Thursday, April 28, 2011

Reponsible Inclusion

Responsible Inclusion?

What is this? A new concept I have started formulating. It is an idea, and I am open to opinions and input. We have a problem in Utah. There are positive and negative aspects to how our licensing works here. In Utah licensing is not mandatory.

The positive I see in this:
Women have more options and choices in birth providers, and traditional midwifery is valued and treasured. Some of the art of midwifery is preserved when value is placed on alternative to learning a trade.

I have noticed in my formal education, while I value the many many gains I have through a formal academia setting, that by having the background of being first trained as a traditional midwife that I see things a little differently. I hear things differently than many students. A classroom style setting, no matter how rich it may be, is still a sterile form for learning. When combined with experiential knowledge, they can complement each other, and are both valuable. However, if the only training you have had is in a formal education setting style, I see many people who tend to narrow their views, and see things through a lens, and become closed to new ideas and different ways of learning.

I have noticed that because of my history of being a traditional midwife first I tend to hear the information, and then I start to evaluate it and be more critical of what I am hearing. I am  more active learner, and I hear the truth that rings to me, and I hear the information and see how I can apply it into different areas and utilize the information to the fullest. I also don't hold to any hard-fast truth of how the world has to be, because I realize many concepts are perceptions that come from cultural exposure, and are ingrained.

However, I am grateful for the formal education as well because I believe it has refined my skills as a midwife. I am more effective in communicating with those I work with, with other midwives who have different practice styles, and with other medical providers. I am able to be more objective. I am able to take a step back from my emotions and beliefs and hear and see things from an obstetricians point of view.

As a result, I generally find that once I try to understand a doctor who appears to be hostile. Once I show him I am not threatening to him, and that I appreciate his presence and knowledge when it is needed. Once he sees I am a bridge-builder and the sees that if he works with me that the parents also work with him, he tends to calm down and make every effort to both provide a safe outcome, and honor the parents birth experience.

This is the value of having been formally educated, having been placed in different practice settings, and learning how to come to a common ground. We do not always have to agree on everything to come to a common ground. But when people feel respected and valued, generally they are more workable.

Most obstetricians, nurses, and midwives all want the same thing. They want to see a healthy and happy mom and baby. When we are able to bridge build instead of working off of each other's fear and mistrust we also help our clients have better experiences. Maybe because I built a relationship with an OB, when he had previously seen a train wreck brought in by a midwife who did not know how to communicate with him, or did not transport appropriately because she had so much fear about being devalued and the hospital slaughtering her client... maybe next time he will say, hmmm. maybe there can be a compromise. Maybe we can both listen to women, and provide competent and safe care. Maybe we don't need to scare women into interventions. Maybe instead we need to listen to them, and include them in the decision making process.

As a licensed midwife I see the value of having a license. It is more than just about the ability to carry medications, administer IV antibiotics, or provide RhoGam for my Rh- clients. Having a professionally recognized front to interface with other professionals can be helpful in further bringing validity to homebirth and birth center births. It can provide roads for bettering relationships between professions, and providing smooth transition into a hospital setting when it is the better place for the best outcome. Taking the mistrust and fear out of transport, and working connections with other professionals is ultimately the only way to change views, and to ensure that the fear of "them" coming after us will go away. It is possible, and it may happen with one positive transport and experience with a midwife at a time. But eventually if there is agreement and community among midwives. If there is a level of respect and competency, those views will change. In many countries doctors and midwives are collaborators, and not enemies.

How does this relate to licensure for midwifery? It is legal to be an unlicensed midwife in Utah. Therefore, no matter how "bad" we may think an unlicensed midwife is, it is still legal for her to practice. What I am seeing is that ostracizing new or unlicensed midwives creates a large problem for all midwives.

