September 22, 2009
Licensing, registering and certifying midwives–at what cost?
Many things are said to entice midwives into becoming part of the medical/government/pharmaceutical system. Some compelling arguments that I have been presented with include:
1. Midwives can feminize and change the system from within. We’ll take our herbs, homeopathics and loving care into the hospitals and everyone will see the healing power of midwifery.
2. If we become licensed/regulated, etc., we can work for the very poor who are now unable to access midwifery care.
3. We will be equal colleagues with physicians and will gain their respect. Then, if we need their services, our clients will be treated better and have continuity of midwifery care. We will also be more respected in the community.
These are lofty and tempting goals, especially for women who have chosen a career that is marginalized and abused in Western society. The problem is that these enticements have never been shown to actually come to fruition even years after legalization in government-funded or endorsed practice schemes.
Here in Canada, midwifery has been brought under a government umbrella in four provinces in the last 15 years. What we have seen is:
1. Instead of midwifery softening the “system,” the system has hardened midwives. One example of this regards elective induction.
Prior to regulation, midwives were an alternative for women who were threatened with induction of the birth process at 42 weeks gestation. Immediately after regulation in January, 1998, in the province of British Columbia (BC), midwives began stripping the membranes of homebirth clients at 41 weeks gestational age. The midwives were under threat that their clients would lose the opportunity to have a homebirth. Why? Physicians let midwives know that if they didn’t do things the same way as the doctors, they would not maintain their hospital privileges. When the midwives became regulated, they were told by the government that they would be “autonomous.” However, written into the regulatory legislation is a clause that requires midwifery clients to be seen by a physician before three months of pregnancy.
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In addition, each midwife is required to have hospital privileges. Who gives out hospital privileges? Physicians, of course . It was a case of the whale swallowing the minnow. Midwifery can never be autonomous when midwives need doctors to survive and doctors don’t need midwives for their survival. Believing otherwise is simply wishful thinking.
From 1998 to 2005, women in BC were stripped, induced and pushed into the birth process by their registered midwives because the scientific evidence (Cochrane database) showed that was the best management. This aggressive treatment had not been seen previous to 1998 when BC midwives were working independently and underground. Then, in 2002, Dr. Philip Hall of Manitoba published new evidence in the British Journal of Obstetrics and Gynecology regarding the induction of birth at 41 weeks gestational age. The article, entitled “Nonsensus Consensus,” revealed flaws in the large study that was published in 1992 upon which the induction epidemic was based. Midwives in the province of BC had been inducing women with all the horrible results of that (including one homebirth death after membrane stripping) based on erroneous “scientific evidence.”
Government funded midwives in B.C. were no longer thinking for themselves. They were no longer doing what women have done to and for others back to the beginning of time. Even now, with the evidence overturned, the policy of the BC College of Midwives is to “offer” induction at 41 weeks gestational age but not “push” it until 43 weeks. This demonstrates how insidious the medical pressure is on government regulated midwives.
2. Midwifery is accessed by women who are smart and economically secure, not poor women. Poor women, for the most part, don’t seem to find out that they could have had a midwife until it’s too late in their pregnancies to obtain one of the limited number of placements. Regulated midwives, few in number, are all booked and the number of clients they can take on is capped (government-mandated), so they do little or no outreach to promote their services to marginalized groups.
3. Although midwives in Canada were enticed by the notion that the abusive patriarchy of big medicine would begin to treat them nicely if they did everything by the medical book, this has not happened. The relationship between doctors and midwives is analogous to a family that has an abusive father and many daughters. Some of the daughters will try to get nearer to Dad in the hope that he will change one day and appreciate all their efforts. Other daughters will move as far away from Dad as possible in order to escape the tyranny. For the ones who stay close, the game is endless and Dad never changes. The abuse may take on different forms and come in new disguises but it is always there because, ultimately, the lie is that the daughters’ job is to somehow parent the insane parent.
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With midwifery and “big medicine,” the lie is that obstetrics is scientific, sane and humane. Remember, modern North American obstetrics wiped out breastfeeding, cut episiotomies routinely for 50 years, uses ultrasound routinely, invented the epidural, started the induction and cesarean epidemics, damaged babies with thalidomide and DES, etc., etc., etc. The role of “big medicine” is to get babies out of women’s bodies efficiently, timely and with as large an economic return as possible. Childbirth does not fit nicely into this context. Birth requires a great deal of time and patience to unfold in a healthy way. This dichotomy of structure is the big flaw that permeates the medical birth system. To think that midwifery can change this from within is to relegate midwives to a life of endless frustration.
