[traumaRUs]

lovingpecola - I do sincerely respect your opinion (I've read some of your other posts too). I do agree with you on many aspects though my experience with midwives was related to my own experiences as a young expectant mother. My question is: if clinicals are not done at the hospital and you have no experience with complications, how do you deal with them in the throes of a crisis? My other concern is the liability? What kind of liability insurance must a home-birth midwife have??

I am in no way denigrating what midwives do. It is not my cup of tea but then that is the neat thing about nursing, ER nursing isn't for everyone either - lol.

Thanks very much for your intriguing post.

[lovingpecola]

Thanks for being open-minded Trauma!

As for the complications question: you do learn about complications (what they look like, what to do, why, etc.) in classes and through reading, but, in general, there are far fewer complications in homebirth than in the hospital. A lot of complications in the hospital are "hospital induced," meaning they are complications of interventions, if that makes sense. That being said, there are (of course) sometimes complications in home birthing, and that's when women would be transferred to the hospital to be collaboratively (hopefully) treated by their midwife and OB, with OBs having a lot of experience in the "complications" arena. Part of midwifery education (as far as I can tell right now - in my first semester, and talking with senior students) is knowing when to transfer. I HOPE SOMEONE ELSE ANSWERS THIS QUESTION, TOO!?? because I am in a CNM program, which means I *DO* have clinicals in the hospital, and will probably mostly be working in hospitals, so this is less of an issue for me personally.

As for insurance: That's sticky! Different states have different requirements for malpractice insurance. Some states have requirements, but no insurers offering the coverage. Sometimes the coverage is unaffordable (which is also becoming a huge issue for OBs, too, btw). So, even if recommended or required, some homebirth midwives don't have any. But also, traditionally, homebirth midwives haven't needed any either - because of the kind of relationship they have with their clients. And it is NOT required everywhere. Again, I hope someone else weighs in from the homebirth midwife point of view.

As for CNM insurance, the ACNM offers malpractice insurance, but for CNMs, too, it has been tough. It is sometimes not as big of an issue because CNMs often fall under the hospital's insurance plan (or it's part of their benefits package) from my understanding. But for those who must pay, the cost is rising very fast (as with OBs) and there are *VERY FEW* companies offering coverage.

ibambamama: I have heard that it's a hard to find midwife jobs in NYC because of oversaturation, also. The students who have graduated from my program say that the people who find jobs the fastest are those with the fewest restrictions on where they want to live! Experience as an RN can be good if that's what you want to do. You can also try to get experience in other ways, like doing an internship or externship at a birthing center or something while waiting/looking for a job...Nursing school is really hard (to me) and I can't imagine i would come back after taking a break, it just takes too long to get into the groove of it!

midwifeinthemaking: I do just want to let you know that the ivy CNM programs that I am familiar with (just two of them) don't really give homebirth training experience...just in case you thought you'd get a lot of it in nursing school...apprenticeship programs do, though! My point in saying that is you'd be suprised just how many differences of opinion there are in a group of 14 midwifery students! I think it's great, but it suprised me!

LP

[birthmamaew]

This is such an interesting topic, and a timely one too which I'll explain in a minute. I am currently in a CNM program after recently graduating form my BSN. This is a midlife career change for me, and one I feel is what I am truly meant to do. I think the point that needs to be made is that whether someone is truly ready for a career in midwifery has more to do with what experiences surrounding birth they have had. This doesn't necessarily have to be in the RN role.
I also knew going into my BSN that it was a path to midwifery after having both my children with midwives, one in a hospital, one at home, both in NYC loving pecola! From thoses experiences I decided to dip my toes in the water exploring other means of being around birth before making the committment. With 10 years experience as a doula, childbirth educator and a midwifery assitant for some home birth midwives, I knew I was ready.
It's pretty individual and experience can, but doesn't always need to include nursing to be valuable.
I had a very intersting conversation with one of my instructors the other day regarding this very issue. We have a little micorcosom of people in my program. Some BSN with no nursing, or other experience, some with BSN doula experience, some witih BSN and L and D experience, some with BSN and other nursing experience. In terms of how people are performing academically it doesn't seem to make a difference. Clinically may be a different story, I'm not privvy to those evaluations. Many of the L and D, (and non L and D, as well) nurses say they are having a hard time with the fact that they were once experts on their floors and it's difficult to make the transition back tothat place of not knowing exactly what you are doing. It's an adjustment. That's all.
We have courses dedicated specifically to complications in pregnancy and birth and are obligated to know how to treat those issues in order to pass.
Additionally we have a semester where we basically go to work with a single preceptor in her/his setting practice under their supervision for clients who are willing to have us there. I have seen complications in every setting, and midwives always amaze me at how calm they remain while effectively going about managing the complication. Grace under pressure.
In terms of insurance, each state is so different in terms of their requirements for homebirth midwives. The laws about homebirth itself really varies form state to state. It would be hard to make a sweeping generalization on that one. While I hope to work in a hospital setting, preferrably one with a birth center, if I were to have a homebirth practice, I would certainly want to have a poilcy. Statistics do show, however that nurse midwives are the least liekly to be sued by a pt. Again, I think it has to do with the relationship that gets formed during mom's care. Well, that and there isn't often anything to be sued over.
Whew, nice to be up for some air from studying ladies. Thanks!

