Homebirth midwives: incompetent and unaware of it


One of the biggest problems in American homebirth is that homebirth midwives don’t know what they don’t know. Their background in obstetrics, science and statistics is very limited; so limited, in fact, that they have no idea how little they know compared to those who have far more education and training in these subjects. The tendency to overestimate their knowledge and abilities is called as the Dunning-Kruger effect.

The classic paper on this phenomenon is Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments published in the Journal of Personality and Social Psychology in 1999. The paper reports on a variety of experiments that were used to evaluate individuals’ actual performance compared to predicted performance.

For example, study subjects were given a test of basic logic:

[pullquote align=”right” color=”#c9defd”]Those who know the least are also the least capable of understanding how little they know.[/pullquote]

…Participants … completed a 20-item logical reasoning test that we created using questions taken from a Law School Admissions Test (LSAT) test preparation guide. Afterward, participants … compared their “general logical reasoning ability” with that of other students from their psychology class by providing their percentile ranking. Second, they estimated how their score on the test would compare with that of their classmates, again on a percentile scale. Finally, they estimated how many test questions (out of 20) they thought they had answered correctly…

The results are displayed in the following graph:

Logic test graph

The dark lines represent the test subjects’ rating of their logical reasoning ability and the score they predicted they would get. The dotted line represents the actual score. The graph demonstrates that the ability to correctly predict one’s score is directly related to the actual score. Those who scored poorest on the test of logic grossly overestimated their ability; those who did slightly better slightly overestimated their performance; and those who scored moderately well were accurate in predicting their own performance.

In other words, those who knew the least were also the least capable in understanding how little they knew.

The authors also found that improving the subjects knowledge of logic led to more realistic personal assessments. They divided a new group of test subjects in two. One half received a lesson in logic before the test; the other half received a lesson in an unrelated subject. Those who received the lesson in logic were much more likely to accurately predict performance on the test.

… Before receiving the training packet, these participants [in the lowest quartile] believed that their ability fell in the 55th percentile, that their performance on the test fell in the 51st percentile, and that they had answered 5.3 problems [out of 10] correctly. After training, these same participants thought their ability fell in the 44th percentile, their test in the 32nd percentile, and that they had answered only 1.0 problems correctly…

No such increase in calibration was found for bottom-quartile participants in the untrained group.

As the authors explain:

Participants scoring in the bottom quartile on a test of logic grossly overestimated their test performance — but became significantly more calibrated after their logical reasoning skills were improved. In contrast, those in the bottom quartile who did not receive this aid continued to hold the mistaken impression that they had performed just fine.

Why hadn’t the study participants realized their own deficiencies in basic logic simply by interacting over the course of their lifetime with other people who knew more basic logic?

… [S]ome tasks and settings preclude people from receiving self-correcting information that would reveal the suboptimal nature of their decisions. [And], even if people receive negative feedback, they still must come to an accurate understanding of why that failure has occurred.

That’s why homebirth midwives have no idea how little they know. Because homebirth midwives never encounter anyone in their training besides other homebirth midwives, they have no opportunity to observe that many other health professionals have a much larger knowledge base and a much greater skill set. When disasters occur at homebirth, midwives fail to understand that they were responsible and simply dismiss tragedies with the all purpose adage that “some babies die.”


… [I]ncompetent individuals may be unable to take full advantage of one particular kind of feedback: social comparison. One of the ways people gain insight into their own competence is by watching the behavior of others… However, [our study] showed that incompetent individuals are unable to take full advantage of such opportunities. Compared with their more expert peers, they were less able to spot competence when they saw it, and as a consequence, were less able to learn that their ability estimates were incorrect.

This problem is greatly aggravated in homebirth midwifery because homebirth midwives are literally taught to view anyone who does things differently as objects of contempt. Doctors are supposedly greedy, incompetent and ignore scientific evidence. This attitude is best illustrated by the perjorative appellation of certified nurse midwives as “medwives.” Though CNMs have far more education and training than homebirth midwives, homebirth midwives prefer to pretend that CNMs spent that extra time being “socialized” (i.e. brainwashed) in “techno-medicine.”

The authors conclude:

… [W]e present this article as an exploration into why people tend to hold overly optimistic and miscalibrated views about themselves. We propose that those with limited knowledge in a domain suffer a dual burden: Not only do they reach mistaken conclusions and make regrettable errors, but their incompetence robs them of the ability to realize it.

