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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA


Personnel / Students / Apprentices / Assistants

Easy Steps to a Safer Pregnancy - View e-book or Download PDF - FREE!
An interactive resource for moms on easy steps they can take to reduce exposure to chemical toxins during pregnancy.

Other excellent resources about avoiding toxins during pregnancy

These are easy to read and understand and are beautifully presented.

Subsections on this page:

Group Practice

Ideas on how best to make Group Practice work

I practice full scope independent midwifery funded by the government  here in Ontario. Each full time midwife provides full prenatal care  to 40 women per year, plus act as second midwife at births for  another 40. We order all labwork, US, review results and request  consults as necessary. A woman gets to know up to 4 midwives and we  provide labour care at home or hospital. We have  a clinic for pre  and postnatal care. Our schedule of visits antenatal is the usual  regimen with some variation depending on client needs. Postnatal care  is in the home for the first 7-10 days, then at the clinic until 6  weeks.

We are on call 24/7 but seem to manage a life. A cell phone and pager  is necessary plus the ability to plan your time.

Each practice arranges off-call. Midwives usually have one weekend  per month plus some days, then 2 months complete off call time.  Varying models are being tried to suit lifestyle needs for midwife  without compromising choice and continuity. I am sure that you will  be able to include postnatal care as your remit is only up to 10 days.

It is important that each group have administrative support, to  reschedule appts etc. when you are at a birth. You need to figure out  caseload numbers and plan accordingly. I will tell you that it is much easier to care for women and families  you know.  It is also more rewarding. Managing your time is difficult  at first, but then you discover that the artificial hospital  schedules are eliminated.

BTW, most of our hospital birth clients go home within 4-6 hours.

I would strongly recommend that you get the One to One report by  Lesley Page and Caroline Flint's book , Caseload Midwifery ( I am  not sure of the full title) The Albany Midwifery Practice where Nicki  Leap used to be, had a good working system. The important thing to do is to break into smaller groups, based on geography.

Peer Review

NARM Peer Review Guidance Documents

Quality Management Program from Midwives' Association of Washington State

The Dream Midwife

Mothers Describe Their Dream Midwife

Mothers thought less of me because I was a childless midwife by Gaynor Morrison? - Every day of my 17-year midwifery career I was asked if I had children, but being a mother does not make me a better midwife.

Second Midwife

Policy for Second Birth Attendants from the College of Midwives of BC

Safety In Numbers - How many midwives at a birth? by Chris Warren from the Radical Midwives in the UK

Midwifery Self-Care

Trauma Stewardship - an everyday guide to caring for self while caring for others

Working Without an Assistant

In our area, midwives sometimes work alone at a birth.

What would happen if there were a problem with mother and baby at the same time?

Yes, well, that would be a tight spot. But honestly, I have never been in a situation like that in 22 years. And somehow I don't think it happens a lot because all Dutch midwives  work on their own. The doula will come when called, but she can take 1 hour from our first call to the center till her arrival at the clients house. And since home deliveries are often multips who deliver quickly, often the doula will miss the birth.  But so far no-one here has started a discussion about how much better it would be with two midwives at a birth.

I've done a number of births alone -- and a great many with assistants so "green" that it was almost as if I were alone.

There were a couple of years when I was the only midwife who would travel to some outlying areas. I learned a few tricks about packing and equipment and arrangements. I never felt it was a problem to have only one pair of hands. Even if an emergency happened.

It's nice to have another person to help, and it's nice if they know what they're doing. If it is another midwife, then I pay her more than an assistant because she contributes more (and it's a pleasure to have the company).

It's just a convenience though.

The midwife association in my region decided years ago that we would work in at least pairs "whenever possible" -- and that's really the reason it's still done here, I think. It's done that way because it's always been done that way.

I do think the only strong argument for the necessity of two people on the birth team, is legal protection in case the midwife's version of events is different from the clients. It's good to have a witness if something unexpected happens. It can help avoid misunderstandings or false accusations of conduct. Or even charges of mal-practice.

