Friday, March 20, 2009

HBs, UCs, CNMs, and DEMs

(is that enough acronyms for one day?!)

Today I want to answer a couple of questions that came up following my post about birth centers, specifically comments about HomeBirth, Unassisted Childbirth, Certified Nurse-Midwives, and Direct-Entry Midwives.

From the comments:
"I'm wondering why would you choose a center and not have a baby in your own home??"
"A big reason to me NOT to choose a birth center, is precisely because they are under OB supervision. They are subject to protocol and liability issues, and usually have a strict set of requirements for using their services....Birth centers are great for a perfect birth, but then, if the labor and delivery are that easy, you should just stay home."
"I am in favor of the unassisted homebirth [intentionally birthing without any trained professional present]. I just like the privacy of it. I feel like birth should be more intimate, with family. I also think that a woman should be able to act upon her own intuition. And that is HARD to do when there is someone trained there (be it a midwife or an OB)."

Hmm, I thought I had explained this the first time. ☺
I grew up with homebirth. In fact, my mother's hospital experience with her firstborn (me) was such that she chose to have the other 8 kids at home. (Well, one was was born in the car...but that's another story!) Anyway, I was present for several homebirths during my childhood and teen years, and when we were engaged I told Hubby that I wanted to do that too. He thought it was a little out there but figured if I was doing the birthing I was entitled to call the shots. However, during my pregnancy with Bear we both just had the feeling that I should switch away from the homebirth midwife I had begun seeing and instead see a particular OB. I could speculate all day about why we were led to do that, but the point is that it was the right thing for us at that time and with that birth.
I feel that birth is a deeply spiritual event--we are partners with God in giving a body to a spirit (and getting a body is one of those eternally important things), so I do think that the choice of where and how to give birth is important. A lot of people focus on two people when making their birthing choices (mom and baby), but I include a third. I figure that if I want dad to be part of it all (and I do) then his feelings should matter as well. My Hubby is not comfortable with birthing at home at this point, and since I do have the birth center option, I don't think it's worth disagreeing about. I think it's entirely likely that I will birth at home one day, but I don't think it will be this time.
Also, as I pointed out in the original post, I do not have a jetted tub. I want to labor in a jetted tub darnit!

As for my thoughts about UC (Unassisted Childbirth) here is my response from the comments:
I know that proponents of Unassisted Childbirth feel that the presence of any outsider is a detriment, but I don't feel that way. I actually feel safer knowing that someone is present who is not emotionally attached to the situation--I don't care how much we've studied and prepared, if something goes wrong neither Hubby nor I can be fully objective because it's family. That's why surgeons don't operate on family members. That's why I never want a UC.
In all fairness, I do have to admit that every birth dream I have ever had was a UC. Not just a UC with no professional, but a UC with nobody--not even Hubby--in the room with me. So maybe I'm being prepared for something someday... Maybe at some point I'll plan a homebirth and the midwife won't make it and I'll have an accidental UC, but at least from where I stand now I have no desire to ever plan one.


Now onto the second topic!
My cousin left this comment:
Can you explain your preference for a direct-entry midwife, versus a CNM? I had CNMs for my two births and they were wonderful and helped me so much--and they were there for almost the whole labor both times.