Similarly, homebirth midwives hold overly optimistic views about their knowledge base and their clinical skills. Not only do they reach mistaken conclusions and make deadly errors, but their incompetence robs them of the ability to understand just how incompetent they are.


This piece first appeared in January 2011.

54 Responses to “Homebirth midwives: incompetent and unaware of it”

  1. Rob
    September 26, 2015 at 6:18 pm #

    I have no doubt that there are incompetent home-birth midwives out there but I experience a similar (or higher) level of incompetence with doctors in America.

    Testing well is no guarantee of competence. Most of my doctors do nothing apart from prescribe medication to keep me coming back these days. Most diagnosis is done in the lab through blood work or at the imaging center. My doctors can’t even read an MRI. They have little or no training on the medications they prescribe and often, a simple google search puts my knowledge beyond theirs. In many cases, I would be safer choosing my own treatment as doctors have no stake in our health.

    American doctors are greedy too. Treatment in this country is 10 times more expensive than almost every other developed country and the standard of care is worse than all of our peers. They cause more than 70% of the countries bankruptcies.

    American doctors are not incentivized to cure people. They get paid in full even if they kill you or make you worse. Our medical bills are outrageous, with no correlation to the value of services actually delivered. It is no wonder that some people consider a home-birth to avoid hospital fees which are somewhere between disgusting and fraudulent in nature.

    Doctors are always quick to condem any medical services performed by anyone without a medical degree but that is their self interest talking. The truth is that, these days, we don’t need as many doctors as we have. Much of the work is administrative and process based. The American healthcare system is an abomination and needs wholesale change.

    My son was born in a hospital recently. The actual doctors did very little other that lording over the rest of the staff and complaining about their paper-work burden. The nurses are the ones who do most of the work and receive too little credit imo. I doubt that they would test well though.

    Again, I am not questioning the fact that their are incompetent midwives out there. I just think that there is incompetence in hospitals too. Babies die in hospitals too. Without knowing the specifics of each case, it is hard to know if those children would have lived if they were born closer to a few doctors.

    I am assuming that those parents did see some doctors and had ultrasounds plus blood tests like everyone else. maybe a doctor failed to identify a problem that would have prevented the parents from selecting a home birth.

    • Who?
      September 26, 2015 at 7:00 pm #

      It’s Sunday morning, I’ll play.

      Surely prescribing medication that stops you coming back-because you are better-is exactly what doctors should be doing. And how, if doctors are as greedy as you suggest, is it in their interests to do that rather than keep you coming back for more?

      And then, the classic ignorant ‘expert’ statement: ‘I have now googled and know more than experts with years of training’. Perhaps you should google engineering and go into the bridge or dam building business-a couple of hours sweating over the search engine should qualify you perfectly, don’t you think? All those idiots wasting years at university!

      People with no medical training cannot, by definition, supply medical services. They can however exploit the anxiety and suffering of the worried well by spending lots of low quality but high emotion time with them, and ‘prescribing’ all sorts of useless, expensive tinctures that they, oh so conveniently, also sell. What a coincidence!

      It’s great your baby didn’t need any medical assistance in hospital, but why be pleased when you can whinge instead? Would you be happier had a major intervention been required?

      Your final para is moronic-your thesis is that doctors who failed to pick up something that there is no anatomical or physiological explanation for are to blame for the death of a baby at the hands of a quack? Nice.

      There is incompetence everywhere. Demanding it be stamped out in one area while being relaxed about it being promoted and praised in another defies logic.

      • Rob
        September 29, 2015 at 3:01 pm #

        Prescribing medicine that stops people coming back (because they are cured) is exactly what doctors should be doing. They are incentivized to do the opposite in America. They make more money if you have to come in for an appointment every month than if they see you just once ever.

        I’m not suggesting that there is a doctor’s conspiracy to deny proper treatment. I am saying that American doctors prescribe unnecessary medications for that reason. That isn’t just my opinion. America uses more than half of the entire worlds supply of prescription medications and more than 80% of the pain killers. Either we are the sickest country on earth or something is very wrong with what our doctors are doing.

        Doctors don’t have years of training on medications as suggested. They have very little (or no training at all) on many of the medications they prescribe. Their info comes from drug reps and trial and error on us in many cases. Some doctors don’t take the time to update their knowledge either. New medications and treatments are constantly becoming available and medical opinions change based on new research. Sometimes you need to educate your doctor and yourself to know if you are being treated correctly.

        Pharmacists actually do have training on medications. They should have more input in my opinion. Their training is wasted with their current role.