Any person who was ever alone with another might potentially face accusations years later. And there is really no defense -- other than making sure that you were never alone with them.  Also it wouldn't be hard to see how a particularly vulnerable woman might conclude that the things a midwife might normally do (such as a vaginal exam) could be "sexual", or even "sexual abuse". Without the presence of a witness, how could the midwife protect herself?

So without asking for too much technical detail, how would you 'triage' a newborn resuscitation with concurrent maternal hemorrhage @ your deliveries?

I've done births alone for years and never had to 'triage'.  It just doesn't happen.  Something wrong with babe and that mom doesn't lose a drop of blood.  Mom got a problem?  Don't hear a squeak out of babe who just nestles with dad.  Concurrent problems probably only happen in the hospital.

Maybe you should buy a lottery ticket because you have clearly beat the odds on this one; throughout my career this has been a recurrent scenario. I am sure I could have muddled through all by myself and probably have but with many of the hyper-vigilant bystanders present at births these days, I would hate to try and defend myself if I was unable to resolve this situation in a satisfactory manner.

When a midwife is being investigated, a common tactic is to find out who the assistants were, go after them for info, then charge them with crimes if they don't agree to "roll over" on the midwife.  Worth pondering.


A list of student midwife sites

A Guide to Becoming a Licensed Midwife in the State of California
from CAM - California Association of Midwives

Midwifery Today's Aspiring Midwife Chat

Midwife's Assistant DVD from midwifesassistant.com

Midwifery Student's Bill of Rights - read more about it at Future Midwives Alliance.

This is a little off topic, but sometimes my assistants don't understand why I ask them not to use their cell phones at a birth:
Hospitals Warn Smartphones Could Distract Doctors

April, 2004 - Eagletree Press is pleased to announce the release of the Revised 2nd Edition of Training Midwives - A Guide for Preceptors by Daphne Singingtree and contributors.  If you are midwife who works with student midwives, this new edition of Training Midwives is an important addition to your library. The second edition has been completely revised and expanded from 68 to 132 pages and is available in either a paperback or eBook format.   More interviews and personal stories are included as well as valuable information for both students and teaching midwives.

In addition to the new edition of Training Midwives, there is now an eBook version of the Birthsong Midwifery Workbook as well as our two existing e-documents; Community Midwifery Practice Guidelines and Community Midwifery Procedure Manual. If any of you are involved in schools or study groups, bulk pricing is available on all our products.

Advice About Taking On an Apprentice

What makes a Successful Apprentice?

How does one feel about their apprentices discussing births that don't go well.

My apprentices are not allowed to discuss any birth with anyone other than me.  I encourage them to write up the birth, with all their comments, negative and positive.  Sometimes I learn from their comments and sometimes I can explain to them why I did what I did.  I often find that an apprentice who feels strongly one way in the beginning, will often change her mind in the end about some things.

I have a 3 month period where if it 'ain't happening' we/I can dissolve the relationship.

They work free until they demonstrate some helpfulness.  Then it is very minimal pay, building over time.  The most I've paid is $100.00, unless she works into a jr midwife status, and after she has gotten some hands on training, she is worth far more to me.

I have beginning midwife classes, where i may approach a gal and offer her an apprenticeship.  usually someone from out of the area, because she won't get much business locally.   My criteria?  4 things are absolute...able to do accurate bp, neonatal resuscitation, injections and bimanual compression.  Major big heart helps too..

What do i really expect from my apprentice?  Ability to be calm and quiet, observe well and integrate, and look up in books what she sees.

In the 80s when I was apprenticing we were not allowed to give the clients or prospective clients our personal opinions on any subject.
We were constantly reminded that we were there to observe/learn and that the clients were not interested in our personal opinions.I'm interested on how others handle that and if its still that way ?