When I was a young midwife I was mentored, and welcomed, and accepted. I felt like I had a place. I felt like if I wasn't sure about something I could call about any well-seasoned midwife and ask her and I would not be ridiculed or called out on it. If I made a mistake she would empathize, and tell me of a time she had made a similar mistake. She would assure me that a mistake didn't mean I was a horrible midwife, it was just another learning curve. I felt comfortable enough that when I suddenly had this paper that said I was a Certified Professional Midwife "CPM" but was suddenly scared at being the one who this mother looked up to for reassurance that everything was OK, or for support and a calm presence that knew what to do when everything wasn't OK. That was a lot of responsability, and I was happy that for a few years I could call upon more experienced midwives to continue to mentor me through my transition from student to wise-woman.

I use wise-woman in the sense of that is how many mother see me, but my wisdom has come from seeing that I do not know everything, that I can never go past my limits of safety, and that I still check things out with other providers when I am not sure. My wisdom is that it is best to be humble, it is best to not judge, for you know not what the next birth experience will provide as a lesson!

The problems I see with having a state with two levels of direct-entry midwives are that midwives are less united. When there is a proposed change to the rules or statute both licensed and unlicensed midwives are more willing to compromise. There is an out. We saw this a few years ago when we compromised to not let licensed midwives to any twins, breeches, or deliveries before 36 weeks. The licensed midwives felt like they were safer to compromise, and then decided it was a mistake. The unlicensed midwives stayed unlicensed because they could maintain their rights in those situations. So now we have a larger problem. There are very qualified midwives to are licensed, who know by many years of experience and education how to appropriately screen when these women present, how to monitor, and when to transfer out of care who are not able to attend them.

We have some unlicensed midwives who are also qualified, but do not have legal ability to have all of the medical supports of safety that are sometimes necessary in these situations. We have licensed and unlicensed midwives teaming up to make the best of it. And we have new midwives who have a bitter taste in their mouth. The level of mentoring and acceptance has gone down. Midwives are starting practice without the support of older and wiser midwives. There is mistrust in the community, and a newer midwife may not have the seasoned experience of knowing how to bridge communication on a transport. She may not feel comfortable with some of her skills, but is afraid of what the older midwives may think of her if she calls them and ask their opinion, or calls for comfort after having made a mistake.

With the professionalism of practice, which I believe is necessary for our survival, I also see that there is a division. If our state is to keep midwifery both legal and keep unlicensed midwifery legal, then all midwives need to start working toward a common goal.

Regardless of how another midwife practices, or what her training is, if she is unlicensed then she does have the right to practice, and the parents have the right to choose her. If it is legal, then ostracising her will not make it illegal for her to practice, and she may decide that asking for help is too risky. She may be angry, and may not know how to forge relationships in hospitals. Perhaps, part of the reason the obstetrician was angry when you came in with your responsible well-charted transport. Perhaps he had just taken the client of a newer midwife, who transported, but did not know how to communicate in a way that was effective. Perhaps she offended him because she didn't know how to see things objectively, not react to emotions, and validate and support him in order to foster a working relationship.

Yes, there are some scary ways of practicing. But I know if I have a relationship of trust with someone I am both more willing to go to them for help, and to also accept and consider feedback. I believe I am a good midwife, but my seasoning was not innate! I had to learn out to communicate. I had to learn that scaring my clients with the interventions of hospitals was not helpful when they became necessary.

I had to learn, and I am still learning. These are skills I have gained through many years of experience and through the experience of those who have mentored me along the way.

If you see a midwife you believe is not safe, and it is still legal for her to practice how much better would it be to include her in your circle, to build a relationship with her, to help her, to bring her up to be the competent midwife you are in the same way your mentors and wise-women brought up your competencies and standard of care. How valuable it would be if you showed her how to get the doctor on your side, so he would be willing to not jump to a c-section, so that your laboring mother has a good birth experience when you transport her and stay with her, and show her that the hospital is not always scary, and that she can still have an empowering birth experience.

This is what I am terming, responsible inclusion. We have the responsibility to include all midwives who are willing to be included so that we can work together to build competencies in a whole profession, and to preserve both the profession and the art of midwifery for future generations.

We are at a crossroads, and I hope we make the right decisions. Homebirth is on the rise, parents are wanting it, but if we don't work together we will lose it. If we do work together we will make many gains in the years to come.

Lets move toward the gains!

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