such a limited population SO THAT it is kept safe. If there was a better understanding of these regulations, rather than the assumption that care could be provided for anyone, I think the perception would be much different. Additionally- midwives are NRP trained, carry the same medicines that are available at the hospital to combat postpartum hemorrhage, and have oxygen on-hand. These so-called “lay-midwives” do not simply show up to a birth, hardly trained, unlicensed, and on the wings of a prayer to Lord Jesus that everything will just "be OK!”

At the end of the day, Out-Of-Hospital birth is safe. Very safe. BUT, in the right population and with licensed providers. It might also be argued that for a normal, healthy woman, with a normal, healthy pregnancy, the risk is greater IN the hospital- where she is susceptible to lack of support, restricted mobility, restricted nutrients, and the cascade of interventions. Which is more risky? Does a 32% c-section rate say something for normalcy and ‘safety?’

Just a thought.


  1. I can't believe anyone would walk up to you, you of all people, and start running their mouth about out of hospital birth safety issues! What a total dumbass! How did you not rip their head off?? I am impressed you kept your composure and poise! I might not have been so cool under pressure!

  2. Jenn- I wasn't offended because it really wasn't meant in an offensive way. I actually really like this provider and enjoyed getting the opportunity to listen to their perceptions of the topic. Their downfall was just their lack of understanding about midwifery care and Out-Of-Hospital birth...something that this provider is not alone with. Most of the negative views stem from just not being fully informed about it. I clarified what I could, and ultimately, I'm hopeful that the information will be taken into consideration.

  3. I enjoyed Your post. I used a midwife in Utah for my last 3 babies. The options that were available to us wouldn't have happened unless our very qualified midwife was very educated. I'm so grateful for our midwife and for the successful births we've had. Thank you again.

  4. Very impressive Tara. You seem like a great person as well as a great health care provider!! I wish I had known you over in Lakenheath, but I think we moved before your time there. Anyway, I always enjoy keeping up with you and Glen on FB.

  5. Are the rules different for a midwife who only works in a hospital? I ask because, back in 2003, a midwife was at the birth of my son who was born at 36 weeks, to the day, and I had several of the complications you mentioned plus quite a few more. If it makes a difference, this was on Elmendorf.

  6. Yes,it does make a difference. There are Certified Nurse Midwives (CNM's) and Certified Direct-Entry Midwives/Certified Professional Midwives (CDM's/CPM's). CNM's are Registered Nurses first, who then go on for advanced training in graduate school. CDM's/CPM's are not Registered Nurses first, and begin their training directly with midwifery training. It is a combination of curriculum, as well as an "apprenticeship" (i.e. hands-on, 'clinical' training). The main difference is the education background and the differences that may come with such (i.e. CDM/CPM's are not trained under the Medical Model of Care).

    Further, CNM's can care for higher-risk women and can obtain hospital privileges (as well as do birth center and home birth), while CDM/CPM's can not (nor do they want to...) do deliveries in a hospital. It is only birth center and home birth, in low-risk, healthy women.

    Hope that helps!

  7. Thanks for the info, Tara! With my last pregnancy, I couldn't even get a CNM to see me and I never really knew there was a difference, not even after Doula training, lol.

  8. Good post but I disagree with your comment that MOST women risk out before they ever walk through the door.

    According to Marsden Wagner, MD "There is not a single report in the scientific literature that shows obstetricians to be safer than midwives for low-risk or normal pregnancy and birth. So if you are among the more than 75 percent of all women with a normal pregnancy, the safest birth attendant for you is not a doctor but a midwife."

    The regulations governing the way CDM's practice in Alaska does exclude a lot of women but some of those women are not necessarily high-risk and should be allowed to make a fully informed choice to have a midwife attended out-of-hospital birth.

  9. Love the post glad to see the rules in place should protect both the mother/baby but also the midewife. From being put in a positions that could be dangerous or outside the scope of care!