Notes from a Reasonable Direct Entry Midwife
Today I had the pleasure of talking shop with my brother’s mother in law, Joni Dawning, a very experienced direct entry midwife in Eugene, OR. Joni has been attending births for over twenty years, and she has been a great resource to me over the years I have known her. I hold her in great respect, as she is the kind of midwife that I think is a great resource to her community. She provides a service to her clients that is greatly desired, but at the same time sees herself as a part of a larger system of birth service provision that includes hospitals and obstetricians. Unlike some direct entry midwives (or CPMs in some communities), she respects the limits of what she can offer, and does not see a hospital transfer as a failure in any way.
Recently in Oregon there have been some deaths during attempted breech deliveries at home, all attended by various home midwives of varying skill. Following this there was a discussion in the legislature about whether or not licensed midwives should be completely banned from intentionally attending breech births at home. Joanie wrote a passionate letter about the topic. She shared this letter with me, and to my surprise the letter was not in support of breech birth at home, but rather a plea that the legislature ban breech homebirth. She felt that too may midwives believed that they understood how to deliver breeches, not because they had experience, but because they were just ignorant of the potential risks and the techniques required to succeed. I some cases they just “believed in birth” and felt that the baby would deliver if one would just stand by and watch.
I have always felt that the more one knows the more one realizes what one does not know. I can say from personal experience that as I grow in experience, my knowledge of what I lack becomes only more clear. Joni is the most experienced midwife I know, and in her great experience clearly feels that she cannot safely deliver a breech at home, and chooses not to offer that service.
Here I republish Joni Dawning’s letter to the Oregon State Legislature for review and comment. Joni may be able to respond to comments as well.
“I am a lay midwife practicing for more than twenty-five years in Eugene. Recently, I received an email urging me to submit comments on proposed protocol changes. I tell you honestly that it has been an emotionally agonizing process to arrive at the decision to compose and send this letter. I wish to voice my support for placing breech delivery in the category of absolute risk.
We all enter midwifery with a profound sense of awe of the powerful natural forces of birth. Along with that awe is a sense that the medicalization of birth has detracted from the spiritual, emotional, and physical experience of childbirth for mother, baby, family, community and care provider. I will not argue with that.
I acknowledge that it is clearly possible for vaginal breech birth to occur safely, indeed serenely, and I grieve the inevitable loss of those birth experiences to protocol. I am however, aware of four infant deaths directly attributable to attempted home birth of breech babies. Anecdotally these births have apparently been associated with mistaken beliefs on the part of the midwives and their clients that these births were “normal”. The attending midwives reportedly either did not recognize or did not respond to early indicators of impending complications such as cord compression, footling presentation, and sacrum posterior position in such a way as to prevent these sad outcomes.
Though I believe deeply in parents’ rights of choice regarding both care provider and setting for the births of their children, I also believe that midwives have a core responsibility for self-identifying our own limitations in training, experience and skill as care providers for higher risk pregnancies.
In the mid-1980’s when I was younger and less experienced as a midwife, licensure was touted in discussion as legitimizing our profession. Legislators were told that passage of a licensure bill would mean assuring consumers of care that licensed midwives met knowledge, education, training, experience and safety criteria and thus, should be reimbursed by third party payers. Many of us felt concerned then that, along with licensure, would come protocols restrictive of birthing women’s choices of care.
Though I still believe wholeheartedly in choice, my experiences of more than a quarter century of practice have confirmed for me that it is a midwife’s responsibility not only to assist prospective homebirth clients in making fully informed, knowledge-based choices but also, just as importantly, to acknowledge the limitations of the care she can provide.
Prospective clients often ask a standard set of questions that includes “do you do breeches?” My response is that I believe it is my job as a midwife both to patiently safeguard normalcy and to identify and respond to known risks in such a way as to facilitate transfer of care to a setting where risks might be better addressed if they occur. Though midwives study the mechanism of breech birth in texts, workshops, and lectures to enable us to respond to an undiagnosed and rapid breech birth, it is important to recognize that because breech occurs so infrequently, supervised hands-on training in skills necessary to facilitate such births is not commonly available. I have safely delivered only two “surprise” breech babies whose mothers’ labors were so efficient that they were well progressed through late stage labor when the babies’ frank breech positions were discovered. I have transferred care before labor or transported during labor at least three times that number.
I have come to believe that midwifery and obstetrics are complementary callings and I practice with confidence knowing that I can facilitate my clients’ access to medical consultation or transfer their care in the interest of safety for a mother or baby. I believe that the local medical community trusts that I will endeavor to identify risks, inform and educate my clients, and respond to those identified risks before they become disasters.
Physicians in our community are currently willing to assist homebirth clients by providing ultrasound confirmation of breech position, offering external version when appropriate, and accepting third trimester transfer of care in the event of a persistent or late identified breech. Rarely has the experience of seeking consultative care, transfer or transport been anything other than welcoming and respectful of my clients, their desires for a holistic childbirth experience, and the sometimes difficult choices they have made to enter the medical system.
I am clear with my clients that current local standard of practice is delivery of breech babies by cesarean section; and that the standard is based upon a large cohort study that demonstrated increased morbidity and mortality rates for breech babies delivered vaginally. In contrast to the information I provide, one particular licensed midwife in the community reportedly says “they’ll just cut you!”
I trust that most midwives’ practices are self-governed by a commitment to provide care that is within our scope of experience, education and skill and I am profoundly saddened to have arrived at the point of advocating absolute restriction of practice in order to proactively assure that the disastrous behavior of a few individuals is prevented.
If you’re a radical homebirth supporter, I hope this provides a little perspective. If you’re a physician who thinks that all homebirths are dangerous, consider what is possible with the kind of midwife that knows what she is doing, and knows what she does not know. There is a happy medium, and in that medium great things can happen.