Midwives of the Revolution

Explorations, analysis, and reflections on women's health, midwifery, and politics from a feminist, marxist lens


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Surprise! Anti-Abortion Lies Across America!

Where do I begin with what is wrong with this ad?

The fact that a dad was surprised that he got someone pregnant, for one.

The fact that this suggests a cute baby is all women need to convince them that they should accept and embrace any surprise pregnancy, for two.

That the fact a potential baby has a heartbeat is supposed to sway an actual human that she shouldn’t have an abortion, for another.

But really, the fact that this has been up and prominent on my commute route home for at least two months and it hasn’t been defaced, is what really bums me out. I’m not saying that y’all should go out and mess it up. But if there was a movement to turn the tide against this kind of anti-woman garbage, that might have happened.

We have a lot of work to do to de-stigmatize abortion. These kinds of billboards show us our work is cut out for us. We desperately need a movement in the streets that proclaims that whatever the reason a person wants to terminate a pregnancy is ok.

Only a pregnant person can know if it’s right to continue a pregnancy, whether it was a surprise (for her or the sperm donor) or not. I look forward to the day such messages of reproductive freedom are found publicly and beautifully in public spaces, paid and not.

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Some Things I Have Been Thinking About in the Realm of Reproductive Justice

I wouldn’t be a very good Marxist or feminist midwife if I didn’t have some things to say about what’s going on in the world. But once my first three months of the new job were over, I finally had energy to do more political work, and therefore have had less time for blogging.

I am trying to carve out more time to write on this forum about the ongoing war on women, and what people of all genders and political persuasions can and are doing to fight it. I wanted to share just a few things here about what I’ve been thinking about, and that I hope to explore more in later, more in depth posts.

Hobby Lobby Protest

The Hobby Lobby decision prompted immediate protest at the grassroots

First, the Hobby Lobby Supreme Court decision of last month irked me more than I can say. It was an insult to science and to “freedom” and to women’s bodily autonomy. And so everything I wanted to say about it was published over at SocialistWorker.org, in this piece: “The ‘Freedom’ to Deny Women Healthcare.” I have more to say on the resistance to that decision, especially how defensive everyone is about contraception, but that will hopefully be developed in another upcoming article in that publication.

Also, I follow with great interest the ongoing legal battles over forced surgical birth, and their connection to abortion and other reproductive rights in this country. I really liked this piece, and laud Jennifer Goodall for her courageous stance for normal birth after c-section: “Pregnant Women Warned: Consent to Surgical Birth or Else.” Women losing the right to how they give birth is intimately connected to the right to contraception and abortion — another topic I look forward to exploring more in this space and others. 

Obvious Child

You must see this film. #ObviousChild

On a lighter note, I LOVED seeing Obvious Child in the theaters on its brief stint in my city. What a *fabulous* and hilarious comedy about abortion, of all wonderful things. There is nothing so wonderful as a bunch of sex-positive, abortion-positive, pro-woman people dealing with an unplanned pregnancy in a very real way on the big screen. I have heard people say that if Knocked Up or Juno were about abortion, there wouldn’t have been a story. But guess what — you can have a story when an unplanned pregnancy results in abortion (like half of all unplanned pregnancies do in this country) — that story just happens to then focus on the woman herself. Revolutionary. 

Finally, I am sick to death of the divisive commentary that passes for analysis about why the LGBT movement has made strides, while the war on women continues. This disturbing piece from the Daily Beast, “Ten Reasons Women Are Losing While Gays Keep Winning” has its response from yours truly coming up quickly. Suffice it to say that biological determinism has no role in progressive analysis, and apology about abortion is what got us further entrenched in the war on women, and will not provide our way out.

* * * * *

Too many teasers? Sorry. Let’s say this is my way of holding myself accountable to myself and my readers. It shall be written!