We can draw an analogy by comparing the medical birth system to the government education system. The lie in the education system is that a seven-year-old is a broken eight-year-old who needs to be fixed. A real educator in that system will never be able to do his/her work. He/she will have to create an alternative school or support home-schoolers in order to get any job satisfaction and make a difference in the world. Within a system based on a false premise, one can only become frustrated and bitter. This is what has happened to midwives in the province of BC. Midwives are reluctant to apply to work here in B.C. Many registered midwives are continually in-fighting and changing partners and others are off on stress leave and complain of burn-out.
When the medical birth patriarchy is criticized, midwives are quick to point out the existence of very woman-friendly doctors and nurses who do a wonderful job within the existing system. This is well and good but doesn’t take away from the fact that the entire system is flawed and failing. The classic measure of how well an obstetric system is working is the cesarean rate. That rate is constantly creeping higher despite all the good intentions of the “good guys” in the system. That creeping cesarean rate is the “canary in the coal mine,” letting all practitioners know that the end cannot justify the means any longer.
Wanting to be respected and admired is only human. As midwifery strengthens its professional framework, this respect will naturally emerge. Midwifery needs strong, outspoken, autonomous women to articulate a vision of birth with dignity for all women. Unfortunately, such voices tend to belong to women who are “outside the system.” Once women are in a legalized system, they are silenced. They can be coerced to give unnecessary pharmaceuticals to women and babies (oxytocin, erythromicin, vitamin K) and they become good corporate citizens. The real respect and admiration that comes from knowing that you are true to yourself is missing. This can be a terrible price to pay for a piece of paper and a guaranteed pay cheque.
Midwifery is growing and expanding and, as medicine gets worse, more families are opting out of the hospital birth illusion. We see more and more families choosing to give birth unassisted by medical professionals. We’re seeing more celebrities choosing homebirth. The research studies show overwhelmingly that homebirth is safer, more satisfying and less painful than hospital birth. One need not look far for the evidence that midwifery care produces less trauma to mother and baby than physician care.
Since women can give birth by themselves, the right of each woman to choose where, when and with whom she gives birth is the fundamental principle on which any healthy midwifery model is built. Thwarting the growth of the midwifery movement by making it more and more difficult for new midwives to get training and to launch their practices is ridiculous. Instead of constantly knocking the woman off the ladder on the rung below us, we need to reach down and give her a hand up. Training of the new generation is one of the strong suits of the medical profession and midwives would be wise to emulate that desire to multiply colleagues. The future of midwifery rests in the young women who are now working as doulas. This educated group of women is emerging as the midwives of tomorrow and they need all the support and nurturing that practicing midwives can give them so they can be ready to take up the challenge. When midwives focus their time and energy on training the next generation and quit trying to join the dinosaurs that are on their way to extinction, we will find power, respect and joy in our work.
Gloria Lemay was the 2002 Recipient of the Women’s Voice Award, the 2004 Recipient of Waterbirth International’s “Mothers and Midwives” Award, an Advisory Board Member of the International Cesarean Awareness Network (ICAN) and a Contributing Editor for Midwifery Today Magazine.
For more reading on the politics of licensing/registering midwives see:
http://www.compleatmother.com/articles2/gloria_lemay.htm
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Yes, yes, yes! ove that one Gloria!
You know what, every time I have a chat with midwifery students, they all say the same thing: How shocking and so far away from their dream the work is. They wanted to be with women! Is that to much to ask?
Fortunately, I’m a doula/cbe.
When the Ontario midwives regulated, they immediately started using dopplers at every birth. We had not seen that with midwives before. I was talking to a registered m.w. friend in Toronto and said to her “Would you want to have a doppler used on your baby if you were birthing?” She said “Oh, Gloria, if I was having a baby I wouldn’t have an Ontario registered midwife within 500 miles of me.”
That’s the part I find hard to imagine. Giving my control over to an entity that I wouldn’t be pleased to use myself.
As a 50 year old doula and midwifery student… I thank you for your words, Gloria. They ring true for me. You always say the things that make me say, “YES!” Keep stirring. Much appreciated.
I feel glad as a doula that I have decided not to certify, because this is what I was feeling. That i needed to conform to a system of beliefs that didn’t fit with what I know is safe for women. If a woman chooses to birth at home without a midwife or care giver, and wants a doula, I think I should be there for her. Keep it up Gloria.
