The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA
Better pregnancy nutrition can grow a healthier baby, keep perineal tissues intact and support VBAC
In my experience, there are significant
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This book was written by a couple who
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We are on call 24/7 but seem to manage a life. A cell phone and pager is necessary plus the ability to plan your time.
Each practice arranges off-call. Midwives usually have one weekend per month plus some days, then 2 months complete off call time. Varying models are being tried to suit lifestyle needs for midwife without compromising choice and continuity. I am sure that you will be able to include postnatal care as your remit is only up to 10 days.
It is important that each group have administrative support, to reschedule appts etc. when you are at a birth. You need to figure out caseload numbers and plan accordingly. I will tell you that it is much easier to care for women and families you know. It is also more rewarding. Managing your time is difficult at first, but then you discover that the artificial hospital schedules are eliminated.
BTW, most of our hospital birth clients go home within 4-6 hours.
I would strongly recommend that you get the One to One report by
Lesley Page and Caroline Flint's book , Caseload Midwifery ( I am
not sure of the full title) The Albany Midwifery Practice where Nicki
Leap used to be, had a good working system. The important thing to do is
to break into smaller groups, based on geography.
NARM Community Peer Review
Mothers Describe Their Dream Midwife
Policy for Second
Birth Attendants from the College of Midwives of BC
Safety In Numbers
- How many midwives at a birth? by Chris Warren from the Radical Midwives
in the UK
Trauma Stewardship - an everyday guide to caring for self while caring for others
In our area, midwives sometimes work alone at a birth.
What would happen if there were a problem with mother and baby at the
Yes, well, that would be a tight spot. But honestly, I have never been
in a situation like that in 22 years. And somehow I don't think it happens
a lot because all Dutch midwives work on their own. The doula will
come when called, but she can take 1 hour from our first call to the center
till her arrival at the clients house. And since home deliveries are often
multips who deliver quickly, often the doula will miss the birth.
But so far no-one here has started a discussion about how much better it
would be with two midwives at a birth.
I've done a number of births alone -- and a great many with assistants so "green" that it was almost as if I were alone.
There were a couple of years when I was the only midwife who would travel to some outlying areas. I learned a few tricks about packing and equipment and arrangements. I never felt it was a problem to have only one pair of hands. Even if an emergency happened.
It's nice to have another person to help, and it's nice if they know what they're doing. If it is another midwife, then I pay her more than an assistant because she contributes more (and it's a pleasure to have the company).
It's just a convenience though.
The midwife association in my region decided years ago that we would work in at least pairs "whenever possible" -- and that's really the reason it's still done here, I think. It's done that way because it's always been done that way.
I do think the only strong argument for the necessity of two people
on the birth team, is legal protection in case the midwife's version of
events is different from the clients. It's good to have a witness if something
unexpected happens. It can help avoid misunderstandings or false accusations
of conduct. Or even charges of mal-practice.
Any person who was ever alone with another might potentially face accusations years later. And there is really no defense -- other than making sure that you were never alone with them. Also it wouldn't be hard to see how a particularly vulnerable woman might conclude that the things a midwife might normally do (such as a vaginal exam) could be "sexual", or even "sexual abuse". Without the presence of a witness, how could the midwife protect herself?
So without asking for too much technical detail, how would you 'triage'
a newborn resuscitation with concurrent maternal hemorrhage @ your deliveries?
I've done births alone for years and never had to 'triage'. It
just doesn't happen. Something wrong with babe and that mom doesn't
lose a drop of blood. Mom got a problem? Don't hear a squeak
out of babe who just nestles with dad. Concurrent problems probably
only happen in the hospital.
Maybe you should buy a lottery ticket because you have clearly beat
the odds on this one; throughout my career this has been a recurrent scenario.
I am sure I could have muddled through all by myself and probably have
but with many of the hyper-vigilant bystanders present at births these
days, I would hate to try and defend myself if I was unable to resolve
this situation in a satisfactory manner.
When a midwife is being investigated, a common tactic is to find out
who the assistants were, go after them for info, then charge them with
crimes if they don't agree to "roll over" on the midwife. Worth pondering.
A list of
student midwife sites
Midwifery Today's Aspiring
DVD from midwifesassistant.com
In addition to the new edition of Training Midwives, there is now an
eBook version of the Birthsong
Midwifery Workbook as well as our two existing e-documents; Community
Midwifery Practice Guidelines and Community
Midwifery Procedure Manual. If any of you are involved in schools or
study groups, bulk pricing is available on all our products.