One of the problems with apprentices giving their opinions is that they have very little to draw upon.  Maybe their own birth?  Maybe the three doula clients she has worked for? The client is paying for, among other things, the experience of the midwife she hired.  Not the opinion of the apprentice who has been to four births including her own.  Sometimes apprentices haven't had the time or life experience to be able to judiciously separate information, the evidence-based from the far-out, la-la land opinions.  Sometimes apprentices are so enthusiastic and have just read some really cool herbal solution to some problem and they just can't keep from sharing that with the client.  What they may not know is that this particular client has already tried this, doesn't want to use herbs, or that this particular usage is contraindicated in some way, or that it just plain isn't evidence-based and doesn't work.  I don't mind my apprentices talking to clients, but not at first.  I want them to get a good sense of my practice and I talk to them about everything they say and do being reflective of me.

I had a lady going with me to learn and at one birth I got out of my chair by the laboring Mom to get something and she had took my chair right in front of Mom and assumed my position of catching baby. Instead of causing a stink I just politely leaned over her and caught baby. Afterward in private I advised her she was wrong and never do it again unless I ask her too.

My client got very upset and asked for me to never bring her again.
Some assistants just want to be in charge so bad.

How funny. I had to do that once with a doula. She decided that she was catching baby. It was 10lbs and presented with a nuchal arm /cord and needed some assistance. I actually had to move her aside to do the birth. If the mom had discussed it with me beforehand I would not have minded but even the mom could not figure out why she did it.

I stopped students from giving their opinions years ago as I found they would take up a lot of the clients time with long orations of what they had read so they are told from the get go to keep quiet unless I ask for their opinion and then I only want them to suggest sure fire stuff and keep it short.

Apprentices/Assistants and Money

I'm just curious how other midwives and apprentices work out money matters. I'm mainly talking to practices who do actually pay their assistants/apprentices when they ( the assistant) has become skilled enough to be of value to the practice. NOT THAT unskilled, or "green" apprentices aren't of any value. But most midwives do not pay someone who is learning the basics.

I'm talking about when an assistant has reached the point that she is ready to be a "primary under supervision" and she is on call for births as a midwife's primary assistant.

What is a fair policy if a client is slow to pay. Should a midwife get all of the money, until she has her cut and then pay the assistant, or should all of the money that comes in be divided up as it comes in. What if the midwife decides to do a free or reduced fee birth for someone. Should a primary assistant be expected to absorb that cost, or should she have the choice to opt out if she can't personally absorb all of the costs of being away from home, babysitters, etc.

I know that there are no hard and fast rules. But I would like to hear from other practices how these issues are handled. To the midwives: How much value do you attach to having a reliable assistant ? What kinds of skills do you need her to be able to demonstrate before she is valuable enough to be paid ? Do most of you have them, or are they a rare find ? When you do find them, what kind of compensation do you feel is fair ?

To the assistants: Have you and your senior midwife come to an agreement that works for you ? Please describe it. Do you ever feel like you are being taken for granted or not being fairly compensated for your service ?

I hope this will initiate some good discussion. Our practice will be discussing some of these things tomorrow and because we are 2 midwives and 4 assistants/apprentices we have a LOT to talk about. I hope to take some of your suggestions and comments with me . Thanks.

I charge $250 to assist another midwife who is in the second year of primary practice, and I turned over most of my clientele in her area to her. She still works in my practice, does my billing, etc. The midwife who trained me helped me get going and I am just passing that on to someone I really love.

I personally don't charge apprentices. In fact, I pay them. But I expect a lot out of them. I start out training them to help w/ pp care and pay them $25/ visit once they are skilled enough to do visits without me there. They have to call in from clients' house (if they have a phone) or ASAP. Once they move on to attending births, they have responsibilities added as they master skills. I pay them $25/birth 'til about 25-30 births, then $50/birth 'til 75+ births (more if they are my only assistant there). $100-$125/birth til 100+/CPM/Mi MWs certification. $25 per prenatal in Amish client's home w/o me once they have mastered pn skills. They get "profit sharing" bonuses when they cover phone calls or appt. days while I am gone, or for special conferences. They are dependable, responsible, help out a lot, and usually worth every penny. In 1996, it averaged out to $300-350 per birth to associate midwives and $100-125 per birth to my apprentice who just attended her 60th birth.