[lovingpecola]

I just realized that in my last post I said something about "the students in my program" right after I said something about New York...I don't go to Columbia! Just wanted to clarify, in case people wanted to ask about the program! (But I do know two people there, if you need it LOL)

(I caught this after I pm'd you birthmamaew!)

[nizhoni]

I've been a homebirth midwife for 30+ years and have also worked in L&D, PP, nursery and ambulatory settings. I love doing homebirths. The model is very safe provided the midwife accepts as candidates low-risk women with good OB and medical histories and, of course, a healthy pregnancy course. As far as transfers to the hospital go, I have a long-standing reputation for not bringing in disasters. We want mama and baby to still be in good condition when we arrive at the hospital. I tell my students that they may not know why a complication is occurring, but they do need to be able to recognize that things have deviated from the norm. The three little words: "transport when necessary" are very important to the midwife!

As for malpractice insurance, I haven't had any for many years. I wish I could have access to it, but it is not available to homebirth midwives (either licensed midwives or CNMs). I do feel that homebirthers tend to "get it" about taking responsibility for their own births in a way that most folks don't, and the relationship between midwife and client is very important in supporting that.

Homebirth is legal in every state. Laws governing the practice of direct-entry midwifery vary, although more and more states are moving toward licensure and professionalization of direct-entry midwives. CNM practice is legal in every state but the laws governing CNM practice in some states make doing homebirths easier (or harder!) there than others.

[lovingpecola]

Nizhoni, I didn't know homebirth was "legal" in every state...I thought there were some states that had a "neither legal nor illegal" status? In Nebraska, tspecifically Omaha, the homebirth midwives are underground, and i assumed this was because we didn't have a clear law...do you know anything else about this? It's very interesting to me!

[nizhoni]

Hi Lovingpecola, I should clarify . . . . While it is legal in every state for parents to have a homebirth, the legalities of *direct-entry midwifery practice* vary from state to state. In some states it is clearly legal, in others it is clearly not legal. In some states it is legal by judicial or statutory inference and in other states it is not prohibited but not regulated either. Nebraska is an example of the latter category. For more information, see this link:
Direct-Entry Midwifery State-by-State Legal Status

Unregulated midwifery practice might seem like a plus to some people, but it actually poses a significant problem--I know, since I lived for several years in Utah, a state which also did not regulate midwifery until the midwives finally succeeded in getting legislation passed in 2005. The problem that midwives in unregulated states have is that, without legal status, midwives can (and are!) prosecuted for the practice of medicine or nursing or nurse-midwifery. This can (and does!) occur even without a bad maternal or fetal outcome. In Utah, the case that finally mobilized the midwives was one in which a well-known midwife was charged with 3 felony counts of practicing medicine without a license (5-10 years per count). In one case, she had performed an emergency episiotomy. In another she had administered Pitocin to a woman who was hemorrhaging. And in the third instance, she had administered O2 during a transport to the hospital for fetal heart tones that were problematic. There were no bad outcomes, and indeed she had acted according to the standard of care in midwifery practice. Unfortunately, since midwifery practice was not defined, all of her actions *were* definable as the practice of medicine. Certainly she was hung out to dry by carrying and giving Pit without having the authority to do so; and since oxygen is technically a drug, that was likewise a problem. Ultimately she plea bargained, but hers was the case that finally got the midwives to realize that any one of them could be the next case.

Nebraska has a reputation as being a "tough" state where midwifery is concerned. Perhaps the midwives can create the same success that Utah did, with what is widely considered to be one of the most favorable midwifery laws in the U.S. (It took four or five tries at the legislature and constant work in between sessions, but they did it!)

Having moved from Utah back to San Diego in late 2002, I can tell you that working in a state where midwives are licensed is much easier in a lot of ways. There are still some hassles, but overall it's a big improvement over the challenges we were having in Utah.

