Homebirth midwives exploit poor women of color in developing countries

Got ethics ?

The good news is that homebirth midwives are beginning to recognize that being an “expert in normal birth” is meaningless. Any taxi driver can preside over an uncomplicated birth. Women hire birth attendants to prevent, diagnose and manage complications and homebirth midwives have zero experience with that.

The bad news is that homebirth midwives are trying to get that experience by exploiting poor women of color in the developing world.

That’s the explosive charge leveled at Midwife International by The Alliance for Ethical Midwifery Training.

What is Midwife International?

According to its website:

More than 58 countries lack enough qualified midwives to provide timely access to skilled healthcare for mothers and infants. Our solution is to train midwives who are equipped to work in resource-constrained regions where maternal and child mortality is high and the need for professional midwives is greatest.

Not exactly. Midwife International is a midwifery school, charging exorbitant tuition, using poor women of color as a source of complicated cases, and providing nothing in return.

For this privilege, American students are charged $19,000/yr, PLUS books, supplies, travel, insurance, accommodations, and living expenses.

Midwife International managed to corral a who’s who of American homebirth midwifery into supporting this scheme. Board members included Aviva Romm, MD, Jan Tritten, the editor of Midwifery Today, and Robbie Davis-Floyd, among others.

But, according to The Alliance for Ethical Midwifery Training:

The communities MI claimed to be serving were exploited for the benefit of the MI students and the considerable profit of MI, furthermore, host sites and local midwives were taken advantage of and at times blackmailed into compliance.

How?

… MI is alleged to have:

  • Used bribery to undermine the host site Directors and their programs and to de-stabilize the local programs and clinics:
  • Taken back much need supplies and equipment if the host site Director would not comply with MI’s demands;
  • Negotiated secret agreements with host site midwives to give priority to MI students (many of whom are in the first steps of early midwifery training and whose skill level, in some cases, could best be described as elementary) over their own indigenous midwives who are being trained to meet the ICM Millennium skill goals; and
  • Not compensated host sites at the rate initially negotiated, nor reimbursed host sites for modifications made to their programs and sites in order to accommodate the MI program. In addition, the demands made by MI for accommodations and life style issue for the students and preceptors were unreasonable given the realities of the countries in which the MI students and preceptor would be living.

The website contains testimonials from the women who run the clinics for the underserved and they make for very disturbing reading.

The Alliance identifies the key problem with first world laypeople learning midwifery on third world women:

There is a structural violence that occurs when a person from the west attempts to learn on those who have less power and privilege than they do. There is a long history of exploitation of Black and Brown bodies for the purpose of western power and gain. There is also a long history, even within midwifery, of silencing those who speak out about these issues. What has happened here is that an institution has been built based on each of these acts of violence. We refuse to be silenced. We stand together to share the stories of what has occurred…

The behavior of Midwife International, if true, is starkly reminiscent of the behavior of Big Pharma. The rules and regulations for testing new medications on people from industrialized countries are onerous and expensive because the governments of those countries want to protect their citizens from exploitation. The same protections do not exist in many countries of the developing world, so pharmaceutical companies often test their products there.

Similarly, the rules and regulations for midwifery training in first world countries are appropriately onerous for a profession responsible for the lives of babies and mothers. Hence, the certified professional midwife credential (CPM) is considered inadequate by ALL first world countries, and CPM trainees are not allowed in hospitals where to gain clinical experience. The same protections do not exist in many countries of the developing world. How much easier, then, to foist uneducated, untrained laypeople on those countries.

In light of these allegations, several board members, including Aviva Romm, MD, have resigned, but one must question their judgment for signing on in the first place (and ask if financial compensation was paid to them for their board positions).

The fundamental ethical question remains, however. Is it ethical for homebirth midwives, who cannot meet the standards for education and training of any industrialized country, to “practice” on poor women of color in developing countries? It could possibly be ethical if proper safeguards were put in place, but it is not clear if homebirth midwives would be allowed to care for poor women of color in developing countries if proper safeguards were put in place.

The bottom line, as always, is that the CPM credential should be abolished. There is no need for a second, inferior class of midwife in the US, and there is certainly no need, or benefit, to a second, inferior class of midwife who learns about pregnancy complications by preying on underserved poor women of color in developing countries.

  • CNM

    The Ethical Alliance has posted an update based on the response from Midwife International: http://ethicalmidwifery.org/updates/

  • An Actual Attorney

    OT – yes, CPMs, doctors are actually prosecuted when they kill patients: http://www.sun-sentinel.com/news/palm-beach/fl-pain-doctor-death-penalty-20130903,0,5608603.story

    The state is seeking the death penalty for this guy. I’m not a death penalty supporter, but it does give me ideas…

  • T.

    OT: But this: http://www.cafemom.com/articles/in_the_news/160514/mom_who_was_ordered_to?utm_medium=sem2&utm_campaign=prism&utm_source=outbrain&utm_content=0

    Boggled my mind. Not the actual article, mind you, but the number of comments claiming that it was not breastfeeding that killed the baby and that it was an attempt to bash breastfeeding. Oh my…

    • CSM

      “Methodone”. Grrrr.

    • Sullivan ThePoop

      I do agree that article is bad and does not give all the information. You can take methadone and breastfeed if your infant is being monitored. The real problem was she was taking more methadone than she was supposed to, her child was not being monitored and she was taking other drugs.

      • stacey

        No, the real problem wasn’t the methadone, it was that she BFed while on methadone, another pain killer, AND Xanax. That is a deadly combo, for her as well. And the methadone was likely illegal, because if it had been an RX she would have been monitored more, and would have been able to keep BF while on it. Methadone treated moms are encouraged to BF BTW.

        She should have just used formula, and avoided the deadly drugs that come out in breast milk. This way she could have avoided killing her baby.

  • Dr Kitty

    I did an international rotation as a 4th year (out of 6) medical student ( a month in Broken Hill NSW- where I did EXACTLY THE SAME as the medical students on placement from Australian Medical schools were doing) and a month in a rural hospital in India ( a sister Hospital of Jeevan’s organisation, where we worked as surgical assistants for the most part).
    At no point was I unsupervised or acting independently.
    We paid our own Food and board directly to the organisations involved and as well fundraised to give money directly to the organisations in developing countries (Jeevan’s organisation got £3000 from the 3 of us in my group).

    I feel OK about my overseas electives…but I wouldn’t have done if I’d just been let loose to do my own thing.