Because of them (and it took all 4 of us!), I could attend 2 births, make sure 11 prenatals were covered, and teach birth classes to 5 couples in 7am to 10pm - all in the same day last Tuesday!

I agree that money matters are often very difficult. In my practice when we take on a new apprentice, we explain that we are already living well under the poverty level and cannot "give up" anything that we earn for the apprentice. We also point out that the alternative of going to formal midwifery education at a University will cost the apprentice a significant amount of tuition that she will "save" by being an apprentice. And, that the costs such as transportation, childcare, books, equipment and so on are common to both kinds of "educational" experiences. I find this issue to be a morally difficult one - I hate feeling as though I contribute to unfair exploitation of women who desperately want to be midwives - taking advantage of their excitement and desires, recognizing that we often get quality work from apprentices/students and do not pay for it. And yet, I have to be realistic - when I look at my 1996 tax return and realize that my taxable income was only $4500 and I had 20+ primary clients and did backup for 40+ births - I know that I cannot find ways of further reducing my income and still pay rent, buy food, feed my car, and so on.

However, there are some exceptions e.g. if we end up having to "use" the apprentice's assistance in a way that is beyond what we have agreed to be the usual apprenticeship experience such as having her teach extra prenatal classes because we are at a birth, we do compensate her for these services.

Our regulations (we are not yet bound to complying with these, but do try to follow them where possible) require that we have two midwives at each birth. So, our ideal is to have two midwives and to have the apprentice there as a third person even though the apprentice may actually be doing a significant proportion of the "work" if she is nearing the end of her apprenticeship. We may have a nearly finished apprentice act as the second midwife - but generally only when there is not another midwife available - and will compensate for that.

Once the apprentice is at a point that we (midwives and apprentice) think that she is ready for supervised practice, the arrangements really vary. Right now, none of us can afford to "give away" clients - we even have some uncomfortable situations occur in practices where one midwife seems to always have the lions share of clients and the others are sitting by the phone sending messages out to the universe that they are getting hungry and the bank is wanting money - so, for supervised practice, the arrangement is often - if the supervised midwife can "find" her own clients then she can charge them and pay a backup/supervising fee to one of the midwives. But, if she is getting her "clients" because one of us has found that one of our clients is willing to involve her in the care in this supervised role, then we collect and depending on a discussion among all the midwives, may share some of the fee with the supervised midwife. It seems harsh, unfair but I'm not too sure how else we could manage it financially. When one of our apprentices reached the point of supervision, she wanted us to just divide the "backups" so that she would get to and paid for a equal proportional share of these - but, because that would result in a significant decrease in earnings for all of us, we did not agree. She left and has not been able to find another practice that will agree to her expectations.

I suspect that this would be very different in a situation where a midwife practiced on her own and was looking for reliable help. When I first joined my partner, I know that I was able to negotiate a significantly higher backup fee with her than she had originally proposed because at that time she was on her own and I felt that while I certainly wanted to join her practice, it was not worth my while to be on call all the time for such a small amount of money. Especially when I knew that it would take me some time (about 2 years actually) to really start to build up my own client load so that I had primary midwife fees as part of my earnings.

