Over the past year, I’ve done lots of writing for the bridging programs I’ve applied to. It just sunk in that I have some ready made blog posts!
Following is part of a portfolio I wrote when I started the IMPP program back in November. It’s pretty dry, but it’s a nice overview of my career, and, unwittingly, an outline for future postings. Those future postings will include details-and the magic. Those funny little coincidences that lined up just right for the next step to fall into place.
IMPORTANT: Some things I say at the end of this writing are no longer true. Updates to follow in my next post.
The following narrative is a description of my path through midwifery and related education, including my initial motivations to become a midwife. I also describe my professional experience to date, my current motivations, and my short and long-term professional goals. I then identify and describe my past and current professional strengths and areas needing development, as well as my current transitional needs as I prepare for midwifery registration in Ontario.
I am lucky in that I knew at a young age what I wanted to do. When I was in the 7th grade I thought I wanted to be an OB/GYN; retrospectively, I know that I thought that because I didn’t have the word “midwife” in my vocabulary. I chose to go to nursing school because I received a significant scholarship and imagined I would apply to medical school. Also, my mother was a nurse, so going into the medical field felt very natural.
In my first semester of nursing school, my advisor suggested I do a paper about midwives. In so doing, I was able to put a word to what I wanted to do, and “midwife” was it. This allowed me to proceed through nursing school without needing to wonder, “what should I do?” I was fortunate to work in a tertiary labour and delivery unit as a nursing assistant for three years while in school.
If I had had my way, I would have immediately started graduate school after obtaining my bachelor’s degree. However, life had other plans for me, and I needed the work and the life experience. In the early and mid 1990’s nursing jobs were not easily found, not because there was no need but because of budget cutbacks. Labour and delivery in particular was known to be a specialty that was often closed to new graduate nurses. My first job out of school was in a tertiary level NICU, which I thought would be close enough to labour and delivery that I could be happy working there.
I was quite wrong. It takes a certain kind of nurse to work in the NICU the same way it takes a certain kind of nurse to work in the emergency room or in the burn unit. I left the job three months later. Even then I was able to see the value of my experience there, that I had seen firsthand what a truly sick baby looks like.
I began working in labour and delivery about one year after graduating, at the same tertiary hospital where I had worked as a nursing student, where I stayed for about two and a half years. While I never wavered in my desire to be a midwife, I had to put my midwifery ideals to the side in order to cope with the high risk, high volume setting where midwifery and natural birth were not valued.
I left this job for another tertiary labour and delivery, a university hospital that was and remains affiliated with my nursing school. My primary reason was for better pay and benefits, but a secondary reason was that I thought it would get me motivated to apply to graduate school. Within one month of starting, a series of doors opened that clearly pointed in the direction of graduate school.
From 1995, when I worked as a labour and delivery nurse, until about one year after graduate school, I was also a Navy Reserve Nurse Corps officer. One of the ways this experience shaped me is that I have respect for the chain of command, including that I am a part of it, and the ability to be a team player. While I certainly prefer decisions to be made by consensus, I am willing to defer to a group decision even if I do not agree with it if it is for the common good of the group.
Back to graduate school. In our first week of the midwifery program, I shared with the class that I may do home births in the future, but only after working in a high volume academic setting for the experience. I had been heavily influenced by Penny Armstrong, co author of “A Midwife’s Story” and “A Wise Birth”. The latter of the two remains a favourite of mine. Her path went from nursing training in the UK, to midwifery in the United States, to a home and hospital birth practice, to an independent home birth practice. Home birth was appealing enough that it became a goal, but I did not necessarily have an aversion to hospital birth, which seemed pervasive in the natural birth culture.
I did not imagine that home birth would be my first job out of midwifery school, yet that is what happened. I worked for Homefirst Health Services, a physician run home birth service with a long history in Chicago, for nine months, during which I attended about fifty births. We chose to part ways for a variety of reasons, but the experience from this job is a cornerstone of how I currently practice.