Carla HartleyI remember NOT being excited when Canadian midwives were becoming licensed in Florida and my friends calling me later saying” You were right…we created a monstor…we can’t practice for women any more. and when my Canadian friends were becoming “official” and them not liking my predictions…. the outcome would be what it is. Everyone know how I feel about licensing and de-runging and The Big Push…..but nobody articulates it better than Gloria!
Why why why does anyone think we can offer more women a better service by emulating a profession whose philosophy does not value women or babies or birth and whose intention is to redefine a NORMAL process as a medical one so they can own it.
I have never for one second understood the rationale of licensing midwives for it is THE TROJAN HORSE. If we buy into the idea that midwives need to be regulated or licensed we not only are saying that midwives can be dangerous and SOMEBODY (guess who?) needs to watch them…..BUT WE ARE SAYING THAT BIRTH IS DANGEROUS AND THAT SOMEBODY OTHER THAN THE MOTHER NEEDS TO BE IN CHARGE!
It is not midwives’ rights or titles or credentials that really matter…..It is parents’ rights to choose to have anyone or no one. Now I am fired up and will get that Why I am not Pushing blurb up on my blog!
eeks that did not work right….not canadian midwives becoming licensed in Florida….
Oh Gloria I’m weeping because I know what you’re saying is true and I’m watching women and midwives walking into the jaws of the beast here right now and calling it “babysteps”. 10 years ago in Australia midwives had insurance, visiting rights, relative autonomy of practice. Governments have stripped midwives of this and are handing back carefully sculpted crumbs which cause choking upon swallowing and yet so many of us are choking them down with the arsenic chaser and crying “It’s ok to sacrifice the homebirthers! Homebirth isn’t lost, we’ll even have insurance and be registered woohoo!” Meanwhile those of us who aren’t scared to look misogyny in the face can see what’s really happening and how women are being sold out for the false promise of respectability for some handpicked medwives. If only I could explain what that respectability really costs. Maybe your blog entry will help. Much love from Downunder. J x
Dear Gloria,
I read your anti-licensure blog after seeing a link from the Citizens for Midwifery blogspot. Having read it, I must respectfully disagree with your assessment. You are writing about regulation from the perspective of the midwife, which is really the wrong end of the lens. The reason why midwives should be licensed and certified is because consumers deserve to have access to midwives who are licensed, certified, and regulated. Consumers deserve something better than a black market underground market when they seek a midwife. Consumers should be able to find a midwife in the yellow pages, if that’s what they want, not because they “know someone” to learn who and where a midwife is by word of mouth. A woman shouldn’t have to be afraid that her midwife will be arrested or shut down by a cease and desist order a couple of weeks before she gives birth. A woman shouldn’t have to worry that she will be called to testify for or against her midwife in a trial or be subjected to investigators’ questions or being reported to the child welfare authorities for using an unlicensed provider to give birth.
In no other profession does one see this innately selfish view of licensure — no one questions that docs or nurses or chiropractors or lawyers or plumbers or manicurists should be licensed and regulated by the state. The primary reason for licensure in each of these professions is to protect the consumer. There is no intrinsic reason why midwives should be exempt.
I am a member, Gloria, of the Canadian Maternity Care Discussion Group. From everything I have read on that list, and from the two recent studies published about midwife-attended births in, respectively, British Columbia and Ontario, midwives and their clients are functioning pretty well within the system and Canadian physicians are far more collegial than US docs. Midwife clients in Canada appear to have more options, as well.
Those who read this blog should be aware that Citizens for Midwifery is one of the national association members of the Big Push for Midwives and fully supports licensure of CPMs. Obviously, principles of free speech support making blogspots available to those with dissenting views. But make no mistake, in the U.S. we are progressing toward licensure of CPMs in every state.
Those midwives who choose to operate outside the law are no worse off and, in most cases, are actually much better off, in a state where midwives are licensed. That’s because unlicensed midwives in states without licensure are subject to arrest and prosecution for the unlawful practice of medicine or nursing, whereas unlicensed midwives in a state where midwives ARE licensed are seldom bothered. If they do come to the attention of the midwifery board, our experience in the US has been that they are not charged criminally and the penalties are light.
We invite everyone who reads this blog to come visit the Big Push for Midwives website and find out the latest exciting news about midwifery in the US.