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Resisting a Dangerous Consequence of Privatizing Medicaid

As of July 1 this year, my state has adopted an HMO model for its Medicaid plans. All Medicaid members have been assigned a primary care provider in the network. Many members were bumped from the regular Medicaid onto one of the handful of private insurance companies this state’s Medicaid has contracted with. This will be a disaster for patients in loads of ways: private insurance is part of the problem with peoples’ access to healthcare in the United States. Those insurance companies and the underfunded state programs are really the only ones for whom this can be seen in any way as part of a solution. What a boon for Blue Cross Blue Shield, Humana, and a host of other for profit corporations that they now have millions more customers handed to them from state governments. 

As with all of the reforms packaged with the Affordable Care Act, I am waiting to see how it will all shake out. So far, however, I have noticed that a huge problem for patients is how difficult it is to navigate these plans. And from a provider standpoint, it is much more confusing. Where do we send our OB patients for ultrasound or to see a Maternal-Fetal Medicine specialist when their pregnancy is complicated? Well, it depends on their insurance. Whereas many area hospitals still accept regular Medicaid, many have decided not to contract with some of these new private Medicaid plans. So depending on the managed care plan you were assigned, you may have to travel farther to get care than previously. 

One plan in particular has been on my shit list for years. My clinic actually does have a contract with this company, so this is the first time I’ve seen up close how it operates — everywhere else I’ve worked or had a student rotation at didn’t take it. They used to do this direct marketing thing — set up a booth at the shopping mall or in the neighborhood and offer women diapers, coupons, and other incentives to get them to switch to their plan. The woman would sign up only to find that she now cannot go to the clinic where she already had established care. Luckily, this practice is no longer allowed, so in theory patients are signing up for more above-board reasons.

Their prescription drug coverage remains a reason for me to campaign against them. Regular Medicaid in my state is not perfect — but the drugs they cover actually make medical sense (though there are loads of gaps). Now, when prescribing, we have to look up the formulary for myriad private Medicaid plans. (And don’t get me started on the limitations of contraceptive coverage on regular or these private plans, even with the contraceptive mandate.) Insurance, not public health, is determining many of my medical treatments. This is not a rational healthcare delivery system.

injection medicationThe absolute tip of the iceberg for me, though, with privatized Medicaid, is the requirement for the provider or pharmacy to submit a prior authorization request when prescribing treatment for two conditions that I see pretty frequently: gonorrhea (which includes injection of a drug called ceftriaxone) and Pelvic Inflammatory Disease (PID) (which requires both ceftriaxone and 14 days of oral doxycycline). 

What is prior authorization? Basically, a road-block to getting my patient the necessary treatment immediately at the time of diagnosis. It means that either the pharmacy or I have to submit an form to the insurance company explaining my medical rationale for scripting this drug. We fax the request and then wait 24-48 hours for it to be approved. 

The request is invariably granted. They pay it. Then we have to get the patient back into the clinic pharmacy to pick up the medication, and in the case of ceftriaxone, to get an injection from clinical staff (it cannot be injected in the pharmacy). Some clinics get around this by stocking the medication themselves, but that is not an expense my clinic is able to take on.

These antibiotics are expensive, and should not be. But it is not as though we are throwing either around unnecessarily. Believe me, it is very important to not over-prescribe antibiotics. But is cost the only factor to consider in treatment? Don’t patients deserve to get appropriate treatment for infections that can have some pretty horrific consequences if not treated correctly

I believe that we who hold that healthcare is a right have a duty to work together to crack open the continuing gaps in the new healthcare systems and fight for one that includes everyone (and yes, that means including undocumented immigrants) and covers all basic healthcare as a human right. I plan on campaigning against privatized Medicaid, and this is just one example of how a for-profit corporation is putting their profits ahead of public health in that privatized system.

To that end, I wanted to share with you a letter that I sent to that private Medicaid contractor that requires prior authorization. I was fed up. And two weeks after sending it, I received a call from one of their representatives asking for more background on why I sent the letter. I’m not convinced this is the end of it, but I am happy to say that the representative reported to me that she would pass my concerns on to people [who I deduce are the company pharmacists] that make formulary decisions. 

If you are a healthcare provider dealing with this issue in your patient population, I heartily encourage you to pick up the phone and add your voice to the dissent. Or copy and paste elements of my letter and forward on to the insurance company that corresponds in your instance.