        You should drop the personal comments from your responses. This is a discussion thread and if you are offended by opinions that differ from yours, then maybe you shouldn’t participate.

        The idea that it is not possible for an individual to acquire more information than a doctor through research has no basis. The article was focused on the results of logic based reasoning tests. Until we both take the test to see who gets higher marks, it may be wiser not to assume that you are smarter.

        It is possible that I simply don’t have the mental capacity to understand why I’m wrong but…. Then again, the same could apply to you and you wouldn’t know it…

        • demodocus
          September 29, 2015 at 3:55 pm #

          Funny, the only maintenance medication going on in my house is the one for my husband’s glaucoma. Curing glaucoma would be a miracle enough for Pope Francis to consider making you a saint.

        • Poogles
          September 29, 2015 at 4:25 pm #

          “They make more money if you have to come in for an appointment every month than if they see you just once ever.”

          There really aren’t many medications that require a monthly appointment. I take 2 anti-deppressants and 2 vitamin supplements (for diagnosed deficiencies) and I only see my doc for my yearly appt and bloodwork or if I get ill enough to need to go in and be seen.

    • Azuran
      September 27, 2015 at 5:41 pm #

      If you think your google search puts your knowledge above them, you are an idiot. Just as this post so clearly explained, you are so incompetent that you cannot even see it.
      And your generalist not knowing how to read an MRI is totally normal. That’s called specialization. You want an MRI you ask a neurologist or a radiologist. Reading MRI has never been the job of a generalist. And guess what, your neurologist probably have no idea how to treat cardiac problems, that’s up to cardiologists and cardiologists have no idea how to do a c-section.
      Your doctor’s job is to take care of uncomplicated health problems, to know the basics of everything and to recognizes problems that needs specialists and refer you when appropriate. A specialist’s job is to focus all his time and skill on one particular field of medicine.
      Also. Whenever a baby dies in a hospital. What do you think happen? There is an investigation and if medical incompetence is found, the doctor responsible will be held accountable.

  2. no longer drinking the koolaid
    September 25, 2015 at 1:13 pm #

    To illustrate the point. Read a recent discussion about a woman with an “irritable uterus” US showed a short cervix when she was having contractions at a previable gestation. The OB put her on a med to stop the contractions and another for the short cervix.
    The midwife involved kept saying it was an irritable uterus and was offered homeopathic remedies to fix that issue. No mention of the risk of preterm delivery, her high risk status and need for transfer to OB/MFM care for mom’s and baby’s sakes.

    • Bugsy
      September 25, 2015 at 8:06 pm #

      Eeck. Makes me appreciate that when I started effacing at 29 weeks w/ #1 (and bleeding & contractions to boot), there was a medical team right there to give me terbutaline shots & steroids.

      How did the patient fare? Hoping she continued to go with the OB’s advice.

  3. yugaya
    September 25, 2015 at 7:05 am #

    Latest crop of incompetent lunatic killer CPMs I came across are not some back alley quacks, they are sitting on Indiana Midwives Association board: http://www.indianamidwives.org/board.html

    Jennifer Williams, CPM, the VIce President there is the one who illegally attended HBA4C of a 11 lbs baby born to a woman of advanced maternal age who had a history of shoulder dystocia and macrosomic babies: http://treasuresfromashoebox.blogspot.hu/2010/08/michael-rays-birth-day.html

    Indiana is also the state in which CPMs will illegally attend HBA3C of a woman with classical incision, history of DVT, severe post term pregnancy over 44 weeks with membranes ruptured for two days: http://www.ican-online.org/blog/2011/04/cam-birth-story-janels-hba3c/

    No wonder these substandard care providers end up as serial killers who go on to kill one baby after another in a matter of days:
    “The first was on Aug. 2nd when Parker took a woman to an Auburn hospital
    when she was having trouble delivering her child. Then on Aug. 3rd
    Parker helped a woman deliver a baby that wasn’t breathing and had no
    pulse. That child later died at the hospital. Then a few days later,
    on Aug. 7th, Parker was helping a mother deliver twins and the second
    infant was only partially delivered and had to be taken through cesarean
    section. According to court papers, the second child did not survive.”

    ACOG and ACNM must put an end to this or we will be seeing many more deaths soon.