Thanks for commenting, Susan. We do have diametrically opposing views on licensing. I gag when I hear “protection of the public”. Professional bodies do not protect the public, they protect the professionals. If they did protect the public, midwives wouldn’t be injecting every baby with Vitamin K and doctors wouldn’t be mutilating the genitals of 50 percent of the baby boys in the U.S.A. Let’s not be completely ridiculous. Licensing is giving money over to a protection racket and, if you want to hear it from a physician’s point of view, buy a copy of Medical Mafia by Guylaine Lanctot, M.D.
Thanks for calling me selfish, too. That’s the big boogey-man word for professional caregivers—someone might call them selfish and that is the worst sin of all. Well, not in my world. A far greater sin in my estimation is doing to another woman what I wouldn’t do to my own daughter.
Heya!
Frankly, I don’t trust the government, right along with not trusting a lot of midwives either. I don’t think licensure will protect anyone, any more than I think that access to a midwife will (having been sold down the river to a cesarean by a team of MedWives).
But I agree with Susan; women need to be able to find providers without having to be in the network or in the know. And *that* is precisely why I am doing everything I can to get them online. I live for the day that a birthing woman can hop on Google and find every single care provider in her neighborhood, and be able to really, truly choose, without having to navigate some kind of bizarre social hazing maneuver led either by the insurance companies or the insular and xenophobic birth community.
The Internet provides the closest thing we’re ever going to have to true autonomy in choice.
Susan Jenkins seems to think the mere ACT of regulating and certifying anything guarantees a desired outcome. Reminds me of my parents’ and grandparents’ generation, who believed that a medical doctor could do no wrong, let alone walk on water. If that guarantee were true, there wouldn’t be such a word as iatrogenesis, nor thalidomide babies. (http://en.wikipedia.org/wiki/Iatrogenesis). There also wouldn’t be a pharmaceutical lobby that has a stranglehold on the medical model, financially, politically and spiritually. Ms Jenkins also implies that some one put in jail is automatically guilty. Tell that to Steven Truscott, Nelson Mandela, Betty Krawczyk, Harriet Nahanee, to name a few. Ms Jenkins, with all respect, seems to fear ‘unregulated’ midwives. This is part of a belief system that sees the world through a microscope and believes life is a science and everything can be controlled. Pass the forceps, nurse please. The certified and regulated attending doctor told my mother women don’t have enough milk for twins, so she shouldn’t even think about breastfeeding. The tragedy, more than the male lies promulgated about breast feeding, was that women didn’t feel they had the authority to question the ‘certified and regulated’, which seems to be true for Ms Jenkins. I am SURE she means well, I am, but her clients and their babies would do a lot better if she did her homework around the myriad of certified and regulated medically sanctioned interferences a birthing woman must deal with in a hospital, rather than missplacing her loyalities with a professional body and its belief system, which reek of selfishness, myopia, both of which perhaps conceal a fear that life just may be an art, and not a science. Regulate and certify all you want Ms Jenkins, but don’t buy into the medical model that simply does not understand the nature of childbirth. see: http://www.youtube.com/watch?v=siLbqthiTWo
“The reason why midwives should be licensed and certified is because consumers deserve to have access to midwives who are licensed, certified, and regulated. Consumers deserve something better than a black market underground market when they seek a midwife. Consumers should be able to find a midwife in the yellow pages, if that’s what they want, not because they “know someone” to learn who and where a midwife is by word of mouth. A woman shouldn’t have to be afraid that her midwife will be arrested or shut down by a cease and desist order a couple of weeks before she gives birth. A woman shouldn’t have to worry that she will be called to testify for or against her midwife in a trial or be subjected to investigators’ questions or being reported to the child welfare authorities for using an unlicensed provider to give birth.”
You seem to be wildly misinformed about what regulation of midwifery by obstetric rules means. I’m a consumer, I want a midwife who does what I say and not what the licensing body says. In Australia, the more licensing bodies get a foothold the more women are dumped by midwives for not meeting the “guidelines” set by the licensing bodies and it’s justified as keeping women safe from themselves. More women are reported to social services by those midwives and by hospital staff because they beliee themselves to be empowered so to do by the sort of rubbish you’re suggesting. What tosh.
Regulation serves medicalised careproviders, not women, how can you not see that?