We are many. They need to hear from us.

 

***

Hello,

I am writing today because I am very concerned about the prior authorization requirement for medication ceftriaxone (Rocephin) and doxycycline. According to the Centers for Disease Control, a one-time injection of 250mg of ceftriaxone is the most appropriate treatment for gonorrhea (to be prescribed with azithromycin or equivalent). It is also the best treatment for pelvic inflammatory disease, along with 100mg oral doxycycline for 14 days.

As a women’s health provider, many patients present to my office with one or both of these conditions, requiring immediate treatment. Due to your organization’s prior authorization requirement for these medications, my [private corporation contracted] Medicaid patients face an unnecessary and potentially unsafe barrier when seeking treatment for these conditions. The prior authorization requirement means that complete treatment is delayed for these patients. I work in a setting for which transportation to the health clinic can be a significant issue – patients often report they delay seeking care due to economic and transportation barriers. It may not be easy for the patient to present to the clinic on a different day to pick up the prescription from the pharmacy and then receive the injection from our staff.

In addition to facing the stigma and emotional stress of having a sexually transmitted infection or PID, which can threaten a patient’s future fertility, this added barrier of delaying ceftriaxone treatment not only increases the emotional toll of such an infection – it also increases the threat of antibiotic resistance. If patients are not able to complete the full dose of the last remaining medication we have to treat gonorrhea, we could see an increase in resistance. Injection treatment for gonorrhea is supposed to help decrease antibiotic resistance. The prior authorization requirement runs the risk of making this an infection that can become even more threatening in not only the community I serve, but on a larger scale as well.

I am extremely concerned about the barrier that prior authorization requirement for these two medications creates for my patients, who deserve nothing less than safe and compassionate quality healthcare. I hope you will add ceftriaxone and 100mg doxycycline to the preferred drug list immediately, so we can enhance our patients’ access to care and improve public health.

Thank you for your attention to this matter. I look forward to hearing from you

Sincerely,

A Concerned Certified Nurse Midwife

Clinic X


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Clinical Resources for Providers & Patients

One of my major roles as a provider is to counsel patients about their health and link them with resources. I also spend a great deal of time educating myself about women’s health, since being a clinician requires lifelong learning — especially evident at the beginning of my career. I have compiled a pretty sweet resources list that I wanted to share, featuring legit, evidence-based sources that I trust.

I’ve arranged it by subject area and include a bit of info about its intended use. Enjoy, and please provide me with feedback — what works, what could be added, what’s maybe not so good.

Holistic Approaches Women’s Preventive Health & Primary Care

From the website: “Bright Futures for Women’s Health and Wellness implements and evaluates culturally competent, evidence-based consumer, provider, and community tools for women across their lifespan. Bright Futures for Women’s Health and Wellness materials help women of all ages achieve better physical, emotional, social, and spiritual health by encouraging healthy practices.” That side Includes resources on physical activity, nutrition, emotional wellness, and maternal wellness.

This is a great handout for patients developed by the Western Australian government’s public health department on sleep hygiene that I use often.

I post this visual aid developed by the Harvard Medical School in my exam rooms, to demonstrate a healthy food plate. It’s improved over the FDA’s food pyramid.

A good complement is this schematic of the Healthy Mind Platter, to demonstrate mental activities essential to mental health promotion.

Say what you will about the US Preventive Services Task Force (USPFT) — their resources are incredibly useful. This source walks you through the organization’s screening, counseling, and preventive medication recommendations.

This government site includes resources for patients and clinicians, including continuing medical education (CME) that midwives, other APNs, and docs might find useful. Topics include: CancerDiabetesGenitourinary ConditionsGynecologyHeart and Blood Vessel ConditionsMental HealthMuscle, Bone, and Joint Conditions, & Pregnancy and Childbirth

I really don’t know much about this organization, but what I’ve seen looks pretty great: Integrative Medicine for the Underserved provides community and resource-sharing for folks interested in this area.

