I have been writing about a Midwifery that is a holistic, dynamic, organic and hence, growing and ever changing entity only, increasingly, I think that those possibilities exist only in my mind. Increasingly, and with the same discomfort with which I have been forced to acknowledge, at critical points in my life, the pain and disorder that existed in my own childhood; I see Midwifery taking on the dynamics of a highly dysfunctional family. Midwives who "color outside the lines" or who fail, in some way, to ensure that "outsiders" don't know "our" business; are threatened, bullied, maligned, blacklisted or, in some other way, isolated and rejected by their peers. Just as in family systems where whole lives are lived in closely guarded spaces of secrecy and anger and the one who begins to tell the truth becomes the scapegoat; so it often is in Midwifery. In an ironic twist; all of these things are fueled by fear and, as all Midwives know, fear is the enemy of birth--of a person, an idea or a profession.
Midwifery is a work that creates "wounded healers" in the words of the Dutch Theologian and Priest, Henri Neuwon. Or perhaps it attracts them. Many midwives, at least many I've come to know, have, like me, come from difficult backgrounds of deep, emotional and spiritual, challenges. Many of us are attracted to midwifery because our relationships with our own mothers were or are, fractured and painful. Midwifery embodies the promise of 'healthy mothers and healthy families' and when that is combined with creative energy, a native and wily intelligence, and a recognition of the need for deep healing in oneself and in any other person; I think what you end up with is a Midwife. In the last few days, I've gone back to my old, 1974 copy of Spiritual Midwifery just to remember; just to try to find my own way 'back to the garden' of innocence and the solid wonder of having opened a book and found my life; my vocation. I've sat here with the book open on my lap, concurrently looking up at the computer screen to read a painful letter from another midwife being attacked, in a torrent of angry accusation and rejection; by another midwife for speaking out about Midwifery education and about concerns, many of the same I have written about in this space, that Midwifery is not set up to be a sustainable health care profession that we can pass on to our daughters and granddaughters knowing that they will have something we have not had: a unified, profession of midwifery as the basis of our maternity care system in the U.S. I read this angry, fear-driven letter and, moving to another letter written to me by someone in the Midwifery leadership a week or so ago that tells me that "the BMJ study proves that more education doesn't improve outcomes" and " I don't see that CNM's have any more economic security; a lot of them are losing their jobs so I don't see how a University education of the kind you're proposing insures anything". Sighing deeply, I respond that I hadn't thought that the BMJ was designed to prove that contention and therefore, can't. I comment that a CNM, as a Registered Nurse, is still very employable, with a well paying credential as a Nurse even if she can't, regretably, find a job as a Midwife. A direct entry midwife, in contrast, may have nothing else, no other education or training, with which to make a living. I think that's a very big problem and I find it very concerning that the people in "leadership" positions in Midwifery can make such unsupportable statements or fail to see the connection between a broader, more diverse education and a more viable and sustainable, Profession.
Continueing to read, from Spiritual Midwifery: " A Midwife must be an avid student of Physiology and Medicine. She should read and study constantly in a never-ending quest for new information. She should never assume that she knows everything there is to know. A new piece of information she learned yesterday may be essential and life-saving tomorrow." I can remember reading those words breathlessly and I took them to heart. I wanted to know everything and I worried that there would be something, at some critical moment, that I didn't know and my greatest fear was that I would fail a mother or baby who had entrusted themselves to my care. I was in Nursing School at the time; I had seen people die of cancer and liver failure and heart disease. I had spent time in pediatrics with a family whose baby was dying from biliary atresia; a disease that had claimed the life of my oldest sister; a sibling I never knew. I had watched, helplessly, as a Native-American woman from our local Ottawa village was brought into the E.R. of our hospital having eclamptic seizures; she died 20 minutes after she was brought in. It never occured to me and I never read in Spiritual Midwifery, or any of the other texts I began studying with such young passion; that "birth was safe" and that's all you need to know, or believe. I am sure I would have thought the idea insane. I thought I had to really, truly know what I was doing in attending births at home or someone was going to die! Now, that may seem an exaggerated bit of hyperbole, but I really felt that way. It was years before I ever heard the "birth is safe" mantra and even though my experiences had thus far validated that claim; I continued to believe, and practice, with the idea that the most important thing I had to know how to do was respond appropriately to a complication or emergency.
I wanted to become a midwife to serve my community! I saw my role as something like that of the local volunteer fire department or other "public servants" who learned a set of skills and a knowledge base and were then prepared to give back! I wasn't trying to create a "Profession" for myself. I was, after all, fully immmersed in the hippie culture that held suspect anything so "over 30" as a career or a regular paycheck beyond what was needed to buy food, clothing and shelter and, as all of us knew, those things could be done far more cheaply and with greater "soul" than most people thought. I wasn't "mainstream" then. I wasn't a mother. I was just another idealistic hippie girl looking for way to make a contribution and Midwifery was going to be my way. Midwifery was in a resurgence in this country and it brimmed with the enthusasm normally reserved and celebrated by those reinventing the wheel! I thought I had discovered a splendid secret and a real way to change the world! Spiritual Midwifery, as a book and a concept; changed the direction of my life from the moment the book came to me.