Around here, it is pretty common for the midwife to collect her own fee from the client , and the assistant collects her own fee. If the MW accepts a reduced fee, the assistant may never even know about that arrangement and is usually paid her full fee (350-400$ around here). The assistant is encouraged to collect her fee at the 36 wk home visit, although that does not always happen. The asst. does the 36 wk visit, attends the birth, and does one of the PP visits. Most of the MWs are pretty good about reminding the parents to pay the assistant. An unskilled, just starting out assistant usually attends births at her own expense. The paid assistants are certified in CPR and neonatal resus.. I heard about a local hospital oriented doula who had only been to a handful of births and is charging $500.00. Now why can that happen when a skilled home birth assistant, and sometimes the midwives HOPE to get paid SOMETHING?

I find your questions very interesting. What is the value of an apprentice/assistant? What is the value of a preceptor/teaching midwife?

I do not pay any monies to apprentices. What I do is spend hours and hours with her teaching her, instructing her, reviewing her academics, providing her with invaluable experience, etc. If she were to pay for a program which supplies those things, she would not be able to afford it!

I do not take advantage of my apprentices. She is never expected to do any chores or assignments which are not midwife related. There are, often, exercises which at this point resembles some of the exercises seen on the movie Karate Kid (wax on, wax off).

Almost everything I do takes twice as long because I double check everything from charting to supplies to sterile technique.

So why do I take the time to apprentice? One day that apprentice will cross the line to become a fully qualified midwife. At that time she will be available to assist me at births. I pay fully qualified midwives $150.00 per birth to assist. They are called near the end of 1st stage labor and is released to go shortly after the delivery of the placenta. Sometimes that is only 2 hours, sometimes it is 8 hours. It seems to average out.

For the hundreds of hours I put into her training, I do not receive a dime. For her hours of assistance, she receives a plethora of experience!

Every midwife is different in this area none of which is either right or wrong.

Thanks for your interesting reply. In our practice, the apprentices work, and are very self-motivated in our study. Our midwives teach us at a once-a month study group, and at births, but really don't have time for us to "sit at their feet and be a sponge". I'm sure you do spend a lot of time with your apprentice, and it is worth it to her to work for you as a trade off. But it's very different with us. Our midwives simply could not handle the demands of our busy practice without our help. We cover 1/3 of the geographical area of NC, and do about 50 births a year. We also have 31 children between us !!

When someone really green comes in they don't get paid until they've been to several births and done a lot of pre and post natals, and demonstrated a desire to pursue some related form of study as an individual. For example, 2 of us are certified birth assistants, one of us is a lactation consultant, and one of us is a certified childbirth educator.

Thanks to everyone for all of your input. From the sounds of it, I think I'm in an enviable situation since I'm paid quite well ! I'm very thankful!

Midwife Mentors / Preceptorships

I would like to know what your opinion is on how to ask for an apprenticeship, and what exactly should be spelled out as far as expectations before the apprenticeship starts.

Actually, I was thinking about going into midwifery myself, after my newest arrival is old enough.  I've thought long and hard about what kind of person would make a good teacher, and this is what I've come up with:

These are just some of the things to think about.  Ask yourself this question in searching for a mentor:  Would you want this person to deliver your child?  If you can answer with a "MOST DEFINITELY, YES!", then she would probably be a good teacher.

I have to say I disagree with you here. Being a good midwife and being a good teacher do not necessarily go together. I apprenticed with the midwife who delivered my babies and only found that she was very, very different in that relationship than she was when she was my midwife. In fact, that was a huge part of the problem. I had put her on a pedestal, and came to find that our dynamic as student/mentor was not consistently harmonious. I was devastated to have to come to terms with that reality. However, we love each other immensely and respect each other's talents and we are MUCH BETTER when we are not working together in the capacity of teacher/student. I don't like her style of teaching at all. She is a brilliant midwife, but she did not teach me the way I needed to be taught; and she admits now that she didn't know how to teach me either. She was frustrated with me because I could not be how she needed me to be, I did not have the basic foundation she needed. I was also constantly tormented in that relationship, and really gave my power away. Although it was tumultuous and painful, she admits now that I helped her get clear about what she needs and wants in an apprentice (I was her first). I , too, am more clear about what I need and want in a mentor-midwife. I am working with someone new now, who has a very different personality type and WAS NOT my midwife--I will let you know if it it works out.