After Homefirst I worked for two and a half years as an employee in a two doctor, two midwife, hospital birth only suburban private practice. I shared 50/50 call with the other midwife. My physician sent me to a c-section first assist course during this time. I was let go due to the rising cost on malpractice insurance.
My next job was as a hospital employed CNM in the city of Chicago. The practice had 3 full time equivalent (FTE) midwives, 2 full time and 2 half time. A few months after I started to work there, the hospital lost a major board of health contract that was our primary source of patients. At that time, one of the half time midwives (hereafter referred to as “Jewel”) chose to decrease her hours to as needed labour and delivery coverage, and began to make plans to open a private practice she had been considering for years.
Several months later, despite many efforts to increase our volume, the hospital eliminated the midwifery service. In the same week, Jewel was seeing her first patients in her new office. I joined her at that time as a partner. Our collaborating physician was happy to keep our privileges active but we had to buy our own malpractice insurance. Simultaneously, a home birth midwife in suburban Chicago had to suddenly close her practice, and since Jewel had a history in the home birth community in Chicago, we started to get phone calls for women wanting home birth.
And thus our practice grew, from 30 births in 2005, 50 in 2006, 70 in 2007, and 80 in 2008. These numbers do not include those that risked out; our peak year, 2008, had 100 women registered for care that either risked out or transferred care for non-medical reasons such as moving. Our home/hospital ratio was about 60%/40%; after transfers are considered, that ratio was about 50/50. In 2006 we changed our affiliated hospital. In mid 2007 Jewel sold the practice to me and stayed on as an employee, and in late 2007 we hired another midwife. Jewel left the practice in 2008 to pursue teaching. In late 2008 our affiliated hospital abruptly closed, and with that closure we lost about 40% of our patients who wanted hospital births. Shortly thereafter I had to let go of our other midwife, in part because I didn’t have the volume to justify having a second midwife.
While managing my now solo home birth private practice, I approached several hospitals with my practice profile and was summarily ignored or flatly denied. Some OB department chairmen expressed that they may approve privileges at their hospital if I stopped doing home birth. After six months of closed doors, I made a conscious choice to stop trying until I could gather more internal resources, and to put more of my attention to my business and my existing patients.
In 2009 and 2010, I began to realize that not being able to get on staff at a hospital is a widespread occurrence in midwifery in the US. The same problem has happened in New York City, Connecticut, New Mexico, and New Jersey. The proximate cause in some of these situations was a collaborating physician who moved, retired, or stopped doing OB, or of hospital policies or bylaws changing in such a way as to make a private midwifery practice unable to continue in that institution.
In late 2010, I emailed the American College of Nurse Midwives (ACNM) for a membership related question, and as an aside I asked how many home and hospital birth practices there are in all of the US. The answer: 60.
It was then that I accepted that this is a systemic problem and I was not being uniquely persecuted. I also understood that I had unwittingly accomplished something remarkable-helping to build a home and hospital practice in a country where such a model constitutes a single digit percent of all CNM practices. I never intended to be a revolutionary; I just followed the next opportunity. The end result, until late 2008, was a home and hospital practice where I was, without question, the most professionally satisfied in my ten-year midwifery career.
Simultaneously, I realized that my business had morphed into something that, long before the business existed, I explicitly stated I did not want: a solo, home birth only practice. While I certainly could have rebuilt my practice, I talked with a midwife student whose husband was moving to Toronto, and her description of Ontario’s system of midwifery care is exactly what I want. I could work in a system where home and hospital birth midwife practices are not only the norm but also an expectation of the profession.
Once I gave myself permission to close my business, and not having any other ties to Chicago other than ten years of deep friendships, moving to Canada became a very easy decision. Given my personal experience and the experiences of other midwife practices, I concluded that it would be easier to move to Canada rather than engage in a David and Goliath battle with Chicago’s hospitals. To move virtually anywhere else in the US would risk the same set of problems.