    • Captain Obvious

      Our hospital has a mission that goes to Haiti every year for two weeks. Only doctors and nurses go. Equipment and supplies are donated by local hospitals and clinics. Everyone is fully trained and volunteering their time. No one is “practicing” on the Haitians.

  • Ducky7

    This is disturbing. I don’t take it as an indictment of midwifery practice in general, but I do hope it is a wake up call to prospective international volunteers and “service learners” everywhere. We often have a perception that in many places of “need” it is better to have an inexperienced “educated” outsider go and roll up their sleeves however they can, than to find ways to invest in local human capital. In my experience in a country saturated with foreign volunteers (Guatemala), that is just not the case. More often than not, volunteers receive much more than they give, and don’t even realize it. (And unfortunately, their placement organizations often receive the most of anyone, especially in the case of paid programs.) International aid on a small scale is most successful when outsiders make a long-term investment and commit for the long haul to supporting *local* education and professional development – when outsiders come in and learn off of locals it is entirely counterproductive.

    If you are going to “volunteer” abroad, you better damn well:
    (1) Already *have* a professional skill-set that *locals* in the place you’re going consider useful — and if not, be willing to bend over backwards to try to find ways to be useful to the people hosting you.

    (2) Think critically about what you are taking from the host site, and if you are giving back a fair amount in return, financially or otherwise.
    (3) Be willing to stay awhile. If you’re there less than three months, you’ll have no clue whether what you’re doing is constructive or not. 3+ years would be optimal.

    • Clarissa Darling

      I was listening to a radio program where the host was interviewing
      a travel writer about “transformational” family vacations (as opposed to a pack the kids in the minivan and head to a commercial tourist destination family vacation I suppose). I was so disgusted to hear the writer say that the next time he traveled to Africa he wanted to “book
      time” in an orphanage so his kids could interact with the locals and gain a sense of perspective about how underprivileged children lived. Here was a guy who looks down on people who take their kids to Disneyland essentially treating the HOME of impoverished children as an entertainment complex of sorts for his own privileged kids. It seemed he was motivated less by a desire to help and more by a desire to have his kids check the “good humanitarian with a global perspective and appreciation for non-western cultures” box on their list of characteristics. I commend people who volunteer abroad as they often perform a much needed service but, I do worry that those who are not doing it for the right reasons have the potential to do more harm than good.

  • Jessica L.

    As a student midwife myself (one who has a great deal of respect and appreciation for physicians and a desire to have a collaborative and friendly relationship with them), I am very concerned about the alleged practices of Midwife International and if what is being said is true, I think they need to be shut down immediately and need to pay back the moneys owed to the international host sites. However, to use the apparent corruption of one organization to state that the CPM credential should be abolished is beyond absurd. If you want to make some other argument about why the CPM shouldn’t exist, you should do that. But the argument you make here really doesn’t deserve the time of day. Do we not remember the many disgusting things done by physicians throughout history? Surgical experiments on African slaves, Tuskegee, medical experiments during the Holocaust, syphilus experiments in Guatemala, these are just the beginning. What about the OB-GYNs who coerced at least 148 female inmates in California prisons into tubal ligations between 2006 and 2010? Does this mean there should be no more OB-GYNs or other doctors? That would be absurd. If you’re concerned about “preying on underserved poor women of color in developing countries,” you should remember the history (including the very recent history) of your own practice. It’s important to note that before you began addressing the issue of Midwife International, plenty of CPMs, CNMs and others from around the world (including people from the host sites working with MI) were already outraged, writing about, and working to stop the harm caused by Midwife International (see http://ethicalmidwifery.org/). Midwives are not going anywhere; we love what we do and the women who work with us love what we do. Physicians and midwives will continue to inhabit the planet together; a little mutual respect could go a long way.

    • The Bofa on the Sofa

      If you want to make some other argument about why the CPM shouldn’t exist, you should do that.

      Apparently you are new here.

      • Guestll

        +1

    • moto_librarian

      This only serves as further proof that the CPM should be abolished. It is a substandard credential when compared to the CNM.

    • moto_librarian

      So Jessica, are you studying in the U.S.? If so, are you working towards a CPM or a CNM?

    • CSM

      Why is it that when midwifery is being criticized, the answer frequently is ‘Medicine is just as bad’? I remember conversations with my preceptors:
      - Oh look, we misinterpreted this research.
      - But Dr XYZ does it all the time!
      - Oh look, this was a near miss.
      - But hospitals have them all the time!
      - Black cohosh tincture from a herb shop isn’t necessarily safe.
      - What? Remember Vioxx?
      There has to be a name for this particular logical fallacy. Does anyone know?

    • stacey

      It is not absurd, and Dr AMy has argued against the CPM many times.

      CPMs are not real MWs, they are NOT qualified, nor allowed, in any other developed nation. A CPM cannot even go to a country that uses MWs for all pregnancies either! The rest of the world has standards. there is no need to respect unskilled providers.

      It is NOT about OBs and MWs on the same planet. It is about OBs, MWs, and undertrained birth junkies (CPMs…). CPMs have no business near pregnant or laboring women, they are a menace. ALL the data points that out.

    • CSM

      Sigh. I’m in a melancholic mood today and the last sentence made me wanna post again. I don’t see how docs are going to respect someone who claims to be ‘evidence-based’ while essentially believing in magic. You know what my school’s graduation gift was? A homeopathy kit. I cried a little bit. I’m talking about registered midwifery here. Although I heard University of Toronto is looking to introduce woo into med schools…whatever sells, I suppose. Come to think of it, our minister of science is a devout Catholic and a chiropractor, how awesome is that?

    • KarenJJ

      ” Do we not remember the many disgusting things done by physicians throughout history? Surgical experiments on African slaves, Tuskegee, medical experiments during the Holocaust, syphilus experiments in Guatemala, these are just the beginning. What about the OB-GYNs who coerced at least 148 female inmates in California prisons into tubal ligations between 2006 and 2010? ”

      Why the hell is this an argument against Dr Amy’s post?

      This goes back again to midwives comparing themselves to doctors and saying ‘well look what they got away with’. So what? That doesn’t mean midwives should be able to do it now. I have no mutual respect for midwives (or doctors or whoever) that support such practices.

      And it’s good that midwives are going nowhere. CPMs however are not midwives. Not where I live.

