The Midwifery Path
Should I pursue the direct-entry/homebirth path or the CNM/hospital birth path?
There are ways to become a nurse-midwife without having to work as a nurse and
kowtow to doctors. Some BSN/MSN programs accept students for their nursing degree
at the bachelor's and the master's level from the beginning, so you start as a
nursing student and move directly into the master's program and graduate being
able to sit for your boards. The University of Pennsylvania is one such program
and I know there are others. In addition, it is possible to get your nursing degree
and get accepted into a master's of nursing program without ever having to work
as nurse. The caveat is that these programs often want you to spend some time
working with a labor and delivery nurse because it is perceived that the culture
of birth in the hospital is an important part of the learning experience.
Going to nursing school to become a midwife did *not* indoctrinate me into the
medical model. It gave me a healthy understanding of the system and a big reminder
that the work I want to do as a midwife is very important. I actually work labor
and delivery while I am in school for midwifery, and I love it, because I am supporting
my families in ways they wouldn't receive in most hospitals with many nurses.
You would be surprised, however, at some hospitals and the approaches they take
toward childbirth--some are very progressive. Try checking out "Planetree"
hospitals; it's a philosophy I'm sold on if I ever have to be in a hospital.
- Melissa R.
I am not a midwife yet; I'm a doula and aspiring/struggling midwife. I entered
one of the three-year CNM programs for nonnurses and left before completing it
mostly for financial reasons, but also because I felt those three years would
be better spent studying midwifery rather than nursing. I strongly believe that
midwifery has an authentic body of knowledge and does not need to "justify"
itself to anyone. On the other hand, I also feel called to spread the word about
midwifery through research and teaching. My solution/goal is to become a licensed
midwife and also pursue an advanced degree in public health or a related area.
If those with an academic bent only follow the CNM route, then I believe the scientific
establishment will continue to disregard and disrespect us, mostly out of ignorance.
I think that direct-entry midwives must challenge the system from within as well
as from without.
I also had no desire to become an RN, but I did want to be a midwife. I chose
to go the route of a CNM and I'm glad I did. The program I chose, the Institute
of Midwifery, Women & Health (Pennsylvania) I could complete from home and
a bachelor's degree of any discipline is accepted. A BSN is not required.
Being an RN on an OB floor gave me a lot of experience. Lest you think it makes
me a "medwife," you are wrong. Perhaps it helped that I had been a childbirth
educator with an independent group for 10 years before I went to nursing school
that gave me my base/belief: birth is normal and natural. On the OB floor I worked
as an RN weekend nights in a community hospital where I had a lot of autonomy
(docs don't want to be bothered then - which to me was a good thing!). I worked
many extra shifts with the RNs who had the innate abilities and insight I wanted
to learn about - again, not necessarily medical things. Because of my reputation
as a CBE (and some RNs thought I was a pain in the neck and "out there"
in my beliefs) I usually had the patients others thought were a bother, the ones
who wanted active labor & births, which is exactly what I wanted anyway. Along
the way, some of the RNs & MDs also learned and changed their practices, or
at least tolerated and "allowed" me to work actively with patients.
I had wanted to go right from nursing school to midwifery school, but once I
was on the OB floor, I realized there were things I needed to learn and do. I
put off midwifery school until I had three years of OB experience. While I was
very anxious to get on with it and become a midwife, the time as an RN on the
OB floor was invaluable. I am now a CNM with a master's of science in midwifery
and I am at a freestanding birth center (midwife owned/operated). A few of our
moms choose to use the hospital and I am comfortable in the hospital setting and
know what we face there. As a CNM I also have privileges at the hospital, which
the licensed midwives in the state I am in do not.
- Donna Harvel Balo, CNM, MS
I share my experience as someone who has the heart of a midwife yet has chosen
to work within the medical system. When I birth, I will choose to birth at home.
I love and respect my sister midwives who are working on the home front keeping
the true art alive. But knowing how horrible most hospital birthing experiences
are for women, I had to go into the system and try to change it.
The hospital birthing unit I work at operates with a midwifery philosophy largely
due to the nursing staff. This unit does waterbirths, has an episiotomy rate of
less than 1%, an epidural rate of 18%, 65% of our women delivered without any
medication, and the cesarean rate is less than 20%. Women birth their babies in
the shower, on the toilet, standing, squatting--whatever works for them. Our hospital
has the highest breastfeeding rate in the state (89%). We offer yoga, hypnotherapy,
Reiki, and we have an herbalist who works with the unit. The unit buys her products
and the nurses give them to the moms (healing sitz baths, teas, and salves).
Nurses become handmaidens only if they allow it to happen. The only way hospital
birth will improve is if women who truly care about birth remain in the field,
or go into the field and settle for nothing less. At the same time, the only way
the true art of midwifery will survive, and the only way to ensure that homebirth
is a legal option for women in every state, is for women to choose direct-entry
and fight the fight on the "home front."