The biggest challenge we are facing in California currently is that licensed midwives are required by law to have "physician supervision." The California Medical Association insisted on this proviso in 1993 as the means of removing their opposition to the Licensed Midwifery Practice Act. However, the California Association of Professional Liability Insurers (a major trade association) has threatened any MD who provides LM supervision with revocation of their malpractice insurance . . . retroactive three years! Because of this interesting Catch-22, the Medical Board of California has thus far agreed not to pursue midwives who are practicing without physician supervision. An attempt was made by the MBC to redefine the term "supervision" but CAPLI threatened to sue the Medical Board of California (!!!) if they allowed that to occur. The MBC backed right down and turfed the matter to the Attorney General's office for further consideration. (I was at the meeting where that occurred.) That was about three years ago. Interesting, eh? So midwives considering legislative remedies need to make sure they avoid these pitfalls.

I would like to see greater cooperation between CNMs and LMs/DEMs where legislation is concerned. CNMs and direct-entry midwives often share many more commonalities than differences and it would be terrific if we could embrace that fact and work more unitedly. It has been my experience from 30+ years involvement in midwifery that CNM practices are also frequently targeted for elimination by those with whom they are in competition. While there are, of course, challenges to deal with in creating more unity between midwives, having a unified force would help to meet the survival issues faced by all types of midwives (and not only in the United States). You know, the more experience we gain politically, the more adept we become! Hat tip to those intrepid ones who take it on!

[hebamme]

Dear midwifeinthemaking,
I have both, nursing education, and I'm a UK midwifery graduate.
I worked as a nurse on and off for several years before becoming
a midwife, and I never liked nursing as much as midwifery.
Go for it,
hebamme

[gotnurse333]

Originally Posted by SebagoLaurel

I am getting very frustrated at the constant comments and advice to those considering advanced practice with no experience. While I do not for one minute doubt that 1 or more years of experience as an RN is a good thing, or even that they probably do have an advantage over those of us with no experience.

However, I just graduated with about 20 GM students with no experience in a Family Nurse Practitioner program. We have 100% pass rate on the exam and I believe just about 100% hiring rate after graduation. Many of us did clinicals with NP's with no RN experience (nor interest in it, nor felt anything missing).

I think the area you work in makes a difference. If planning to work in acute care or ER, probably experience as an RN in such a fast pace environment probably helps.

My only point is that more and more of us are joining the ranks with no RN experience (I had almost a year, but am SO thankful to skip any more - I think nurse managers have an obligation to treat new nurses like sh&*^, looking only for what you do wrong - heaven forbid a compliment for a rough, busy night spend successfully helping very sick patients). I am SOOO much happier working directly for a doctor - feel like I am being treated like a professional with a lot left to learn, versus a peon with no brains.

Some of my class got the NP (finished school and passed test), but are choosing to keep jobs as RN to continue getting the experience for their area, but at least dont have to worry about going back to school later.

I am sure I will be blasted for this, but I think we all need to get to the end of the journey in our own way. I just hate to see anyone motivated to move on stop and quit now. So many people find it hard to go back to school later - people get married, have kids, life happens. If you have the means and motivation to go on, go for it.

It is similar to getting your MBA. When I got mine, after several years of experience, it frustrated me to meet those who had the nerve to go for it with no work experience. How dare they! I had to work hard before I went - why shouldnt they? Well, I got over it. Yes, I brought a lot of experience to the table due to real world experience first, but you know what? Those I kept in touch with did alright. Just took a different route than I did.

SebagoLaurel, I am graduating this December with my BSN and planning to apply for FNP program following one year of working as a telemetry RN. I really do feel like new RN's aren't treated so well and the workload is just crazy so I want to get back to school and get an NP as soon as possible. But my concern is, how do I convince the admissions committee when I don't have the 10+ yrs of work experience everyone else does? I would appreciate any advice you have to offer!

[midwife2b]

So that's it in a nutshell. It's also the reason I feel qualified to say that, while it's terrific for RNs to have clinical experience prior to entering a nurse-midwifery program, it's not really necessary in order to develop competency since it's within the ability of non-RNs to do so.

I agree with this post. What is learned in midwifery school is not what is learned in an undergrad BS program.
My new partner had absoluely NO L&D experience prior to her acceptance at an IVY LEAGUE CNM program. It doesn't seem to have hindered her ability to find a job or be clinically competent.

I had 24 years of L&D/PP/NBN experience before I even thought about applying. We have a lot of dialog about our patients; while I believe I have an advantage because of my years of L&D I do have to remember a lot of that was high risk and preterm experience. SHe has current experience in normal, low risk births. It all evens out in the end.

Experience is nice but not necessary.