  • Susan

    I just read that on that site that some of the Board members you named have resigned–

    Responses from Advisory Board Members who have resigned:

    From: Vicki Penwell

    To: The Alliance for Ethical Midwifery Training

    In light of the recent serious allegations against Midwife International from numerous sources, which I just read in full from the ethical midwifery website tonight, I have just written to resign from the advisory committee of Midwife International, a role that I held in name only, as I was never asked to advise in any of the situations now being brought up as unethical.

    My entire life’s work has been a fight for justice and compassion, and to advocate for and model the ethical and respectful care of women, especially those who are disenfranchised and marginalized surrounding pregnancy and childbirth.

    I pray that MI will answer these charges in a transparent and honest fashion as soon as possible, and make right everything that needs to be made right for the clinical sites they were involved in, and the students they enrolled.

    My heart is heavy and full of tears tonight…for our sisters everywhere…

    Vicki Penwell

    From: Elizabeth Davis

    Dear Committee,
    As you may recall from the last conference call I attended, I was disturbed about certain aspects of student supervision and instruction in several international training sites utilized by Midwife International. In light of the current controversy, as well as a general sense of not receiving full disclosure on these issues, I too must resign from my participation in any capacity, effective immediately.

    I do hope you will be able to clear and resolve these issues in a timely fashion.

    Sincerely yours,

    Elizabeth Davis

    From: Aviva Romm

    To the Midwifery Community,
    Earlier this year I accepted a volunteer position to join the educational advisory board of Midwifery International. While the position includes a nominal payment, I declined to accept any money prior to joining and instead asked that my pay be donated back to a midwife in need seeking education. Sadly today it has come to my attention that MI has come under serious accusations from members of the midwifery community. I was unaware of any issues until today– none had previously been brought to my attention. I had heard of no grievances or wrongdoings and I have resigned given the lack of clarity in the situation. I do hope that this situation will be peacefully and easily clarified, and if any rectification need be made, that it be done. I really have no idea what the issues have been and have had minimal contact with the organization. I just wanted to share that I am not in any way involved with MI so please send your concerns and grievances directly to MI.
    Peace,
    Aviva

    From: Robbie Davis Floyd

    I no longer serve on the MI Advisory Board, which has been disbanded in any case, and do not wish to participate in any way in this ongoing discussion/controversy. I cannot possibly inform myself well enough about all the issues involved to be of any use at all in this ongoing situation. I ask that you please remove my name from any mention on your site and cease any communications with me. PLEASE!”

    From Robbie Davis-Floyd

    • moto_librarian

      Pretty clear that they are in full CYA mode now.

      • The Bofa on the Sofa

        Actually, what is even more clear is that the whole “MI Advisery Board” was a complete sham.

        • Deborah

          Yes exactly. The Board you have when you don’t have a Board. Helps create the illusion of professionalism……just like the CPM “credential”.

        • AlisonCummins

          Interesting that the people on the “board” claim they don’t have the time to look into the issues and they never took any initiative to inform themselves about the practices of the organization. It sounds like they were waiting for calls: “hello Board, I’m about to do something unethical, we’re cool with that, right?”

          My first thought is that board members should be paid so that they can afford to make themselves available. Saying that you declined payment and couldn’t be bothered to do a job you weren’t being paid for doesn’t make you look good, it makes you look unprofessional.

          • KarenJJ

            Yeah, it’s a professional masquerade. We want to look good to other people that pay for our services, but don’t want to take any responsibility for actually improving anything for women and babies.

      • Captain Obvious

        Watertub, I mean watergate, er, waterbirth?

    • PrimaryCareDoc

      Interesting that Aviva Romm makes it clear that she wanted her salary donated to a student midwife in need. Clearly MI never did that, as they make it very clear on their website that there is no financial assistance available.

    • HolyWowBatman

      Wow, Vicki Penwell, that’s a name for you right there….pot call the kettle black much?

  • Susan

    I wonder if the Human Rights in Childbirth people have a position or will they continue to act like they should be named Midwife Rights in Childbirth?

  • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

    ugh they can do anything they want to those women. Psychos who want to abuse or try out new techniques will flock to this kind of program.

  • CSM

    This so-called ‘midwifery tourism’ exists in Canadian midwifery as well. There is an option to do an international clinical placement in your 2nd year (read, no experience). Whether or not these students get a preceptor is unclear; but I’m fairly certain that they can do pretty much whatever they want out there as opposed to a typical while client in a highly regulated Canadian hospital where sometimes all you do is stand there because noone wants a junior student anywhere near the process. So yes, lots of extra ‘catches’ and looks really awesome on the resume. Sadly, not everyone sees the irony of proclaiming oneself a supporter of diversity while exploiting it.

    • studentmidwife

      actually it’s in third year of the program, the students will have already done one midwifery clinical placement as well as skills learning. The rules for going out of country are pretty strict.

      • CSM

        Regardless of the year – since there is anywhere between 2-6 years anyone can spend in the program, I’m pretty sure the option was available earlier than ‘Interprofessional Placements’. Even if memory fails me, a student in the 3rd year would have finished 4 months of clinical training of varying quality (preceptor dependent) and a short workshop on emergency skills/clinical skills. I remember that most of my classmates were not able to tie a hand knot at the end of it. I’m sure ‘the rules’ are strict but I imagine that hands on involvement and opportunities to handle difficult scenarios would be much more plentiful during such placements.

        • ActuallySkeptical

          There are lots of arguments against students from high-resource countries learning on the bodies of women in the Global South, and lots of reasons why it’s problematic that we integrate these experiences into our clinical training, but at the time I did my “international” placement (which I did not out of country but back home in Nova Scotia) I had done a full year of hands-on training, between midwifery, obstetrical, and nursing-centric placements, including some time in the NICU. I don’t know when (or where) you trained, but by the time I did my elective I could certainly tie a hand knot and indeed did complete repairs (within midwifery scope) independently.

          I think the ethical concerns around “midwifery tourism” are many, and need to be addressed, but those of my colleagues who did choose to do out-of-country placements described a situation quite different from the one you’re depicting. (Indeed, my experience in Canadian hospitals was quite different that what you describe; I think the last time I just stood there because nobody wanted a junior student participating was the first birth I was ever at.)