Reproductive Health

CARDEAI recently learned about CARDEA by participating in an excellent series of CME events about providing care for transgender clients. They have lots of resources and offer training on a variety of topics you can peruse here. They seem to focus on reproductive health and “wraparound” services.

For STI prevention, treatment, and counseling, the CDC is tops. I have read the CDC’s STD Treatment Guidelines front to back more than once. If you provide any reproductive health services, it’s a must read. This is a library of resources straight from the CDC.

After you’ve done the CDC thing, I encourage you to hang out with the American Sexual Health Association. Their Herpes Resource Center is fantastic, but their overall positivASHAe and holistic approach to sexual health shines through everything they do. I’ve not used them, but they have brochures on STIs and other sexual health topics you can order for your clinic that look pretty good. And an intriguing book they recently published: Creating a Sexually Healthy Nation. Yes, please.

The National Chlamydia Coalition is seriously dedicated to our most common bacterial STI, chlamydia!

There isn’t any current medical consensus on the breast self-exam (BSE), but I still teach and encourage it, as it promotes awareness of the woman’s body. Here’s a link to a good teaching tool for the BSE.

I like this handout on kegel (pelvic floor or vaginal) exercises. Yay, vag workouts!

This is a comprehensive guide to female sexual health and wellness that everyone should read! It covers everything and is basically a course on female sexuality. Woot! Thanks again, ARHP!

General Clinical Practice

This Health Literacy Universal Precautions toolkit “offers primary care practices a way to assess their services for health literacy considerations, raise awareness of the entire staff, and work on specific areas.”

Cervical Cytology & Pathology (AKA Pap Stuff)

ASCCP_HeaderGraphicThe medical world hasn’t entirely caught up yet, but the American Society for Colposcopy & Cervical Pathology released its consensus guidelines on pap screening and followup a couple years ago. Hang out at their website to get the backstory and summary of screening and management guidelines.

OK, so this resource for clinics on managing HPV did get some funding from some pharmaceutical giants, but provides guidance on HPV management on a wide variety of issues/from different angles.

Family Planning & Abortion

For contraceptive prescribing, always start with the CDC. Here’s their Selected Practice Recommendations on Contraceptive Use. And don’t forget the Medical Eligibility Criteria.

My favorite new thing from the CDC. Highly recommended reading on providing comprehensive family planning services.

I am a proud member of the Association of Reproductive Health Professionals (ARHP)! Here is a page full of their patient fact sheets and patient resources on family planning.

The You Decide Toolkit is also from ARHP and “is designed to help health care providers better understand and speak to the risks and benefits of hormonal contraception.

The mama of all abortion resources is the National Abortion Federation. Their site can connect you with all the info you could ever want — from medical to political to funding issues.

RHAPThe Reproductive Health Access Project “seeks to ensure that women and teens at every socioeconomic level can readily obtain birth control and abortion from their own primary care clinician.” Their site has invaluable resources, from contraception info to miscarriage management to tools to help primary pare providers integrate comprehensive reproductive healthcare into their practice.

Backline, Connect & Breathe, and Exhale are all terrific organizations dedicated to providing options counseling and pro-choice, affirming post-abortion counseling.

Bedsider is a pretty hip, patient-centered site for helping people find the right birth control method.

It may not be the best place to work, but Planned Parenthood is still the best and biggest organization nationally providing evidence-based family planning services. Their site has lots of great health info.

The University of Chicago recently unveiled the guide Accessing Abortion in Illinois, which provides a very holistic approach “to help health and social service providers advise pregnant persons who may be seeking abortion care in Illinois.” Rad!

Pre-Conception & Fertility Promotion

CDC at it again — here’s a pretty old but still useful guide on improving preconception care as a public health concern.

Loads of stuff on planning pregnancy. March of Dimes has this stuff on their website on pregnancy planning, but no great stuff you can print (or integrate into your electronic medical record handouts).

I don’t know much about this organization, but Attain Fertility seems to have some good stuff for helping people get pregnant and info on IVF and fertility treatments.

I found this resource list that seems pretty comprehensive, including transgender parenting, same sex parents, and single parenting by choice. Nice!