Many of our local midwifery students are very frustrated about finding preceptors.  Here's something I wrote to one who was lamenting the large number of midwifery students relative to the number of local midwives:

It's not just the number of students looking for midwives. It's the clients themselves.  I know that it's not always easy to think from their point of view when you haven't been through many cycles of bonding with your clients, but if YOU were having a first baby or a first homebirth or a first waterbirth, how happy would YOU be with a student midwife at your perineum?

Students would have to offer a significant monetary incentive to the families . . . around $1000 each, I would think, in order for the mom to have the student catching instead of the midwife if it can mean the difference between tearing and not tearing.

The populations that are well suited to the apprenticeship model are those where women are having many babies, and by the time they get to their 3rd or 4th, they're happy to have the apprentice who was at their 1st and 2nd births catch their baby, especially if she's provided some prenatal and postpartum care through previous childbearing cycles.  This just isn't going to happen in our local population.

This is why the El Paso clinics are such a boon . . . they offer a win-win for the birthing women and the student midwives.

After I got back from El Paso, I dreamt about opening a similar birth center in this area, so local students could gain experience with Medi-Cal clients, who might not be so picky about their care as the more typical homebirth client.  Well . . . it's hard enough for ANY birth center to make it in this area, let alone a teaching birth center.  So, I'm still waiting to win the lottery in order to realize that dream.  Fingers crossed!

You might ask on the apprentice lists about how other students have found practical opportunities.

As an aside, I think that some of the midwifery schools do students a disservice to lead them to expect to be able to find a local apprenticeship opportunity.  I truly have NEVER heard of it in this area.  Really, truly, seriously. That doesn't mean it hasn't happened, but I don't know anyone who didn't have to go to El Paso.  It's a bummer, believe me.  I was 38 when I went, and that was a difficult adjustment, but I made it through and am glad of the experience.

As another aside, the births in El Paso are much easier than most of the births we see here, with our over-stressed mamas. It really is a good place to get experience, for a lot of reasons.

Again, the apprentice lists would be the place to get current information.

I have tremendous compassion for midwifery students who are so full of the desire to help women and are so frustrated that they can't seem to find their next step on their midwifery path.  If it helps, you can think of this as the prodromal phase of your own labor and can be a lesson in working with women when the opportunity comes.

Accepting Responsibility for Another Midwife's Client

Okay, here's what I wrote up as guidelines for accepting referrals from other midwives (in the case of referring midwife being out of town when client is due or if midwife lives far away and client is having fast labor, etc.):

  1. I need access to a complete chart before the onset of labor, which includes appropriate labwork, a good EDC based on clinical evidence, a complete history and physical exam results, an adequate number of prenatal visits, and delineation of risk factors . I need to know that the client meets MY risk criteria, which may be different than those of referring midwives. Once I have had a chance to examine the chart and consider the risk factors, I will either accept or reject the referral.
  2. It will be the responsibility of the referring midwife to make sure that the client has the homebirth environment satisfactorily prepared for the birth, including birth and baby supplies on the premises. It will also be the responsibility of the referring midwife to have done complete informed consent for homebirth and to have had previous discussions with the client about arrangements for emergency transport, etc.
  3. The client at risk for a fast labor or due when referring midwife is out-of-town needs to be aware that I may be called in to attend the birth as back-up midwife, and perhaps how to contact of me (once I have a copy of the chart and have agreed to be back-up midwife).
  4. The referring midwife will directly reimburse me for services rendered. My standard birth-only fee is $800, with follow-up PP visits at additional cost. I may consent to a sliding scale fee, if agreed on beforehand, if the client is a cash-payer whom the referring midwife is charging based on a sliding fee scale. My fee for service will be charged regardless of the referring midwife's ability to collect from any particular client.


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