          • CSM

            “I think the last time I just stood there because nobody wanted a junior student participating was the first birth I was ever at.” This is because you were allowed to participate. By the woman primarily, by your preceptor, by the OB. That’s the whole point. I used to work in a hospital (L&D) in a third world country several years ago and I’d be surprised if you told me that ‘birth participants’ for these women are entirely consensual. Funny that, I know a midwife who is not Canadian and is actively disliked by her white Canadian practice colleagues for not being able to provide eloquent informed choice discussions. While some of those midwives got a good chunk of their clinical experience overseas and were not providing any informed choice discussion to the women they ‘cared for’ because well, they weren’t fluent in their languages. Oh the irony..

            As far as training goes, I think I know what you are referring to. 4 months of introductory midwifery placement plus a 120 hr OB placement plus 2 weeks following an NICU nurse plus 4 weeks following an L&D nurse. Sure, we learned something. I’d call it entry level stuff. Entry level training = entry level perineal repairs. Been there, still humble.

          • Antigonos CNM

            Yes, I was thinking about the language problem. I work in a country where the “lingua franca” — Hebrew — is not understood by many recent immigrants such as Jews from Ethiopia or even the former USSR, let alone from various other countries. Communicating with them, even for basic information, let alone teaching, is very difficult. How can an English-speaker be catapulted into a country where she will tend uneducated women who probably are speakers only of the local dialect, and function?

          • CSM

            Well, at the hospital where I worked (and delivered at the time!) communication wasn’t necessary because the notion of either choice or consent was non-existent. A woman shows up in labour, gets her hairy bits shaven, gets an enema, gets an ARM, and stays in a room filled with other labouring women until it’s time to push. Then moves to another room, gets on a delivery table, and pushes until the baby is out. If there’s a problem, a doc is called, he/she does whatever is needed and goes away. If the woman doesn’t cooperate, she gets yelled at although some nurses/midwives were empathetic. No lingua franca necessary, really.

          • CSM

            Now imagine teh godly presence of a white woman from the west in her 300 dollar Birkenstocks and impeccably straight teeth…

          • emkay

            yup :S this sounds familiar. it is THIS that birth rights advocates should be fighting…

        • studentmidwife

          i completely agree with your point about students doing out of country placements before having skills that are actually useful to the women they would be serving. However the international placement is in fact third year at the end of the inter-professional placements.

          • CSM

            Then I apologize for my failing memory. Still, IMHO, even at the end of our interprofessional placements most of us were not really capable of anything clinically coherent (including myself).

  • H H Williams

    Amy Tuteur, it is completely unethical of you to post all of that without getting MI’s side of the story.

    • Karen in SC

      It’s a blog post, it’s totally up to her what she includes or doesn’t. Why do people always get blogs mixed up with investigative journalism?

      • The Bofa on the Sofa

        Besides, instead of complaining, let’s have someone from MI come in and tell us their side of the story? That would mean actually addressing the points, though, and not just hurling invective.

        It’s just like the “you can’t criticize, you don’t have all the facts!” “OK, then, tell us those facts that are missing?” “This is libel, I order you to take it down at once!” “Ok, so then tell us the facts so that Amy can set the record straight?” “Your meeeeeeeeeeeeeeeeennnnnnnnnn!!!!!!!!!!!!!!!!”

        How many times has this played out?

    • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

      The specific misconduct allegations are not the real problem. The power imbalance between first world white women and midwives is bad enough for a certification that really requires very little actual training. Being a third world woman of color would amplify this issue x1000. There is NO REAL ACCOUNTABILITY for cpms anywhere, its crap.

      You know what an innocent person would say about the specific allegations? They would deny it. So would a guilty person (probably).

    • T.

      Sometime there is no “two sides” of the story. I claim the Earth is not flat. I don’t need every time I post a image of a round Earth to call in somebody of the Flat Earth Society to give us their side of the story.

    • moto_librarian

      Maybe you would care to enlighten us, H H Williams?

      • The Bofa on the Sofa

        The problem is, there isn’t going to be much that is factually incorrect (oh, we might find out silly stuff about why so and so resigned, etc, but that won’t change the facts about the practice). The dispute is going to be over MI claiming that they aren’t exploiting anyone.

        That’s their side of the story.

    • Fred

      Yes. Just like every NCB blog that criticizes Dr Amy gets her side of the story too.

      • Karen in SC

        Touche

  • Anj Fabian

    Back in the day, we called this “imperialism”.

    • auntbea

      Now we call it “neo-Imperialism”! Clever, huh?

    • http://gamesgirlsgods.blogspot.com/ Feminerd

      Sometimes Orientalism too. The fetishization of Black and Brown bodies and cultures, with more than a whiff of White Man’s Burden thrown in.

  • hurricanewarningdc

    I’m not questioning the above post, but what are examples of good organizations that are training midwives to assist in villages/countries where there aren’t enough doctors to go around? (E.g., I have a friend who is a nurse/CNM, and who within the Peace Corps, set up maternity services in West Africa.) I’m sure that most here have seen some of the horror stories that come from impoverished countries lacking in medical care, equipment, and education. There must be some good groups that are doing this training to save lives overseas… versus using the effort or claims of efforts to promote domestic services and a bottom line. Any good ones (and related literature) to share? thx

    • TheOtherAlice

      There are a ton of programs training local women to be midwives, which I believe is the best way to do things. That way, the skills stay within the community and it also provides the trained women with a skill they can charge for. The best way to find them would be to google ICM Millenium programs.

    • Guestll

      Google the College of MIdwives, Hamlin Fistula. They’re an excellent example of what The Other Alice is referring to (below).

    • Bombshellrisa

      Pronto International-they also train all members of the medical team in low resource areas.

    • Susan

      I have a friend who was a CNM working with Doctors without Borders but I believe that though I am sure she learned a lot from the experience she actually became a CNM in order to qualify to work with such organizations not the other way around. She was formerly a CPM but went back to school with that goal in mind. I have another RN friend that volunteered to teach basic hygiene type things in a central American country but again the goal wasn’t her own education. Actually, come to think of it I know tons of docs and RNs who have gone on trips to help the underserved but it was never to “practice” on the people they were serving.

      • The Bofa on the Sofa

        When my wife was in vet school, she did a couple of turns on a program called “Remote Area Veterinary” where she would spend a week along with a whole host of other volunteers doing a spay/neuter clinic. She used it as practical experience in her vet training, and even got her first surgery experience with it, but it was not part of her schooling.