Before & BeyondBefore, Between, and Beyond is “the national preconception curriculum and resource guide for clinicians.”

Every Woman California is a public health initiative in that state with resources on preconception heath that may be useful to folks in other areas.

Pregnancy

More goodness from the CDC. Links to pre-conception, contraception, pregnancy itselfpostpartum, and even basic infertility care and resources.

And from a different government agency (why are there so many?) through US Department of Health & Human Services, there’s this resource, with same topic areas covering pregnancy.

Childbirth ConnectionChildbirth Connection has almost 100 year old roots in being a resource for mamas in the US. This site is at a higher literacy level than many of my patients, so I mainly use this for my own reference on pregnancy, prenatal care, labor and birth issues, postpartum, and lactation. Others may find its utility as a direct patient resource. Fantastic, pro-woman, pro-midwifery organization and site.

Mother To Baby has a great collection of patient handouts on medication use in pregnancy that I frequently use. English & Spanish! They will also personally answer your clinical questions about drugs in pregnancy for stuff that’s not on the website. They also have evidence-based fact sheets on illicit drug use in pregnancy, but so far only cover three.

This is a patient worksheet you can use at the 6 week postpartum checkup, brought to you by our friends over at ARHP.

Woah! This app looks pretty cool — for mamas to trace embryonic and fetal development.

Some Sites for Continuing Medical Education

ARHQ sponsors some great, free, evidence-based CME activities on disease prevention and care management that you can find here.

More goodies from ARHP can be found in these Clinical Minute activities on family planning issues. They also have great webinars that may draw from their annual Reproductive Health conference content. As if that wasn’t enough, they also have CORE for additional repro health curricula.

Before, Between, & Beyond has CME on preconception topics.

Medications

I often use GoodRx.com to find drug discounts and coupons for uninsured patients. The site can text or email the coupon to the patient. You just have to find out which pharmacy they want to use.

Target and Walmart both have cheap generic medications available. If patient is uninsured, try to prescribe drugs off these lists and explain why you recommend filling the script at those stores.

ARHPedia_logoARHPedia (sound familiar?) is another source through ARHP: “the comprehensive source for resources on pharmaceutical products,” including coupons/samples/vouchers, patient education, patient assistance, and more.


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Updates Galore!

I have made it past the 3 month mark…it’s hard to believe it’s only been three months. Almost four now, but still…

Here are some highlights and lowlights from my world these days…

1. Looking forward to the Socialism Conference.

It’s this weekend — an extended conference this year, it started today. But I can’t take any days off work until my six month work anniversary, so I’ll only be attending Saturday and Sunday. Here are some talks and featured events this year that I’m looking forward to:

Special Education & Disability Rights

Marxism and indigenous feminism

Women, race, and class: A history of Black feminism

Who needs gender? A Marxist analysis

Capital’s missing book: Social reproduction theory and the global working class today

Who cares: Work, gender, and the repro­duction of labor power

From criminalization to “rape culture”: Re­thinking the politics of sexual violence

From restrictions to criminalization: The fight for reproductive rights today

Capitalism, socialism, and mental illness

What should socialists say about privilege checking?

Microbes and Marxism: Capitalism and public health

“Obamacare” as neoliberal health care reform

…OMG there is so much! Obviously won’t be able to make it to all of those sessions, but those are some of the ones I thought might be of particular interest to readers, and which speak to some topics I’ve been thinking about/excited about lately.

2. I’m sick of the judging.

I feel like everyone I work with is burnt out and cynical. I’m sick of victim blaming, slut shaming, poverty-ignoring, moralizing attitudes coming from people I work with. Especially the OB I work with. It’s poisonous, and trying to figure out how to respond with fierce compassion. Patients and staff deserve to feel human. 

3. Getting into the hospital…

This will of course bring new challenges. Now, I kinda have it good. Getting used to being in clinic full time, getting to know my patients, learning what basic and expanded skills I need to have for clinic. But it will be nice, come September (fingers crossed!), to have hospital privileges so I can actually start to be present with my patients in the hospital. I still have to have a bunch of deliveries supervised by the aforementioned physician, and hopefully by some midwives I’ll be working with, but it’s good to know it’s on the horizon. 