My current motivation, then, is to work the way I want to work in a system that supports what I have to offer. The Canadian Midwifery Regulators Consortium website offers a side-by-side comparison of Canadian Midwifery Practice and common midwifery models outside of Canada. Virtually everything in the right hand/Canadian column describes my practice from 2005 through 2008. My practice was low volume, high contact, and independent; and I am a businesswoman as well as a midwife.
My short-term professional goal is to become registered and integrate into Canadian midwifery. After four years of business ownership, I want to be a worker among workers, learn Canadian midwifery, and enjoy the adventure of creating a new life.
My long-term goals are not as well defined, as my life has consistently taught me that following the next opportunity lead to outcomes that are vastly different from any of my own projections. At this time, my favourite long-term projection is to help Canadian midwifery with my particular skill set. While I don’t aspire to own another business, I like the idea of going to a province where midwifery is newly regulated, helping a new practice get started, and moving on to another. I’m not interested in the legislative aspects, just the business side of building a practice. I also would like to move to Vancouver; however, I understand that I will need to spend at least one year as a new registrant/supervised midwife in Ontario. My goal of getting registered as a midwife in Canada is a higher priority than moving to Vancouver.*
My strength, in the broadest sense of the word, is communication.* Written or spoken, individual or group, I am at ease. I form relationships easily, with patients and with colleagues. A strength that is linked to this is that I walk easily between the world of home and hospital birth. Indeed, in many situations I sometimes felt like an ambassador from one to the other; countering a hospitalist’s belief that home birth is unscientific and imprecise, or soothing a home birth mother’s fear of the perceived brutality of a hospital.
I am also skilled at delivering bad news with sensitivity. More recently, I have become more comfortable with directness and conflict resolution. Underneath all of this is a worldview that we are all in this together, be it baby having or life. It’s a paradigm that, generally speaking, has served me well.
More specifically, my strengths include my background as a business owner, my certification in c-section first assist, and my family planning background. While I understand that family planning is not currently within Canada’s midwifery scope of practice, two midwives, one from Ontario and one from BC, have mentioned that it is a long term goal of the profession to add family planning to our competencies. When that time comes, I am able to contribute.
My professional areas needing development are, broadly, learning about a new system, which includes the factual pieces as well as cultural differences. I am proceeding with confidence in my midwifery knowledge and skills, but am aware that I may be in for more learning opportunities than I am able to currently articulate.
My major transitional need is newborn care through six weeks. In my previous model I have not been responsible for newborn care beyond the first week of life. On a more mundane level, I am expecting the metric system and spelling differences to present a learning curve.
I appreciate the opportunity to be a part of this program and to proceed with achieving my ideal model of practice.
* THE IMPORTANT CHANGES:
Future goals: I have no flippin’ idea. I currently AM interested in legislation and getting involved with the AOM. Maybe I WILL move to Vancouver, but if my history is a prediction, I’ll be in Ontario for ten years. I seem to be on a ten year-ish cycle: I grew up in Florida for about 11 years, lived in Cleveland for ten years, and when I move, will have been in Chicago for ten and a half.
Communication and learning cultural differences: Interestingly, in a recent interview I said that communication may be my biggest challenge, in relation to learning about a different culture. I’m totally projecting the Canadian stereotype: “Those Canadians, they’re so polite.” I’m not impolite, but my directness can be startling to people. That’s not an American thing, it’s a me thing.
A cultural difference I’ve read and been told about between Canadian and US culture is that Americans are about the rights of the individual, while Canadian culture is more focused on the common welfare of all. One person told me, “If one kid is allergic to peanuts, no one else brings peanut butter sandwiches to class, and that’s the expectation.”
While that’s something to look forward to, I’m expecting that, sooner or later, I’m going to inadvertently say something that steps on someone’s toes. I’m pretty good at restraint of pen (or of keyboard, as the case may be), but sometimes my mouth works before my inner censor can stop it.