        Moreover, while it would have been better to get more regular vet services in the area, they weren’t typically dealing with health issues, but were doing spays and neuters. Therefore, it would be advertised as such, and all the local pet owners could bring in their dogs and cats for that purpose all at the same time.

    • Certified Hamster Midwife

      In particular, look at the Hamlin College of Midwifery. http://www.hamlinfistula.org/our-activities/midwifery-school.html

  • Stacey

    To anyone that says “Well, these MWs are better than nothing”
    I say: NO, you CAN make a bad situation worse. Practicing on poor moms is not OK. Talk about disgusting.

    Do you really think financially motivated HB MW training in these places is really helpful to the locals? Bringing in a bunch of unskilled birth junkies, that have little to no training, and loosing them on the locals, that have a dire need for actual care?

    Plus, they come with all their horrible misinformation too, about anti vaxx, and how birth is safe, and docs are bad, Cs is bad, and other such nonsense. Can you imagine the damage one of these places could do, if the wanna be MWs were able to communicate their bad beliefs? I’m sure its nothing compared to the deaths they cause, or at minimum, are unable to prevent, but still.

    • Gene

      I wonder what the midwifery students (I suppose you could call them that) think of the morbidity and mortality that they see first hand while there. Do they think it won’t happen “back home”? Do they tell these mothers and families that their babies and/or wife/sister/daughter was not meant to live?

      • Karen in SC

        Yes, and I’ve read that mortality is explained by poor hygiene, poor health, etc. Wasn’t it an Ina May story about how a family that had a neonatal death was so so grateful that the midwife was able to save the mother? I’m sure that is a very skewed retelling…

    • The Bofa on the Sofa

      When Opti-grab came out, I thought it was the
      greatest thing ever, and I bought a pair. And this is the result.
      (Mr. Reiner removes his pair of dark glasses to reveal…) This
      little handle is like a magnet, your eyes are constantly drawn to
      it and you end up cock-eyed. Now as a director I am constantly
      using my eyes and this Opti-grab device has caused irreparable
      harm to my career. Let me show you a clip from my latest film
      where my faulty depth perception kept me from yelling cut at the
      proper time. (scene of a little red sportscar speeding off a
      cliff. Reiner yells “Cut!” just after the car goes over the edge)
      If I had yelled cut on time, those actors would be alive today.
      That’s why I am spearheading the ten million dollar class action
      suit against Mr. Johnson and his irresponsible selling of a
      product he didn’t even test on prisoners. Thank you.

      See? Midwives just don’t want to make the same mistake that Navin Johnson did in The Jerk.

  • Stacey

    HB MWery training is a pyramid scheme, and like other such schemes, relies on exploitation at every level other than the top.

    The lie is that HB MWs are skilled, wonderful, revered women, and they make good cash, actually great cash for a trade that requires no formal education. This is propped up the the community, and we all see the stars of HB MWery, killing at will, and being worshipped. They tell excited young women and moms how great it is, and rely on this to make money off them.

    However the truth is, few HB MWs ever do more than a few births a year, in Oregon something like 80% of births are done by a small handful of MWs, while the majority of MWs do 1-5 a year. This means not enough preceptors, and the ones that exist are in demand. In order to get their pitiful credential, they need “catches”. There is a whole network of poor brown bodies, and naive, wanna be MWs, to exploit for cash regarding this critical “training”.

    You can go volunteer, and PAY highly to do it, at birth center (maybe2?) in El Paso. These prey on illegals and border crossers that want a better life for their babies, but fear the hospital for cultural and legal reasons. They prey on the Mexican and S American communities. The training is a joke, sometimes good, other times nonexistant, and wanna be MWs are used as paying labor, 4 to a room, worked non stop. (They see 40-60 moms a month, I would hate to see the death rates.)

    Then there are the overseas places. Take the Casa above and multiply it by
    100. Put ignorant wanna be birth junkies, with no education, in a critical situation. what do you think is gonna happen? I don’t know a lot about it, but do know this is an awful thing and proves that HB MWs are just overprivilaged white women.

    Not only are poor women exploited, but some women that have no business being MWs get enough catches that they become CPMs and come back to kill. Darby Partner, killer of Shazhad Sheik, recently got her CPM this way, by paying to volunteer at the ElPaso Center. when no one local would train her, because she is dangerous, she was able to go “pay to play”, and come back with a shiny new credential to fool moms with.

    • Squillo

      Interestingly, Darby Partner is listed as a signatory to the Alliance for Ethical Midwifery Training’s open letter to MI.

      • moto_librarian

        Really? The GALL of that woman!

      • Stacey

        Of course she is, she complained about the treatment of the trainees.
        But she did get her catches in a similar way, so I guess it was good enough for her, untill she didn’t need it anymore….

        She has TONS of gall, or maybe it’s just ignorance?

        • Squillo

          I think it’s less ignorance than lack of self-awareness plus narcissism coupled with hubris.

    • Bombshellrisa

      The first name on the list is someone who did “graduate” from the place in El Paso. A great many of those people “did rotations” in places like Vanuatu and Manila. Yet another one of those women who signed the open letter was born on The Farm and became a midwife training there.

  • The Bofa on the Sofa

    Who is the “Alliance for Ethical Midwifery Training”? I am actually impressed that they have enough clout to get a board member to resign. Or was it a case of they brought this crap to the attention of the board, and certain members, being unaware it was going on, got an ethical streak?

    • auntbea

      Or there was someone ready to take legal action separate from the Alliance?

    • Squillo

      The roster of signatories is populated with CPMs and others with no designation. The testimonials look to be from those affiliated with midwifery clinics in developing areas that have had dealings with MI. Several of them are CPMs.

    • Squillo

      Both orgs look fairly dodgy to me. Neither organization lists its board members/staff/officers on its website. The Alliance for Ethical Midwifery Training has a list of signatories to an open letter, but that’s it. Apparently, at one point AEM listed MI board members on its site, but was asked to remove the names (which they did), so MI may have made its officers’ names publicly available at one time.

      • The Bofa on the Sofa

        So it sounds like AEMT is a bunch of midwives with MI connections that suddenly got a conscience?

  • moto_librarian

    Here in the Western world, we have a privileged group of (mainly) white women whining about not getting support for their ill-informed birthing “choices” while our sisters in the developing world can only dream of having access to safe medical care during pregnancy and childbirth. Now these idiot “midwives” who encourage women in the developed world to take stupid risks with their own babies and lives have gone a step further, and are using women in the developing world to get their requisite number of “catches,” despite their lack of education and training. It is utterly monstrous. Every person who professes to care about the lives of women and children should be up in arms about this, but once again, I’m sure we’ll have an influx of midwife apologists who continue to disguise biological essentialism as a form of feminism.