    • The Bofa on the Sofa
      September 25, 2015 at 9:29 am #

      Hey, but we know there is nothing wrong with responsible home birth with qualified midwives. Hence, that makes a HBA4C with quackaloons*** acceptable

      ***any midwife willing to do a HBA4C is a quackaloon, pretty much by definition

    • Guest
      September 25, 2015 at 9:35 am #

      As you are aware, CPMs practice is legal in many states and exists underground in states where CPMs are not legally licensed to practice. ACOG and ACNM are both aware, as are legislators and Departments of Health and Professional Regulations. They are not held accountable and we are already seeing too many risks taken, too many poor outcomes and most certainly too many deaths.

      CPMs use grassroots political action to promote their agenda, invoke a martyrdom complex through which they can claim the basic need they provide as a service to a perceived gap in intrapartum options and care for mothers.

      Many states legalized CPMs during a period of paucity of data. With so much data that demonstrates the dangers of CPM practice, as well as the willingness of CPM culture to practice far outside a low risk profile, it is astounding that states haven’t reconsidered or reversed that decision. Furthermore, it is beyond my comprehension why CPMs are not consistently prosecuted for overt practice in states without legal CPM status.

      ACNM provides a collaborative front with MANA and while I don’t believe ACNM accepts the poor outcomes, they have done nothing to demonstrate their stance against it. ACOG has the resources and strength to take a stand and I am hopeful their lobbying at the state level prevents additional states from legalizing CPMs.

      I’ve read SOB for a long time and it seemed CPM related posts used to prompt a lot of discussion. More recent posts have less discussion, yet the casualties and legalization of CPMs continue on with little ability to stop this movement. There are some really amazing contributors to SOB, so collectively, where can it go from here? When and how does this end? Mothers and babies are being lied to, risked with and injured or killed under the guise of CPM and underground practices. Professional organizations, State Boards, Hospitals and providers know this, but yet it continues. I’m tired of it, you’re tire of it, but how do we stop it?

      • yugaya
        September 25, 2015 at 11:04 am #

        1. ACNM must get its act together and go public with same stance that ACOG took earlier this year – all women deserve a uniform standard of ethical care, and CPMs are substandard. Give a definite deadline for weeding them out as pseudoqualification and stop talking with those unwilling to accept uniform risking out criteria and collaborative care regulation.

        2. Get the safer homebirth petition translated into organisation and put the grassroots forces already at work here and elsewhere both online and in real life to better use.

      • no longer drinking the koolaid
        September 25, 2015 at 1:16 pm #

        Current CPM bill in the House in Michigan and the Michigan ACNM affiliate has chosen to take a NEUTRAL stance per their letter of testimony.

    • ForeverMe
      September 25, 2015 at 12:45 pm #

      Oh, my. The 11 lb baby born to the grandmother – (as if HBA4C isn’t enough- “sunny side up”! Shoulder Dystocia! “cord wrapped around his neck!” ) – his face was *so* blue. Yet she captioned the image “he looked perfect to me!” Plus, of course, she was in a pool – surrounded by her other children- when he got stuck. She is so lucky he’s alive. Yet she has no idea (or refuses to acknowledge) that she risked her baby’s life to give birth at home- and almost lost him.


      • yugaya
        September 25, 2015 at 2:27 pm #

        She brags around the internet regularly how “monumental” her births against medical advice were, considers herself a good Christian even after admitting that she lied on birth certificate and to medical care providers to hide Jennifer Williams illegally attending her two insanely high risk homebirths, and even has a side business of teaching other women stuff that includes advice about giving birth.

        And that last baby boy was a repeat SD.

    • AA
      January 16, 2016 at 2:06 pm #

      When the woman in story 2 was on enoxaparin, she repeatedly keeps referring to it as the “stupid hospital”. The hospital staff advised her to come into the hospital as soon as possible because of her DVT. Yeah, so “stupid” because they wanted her to come in ASAP for fear of what could happen if the clot migrated. The baby was also admitted to the NICU for over a week and was ventilated for at least part of the time there. ”

      I felt for a while that I failed as a mother because I could have changed all these things had I been educated and persistent.”
      She thinks all of these things could have been changed had she drank water and taken a bath when she initially called the hospital in early labor.

      She was also very concerned that in the future, if she didn’t successfully have a VBAC “What if I didn’t get my vbac, and I was a co leader? How would that look?”

      Is it possible to be any more myopic?