We are fighting for the same cause but on different fronts. Hospital birth is
not ideal birth, but it is the route most women in this country choose. One way
to enlighten and reach more women is for some of us to work within the system
and offer women another way.
Listen to your heart and you'll find your path. My hope as a student midwife
is that no matter what path midwives have chosen, we band together and support
each other. We will be more powerful as a united group than a divided group.
- Annie C.
I graduated from nursing school in June 2001 and I am currently working as an
RN in labor and delivery. I went to nursing school so I could go on and become
a CNM. I believe wholly in the midwifery model of care, and I often debate which
path--CNM or licensed midwife (LM)--is best for me. In my community there is very
little respect for LMs (unfortunately), but CNMs are slowly gaining ground and
making changes. I have chosen to pursue the CNM route hoping I will be able to
have a little more power to help women have better births in all settings. Ideally,
I would like to have a homebirth practice, but I want to be able to help women
who choose to birth in hospitals have a good experience.
I do not feel that going through nursing school indoctrinated me with the medical
model. I still believe very much in the same ideals about birth care that I did
before I went into nursing school. If anything, my nursing training enabled me
to fully explore all of the evidence (that much of the medical community ignores)
that supports homebirth and low-intervention births. Nursing embraces a much more
wholistic model of care than the medical model and is closely related to the midwifery
I do have frustrations working in a hospital environment and working with nurses
and physicians who think homebirths are foolish and that all women need Pitocin
and epidurals. However, there are some who do not feel this way, and I cherish
the opportunities I have to serve women who choose to birth naturally. If I want
to make a difference in women's health and childbearing, I may have to work within
a system I do not agree with. Only by gaining the respect of the community will
I be able to influence it to change.
One of the nurses I work with said to me, "Midwives are dangerous."
Her statement was based on one experience with a midwife many years ago who made
a poor decision. Unfortunately that happens, but the other truth is that we are
all human, and we all make mistakes. I see doctors making poor decisions all the
time. In order to change the point of view that she expressed, we need midwives
demonstrating safe practice and good outcomes in places where they can be seen.
- H. Horn, RN
I work in an L&D suite in a hospital. Let it be known that I *never* kowtow
to the physicians or hospital system. As a Birthworks-certified childbirth educator,
I am committed to a woman's instinctual ability to birth. I can help women get
the birth they hope for. I am blessed to work in a hospital that supports natural
alternatives (volunteer doulas, and 49% of our ladies delivered in the water in
2000-2001). If a doc suggests an intervention that is not in sync with a mom's
birth plan, I think nothing of asking him to step out into the hall to discuss
the rationale. Not all nurses are forced to bend to the system. Some of us work
very hard to keep the system supportive of our moms and their choices. There are
plenty of hospital horror stories out there, but all hospitals and all nurses
should not be labeled.
- Sharon Breidt, RNC,CCE
I chose to give birth in a hospital with a midwife mostly because I knew I needed
to be taken care of postpartum, something that would not have happened so well
at home. I also knew that the hospital environment had changed since both my grandmother
and mother homebirthed--a choice they made because of the barbaric OB interventions.
My midwife trusted me and my body in its ability to give birth. I was in too much
pain to lie still for the hospital nurse to put an IV in (I was in transition
when I got there) so we didn't. The result was a completely unmedicated birth
from start to finish. My husband did acupuncture to stimulate my oxytocin to help
deliver the placenta. My baby was born with a hand presenting, meconium when the
waters broke, and the cord wrapped around her neck. My midwife was great in this
situation. I can only imagine how many other women she has touched and given a
safer hospital birth than if they had been attended by an OB.
As for education brainwashing you, that is a choice you alone would make. If
you are truly firm in your trust of women, nothing will shake that. I went to
acupuncture school after deciding to not go to medical school. My undergraduate
degree was in biochemistry and molecular biology. I was told by some of my teachers
that my western background would make my acupuncture studies more difficult. I
did not believe them. In fact, it helped my understanding.
Follow your heart and touch as many women as possible by giving them the gift
of midwifery care. May spirit be with you and guide you to the right path.
PATHS TO BECOMING A MIDWIFE: GETTING AN EDUCATION, a Midwifery Today book. The quintessential
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Question of the Week
Q: A mom just delivered after a 43-week pregnancy.
The labor was terribly long but OK for her. The baby looked 40 weeks; the gestational
age came in at 38 weeks. There is no way we were off on dates. She had a circumvallate
placenta. The cotyledons were really mushy where they tore really easily. I've
read that a circumvallate placenta has a higher risk for postpartum hemorrhage,
which she had--a long, trickle bleed. Why or what causes this type of placenta?
Did it cause her baby to stay in so long yet look and test out to be a normal,
- Heather Zanon, midwife and mom
Send your responses to:
Question of the Week Responses
Q: A doula client, due in April, is a repeat client.