  • PrimaryCareDoc

    Here’s what they have to say about financial aid: Midwife International does not currently offer scholarships, grants, loans or other financial aid. Because our educational programs are service-based, we encourage students to engage friends, family and community in support of training midwives and improving maternal/infant health in undeserved regions. If you don’t have the money to pay tuition and expenses, raise it! Though we do not offer scholarships at this time, our team can help you reach your goals by providing fundraising materials (presentations, samples letters, etc) and strategy ideas.
    ______________________________________
    Oh, that’s professional. Hit up your family, friends and community to pay your tuition. I should have thought of that for med school! After all, I provide a valuable service to the community, right?

    I can’t even figure out what they’re selling for $19,000 a year. Is there a degree at the end or not?

    • Amy M

      How can even THESE midwife-wannabees think it is worth paying upwards of 19K/yr (with all those other expenses) to learn to “hold the space?” If they are paying that much, why not go to nursing school and get a CNM? At least then you can get a student loan. Hey! Let’s blow our life-savings to go to Africa and be racists and kill people so we can come back to the US with a made up credential and kill some more people and earn back the money we spent! That makes no sense at all. Clearly, long term thinking is not their specialty.

      • moto_librarian

        Most of them could never hack nursing school, let alone Masters level midwifery training. It’s too hard, dontcha know?

        • Amy M

          I wonder though, considering some of the crazy hoops some of them go through to cover tracks, is it really stupidity? Or just laziness? I’m sure some of them are truly morons, but I bet some are quite intelligent, and just don’t want to do the work. And there’s the backwards ideology aspect of course. It’s too bad, really.

          • CSM

            It could be unwillingness to be a part of the evil system. It could also explain why say, many registered mws in Canada finish their degree, get licensed, and then rebel against what they were taught. I’m not sure if an educated fool is less harmful.

          • Young CC Prof

            You need to pass math to get into nursing school.

            Believe me, I’ve personally met dozens of students who want to be nurses but can’t get through algebra, and I estimate there are hundreds in my institution at any given time.

      • The Bofa on the Sofa

        Good point. Note that the most common objection to getting a CNM is the cost. So much for that nonsense.

      • Amazed

        But if they go to nursing school, they’ll be limited by their education! That’s what a mother lawyer claims in our favouite site for loonies.

        Besides, it’s always better to pay, do nothing, and get a degree than pay, work your butt off, and get a degree.

        Poor mothers in undeveloped countries…

        OT: a few years back, the esteemed Claire Loprinzi came here, invited by our very own local loonies and declared, and it’s a citation, “My mission in your country is to convince Bulgarian women to give birth naturally.” Funny but a friend of mine who was a big fan of natural and was looking into all authentic birth became more responsive to the idea of interventions and – gasp – C-section after that. As she claimed, “I smell a fanatic here and if she’s the face of natural birth, don’t count me in.” Ms Loprinzi had just put too muc salt in the meal, as we say. Convince us to give birth naturally? Why not “point out the benefits of natural birth”? She absolutely sounded like a fanatic.

        Oh and as far as I know, she said that without medical interventions, some babies would die and we have to accept it. Not exactly a fine tune to many of the women who were looking forward to hear what she had to say.

        • The Bofa on the Sofa

          But if they go to nursing school, they’ll be limited by their education! That’s what a mother lawyer claims in our favouite site for loonies

          That’s so bass ackwards to be bizarre. You know who is allowed to work with the least amount of limits? Doctors. Doctors are allowed the most freedom to use their best judgement about diagnoses and treatments, because of their extensive education.

          Education begets freedom, not limitations.

          That doesn’t mean that doctors are allowed to run completely willy-nilly, but you would be surprised. Folks like Jay Gordon flaunt things like AAP standards, and the org stays pretty silent, under the guise of professional freedom. Stan Brzynski is a complete slime, doing nothing medically useful or even approved, but efforts to stop him have gone nowhere.

          • Amazed

            Well, try to explain it to the mother lawyer at the MDC. She’s so eloquent that she almost can have ME convinced! Me, of all people! You know, don’t take away my choice only because you didn’t research your midwife better, this kind of stuff…

    • AmyP

      For $19k a year, you could get a real nursing degree in the US and be of some use to your fellow man.

    • Certified Hamster Midwife

      I wonder how many people have set up Indiegogo pages for this.

  • Bystander

    Possibly ethical? Under what circumstances? Not only do developing countries have no need of untrained and untrainable idiots of good intention, but even regularly competent professionals are barely adequate. You have complex obstetric situations often with complicated health situations, limited resources AND if you’re to be any good, need to know how to communicate the knowledge you have to your colleagues in a professional, clear manner. Regular, competent people who can cope fine within a well-resourced hospital setting just aren’t good enough. But of course, the worst clowns aren’t competent enough to know that.

    And don’t even get me started on the patchy, here-today-gone-tomorrow nature of all such ‘help’. It doesn’t build, it actively destroys the development of local provision: witness the attitude of medical students here http://www.theguardian.com/global-development/2013/feb/13/ghana-tv-maternal-health

    Anyone thinking of doing a bit of good by volunteering in the Third World, please don’t. Stay at home and help instead.

    • TheOtherAlice

      Exactly! Schemes like this only increase the dependence of under-served communities on outside help. At the very least, they could train local midwives. Frankly I wouldn’t be surprised if the local midwives had a higher skill level than the CPMs flying in. The only exception to the rule of training local people instead of importing help is where there’s a severe lack of local skill and an immediate need. But even then, training people who come from and will STAY in that area is vital for long term care.

      • Antigonos CNM

        In my 1975 edition of “Maggie Myles”, the standard midwifery textbook used in the UK back then, it was noted in the preface that the “export of trained professional midwives” was one of the things the UK could be proud of, training, at that time, approximately 5000 women from Commonwealth and African and Asian countries to return to their native lands with the British State Certified Midwife qualification [at that time, for the British equivalent of registered nurses only]. Certainly, when I went to London for my oral exams, there were a great many black and asian women also sitting their exams.

    • Amy M

      What would be most helpful for communities like that? Equipment and supplies?