  4. monojo
    September 24, 2015 at 3:18 pm #

    OT (but related): UPMC in Pittsburgh has suspended its transplant program after 4 patients have died of a mold infection. They’ve started their own internal investigation, and called in the CDC and the state health department to help them investigate.http://www.post-gazette.com/frontpage/2015/09/21/Mold-infections-leads-UPMC-to-shut-down-transplant-programs-at-Presby/stories/201509210177 They’ve alerted the media, and have been issuing updates. Contrast this with the way midwives handle things when they go wrong: hiding, manipulating, or just plain not collecting data. Saying things like, “it was God’s will,” and “bad things happen in the hospital, too.” Actively rejecting any attempt to learn from mistakes and get better. It’s disgusting.

    • MaineJen
      September 24, 2015 at 3:28 pm #

      What? They haven’t started “Doctors in Chains,” and continued doing transplants under the table (wink, wink) at home? Conveniently losing records (or not keeping them at all!), dumping patients at other hospitals when they go south? Shocking…

      • Daleth
        September 24, 2015 at 4:48 pm #

        That is, actually, SUCH a great comparison. What a contrast.

    • Megan
      September 24, 2015 at 5:14 pm #

      When I was a resident we had one case where the two pieces of the Gomco clamp for circumcision were separated in the autoclave and the wrong size parts were put back together. As a result, when we did the circ the clamp didn’t close tightly and the baby had a lot of bleeding. No lasting harm happened, but it was enough to spur a whole change in how the clamps were labeled, sterilized and repackaged. So one error that caused no lasting problems led to widespread system changes. We also did debriefing with the parents, made sure they understood what happened, what changes were taking place to ensure it didn’t happen again and made sure the baby had close follow up and good aftercare.

      For CPM’s however, even a dead baby prompts no introspection or review of care “procedures.” The differences between real medical professionals and CPM’s are so striking in this department. There is no desire on the part of CPM’s to improve safety or outcomes. Real medical professionals constantly engage in review of procedures to ensure safety is optimized. Errors are used constructively rather than swept under the table.

  5. demodocus
    September 24, 2015 at 2:51 pm #

    Interesting how the 4th quartile tended to underestimate their abilities

    • Roadstergal
      September 24, 2015 at 3:29 pm #

      I wonder if people who generally approach the world with ‘there is always more to know’ tend to acquire more knowledge – and therefore the knowledge and underestimation are linked?

      They still rated themselves higher than those under them – just not as high as they actually scored. Might not be significant, but it’s fun to speculate. 🙂 (Where are the error bars??)

      • Angharad
        September 24, 2015 at 4:20 pm #

        I’ve wondered if they tend to overestimate what other people know. I’m always surprised when people don’t know things that I consider very basic, even though sometimes when I think about it I realize there’s no real reason they would know.

        Real-life example: I learned from this blog that the CPM credential is basically fake. I’ve mentioned this to a few friends in passing and none of them had ever heard such a thing. I was surprised, but then again, if I hadn’t found this blog, I wouldn’t have known either.

    • The Computer Ate My Nym
      September 25, 2015 at 3:30 am #

      I noticed that too. Actually, everyone, regardless of their actual ability, thought themselves just a bit above average. Perhaps that’s some sort of innate bias, i.e. maybe most people simply perceive themselves as a bit better than average in any given thing. (Unless they have feedback that says otherwise, i.e. I’m pretty sure I’m lowest quartile for musical ability. Though if you asked me to rate my ability in reasoning I’d be right on the line that everyone else is in thinking I’m a bit better than average at it.)

  6. Mel
    September 24, 2015 at 2:24 pm #

    From Car Talk: Do two people who know absolute nothing about a subject together know more or less than one person who knows absolutely nothing about the same subject?

    My family’s response – as well as Ray and Tom’s – Two is so much worse than one. One clueless person is limited in the amount of false information they know by their own efforts. Two or more clueless people can trade wrong information and begin to create their own false theories with the encouragement of the other person.

    By the time you’ve created MANA or any agency involved with CPM’s, the clueless are running a heath care empire.

    • RMY
      September 24, 2015 at 4:47 pm #

      Never underestimate the ability of a group to find the stupidest idea and run with it.

    • nomofear
      September 25, 2015 at 1:19 pm #

      As per the old demotivational saying, none of us is as dumb as all of us.

  7. Dr Kitty
    September 24, 2015 at 1:56 pm #

    I’m reminded of all the times that I read my mother’s medical indemnity organisation’s cautionary tales of medical malpractice booklet as a high school student, thinking “OMG, how could that Dr have screwed up like that, surely any idiot would do better”.

    Now, as a Dr, I read those same cautionary tales and think “OMG! I could easily have done that!”.

    To lay people, medicine appears easy:
    Symptoms are X, therefore diagnosis is Y and treatment is Z.

