- We have to make it easier for people to know
if they're with a safe provider
and just the nature of how this works,
being with a CPM or a lay midwife
or a direct-entry midwife
is going to be a little bit less reliably safe.
(upbeat music)
I love midwives, do not get me wrong.
I work with midwives here in New Zealand every day.
I worked with midwives back in the States.
I just think that the way that we have such little oversight
and standardization of training for various types
of midwives is problematic.
So you can see here, certified nurse midwife,
Certified Midwife, Certified Professional Midwife,
Direct-Entry Midwife, and Lay Midwife.
These are all allowed to call themselves a midwife
in the United States.
Most midwives in the U.S. are certified nurse midwives
and certified midwives, and those would fall into a category
that do have oversight in training.
So certified nurse midwife
and certified midwives, CNM and CM.
These are going to be, like, top level of midwife
in the U.S.
This is what, in other countries,
would generally be considered a midwife as well.
The other categories we go over would not be categories
of midwives that are largely recognized
in other places in the world.
I mean, there may be some places, but not generally.
You have a graduate degree required to have certification.
For nurses, they go to nursing school first
and then they go on to get their CNM.
For certified midwives is a graduate degree,
but it's not a nursing degree.
Does that make sense?
So they both have high level education,
but one of them is a nurse and the other is not.
They have a certifying organization,
The American Midwifery Certification Board.
Nurse midwives are licensed in all 50 states.
Wow, I didn't know
only eight states licensed certified midwives.
Primarily attend births in hospitals.
Now, the reason for this is
because most hospitals do not allow people to attend home
or birth center births and also hospital births.
This is different from other places in the U.S.
and this is one reason that home birth in the U.S. is a bit
less safe than in other countries.
It's because whether outwardly visible
or not, there is an inherent incentive for people
who are delivering babies at home
or in birth centers to keep patients
there as long as possible.
I'm not implying there's a monetary incentive
from this standpoint.
It's just a subconscious desire
for the patient's best interest to be able
to stay with them.
And if you transfer to a hospital
where you don't have privileges,
you can't continue to birth.
The juxtaposition of that here in New Zealand where I work,
the midwives, if they are planning a home birth
and then they end up needing to come to the hospital,
the midwife comes with them and is still able to attend
and facilitate the birth in the hospital,
even if they require intervention from obstetrics.
Like I don't deliver babies here
unless I'm doing, like, an operative delivery forceps
or a vacuum or a C-section
because the midwives come with them and they get to stay.
Whereas back home, the good midwives would come
as essentially visitors or come
and help attend the birth
if they had to transfer a patient to a hospital.
But I would have midwives occasionally just drop people off
at the door.
No handover, I don't get any information
on, like, what's going on, what's been going on.
It's all secondhand through the patient,
which is not the best way to transfer care.
So this is a problem that would be needed
to be fixed on the hospital side.
Midwives who are certified nurse midwives
or certified midwives who are boarded
by the American Midwifery Certification Board
should be able to come with their patients
and deliver the baby in the hospital.
There's a lot of reasons that hospitals don't do that,
and a lot of it has to do with liability insurance,
applicability, getting privileges is complex
and that's just not what they've traditionally done.
But that has to change, it needs to change.
However, once you start adding in the fact
that there are certified professional midwives
only require the equivalent of a high school diploma
with some additional certification
from North American Registry of Midwives,
you have a bit of variation in these people's skill levels
that's more broad than additional CM and CNM programs.
There can be variation in all skill levels of all kinds
of healthcare providers,
but a lot of certified professional midwives will be capable
of providing low risk pregnancy care.
But there's a lot of variation in what the requirements are
for them to complete that program.
And so by saying that I would not personally use a CPM
and I would not recommend people use a CPM,
I'm not saying everybody who is a CPM is dangerous
or unqualified.
I'm not saying that at all.
I just think the general public doesn't have a way
of knowing that information.
And we have to make it easier for people to know
if they're with a safe provider
and just the nature of how this works,
being with a CPM or a lay midwife or a direct-entry midwife
is going to be a little bit less reliably safe.
I think the clinical requirements
for midwifery training are really interesting.
And again, I really want to reiterate,
I think that New Zealand's system of care
where every single person is cared for
by a midwife is superior to the United States.
I am very, very, very in favor of midwife care.
I think over medicalization of birth is a problem.
I think midwife should be primary caretakers for people
who are pregnant,
and obstetrics should be a consultation when needed.
I just don't think that the setup
that we have in the United States at the moment
makes that very safe.
So you're looking at certified nurse midwife,
certified midwife, and certified professional midwife here.
So graduate degree, certification does not require
an academic degree, but does have some competency
and specifications on knowledge and skills.
NARM requires that the clinical component
of the educational process must be at least two years
in duration and include a minimum of 55 births
in three distinct categories.
For reference, that is less than I did
in my first six months of residency,
and I was in residency for four years.
I don't know if that's enough or not.
I'm not saying it's definitely not.
I'm just saying that's not very many
'cause 55 birth may sound like a lot to people
who don't attend births.
There's so little congruency
across all of these various people
who can call themselves a midwife.
And I don't think that the owner
should be on the general public to decide
if they think somebody has enough training or not.
Being able to say I'm a midwife
should mean that you have enough training anywhere you go
to be a licensed birth attendant.
There's no possible way that you attend that many births
and get an understanding the breadth
of things that can go wrong and how to manage them.
No way, and I don't know what the requirement
is though for certified nurse midwives either.
So there's also a difference with the training
in that I don't know about CPM or CNM or CM,
but with us, you know, in the six months
that I first was in residency
and delivered that many babies,
I also was, like, peripherally involved
in hundreds more deliveries and daily discussions,
about 10 to 20 patients who were in labor or had had a baby,
and talking about the various complications
that they had had and how you managed them.
And, again, I'm not saying that midwives
should have the breadth of training
that we have as obstetricians, that would be ridiculous.
But I am saying that there is something to be said
for the way that the training happens,
whether you're in a big group environment
where every day, you're discussing 10 or 20 people
who are pregnant and the complications that they're having
and how to manage them
and in addition to that, you are attending births
and doing prenatal care versus just having these 55 births
that happen over the course of two years
or whatever, where those are the only 55 pregnancies
that you've even peripherally been involved in.
Does that make sense?
So I might have delivered 200 babies
in residency, but in addition to that,
there were a thousand pregnant people
that I helped decide the course of management
for their pregnancy and prenatal care,
which is a huge learning opportunity as well.
But that is less likely to happen
in small midwifery programs.
And again, I don't know that this is as easy
as just saying, "Oh, you need X amount to be capable."
I just don't think that all of these people
should be able to call themselves midwives.
I just think that it's misleading for the public.
And my whole point in this is not that any of these people
should be disallowed
from doing whatever it is they're trained to do.
I'm not one for gatekeeping.
I just think that the lack of a consistent meaning
for what level of training it is
when you are called a midwife is concerning.
And if it's confusing to me,
it's definitely confusing to the general public
who's trying to make decisions
on who is equipped to safely care for their baby.