4. Got a rad shout-out by the fabulous Feminist Midwife!

My friend, mentor, and trail-blazing hero over at Feminist Midwife gave me and a fellow red midwife a lovely mention in her recent post here, honoring the work of sharing the journey via the blogosphere. Thanks, FM!

5. Feeling appreciated

Though every day is emotionally and clinically challenging, it is also rewarding. I am feeling every day that I make a difference when I provide good care, and I can see it in my patients’ faces and in their continuing to come in for care and opening up to me. Another perk is outside of clinic — being known among friends, fellow activists, and family, as someone who knows some things about reproductive health — and who can be trusted to ask about it. Maybe it’ll get old one day, but I doubt it. I love those calls/texts/FB messages about family planning, pregnancy, and sexual health. So, thank you to those folks who have come to me with those questions, and I hope I have been helpful. 


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Why You Should Choose a Nurse-Midwife for Your Pregnancy/Primary/Well Person Care

When I started on this path, I was in my mid-twenties. None of my close friends had ever continued pregnancies or chosen to parent. This is partly why midwifery had never occurred to me as a career at that stage in my life — none of us were in that place in their lives. But now that we are approaching “AMA” or “advanced” maternal age, or the ripe old age of 35 (haha), many of my friends are now starting families (or trying to). Lucky for them, they now have a midwife friend! 

So, this is an open letter to all my baby-making (and aspiring baby making) friends and family. 

My basic advice/message is:

Choose a nurse midwife for your pregnancy care!*

Here are 5 reasons why many pregnant people should consider using a certified nurse midwife (CNM) as their prenatal care provider and birth attendant.

1. Client education and counseling

Nurse-midwives aim to spend time with our patients and get to know you. We want to know what is important to you and meet you there. If you want a provider to listen to you and to openly and without judgment respond to your concerns about pregnancy and birth, you have a pretty good chance of finding this in a nurse-midwife.

2. Supporting physiologic processes

This is a hallmark of midwifery care. Take initiation of labor, for instance. A midwife will take a holistic approach — to ensuring your due date is correct, to providing physiologic means of helping you go into labor on time, and choosing not to admit you to the labor and delivery unit until you are really in labor. All of these are part of an approach that supports the pregnant person’s ability to have a baby when it’s time. It may also mean helping you push your baby out to minimize trauma and tearing of the perineal muscles, and certainly avoiding cutting your muscle to make room for baby’s head or shoulders (episiotomy). 

3. Evidence-based practice (EBP)

From my first semester in nursing school, EPB was drilled into my brain. I can’t tell you how many papers I wrote about EPB…but I’m glad I did, because it instilled in me a drive to provide care that is based on rigorous review of current evidence and is patient-centered. What does this mean? A good provider (social worker/doctor/physical therapist, etc.) draws upon current research and literature reviews to determine how they practice. I am very proud that this is a centerpiece of nurse midwifery education and culture. Not that seeing a CNM is any guarantee of this, but it certainly something that most CNMs should be familiar with. The CNM professional organization put together this fabulous resource compiling data about how we use EBP – Midwifery: Evidence-Based Practice. Our practice is not (or at least should not be!) based on expert opinion, tradition, convenience, fear of malpractice lawsuits, or other provider-centered philosophies — but rooted in solid evidence and a patient-centered approach. 

 

4. Labor support!

The best midwives will support you while you’re in labor — not just leave you to labor on your own and then show up at the end to do the delivery. In some busy practices, that may not be possible, so I always encourage pregnant people to find out what their provider does. Midwives are trained in labor support, meaning they can help keep you active and can provide comfort measures that can help you out throughout the process. Unfortunately, many physicians do not (but should!) receive training in normal birth, and often do not know what to do to promote your comfort during labor other than offer drugs. Midwives understand that labor is hard work and can support moms through it. 