    The reality is more like:
    Symptoms are X, diagnosis might be Y, Z, A or B.
    On the balance of probabilities and your gut feeling, you think it is probably Y.
    You can treat Y with drug C or D.
    C has minimal side effects, is cheap and effective, but will cause serious harm if the diagnosis is really Z, which is the next most likely possibility.
    D has potentially lethal but rare side effects, is expensive, but will also treat condition A. Condition A is rare, but the most serious, with prompt treatment being vital.
    What treatment do you pick now?
    What dose?
    For how long?
    If things don’t improve, when and how do you decide if what you’re looking at is a simple treatment failure, or a misdiagnosis of the underlying problem?
    How are you going to check?

    In medicine not knowing what you don’t know will kill people.

    • Megan
      September 24, 2015 at 3:02 pm #

      Yes! Great explanation!

    • mythsayer
      September 24, 2015 at 7:21 pm #

      I understand your dilemma on both ends. You don’t want to treat with the wrong drug which is understandable, but no treatment at all can also be bad.

      Take me, for example. It’s pretty clear I have some kind of autoimmune disease, but right now they won’t go beyond undifferentiated connective tissue disease. Plaquenil turned out to be toxic for me. Next up is methotrexate, a chemo drug. I’m not “bad enough” off for that. Prednisone is proven to help me…I’m in nearly no pain when I take it, but it’s dangerous, so they won’t give me that.

      Meanwhile, I’ve gone in the last five years from having just pain and nerve damage to now a hole in my nasal septum with mucosal sores that won’t heal (and a tumor that was just removed from my nose), nodules in my lungs (which weren’t there 2 years ago but showed up after I complained about labored breathing), and high potassium. In addition to the other things that were already wrong (every small joint symmetrically swollen for example).

      I keep saying I’ll be practically dead by the time they decide it’s really lupus or sjogrens or MCTD. It’s clearly progressing and every symptom (there are so many more) is explained by autoimmune issues. It’s just that my ANA refuses to budge from 1:160 (again, high but not enough).

      So what do you do? Take a risk on the chemo drug or evil prednisone? Or just let the patient progress? I understand the issue…but coming from a patient, DAMN is it frustrating! At this point, I’ll take anything to feel better…is pneumonia from prednisone really more of a risk than potential kidney failure, or pulmonary problems? I feel for you…I really do. And for all the frustrated patients out there, too.

      • Mishimoo
        September 24, 2015 at 7:37 pm #

        I hope they figure your health stuff out soon!! Prednisone was amazing for me. Almost no pain, euphoria (probably the lack of pain but it can be a side effect), minimal swelling, etc. Sadly, I ended up with some weird bleeding at the same time, so I am not willing to have it again. Even if it was just a weird coincidence I don’t want the anxiety over “Am I bleeding everywhere again?”.

      • KarenJJ
        September 25, 2015 at 5:14 am #

        I hope you get some answers soon 🙁 Immune system things are awful to diagnose and so many of the symptoms come in flares and seem to fall under the “are you depressed?” or “malingering” or “attention seeking” – hopefully you’re not getting that… I felt like a frog in a pot of boiling water – every incremental change I was sort of getting used to and it wasn’t until I was properly diagnosed and treated that I could finally work out what was “normal” again.

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      • Dr Kitty
        September 25, 2015 at 8:28 am #

        Oh that must be awful for you.
        I have a LOT of patients on methotrexate (Rheumatoid, IBD, Psoriasis) or Prednisolone (PMR, RA, Gout).
        Most of them do very well, with good symptom relief and few side effects.

        Maybe our local Rheumatologists are more gung-ho about starting MTX than yours? They’ll usually consider a three month trial of it for anyone with normal enough baseline liver function and blood count.

        All the blood tests are a pain for the MTX, but many of my patients report very little in the way of side effects otherwise, and get annoyed if we have to omit a dose because of a wonky blood test or viral infection.

        Of course, when it goes bad with MTX, it goes really bad, but I’ve seen a lot of good outcomes with it.

        It is worth asking about a time limited trial of MTX with close monitoring?
        Even just to find out if it is helpful?

        Pred tends to work well, but the side effects tend to be more of an issue in the long term, with most people eventually having issues with bleeding, weight gain, mood changes or bone density.

        You’re in such a difficult position. I hope you find something that works well for you.