One of the other things Ina May had to say back then was this: "The Spiritual Midwife tries to find a way that she can practice without charging money, as this makes it easier to keep birthings spiritual. Her husband and/or community can assume her support. If she is helping ladies for free, she has a better moral position if she needs to talk to a lady about her attitude."
Wow.....yeah. I was all over that one! And you know what? I still believe it. I still believe in this old model for community midwifery! I still find it easier, in terms of serving women and families, to not charge a set fee and yes, I do work for "free". I think it's very, very hard to have the kind of honest, real, substantive and responsible relationship one needs to have with women and families who birth at home when I am charging them for something as personal and intimate as home birth midwifery is and must be. I think it's one of the unnamed and avoided confrontations we're having in this debate over the "Professionalization" of Midwifery. I still believe; and do my best to live the idea that Midwifery is a relationship and relationships that are paid for are, well, we have a name for them..... The truth: I hate asking for money to do this work. A few years ago, I set aside my "fee schedule" my "sliding scale" and told folks' that they could just make a donation to my practice in an amount that felt fair to them. I asked them to make a minimum of $500.00 downpayment when we decided to work together ( I cleverly called this my "acceptance of care" fee ) which covered my own costs in providing care--my gas and car upkeep, my supplies and equipment, their birth kit, newborn screening card and something left over to compensate my family with some pizza in my absence. I loved it; my clients loved it. It worked really well for all of us. But my midwifery community didn't like it and I got my own nasty and mean spirited letters and peculiar phone calls; I was told that I was "undercutting" them by charging so little. Now, I didn't gain any extra numbers of clients that I could tell during that two year period; I did several repeat clients and a few new people but, no big change. I didn't take any clients away from other midwives. But midwifery was on it's way to become a "Profession" and my old timey ways' weren't keeping up with the trends. I have been a less happy midwife ever since! I went back to a more or less "set" but still ( by community standards) low fee and I continue to make payment arrangments with people; on my paperwork, it says very clearly, that I "neither accept or reject clients based on ability to pay" and I can't imagine working any other way. Insurance reimbursement? Nope. The idea that people won't "appreciate" what they get if it isn't expensive? The hospitals and doctors get "so much more for so much less". So???? We're Midwives. We are Midwives.
I understand that we have to move Midwifery forward; that we have to alter our educational practices to encompass a different set of values and needs. I have been able to practice midwifery because "my husband and/or community assumed my support" but, our daughters are unlikely to find that easy to come by. They need a Midwifery profession that will feed them; body, mind and spirit. They need to feel proud of their academic and professional accomplishments in ways that their peers and parents and grandparents can appreciate. Midwifery needs to be able to serve the majority of women in America; not 2-10% ! We live in a global economy; we need a Midwifery that, as Navelgazing Midwife has pointed out; meets the WHO definition of a Midwife in all spheres; to practice in all settings. We need a midwifery that is cooperative and accountable to the other health care professions with whom we MUST collaborate and work alongside to ensure safe practice! We need to do something along the lines of what has been done so successfully in places like New Zealand where Midwives all came together with consumer groups and other health care disciplines to focus on evidence based practice and the formation of a maternity care system that places Midwifery at it's center and that has created a degree-granting educational preparation that is respected and accepted in all sectors. In New Zealand, Midwifery is a popular professional destination for women and it attracts mature, intelligent and skilled people with a deep commitment to maternal-child health. It took them many years and yes, some compromise, but, their education is broad, liberal, interdisciplinary and includes apprenticeship in all settings--home, hospital, clinics, rural and urban practices. How in the world could that be bad? Midwifery is now fully included within their admittedly more socialized health care system with all care paid for in full! That, in the modern sense, is the equivilant of "the community assuming the support of the midwives".
The fear that drives the rejection of examining new models or promotes a rigid clinging to concepts of "apprenticeship" and "woman centered care"as sacred cows; or the idea that altering our education to meet new needs and desires takes something away from midwifery, is preventing the labor from bringing something to birth! We are a "post dates" pregnancy holding off any intervention until there are no more choices left. That is not wise. That is not being "with women". It is telling the women--the vast majority of women, that what matters in midwifery is the midwives alone; our comfort level and our standards. It seems, and is, inflexible and exclusive; not diverse or expansive.