I do not actually prefer DEMs over CNMs. (DEM= direct-entry midwife, CNM= certified nurse-midwife) I have no preference whatsoever. However, in many states the law has a great deal of preference, so that is why I was so pleased to hear that here in Alaska DEMs can get as much respect (ie, birth center privileges) as the CNMs can.
Here are the basic differences:
A CNM certifies as a nurse (2 years) and then becomes a midwife (around another 2 years). In her nurses training she spends time changing bandages, emptying bedpans, and doing other things that have nothing whatsoever to do with pregnancy or birth. CNMs almost always work under the supervision of OBs, and as such are subject to their policies (or the policies of the hospital), including forced timelines for laboring and so on. Due mostly to their background in nursing, many CNMs have a fairly medicalized view of birth. Many women find comfort in the CNM's more extensive training, and/or in the fact that she works in a facility with access to medications, interventions, and OB oversight.
A DEM does not go to nursing school. She goes directly to midwifery school. (Actually some 'granny midwives' do not attend any school at all, but just apprentice with a practicing midwife and sortof pick things up over time--some women are comfortable with this but I'm not.) DEMs focus all their study on pregnancy and birth, so on the one hand they do finish their training sooner, but on the other hand they usually spend much longer as 'interns' or 'assistant midwives' before taking the lead role at births. I feel that their more specific training as well as the longer time assisting is of great benefit in a caregiver. In my understanding DEMs are more likely to have a knowledge of herbs (some are trained herbalists), and they almost always have a more wholistic view of birth (rather than a medicalized one). DEMs attend homebirths and sometimes birth center births, and are more likely than CNMs to have experience with handling "high risk" situations such as vaginal breech or twin deliveries (CNMs are commonly required to hand those cases off to their supervising OB). In a number of states DEMs and homebirths are illegal.

I do not have a particular preference about being attended by a CNM vs a DEM. I do have a preference about where I give birth though, so depending on where I choose, that will dictate somewhat about who can attend me.


Mallory said...

I totally respect your choice. I can relate to a hubby with homebirth fears. And I think that the husband should have a major input as to where the baby is born! And God, too! Afterall, we are birthing these kiddos for Him! :D

Lisa said...

That is really great information. For example, I had no idea that CNM's at free-standing birth centers would have to follow more hospital-like policies (did I get that right?), and it never occurred to me that a DEM would probably have more experience with risky births than a CNM. I'll probably never actually need this info personally, but it is still something to think about.

Emily said...

I agree with your comparison of CNMs and DEMs. I don't personally have anything against birth centers; I was looking into one myself at the beginning of my last pregnancy. But overall, I just don't care for having parameters placed on my pregnancy/labor. Which is why I chose UC, ultimately. It just depends on your personality I guess.

In other news, I have nominated you for the Lemonade Award! Check it out if you want to accept!

Kelly said...

I live in one of the "enlightened" states that have outlawed home birth and DEMs. *sigh*

In the birthing community, at least local to me, we often refer to "CNMs" as "Medwives" [instead of "midwives"] because, here at least, they very often practice just like "Jr. OBs".

I think you have very sound reasons for making the decisions you've made! Good luck. :)

firefighter girl said...

I was lucky enough to have both my babies in a birth center with really great CNMs. Frankly, I wasn't comfortable at home because I lived in duplexes with thin walls, and I labor LOUD! I didn't want to have to think about anything else, like what the neighbors would think. And I wanted the option of definitive care close by if that were necessary- and in the first case, it was. But even as the CNM wheeled me into the hospital from the car, she hid MixMan under a blanket so he wouldn't be subject to various injections/eyedrops/etc.
Of course, this is Eugene, where bare chested women in birkenstocks and dreadlocks roam downtown in the summer, so there's no surprise there. I'd hate to have had my babies in any other state, though- I can't imagine not having whichever option I felt most comfortable with.

Jessica said...

I find it interesting to hear about women's experiences with different midwives - they can be so different, even withing the category of CNM or DEM. I had a CNM with each of my first two, but the experiences were very different from one another. My first CNM coached me through 7 hrs of labor and didn't let me get into the bed until I was ready to push (for which I am eternally grateful - I was so naive!). My second, though, just checked on me occasionally as I laid in the hospital bed for three hours in late labor, then put on a cap and caught the baby. I realize I was only there for three hours before pushing my baby out, but the CNM really didn't do anything different from a good OB, in my opinion. (Btw, my first was in ID, the second in WA)
This time I've hand picked my midwife team, who are both Licensed Midwives (I believe that's the same as a DEM, since they both graduated from the Seattle Midwifery School), and are much different from the CNMs. My LMs have a much greater knowledge of natural remedies for basic disomforts and illnesses, and actually advocate for all things natural in birth rather than just allowing it if you ask for it.
Anyway, sorry this is so long, I was just amazed at the differences in midwives through each of my experiences and wanted to share!

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