      • Roadstergal
        September 25, 2015 at 1:09 pm #

        🙁 Have you been able to see a bona fide rheumatologist? We had a patient advocacy meeting a few weeks ago, and the overwhelming message was that the patients were happiest when they found a rheumatologist who would work with them to find the cocktail that gave them the best relief with minimal effects. Some were driving 3 hours or more to see a good one, sadly. :

        (Lupus is difficult, because even more than a lot of inflammatory diseases, it’s many different diseases under the ‘SLE’ umbrella…)

  8. Squillo
    September 24, 2015 at 1:14 pm #

    Not only do they hold inflated notions of their own skills and knowledge, they seem to have no interest in examining or improving them, if the materials and services provided by their membership organizations are any indication.

  9. Squillo
    September 24, 2015 at 1:12 pm #

    Because homebirth midwives never encounter anyone in their training besides other homebirth midwives, they have no opportunity to observe that many other health professionals have a much larger knowledge base and a much greater skill set.

    This is key. Moreover, in the U.S., a homebirth midwife may never have worked with a practitioner other than her single preceptor before setting out her own shingle. That’s part of what makes the CPM credential such a bad joke. In real health professional schools, there’s an ever-increasing emphasis on interprofessional training precisely because it makes for better practitioners and safer practice. That SF General Hospital midwifery practice that the NYT featured awhile back because of its surprisingly good outcomes? That’s partly because at UCSF, medical residents and midwives train together and because they work together in an unusually cooperative way.

    • September 25, 2015 at 4:54 am #

      I’ve written about this before, but it bears repeating. Any midwife, of any qualification whatsoever, CANNOT get anywhere near the same experience doing homebirths that she can in even a brief hospital rotation.
      A mid-sized labor and delivery unit does approx. 300-350 births a month. This averages out to [again, all rough approximations] 10 deliveries a day, or 3-4 per 8 hour shift. A full time staff member works 5 eight hour shifts a week. That means she will be involved with, if not actually delivering, 15 to 20 births A WEEK. Or between 60 to 80 births a month.
      Your homebirth midwife cannot really attend more than 1 birth a week, 2 if she’s really pushed. After all, she has to sleep, eat, see her patients antenatally, and just have a life. Often, the demand is so small she doesn’t even have a client per week. But, for the sake of argument, she is doing 4 births a month. That averages out to 48 a YEAR.
      Now, I know that’s all fantasy on one level. I have had periods of several weeks when every shift I worked in a hospital had exactly zero patients in labor, and, OTOH, a maximum of 14 births in one 8 hour period [we even ran out of stretchers in the hallway]. But the averages, over a long period do work out that way.
      I tend to joke and tell people who ask me how many births I’ve attended that I stopped counting after 3,000. But I began my hospital career in 1967, and only moved to clinic work in 2001. Work it out for yourself. Who’s got more experience?

      • areawomanpdx
        September 25, 2015 at 9:39 am #

        Non-nurse midwives attended around 1200 births in Oregon last year. A large proportion of those deliveries were attended by DEMs at three large birth centers. There are exactly 100 active DEM licenses plus a group of vocal and active anti-license midwives who are skirting the new “mandatory” licensing law. That is an average of about 12 deliveries in a year for each active license, and it is pretty clear that a small number of particularly active midwives are delivering more than that and the vast majority of licensed and non licensed homebirth midwives are delivering 3-5 babies in a year. That is nowhere near enough deliveries to even keep your fake skills up. Not only that, but they all talk about the thousands of babies they’ve delivered, which is clearly a lie.

  10. fiftyfifty1
    September 24, 2015 at 12:44 pm #

    The Dunning-Kruger effect explains a lot and does a nice job of predicting how most people improve their self-awareness as they gain exposure to factual knowledge and feedback.

    But I swear there is a subgroup of people that the D-K effect can’t explain. They start clueless and they STAY clueless, no matter how much feedback and how many opportunities to learn they might be given. A lot of homebirth midwives fit in this group, I fear.

    • MaineJen
      September 24, 2015 at 1:01 pm #

      True believers.

    • AirPlant
      September 24, 2015 at 1:10 pm #

      It feels good to feel like an expert. You get to be all smug and knowing and feel like a BAMF most of the time. When learning new information makes you realize that you are not as good as you thought that you are, for a certain personality it can be easier to just go on lockdown and NOPE NOPE NOPE all your cognitive dissonance away. If you think about it would you rather think of yourself as a professional, knowledgable expert in a process as old as humanity who helps mothers and babies through a glorious, holy rite of passage that begins their life long bond or would you like to find out that you are a reckless, ignorant anachronism, and the only thing between you and a negative outcome is pure luck.