      • Anj Fabian

        Sustained support for infrastructure, especially a clinic that not only treats but trains as well.

      • Guestll

        Money.

        • Amy M

          Well yeah, but who would I write the check to?

          • Guestll

            Unicef, Plan, Free The Children, World Vision, all do great work. Hamlin Fistula in Addis (also rural Ethiopia) trains midwives and performs low-cost fistula repair.

          • Amy M

            Thanks! (I am not very articulate in print..Guestl, this is what I was trying to ask, which groups are helping the most, and how are they helping–do they send money directly? do they send equipment and supplies? do they send people to train locals?. I would be happy to make a donation to one of those groups. The only one I’d heard of was Unicef.)

          • Guestll

            All of the groups listed above do good work. I prefer one to the rest, that’s because I work for them, but all of them do good work in support of people suffering the effects of extreme poverty. Annual reports are available online, generally audited financial statements are as well.

            The model for aid (excluding emergency relief) in the developing world is based on capacity building. The Wiki is decent: http://en.wikipedia.org/wiki/Capacity_building

            Does it make sense to you (once you’ve read the link?) NGOs allocate funds from donors (like you)/government/corporations/grants to build abilities, skills, resources, with the goal of implementing long-term positive change to infrastructure/capacities.

        • T.

          Throwing money at a problem is not going to solve it. Particularly, throwinng money at the developing world is not going to help. At all.
          What would help most is, sadly, a touchy subject and as such not said aloud.

          • Guestll

            Who said anything about throwing money at the developing world?

            Have these things been accomplished for free? http://www.un.org/millenniumgoals/poverty.shtml

            Your breadcrumbing intrigues me. Please, elaborate.

          • T.

            Nothing can be accomplished for free. However, signing a check to an organization is in general not a tremendous effective way to make a difference and can have serious warped effects.

            You mentioned Unicef. Aside that all the UN affiliated organization use most of the money for administration and data collecting* (the second thing very praiseworthy, but perhaps not where most people wish to see their money going to) what hurts all of the UN agencies and the UN itself most is the chronic delay in the money the various countries should give to them (the UN is supported by agreed-upon donations from member countries. Which are always late). The most efficient way you could help ALL of them would be by campaigning and lobbying to ensure your politicians give what they have agreed to give.

            If you want to help people in a poor country,but don’t like to involve in politic, I would suggest to hire some immigrants to do some jobs for you. Did you know that the return money of the emigrants people is three times larger than aid budget worldwide? Also, this kind of “help” does not have as many warping effects and doesn’t turn people into passive recipients of help.

            http://www.theguardian.com/global-development/2013/jan/30/migrants-billions-overshadow-aid

            The most useful thing would be birth control. Possibly in the form of condoms. Even more so in the countries where AIDS is endemic. Sadly, many religious organizations refuse to even mention it. There are organizations about AIDS that refuse to work with sex workers.
            It is true, but try to mention it in a conference about helping the developing world, and they will bite your head off.

            *The figure I remember is something like 0.2$ of every dollar going to the children, but I can’t remember if it is about the UNICEF in particular or if it is an avarage including even the worst of agencies, like the FAO. I’ll check in my texts.

          • Tim

            You’re not seriously suggesting that exploiting immigrants to do manual/domestic labor for you @ low pay is a valuable way to provide economic aid to them are you?
            If you’re honestly suggesting paying them however much you would a legitimate contractor or domestic, then cheers, and my apologies for assuming the worst – but I don’t think that’s happened once in the history of ever. Nobody hires Manuel from the home depot parking lot to build him a deck and pays him as much as he would have paid Joe’s Porch Co.
            Instead they pay him pennies on the dollar because he’s willing to do it, since he lives in an apt with 20 other guys who are sending 95% of their meager earnings back home to their families where it’s worth much more.
            If you can genuinely find me one instance of someone paying a migrant worker fair market value for their efforts, I will shut my trap and gladly say I was wrong.

          • Guestll

            It’s exactly what he’s suggesting, and don’t think I haven’t heard it before.

            Exploit the immigrant worker, financially underserved with respect to banking, who wires his money back home to support his family and lives on next to nothing himself. Create a dependency so he’s afraid to speak, afraid to do anything that might rock the boat.
            Why write a cheque of your own, why actually contribute in some manner, why actually look at the problem in a big picture way, why do anything to build education/health/water/sanitation/microfinance/self-sufficiency when, you know, you can enforce the passive receptiveness of a perpetual handout AND pay someone less while you’re at it?
            And feel good about it and recommend it as an extreme poverty reduction measure? Better than a tax receipt, no?

          • T.

            I find very fascinating how well you and Tim have completely twisted my words. Granting, on the internet that is very easy, but rarely I have seen it done so absolutely.

            I have not endorsed the exploitation of immigrants. I have suggested hiring immigrants to do jobs. Is anybody who works exploited? This is quite a step you have managed here. If a company hires immigrants paying good wages and benefits, why should that be exploitation?

            This paragraph in particular:
            “Exploit the immigrant worker, financially underserved with respect to banking, who wires his money back home to support his family and lives on next to nothing himself. Create a dependency so he’s afraid to speak, afraid to do anything that might rock the boat. Why write a cheque of your own, why actually contribute in some manner, why actually look at the problem in a big picture way, why do anything to build education/health/water/sanitation/microfinance/self-sufficiency when, you know, you can enforce the passive receptiveness of a perpetual handout AND pay someone less while you’re at it?” <- is charmingly misleading, because you are talking about workes exploitations, NOT giving work to immigrants. We have the same problems with stageurs in Italy, young university graduated Italian who works for years with NO pay, because more or less what you write.

            So, lets make the two problems the, well, two problems that they are:

            1. Helping developing countries

            2. Problems of "weak" workers in the workplace.

            Talking about 2 is laudable and good and I wholeheartly agree it needs to be addressed. The fact that some immigrants workers (expecially unlawful immigrants) belong in the category of 2 is true, but so do people with big families, people with dependents with disabilities, young people, etcetera.

            You also seem not to count at all young men and women who came to study in your country and may need a source of additional income to go through college. In my office we currently have one as such employed (from Ethiopia). Those are immigrants, too.

            Now lets address what you seem to imply, that in some way just by giving work to someone who happens to come from a different country is somehow wrong. Even if all conditions of good wages and benefit are met.

            Explain me how, because I just can't see it.