When we regulate midwifery practice we immediately remove the right of women to oversee their own healthcare. We put in place paternalistic rules to override women’s own rights to _basic autonomy_ and we privilege the rights of careproviders of all kinds over the rights of women to freely choose who they want attending them in birth. No way will most Australian women be able to access state-run homebirth. Have you seen the rules?? Apart from totally removing the right of women to choose for ourselves, a pretty basic right, these rules also open the way to the personhood of the foetus as staff are instructed to treat woman and in utero foetus as separate beings and staff are empowered thus to force women into hospitals, surgeries, deny them care, remove the baby once it’s born, vaccinate or otherwise interfere with the baby despite the wishes of the parents.
This is what regulation brings, not some fluffy lovely world. I don’t need to be protected, thanks, I can ask a midwife what skills and qualifications she has for myself. I can ask her for the names of other clients, how many years she’s worked, what articles she’s written, her attitudes to pointy issues in birth to see if they match up with MINE not a faceless regulatory institution. If I wanted a faceless institution I’d birth in hospital! My desire for MY birth means I and I alone make the decisions about MY body, thanks very much. I don’t need some paternalistic regulatory body stacked with surgeons interfering in my birth, my relationship with my careprovider, or anything else in my life.
Only women would be expected to roll over and be good when state-run authorities started dictating the terms under which we’re allowed to use our bodies. We have lobby groups in Australia who labour under this misconception too and it’s a tribute to the power of patriarchy and the surgical discourse that you all have such an astonishingly limited notion of women’s human rights. With friends like this we may as well lie down and submit to the nice doctors without a second thought.
No one makes decisions about my body, my birth or my babies but me. End of story.
I haven’t read all the comments, so I am not sure if this has been said or not. Alberta midwives were funded in April of this year, and somethings have changed since it happened. One thing that scares me is that they no longer can accept patients who are having twins. They used to share the responsiblity with a doctor, but now that the province is funding them, they won’t pay for 2 care providers for 1 patient. I think that is just the begginning. I don’t even know what else is changing.
http://www.homebirth.net.au/2009/09/australian-college-of-midwives-draft.html The draft statement from our college of midwives in Australia. Truly appalling. Nothing woman-centred about this at all just a lot of arse covering and surgeon worship.
[…] Many midwifery proponents advocate for changing the laws in the remaining states to make CPMs (or perhaps non-certified midwives as well) legal birth attendants, specifically, rather than relying on the gray area for protection. Not all do, though. Through the years, I’ve read numerous things on the subject, both for and against certification, with those against noting the potential downsides. I was made to think on this subject again with Gloria Lemay’s post. One of the things she notes is that legal midwives are often restricted from being truly autonomous, with the case in point of Canadian home-birth midwives being required to play by the rules dictated by doctors, including trying to jump-start labor at 41 weeks (by stripping the membranes), so these women could still qualify for a home birth, because otherwise they’d be induced at 42 weeks. […]
[…] Previous related post: Licensing, registering and certifying midwives–at what cost? […]
Wow. Just wow.
I agree with Gloria. And it chaps my hide every time I get forwarded an email from MAMA or the Big Push or whoever about how they are working for “federal recognition” here in the states.
I am a certified professional midwife and I am licensed in the state of Texas. My CPM means more to me than my license. My CPM is certification by NARM that verifies that I have completed a course of study and passed a thorough exam. This gives the consumer confidence that I have at the very least been thoroughly trained. Does it guarantee that I am a good midwife who practices safely? Of course not.
My license, on the other hand, only duplicates what NARM has already verified, and allows the state to charge me a $250 “occupation” tax each year to practice as a midwife. La-ti-frickin-da.
I don’t want to be federally recognized, thank you very much. And I have been told that I should support federal recognition of midwives for those midwives who have birth centers and/or who want medicaid and insurance companies to reimburse them for their services. I should do it to help my “sister midwives.”
Nope. You said it right, Gloria: “the end cannot justify the means…”
[…] On licensure and “federal recognition” Posted by Diane on Oct-2-2009 Gloria Lemay » Licensing, registering and certifying midwives–at what cost? “Many things are said to entice midwives into becoming part of the medical/government/pharmaceutical system. Some compelling arguments that I have been presented with include: […]
What about the baby? While all of this fighting goes on?
Well, Janet, we do our best to engage the baby in the fight by wacking the cord off, drying vigorously with rough towels, shining bright lights in the eyes, poking things up the nose and down the throat, etc. but the little bleeders won’t fight back so we wrap them like a burrito and stick them in the hot box. Thanks for asking.
[…] and…one of my all time favorite posts on licensed midwifery. not just because she uses my drawing for outlaw midwife in the post. but because i have not really heard analysis on the canadian systems of health care and midwifery. […]