To get ourselves "Back to the Garden" we have to stay open. We have to listen to our "Prophetic" voices in Midwifery; the voices that still hold onto the old ways and remember what the goals were but who have remained outside the "inner circles" precisely so that they could stay with the women and families and hear what it is that they need and want from us. My life forced me into the "mainstream" of women's lives. My deepest gifts and "calling" are to counseling women, men and families who are struggling under the weight of difficulties, tragedy and complex situations without easy answers. I didn't want to end up there; I would have preferred to stay on the farm with my goats but, my life moved on, I married-- I had babies born healthy at home and I had babies born in hospitals who were disabled and two of my infant sons have died. I spent time learning the language and walk of grief and sadness. I learned through my client families who shared more of their lives than just their births; how to help mend marriages and work with women who became depressed, even after good births because they had too many lingering doubts and hurts from their own childhoods. I learned more than I wanted to about how people make choices about birth and about the reasons some people have no choices at all. My life, now nearly 50 years of it, has been one, long, steep learning curve! I want, now, to give it all back to you; to the women and families and to the Midwifery community so everyone can take advantage of the conversations I have had and continue to have, with women they don't consider 'client material'. I want Midwifery to embark on it's own sharp, deep and creative learning curve! I want midwives to heal their relationships with other midwives so we can end the stasis and move forward.
Midwives have to stop fearing that our inner-workings can't bear the scrutiny of physicians, legislators or the public. Sending up a warning flare or browbeating midwives who speak to these issues into submission and retraction does not solve a problem related to how we are perceived by those who will, in large part, determine our future. We have to remain transparent and open and accept criticism if needs be. We may need to change the way we do some things if we want to grow and remain viable. We should not fear hearing those criticisms nor should we attempt to restrict those who think we really need to take a second look at how we're doing things. We cannot continue to practice in isolation from the rest of the health care system while insisting that they include us! Midwifery is not an island and it most certainly is not some maternal paradise where all women are safe and welcome! For many women, mothers and practioners alike; midwifery becomes a place of uncertainty, financial and social insecurity and professional stagnation! That is not a sustainable vision; these are the marks of an unsustainable profession that won't get serious about examining it's preconceptions and conclusions to see if they work over time.
We are losing women and some women, mistrusting us and our motives; are birthing alone. Every couple of weeks, there is another tragedy on the various forums. Other blogs lump these in with Midwife attended homebirths to our detriment. Most midwives, very understandably, have made a point to stay clear of the UC movement and often refuse calls for help or information from women planning to birth unassisted. With no personal judgement to make about that; I must reiterate here that I cannot refuse to help anyone who asks me, within limits of time, energy, ability and resources. I am of the personal opinion that Midwifery, and very specifically, our "brand" of Midwifery; has created this monster. We have gone overboard in telling women to trust their bodies and birth and we have not done a good job educating women about the inherent wildness and unpredictablity of birth. We seem to not know how to backtrack on this position without risking a wholesale return to the idea of allowing fear to dominate women's thinking about birth and the resultant potential "loss" of midwifery clientele. My response to this is, very clearly, "we have to find a way" because babies are dying and women are suffering because they are not taking any risks into account when they plan these births. I think we have to find a way to retain and regain the trust of these families and also work towards communication about the attitudes and problems that may lead these women; more of them every year, to take these risks. I truly believe that this is a public health issue that Direct Entry Midwifery needs to take the lead in addressing and researching and, most importantly, healing. Sometimes, there are unintended consequences to even the best ideas. I think this is one of those times. These are birthing women who need our help and concern. We must not allow politics to get in the way of compassion and skilled care. There is a reason there are "Good Samaritan Laws" on the books in most States!
I've decided that I'll probably stick with this "theme" for awhile. I'm not done with it or it's not done with me. I am in this wonderful "transition", as is Midwifery. I feel like the woman 'stuck' at 8 cm's who has moved every way she can; changed positions over and over, moaned and rocked and, now, reaches out for the hand of her midwife, her mate, her friends nearby.......there is no comfortable place until the deeper movement begins; the pushing and the force that brings birth. I know, viscerally, that it is important that I continue on in my professional path of counseling and guiding families towards health and well-being. I know, just as deeply, that I have to continue to be honest with myself about my need to ask these, and other, questions about how we care for, and serve, mothers, babies and families in this Country. I think most of you know, by now, that I never write to inflict damage or pain but, sometimes, as in all birth, there is pain. I have found it deeply painful to see what I've had to see over these last two weeks. To not speak to it would be to reinhabit an old life; a way of being learned in childhood--of secrecy, of never owning my own ideas and thoughts because I believed the threats and the attempts to control and I believed that my voice didn't matter........we grow up and, if we're lucky and someone helps us, we learn that these things aren't true.
Midwifery, too, is growing up and she has lots of voices. We can't afford to shut any of them down. We can't afford to give in to fear and to avoid doing the hard work of birth. We have to set an example of peaceful reconciliation and inclusivity; a true and generous inclusion that knows that all birthing women matter and knows, as well, that Midwifery is a wise, old woman---a Crone now---who can embrace paradox, hold the tension between conflicting and overlapping needs and become a true force for good for women and families.