            You also seem to imply that the return money from immigrants has a warping effect on the "mothercountry" economy. I find it possible but I am dubious on it. I know that, say, what the UN did on Timor Leste had a warping effect, but how could return money do something like it? I admit I don't know of any studies about that (I'll check) but I am dubious because:

            1. Many countries have been litterally built on return money. Mine, Italy, among them. The fact that the return money from US and Latin America (mostly Argentina but Brasil too) was used in the late 1800s and all through the 1920s to build Italy is a well-estabilished fact (I'll check the reference books as soon as I am home, but they may be only in Italian…). Not only the children of the emigrants, but also his nephews were sent to university with the return money from the "american Uncle" (up until Fascism, when it was from strongly discouraged to forbidden).

            2. Most of the money sent home is used for the education of children and/or the building of houses. The first thing is know to have the least warping effect on countries economics, and probably among the most important effect in a long-term macroeconomic plan.

            3. Returning home emigrants often bring with them new ideas and the know-how that they have acquired in their emigrant experience. Not incidentally, some totalitarian regime attempts to stop the return home of emigrants (Fascism, as aforementioned). The founder of microcredit (Mohammed Yunus) is a returning-home emigrant, gone to the US to study at college and come back to Bangladesh where he founded microcredit. In his biography the Banker of the Poor he explicity states that learning about how the US was (in good or evil) was important from him. Gandhi had a degree from a UK university, as well. In a less-shining example, several people from Kossovo learnt how to construct houses with modern methods in Italy and used this knowledge to build their home in Kossovo.

            I am well aware that the UN agencies (UNICEF among them) do a lot of good. I am also aware that the use of money is less on the poor and more on their internal need (administrator, data collecting) than on the people they help. You haven't challanged this, I am willing to change my mind if you provide me with data saying it is not so.

            Also, you provided me with the page of UNICEF US. I was talking about UNICEF worldwide. For example UNICEF Ireland uses only 2.1% of its budget on administration, but the problem is that the worldwide budget of the UNICEF may have a very different allocation of resource with more or less virtous countries. I have found only a data that it is 0.2$ on every dollar, but it may be wrong and I'll revise it if you can find a better one.

            I personally find the UNICEF preference on cultural heritage over the lives of children to be downright distasteful, as I don't see "culture" as monolithic blocks but as changing, evolving enthity that modify from the imput from outside and inside. But this may be me :)

            Coming back on political activism: it would be nice if the US ratified the Convenctin on the Right of the Child. With Somalia, and I think South Sudan, is the only country not to have done it (the reason being that the convenction forbids live emprisonment and death penality for children).

            International aid is a minefield. Like peace enforcment, you are damned if you do and damned if you don't. Countries who have succeeded in developing have done it more in spite than with the help of international actors. For example, take South Korea or Japan. China. India. It looks like in many cases a strong government (even, yes, a dictatorship) and a politic of protectionism with a gradual opening to the international markets are far more important than, well, anything else.

            This is very, very hard to do in a place like, say, Africa, which lacks strong enoug governments to begin with, and, which is probably worse, this is a long-term approach. Long term approaches have a big flaws. They work. BUT. in the short term, things don't improve. In the short term, people die still.

            (While I don't completely agree with her ideas, here is an interesting and provocative book about what I am talking about: http://www.amazon.com/Dead-Aid-Working-Better-ebook/dp/B0036FOGTW/ref=cm_cr_pr_product_top )

            tl;dr: giving jobs to immigrant =/= exploitation of workers. Two things. Often they are together, which is bad, but exploitation is always bad. International aid is a minefield, where you litterally can't do anything good enough if you aren't local. The most helpful thing in a long-term view is helping immigrant students to study in your country. Long term and short term oftentime collude (what is good short term is bad long term. Damn economic).

            Also, thank you Guest to have given me the WHO reccomendations on birth control. I stand corrected on it, good to see they do care about the topic :)

          • Tim

            Like I said, I am open to the concept of paying fair market value to migrant workers – it’s just that here, in the US, it does not happen. We have a plethora of undocumented workers, who are regularly exploited by everyone from the agricultural industry (and farms that are part of fortune 500 conglomerates) , the christmas tree industry, mike down the block who needs a new porch built or new floors installed, and jessica who needs a new maid, cook or nanny. I’m not familiar with the situation in Italy, but here in the US when you speak of people sending money home, it is typically not involving legal immigrants, who are generally denied access to the country unless they are highly skilled, or refugees. The people who are sending money home are exploited undocumented workers, who are being bent over backwards by a vicious culture that demands cheap domestic labor, cheap manual labor, and cheap food.

          • Guestll

            Perhaps you should read Unicef USA’s 2012 annual report. http://www.unicefusa.org/news/publications/annual-report/U-S-Fund-for-UNICEF-Annual-Report-2012.pdf

            Some good facts and figures on the unmet need for contraception in developing countries. http://www.who.int/mediacentre/factsheets/fs351/en/

            “However, signing a check to an organization is in general not a tremendous effective way to make a difference and can have serious warped effects.” — Not all non-profits are created or operate equally. Some are great, some are good, some are fair, some are bad. The ones who are great are excellent stewards and they make a real and lasting positive difference. I have seen it with my own eyes.

            I believe there’s a moral imperative at stake here. It’s very easy to point the finger at the inherent flaws in development and resource allocation. It doesn’t change the fact that something needs to be done about it.
            Your paragraph on hiring immigrants makes me slightly ill. Yes, sure, instead of building capacities, let’s encourage these folks back home to rely on handouts from their family, while we benefit from it all the while. Passive recipients is exactly what they are, when nothing is done to change the infrastructure. Whatever, I’m not going to change your mind.

          • auntbea

            “The most useful thing would be birth control.” Evidence, please. That does not come from a newspaper. Or your butt.

          • Houston Mom

            You might want to look into the recent news stories on Give Directly. They are having great success just giving cash to people in developing countries.

    • Guestll

      There’s a time and place for skilled help in developing countries, but badly trained midwives aren’t it.
      I work for an NGO with a 98% focus in the developing world, and I’m frequently asked by well-meaning folk how they can volunteer — build a school, drill a well, etc. That kind of help doesn’t fit in with our mandate of capacity building. So many countries have an entire workforce sitting around doing nothing for lack of training and jobs. We need engineers, doctors, trained professionals to fit specific requirements — not people hammering nails.

  • kumquatwriter

    Out-f*cking-rageous. Only word I can come up with.