Advice About Taking On an Apprentice
What makes a Successful Apprentice?
How does one feel about their apprentices discussing births that don't
My apprentices are not allowed to discuss any birth with anyone other
than me. I encourage them to write up the birth, with all their comments,
negative and positive. Sometimes I learn from their comments and
sometimes I can explain to them why I did what I did. I often find
that an apprentice who feels strongly one way in the beginning, will often
change her mind in the end about some things.
I have a 3 month period where if it 'ain't happening' we/I can dissolve the relationship.
They work free until they demonstrate some helpfulness. Then it is very minimal pay, building over time. The most I've paid is $100.00, unless she works into a jr midwife status, and after she has gotten some hands on training, she is worth far more to me.
I have beginning midwife classes, where i may approach a gal and offer her an apprenticeship. usually someone from out of the area, because she won't get much business locally. My criteria? 4 things are absolute...able to do accurate bp, neonatal resuscitation, injections and bimanual compression. Major big heart helps too..
What do i really expect from my apprentice? Ability to be calm
and quiet, observe well and integrate, and look up in books what she sees.
I'm just curious how other midwives and apprentices work out money matters. I'm mainly talking to practices who do actually pay their assistants/apprentices when they ( the assistant) has become skilled enough to be of value to the practice. NOT THAT unskilled, or "green" apprentices aren't of any value. But most midwives do not pay someone who is learning the basics.
I'm talking about when an assistant has reached the point that she is ready to be a "primary under supervision" and she is on call for births as a midwife's primary assistant.
What is a fair policy if a client is slow to pay. Should a midwife get all of the money, until she has her cut and then pay the assistant, or should all of the money that comes in be divided up as it comes in. What if the midwife decides to do a free or reduced fee birth for someone. Should a primary assistant be expected to absorb that cost, or should she have the choice to opt out if she can't personally absorb all of the costs of being away from home, babysitters, etc.
I know that there are no hard and fast rules. But I would like to hear from other practices how these issues are handled. To the midwives: How much value do you attach to having a reliable assistant ? What kinds of skills do you need her to be able to demonstrate before she is valuable enough to be paid ? Do most of you have them, or are they a rare find ? When you do find them, what kind of compensation do you feel is fair ?
To the assistants: Have you and your senior midwife come to an agreement that works for you ? Please describe it. Do you ever feel like you are being taken for granted or not being fairly compensated for your service ?
I hope this will initiate some good discussion. Our practice will be
discussing some of these things tomorrow and because we are 2 midwives
and 4 assistants/apprentices we have a LOT to talk about. I hope to take
some of your suggestions and comments with me . Thanks.
I charge $250 to assist another midwife who is in the second year of primary practice, and I turned over most of my clientele in her area to her. She still works in my practice, does my billing, etc. The midwife who trained me helped me get going and I am just passing that on to someone I really love.
I personally don't charge apprentices. In fact, I pay them. But I expect a lot out of them. I start out training them to help w/ pp care and pay them $25/ visit once they are skilled enough to do visits without me there. They have to call in from clients' house (if they have a phone) or ASAP. Once they move on to attending births, they have responsibilities added as they master skills. I pay them $25/birth 'til about 25-30 births, then $50/birth 'til 75+ births (more if they are my only assistant there). $100-$125/birth til 100+/CPM/Mi MWs certification. $25 per prenatal in Amish client's home w/o me once they have mastered pn skills. They get "profit sharing" bonuses when they cover phone calls or appt. days while I am gone, or for special conferences. They are dependable, responsible, help out a lot, and usually worth every penny. In 1996, it averaged out to $300-350 per birth to associate midwives and $100-125 per birth to my apprentice who just attended her 60th birth.
Because of them (and it took all 4 of us!), I could attend 2 births,
make sure 11 prenatals were covered, and teach birth classes to 5 couples
in 7am to 10pm - all in the same day last Tuesday!
I agree that money matters are often very difficult. In my practice when we take on a new apprentice, we explain that we are already living well under the poverty level and cannot "give up" anything that we earn for the apprentice. We also point out that the alternative of going to formal midwifery education at a University will cost the apprentice a significant amount of tuition that she will "save" by being an apprentice. And, that the costs such as transportation, childcare, books, equipment and so on are common to both kinds of "educational" experiences. I find this issue to be a morally difficult one - I hate feeling as though I contribute to unfair exploitation of women who desperately want to be midwives - taking advantage of their excitement and desires, recognizing that we often get quality work from apprentices/students and do not pay for it. And yet, I have to be realistic - when I look at my 1996 tax return and realize that my taxable income was only $4500 and I had 20+ primary clients and did backup for 40+ births - I know that I cannot find ways of further reducing my income and still pay rent, buy food, feed my car, and so on.