      • The Bofa on the Sofa
        September 24, 2015 at 1:27 pm #

        I have saying (don’t I always?): People who are not in X don’t understand what people in X do.

        X can be lots of things. In fact, it’s pretty much everything. X could be farming, or waste water treatment, or ditch digging, for that matter.

        My brother is a trucker. He always tells everyone I’m the smart one. However, I don’t know if it’s true, but it doesn’t matter. He knows a shitload more about trucking than I do. We spent on evening boating on the Mississippi this summer, and he taught me a lot about shipping and barges. Stuff I didn’t know anything about. Now, I knew enough to be able to ask good questions, but he’s the expert.

        One of the things that boggles my mind the most is when people think their PhD in some subject means something in another. I always figured, the one thing that my PhD taught me is that to be a real expert takes lots and lots of work. I know what I had to do to become an expert in my field, why would I assume that it takes less to be an expert in another?

        And if you think you are all-knowing, just talk to an engineer about the stuff that they work on. The things they have to (and do) think about are way off scale nuts. We were setting up the lab, and they are like, “How many diffusion pumps are you going to have?” I don’t know, 4 or 5. “Is it 4 or is it 5? And what are going to be their power requirements?” Ask me in 10 years. And I don’t know, I’m going to plug them in. “And how much cooling water will you need?” I don’t know, we just hook them up to the water line. “WE NEED TO KNOW THIS STUFF!!!!!!!”

        Yeah, but I don’t. I just need to be able to connect some diffusion pumps. Oh, and maybe a turbo (BOOM! Engineer head explodes)

        • Amazed
          September 24, 2015 at 3:33 pm #

          Fat load of good did my education do me today when my water pipes decided that it would be fun to make a water garden under my sink. I did manage to screw what was unscrewed (praying that the water garden wasn’t spreading into my neighbour’s flat) and in the process, I found out that dregs of coffee had started taking posession over the pipes. Every plumber could have told me. But I didn’t know.

          The things I don’t know could fill the Alexandrian Library. Why don’t homebirth “professionals” touting over their totally unrelated degrees cannot realize it?

        • KarenJJ
          September 25, 2015 at 5:23 am #


    • Mishimoo
      September 24, 2015 at 7:04 pm #

      Anti-vaxxers are another group with members fitting that description. They start clueless and deliberately stay clueless despite any evidence presented to them. Example: My best friend’s mum who simply could not comprehend why my vaccinated kids were perfectly fine and healthy when I ran out of luck and caught chickenpox. Her reaction to being gently led to the only possible answer (vaccines work safely): “No. I don’t like that. I won’t believe it.”

      • Charybdis
        September 24, 2015 at 7:42 pm #

        Well, Hell! There are PLENTY of things that I don’t like and if I refused to believe in every single one of them, my life would be great! I’d have straight blonde hair, still fit into the jeans I wore in college and chocolate would have no calories. Just how nucking futs do you have to be to think that if you didn’t like something, then you don’t have to believe it? Delusion of the day, anyone? I’m going to be over *there* pounding my head against the wall…..because it feels so good when I stop.

        • Mishimoo
          September 24, 2015 at 8:55 pm #

          Oh, it gets worse :p

          “I don’t have to plant bee-attracting flowers or handpollinate my curcubits, I believe that they will be just fine. I also don’t need to fertilise my garden because I believe my soil has everything it needs for my veggies to grow well.” *moments later* “Why do my zucchinis die at the ends? Why do my tomatoes rot on the bottom before they ripen?”

          • Rosalind Dalefield
            September 29, 2015 at 10:38 pm #

            ‘It was God’s will. Some zucchinis and tomatoes are not meant to live’…sorry, couldn’t resist.

    • KarenJJ
      September 25, 2015 at 5:20 am #

      My thoughts is that they have too much invested and are getting too many mixed messages. Emotionally invested – because being an “expert” feels like something they are entitled to after so many years of “training”. Financially invested – because they have invested so much time and money into the “training” and their career. Socially invested – they have built up a huge amount of social capital by being a “midwife” and for many (most?) of them a victim of “the man”.. and mixed messages because most of the time things go well and women appreciate their presence at their baby’s birth.

      What will they get out of admitting that they know nothing and their midwifery practise is a sham? They lose money, friends, prestige, purpose in life. Much easier to band together with other victims of “the man” and psychologically soothe each other with loads of affirmations and bullshit.

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