I attended her with my mentor midwife a year ago. She had planned a homebirth,
but we transported. It turned out she had a uterine infection and was sectioned
for failure to progress past 4 cm. This time she's opted for a hospital birth
with our favorite doc. An ultrasound shows a very low-lying anterior placenta
right on her c-sec scar. The doctor told her not to worry just yet, that as her
uterus enlarges it is possible the placenta will move up. If not, he said she
would have a scheduled c-section and possibly a hysterectomy if bleeding can't
be controlled. I told her to do some serious meditating and visualizing. She is
scheduled for another ultrasound in eight weeks. Has anyone had this situation
improve? Any tricks we could try?
- Belinda, doula, midwife's assistant
A: A low-lying placenta doesn't actually move, but because of the size
of the uterus right now and more importantly with the enlarging of the uterus
her placenta will look like it moves. I agree that it is too early to be overly
concerned with the location of the placenta. The best thing is for her to know
that it is not uncommon for it to look low and for it to appear to move. She should
relax--stress, which affects her and her baby, is something she has a better chance
of doing something about.
- Heather Morrison, student midwife, hypnotherapist
A: Contact your local HypnoBirthing instructor. Our practice has accomplished
amazing things with hypnosis, the ultimate in visualizations.
- Jenny West, LM, CPM
A: This woman is still second trimester, too soon to give up hope. About
20% of placentas appear low-lying during the first trimester because the placenta
is large compared to the size of the uterus. By 32 weeks, most have moved away
from the cervix. I've seen a few move as late as 36 weeks but no later than that.
Yes, the placenta grows upward with the uterus for two reasons: the rising, stretching
uterine wall literally takes the placenta upward with it, and the placenta tends
to "migrate" toward a better blood supply, which is found at the top
of the uterus. Most placentas move. It must be just a few centimeters away from
the cervix to allow space for initial dilation, then later in labor as the baby
descends the head will compress the placenta edge against the uterine wall and
provide some help there. Identification of the edge of a placenta is tricky and
should be done by someone experienced in ultrasound of pregnancy. There is the
possibility of hemorrhage leading to hysterectomy in the worst-case scenario if
she needs a c-section and the placenta is implanted there. But she shouldn't feel
that that is *likely*. Also, she has every reason to hope for vaginal birth and
should do what she can to make that possible, i.e., use positions in labor to
facilitate progress, avoid epidural, etc. Visualizations are a fine thing to do.
- K.Mm, CNM
More about kidney stones [Question of the Week, Issue 3:50]:
I have regular bouts with kidney stones due to MEN I (multiple endocrine neoplasia
type I) and experienced multiple calculi during pregnancy with my daughter. The
situation worsened when I reached about 6-7 months because of the increased renal
activity that is most vigorous in the last trimester. The stones then were able
to move quickly from kidney to ureter so I found that rather than passing single
large stones I was passing many, many smaller stones
and therefore experiencing pain of longer duration. During labour I experienced
excruciating back pain despite having an anterior baby. My midwives were baffled
and insisted that I actually was experiencing no back pain. In fact, shortly after
my daughter was born, I passed a rather large stone. The stone was moving down
my ureter at the same time as I was labouring. After birth I continued to pass
smaller stones for a while, including a few through my milk ducts.
- Mary-Tim Hare
In my CNM practice we see kidney stones about twice a year. They often crop
up in the second trimester. They are usually painful and diagnosed because of
workup for the pain. They are sometimes silent and seen incidentally on an ultrasound,
in which case they often never cause symptoms. When a patient has pain with them,
it is often acute, and within a few hours becomes localized and severe, usually
causing vomiting because of the pain level. The woman generally has no or minor
fever, and often a normal urinalysis (UA) except for RBCs seen.
Often the first few hours it seems like pyelonephritis but then veers into classic
stone pain. Generally it hurts so much we have the patient in labor and delivery
so we can give adequate pain control. Once UA and ultrasound are done, we support
the patient thru the pain for however many hours it takes, usually a few. Watch
for preterm labor. When the stone passes the pain decreases remarkably, and although
we always have them screen urine thru a filter we rarely identify the passed stone.
If so it goes to lab for composition breakdown.
People who make stones tend to make more sometimes, so they're often put on
prophylactics (we use daily Macrodantin). If they have a mildly troublesome renal
stone that isn't in the pathway to be passed down the ureter and will likely remain
in the kidney, it sometimes causes mild chronic renal pain and intermittent RBCs
in the urine, and occasional bladder pain from the "gravel" that breaks
off the stone and irritates the bladder. So we prophylax these women also because
they're also at high risk of getting a urinary tract infection. The nice thing
is once they've birthed and the pressure is off the ureter from the uterus, the
problem seems to go away.
- Kathleen Murray
I have a friend who also gets kidney stones during her pregnancies. In her case,
I believe it's from her eating so much extra protein. Excess protein "kicks"
calcium out of the body, sometimes resulting in kidney stones. She is normally
vegetarian but will crave and therefore eat meat during her pregnancies.
- Jen Lehman, CD, CBE
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