However, there are some exceptions e.g. if we end up having to "use" the apprentice's assistance in a way that is beyond what we have agreed to be the usual apprenticeship experience such as having her teach extra prenatal classes because we are at a birth, we do compensate her for these services.
Our regulations (we are not yet bound to complying with these, but do try to follow them where possible) require that we have two midwives at each birth. So, our ideal is to have two midwives and to have the apprentice there as a third person even though the apprentice may actually be doing a significant proportion of the "work" if she is nearing the end of her apprenticeship. We may have a nearly finished apprentice act as the second midwife - but generally only when there is not another midwife available - and will compensate for that.
Once the apprentice is at a point that we (midwives and apprentice) think that she is ready for supervised practice, the arrangements really vary. Right now, none of us can afford to "give away" clients - we even have some uncomfortable situations occur in practices where one midwife seems to always have the lions share of clients and the others are sitting by the phone sending messages out to the universe that they are getting hungry and the bank is wanting money - so, for supervised practice, the arrangement is often - if the supervised midwife can "find" her own clients then she can charge them and pay a backup/supervising fee to one of the midwives. But, if she is getting her "clients" because one of us has found that one of our clients is willing to involve her in the care in this supervised role, then we collect and depending on a discussion among all the midwives, may share some of the fee with the supervised midwife. It seems harsh, unfair but I'm not too sure how else we could manage it financially. When one of our apprentices reached the point of supervision, she wanted us to just divide the "backups" so that she would get to and paid for a equal proportional share of these - but, because that would result in a significant decrease in earnings for all of us, we did not agree. She left and has not been able to find another practice that will agree to her expectations.
I suspect that this would be very different in a situation where a midwife
practiced on her own and was looking for reliable help. When I first joined
my partner, I know that I was able to negotiate a significantly higher
backup fee with her than she had originally proposed because at that time
she was on her own and I felt that while I certainly wanted to join her
practice, it was not worth my while to be on call all the time for such
a small amount of money. Especially when I knew that it would take me some
time (about 2 years actually) to really start to build up my own client
load so that I had primary midwife fees as part of my earnings.
Around here, it is pretty common for the midwife to collect her own
fee from the client , and the assistant collects her own fee. If the MW
accepts a reduced fee, the assistant may never even know about that arrangement
and is usually paid her full fee (350-400$ around here). The assistant
is encouraged to collect her fee at the 36 wk home visit, although that
does not always happen. The asst. does the 36 wk visit, attends the birth,
and does one of the PP visits. Most of the MWs are pretty good about reminding
the parents to pay the assistant. An unskilled, just starting out assistant
usually attends births at her own expense. The paid assistants are certified
in CPR and neonatal resus.. I heard about a local hospital oriented doula
who had only been to a handful of births and is charging $500.00. Now why
can that happen when a skilled home birth assistant, and sometimes the
midwives HOPE to get paid SOMETHING?
I find your questions very interesting. What is the value of an apprentice/assistant? What is the value of a preceptor/teaching midwife?
I do not pay any monies to apprentices. What I do is spend hours and hours with her teaching her, instructing her, reviewing her academics, providing her with invaluable experience, etc. If she were to pay for a program which supplies those things, she would not be able to afford it!
I do not take advantage of my apprentices. She is never expected to do any chores or assignments which are not midwife related. There are, often, exercises which at this point resembles some of the exercises seen on the movie Karate Kid (wax on, wax off).
Almost everything I do takes twice as long because I double check everything from charting to supplies to sterile technique.
So why do I take the time to apprentice? One day that apprentice will cross the line to become a fully qualified midwife. At that time she will be available to assist me at births. I pay fully qualified midwives $150.00 per birth to assist. They are called near the end of 1st stage labor and is released to go shortly after the delivery of the placenta. Sometimes that is only 2 hours, sometimes it is 8 hours. It seems to average out.
For the hundreds of hours I put into her training, I do not receive a dime. For her hours of assistance, she receives a plethora of experience!
Every midwife is different in this area none of which is either right
Thanks for your interesting reply. In our practice, the apprentices work, and are very self-motivated in our study. Our midwives teach us at a once-a month study group, and at births, but really don't have time for us to "sit at their feet and be a sponge". I'm sure you do spend a lot of time with your apprentice, and it is worth it to her to work for you as a trade off. But it's very different with us. Our midwives simply could not handle the demands of our busy practice without our help. We cover 1/3 of the geographical area of NC, and do about 50 births a year. We also have 31 children between us !!