5. Greater chance of normal birth

According to a recent survey of research on midwifery, you are more likely to experience the following when getting care with a certified nurse midwife: 

• Lower rates of cesarean birth,
• Lower rates of labor induction and augmentation,
• Significant reduction in the incidence of third and fourth degree perineal tears,
• Lower use of regional anesthesia, and
• Higher rates of breastfeeding. (Newhouse, Stanik-Hutt, White, et al, 2011)

These are not reasons you should not use a nurse midwife

1. I want an epidural

If you choose to have your baby in a hospital, your nurse midwife can still order you an epidural, if that is the anesthesia/analgesia option of your choosing. 

2. I want to have my baby in hospital

No problem – the vast majority of midwife-attended births are in hospitals. You may not even realize it, but there may be midwives at your local hospital. 

3. Midwives don’t know enough stuff

So you may have heard that terrible slam Bill O’Reilly made about advanced practice clinicians (APCs, formerly known as mid-level providers, yech!) — worried that the increase in care by folks in these professions aren’t qualified be good healthcare providers. (Yeah, I know, my readers are big O’Reilly fans.) “Lenny from community college” couldn’t possibly be my provider, he said of physician assistants! (See the response from the American Academy of Nurse Practitioners here.) Even so! Many people don’t know what training we receive. O’Reilly’s ridiculous comments (among thousands he’s made over the years) aside, becoming a CNM is no joke. I’m proud to say that I have attended many community colleges throughout my education, but I also will report that CNMs are required to have a bachelor’s degree, be a registered nurse, hold a master’s degree, pass a rigorous certification exam, and become licensed through the state they live in as both a registered nurse and an advanced practice nurse. We are very well prepared to take care of people when it is within our scope of practice.

4. I want someone I can see always, not just when I’m pregnant

No problem! Loads of midwives work in settings where they can provide well woman, gynecologic, family planning, and even primary care. It depends on how the midwife’s practice setting works, but in many cases, you may be able to see your CNM across the reproductive lifespan. 

5. Doctors know best

Haha, I know no one reading this blog would think that. But I really ran out of reasons why you should not see a midwife. 

***

So…if you are low risk (not diabetic, chronically have high blood pressure, etc.) you may be a great candidate for working with a midwife! Get out there and FIND A MIDWIFE!!! And if there isn’t one in your area…well, shoot. Maybe you should get on the path to become a midwife, or tell someone you know who would make a great CNM to get on that path. We need more great women’s health providers. If you are feeling the call…better answer!

 

Reference:

Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nursing outcomes 1990-
2008: a systematic review. Nurs Econ. 2011;29(5):1-22

*Or your well person/family planning/gyne/primary care. More on “women” later…


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How I Got Here; Or: Why I Am a Nurse-Midwife

Now that I’m here, I’ve jumped through the hurdles of getting my degree, passing boards, getting licensed, and becoming employed, I thought it would be nice to reflect on how I got here. It’s easy to take for granted sometimes, now that I just wake up and go to work every day. But I’m doing what I set out to do! I’m midwifing! So…how did that happen?

Back in the day…

My background is in languages and literature. I studied English and Spanish in undergrad. Like many undergrads, I had no idea what I would do when I grew up…Like many women, I thought I was “bad” at science and hadn’t really taken myself seriously in that regard. When the nursing shortage blew up in the mid-2000s, my mom suggested I look into nursing. I didn’t really think it was for me. I had the old-school pre-feminist movement (and very middle class) idea about nurses as doctor’s handmaidens and couldn’t see myself doing it. But then I started looking into it, and taking my prerequisites for nursing school (adventures to tell of another day), and more and more found it seemed like the right next step for me. Hands + heart + science + possible unionism + healthcare activism…that I could get into.

I originally planned to be a WHNP. When I started nursing school, I had never attended a birth, and I really didn’t know much about midwifery. I liked the idea of working with women, but I didn’t want to try to get into a program/field that I wasn’t as passionate about. I knew folks who were planning to be midwives, and they were excited about Ina Mae Gaskin and doulas and home birth. But I was in my mid-twenties, and no one I was close with had had a baby yet, and these topics were remote from my experience. The abortion world was more my bag, and I knew that as a WHNP, I could possibly train to provide early aspiration abortion or at least do lots of cool family planning work.

Trust Women Tiller

Then, I fell in love with birth and also realized that, as I later saw expressed beautifully in the documentary After Tiller, trusting women and being pro-woman/pro-abortion was midwifery. The issues of birth and family planning and abortion are inextricably linked. And, from a practical standpoint, I realized that it made sense for me to provide pregnancy and birth care as well as the other family planning and gyne care I would do as a WHNP. Why hand off patients to another provider to attend the birth, when I could actually be the one to be there for the whole lifespan? So, during nursing school I asked the women’s health department if I could switch to midwifery. They OK’d me.

An Alternative Route

For a variety of reasons, my path to practicing midwifery has not been traditional, at least how it’s done “typically” by CNMs. According to tradition, an RN works in labor and delivery, then goes to midwifery school, then works as a CNM. When I finished my nursing program, nursing jobs in labor and delivery were hard to come by. I got one interview on a hospital unit but did not get the position. I applied to dozens of others. I also had put out my feelers for work in abortion care and managed to get a position through a student colleague connection, at the abortion service in the county hospital.

My first nursing position was a nightmare, but it paid the bills for my first semester of midwifery school and gave me valuable insight into the lives of women seeking abortion in fairly desperate situations. I then got a scholarship so I didn’t have to continue working as a nurse during my program, but it required me to complete it in two years. I babysat for a wonderful family and watched their family grow throughout my graduate studies. Then, as I was completing my final semester of my masters program, I landed another position in abortion care, which eventually turned into a broader family planning nursing role. That is the last job I held until beginning this current job.

After I passed my boards (got certified by the American Midwifery Certification Board), I again looked for jobs around my city. This time around, I had more interviews and got a lot more interest, but still, employers and even my mentors questioned if I could work as a full-scope (meaning: catching babies, not just working in the office) CNM without having worked as a nurse in labor and delivery. Some suggested that I should swallow my pride and try to get such a position and then try again in a year or two for a full scope  job. It was a full six months between my initial interview and my start date for the position I landed, and there were times that I considered this option. Luckily, this position came through, and I got to do things the way I originally thought I could (more or less).

Acceptance

What is midwifery? Is it only possible to be a midwife if you’ve been a nurse during hundreds of births, many of which were probably complicated or high risk? I don’t think so.

It’s hard being one of the handful of people who graduated from programs like mine, that allow you to graduate without having to work labor and delivery, having to prove that you belong and that you can hang with the more experienced nurses. But I am not alone, and I’m grateful for others who blazed the trail before me — whether they intended to or not.

Midwifery is a whole lot of things.* True, the only births I’ve attended are the ones where I was doing the baby-catching (or doing labor support in a few instances). I haven’t seen a ton yet. My career is young. I am humbled by all I have to learn. But I have also worked in women’s health for over six years, and have learned compassion and to not judge women’s lives and choices. Midwifery is trusting women, it’s listening to women, and it’s being present with women. You can’t learn that from a textbook or demonstrate that on a board exam, but you can show it in the type of care you give. I am confident that, as one quarter of women in the United States will have an abortion before the age of 40, my background in abortion provides a ton of useful clinical and emotional skills to be a good midwife. Good midwifery care has to include all phases of the reproductive lifespan, including abortion. (And hopefully one day CNMs will be legally allowed to provide spontaneous and elective abortion care in all states!)

Now

Tomorrow will mark three months as a practicing CNM, but I think I’ve been practicing the midwifery model of care for more than that. I respect that other midwives took other paths — and they may have done so out of their own necessities. I hope that as I enter the birth setting again in a few months, when I get my hospital privileges, I can continue to safely develop my labor and birth skills and humbly continue my journey with new mentors and teachers.

 

*There are, of course, other paths to midwifery outside of nursing. I respect direct-entry or certified midwives, but I don’t claim to know much about their paths. I can only speak as someone that went the CNM route, and know that non-nurse midwives have their own contributions to women’s healthcare that may differ from where CNMs might be coming from (e.g. Ina Mae Gaskin).