When someone really green comes in they don't get paid until they've been to several births and done a lot of pre and post natals, and demonstrated a desire to pursue some related form of study as an individual. For example, 2 of us are certified birth assistants, one of us is a lactation consultant, and one of us is a certified childbirth educator.
Thanks to everyone for all of your input. From the sounds of it, I think
I'm in an enviable situation since I'm paid quite well ! I'm very thankful!
I would like to know what your opinion is on how to ask for an apprenticeship,
and what exactly should be spelled out as far as expectations before
the apprenticeship starts.
Actually, I was thinking about going into midwifery myself, after my newest arrival is old enough. I've thought long and hard about what kind of person would make a good teacher, and this is what I've come up with:
I have to say I disagree with you here. Being a good midwife and being
a good teacher do not necessarily go together. I apprenticed with the midwife
who delivered my babies and only found that she was very, very different
in that relationship than she was when she was my midwife. In fact, that
was a huge part of the problem. I had put her on a pedestal, and came to
find that our dynamic as student/mentor was not consistently harmonious.
I was devastated to have to come to terms with that reality. However, we
love each other immensely and respect each other's talents and we are MUCH
BETTER when we are not working together in the capacity of teacher/student.
I don't like her style of teaching at all. She is a brilliant midwife,
but she did not teach me the way I needed to be taught; and she admits
now that she didn't know how to teach me either. She was frustrated with
me because I could not be how she needed me to be, I did not have the basic
foundation she needed. I was also constantly tormented in that relationship,
and really gave my power away. Although it was tumultuous and painful,
she admits now that I helped her get clear about what she needs and wants
in an apprentice (I was her first). I , too, am more clear about what I
need and want in a mentor-midwife. I am working with someone new now, who
has a very different personality type and WAS NOT my midwife--I will let
you know if it it works out.
Many of our local midwifery students are very frustrated about finding preceptors. Here's something I wrote to one who was lamenting the large number of midwifery students relative to the number of local midwives:
It's not just the number of students looking for midwives. It's the clients themselves. I know that it's not always easy to think from their point of view when you haven't been through many cycles of bonding with your clients, but if YOU were having a first baby or a first homebirth or a first waterbirth, how happy would YOU be with a student midwife at your perineum?
Students would have to offer a significant monetary incentive to the families . . . around $1000 each, I would think, in order for the mom to have the student catching instead of the midwife if it can mean the difference between tearing and not tearing.
The populations that are well suited to the apprenticeship model are those where women are having many babies, and by the time they get to their 3rd or 4th, they're happy to have the apprentice who was at their 1st and 2nd births catch their baby, especially if she's provided some prenatal and postpartum care through previous childbearing cycles. This just isn't going to happen in our local population.
This is why the El Paso clinics are such a boon . . . they offer a win-win for the birthing women and the student midwives.
After I got back from El Paso, I dreamt about opening a similar birth center in this area, so local students could gain experience with Medi-Cal clients, who might not be so picky about their care as the more typical homebirth client. Well . . . it's hard enough for ANY birth center to make it in this area, let alone a teaching birth center. So, I'm still waiting to win the lottery in order to realize that dream. Fingers crossed!
You might ask on the apprentice lists about how other students have found practical opportunities.
As an aside, I think that some of the midwifery schools do students a disservice to lead them to expect to be able to find a local apprenticeship opportunity. I truly have NEVER heard of it in this area. Really, truly, seriously. That doesn't mean it hasn't happened, but I don't know anyone who didn't have to go to El Paso. It's a bummer, believe me. I was 38 when I went, and that was a difficult adjustment, but I made it through and am glad of the experience.
As another aside, the births in El Paso are much easier than most of the births we see here, with our over-stressed mamas. It really is a good place to get experience, for a lot of reasons.
Again, the apprentice lists would be the place to get current information.
I have tremendous compassion for midwifery students who are so full
of the desire to help women and are so frustrated that they can't seem
to find their next step on their midwifery path. If it helps, you
can think of this as the prodromal phase of your own labor and can be a
lesson in working with women when the opportunity comes.
Okay, here's what I wrote up as guidelines for accepting referrals from other midwives (in the case of referring midwife being out of town when client is due or if midwife lives far away and client is having fast labor, etc.):
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