Oh, and before I get all the comments about how I’m shoving all NCBers in the same box…she may be the only one who would VBAC unassisted with a 99% chance of uterine rupture, but she sure isn’t the only one who thinks scientific evidence is bunk.
Oh, and before I get all the comments about how I’m shoving all NCBers in the same box…she may be the only one who would VBAC unassisted with a 99% chance of uterine rupture, but she sure isn’t the only one who thinks scientific evidence is bunk.
Forced c-sections for all!! Muahahahahahahahahahaha!
That was a joke for those of you who are humor impaired. What is true is that I have an agenda. Top of the list? Safer mamas and babies.
I’m writing about this for two reasons. First of all, someone in the Fed Up Facebook group posted one of the ACNM Objectives for Healthy People 2020 and asked the Skeptical OB to write a blog post about how we can increase physiologic birth in hospitals:
As far as what I hope to achieve…
I don’t necessarily want to have the CPM credential abolished, as many of my readers do, but I do think it’s redundant with the existence of the CM (A CM is a direct entry midwife with the same midwifery training and examination as a CNM but no nursing, currently only legal in New York and Rhode Island). If it’s going to stick around, it needs to require a minimum of a Bachelor’s degree from an actual accredited university (i.e., not Birthingway, Aviva Institute, National College of Midwifery, etc.), with the same science courses BSNs are required to take and pass with a B or better. If every CPM had the education that graduates from Bastyr have, I might be satisfied. I also want the NARM to reflect the same level of difficulty and accuracy as the AMCB exam (that CNMs and CMs take). If the requirements for a CPM aren’t changed/made more stringent, then I do want the credential abolished and would be happy to make the Certified Midwife (CM) a national certification.
Other things I’m working for:
What changes do YOU think will make childbirth safer?
Astraea blogs about midwifery in Oregon and shares her own homebirth horror story over at Oregon Homebirth Reality Check. We felt this recent post of hers was so important that we arranged for it to be be re-posted here as a guest post. You can read the original post here.
Any plan is arguably only as safe as its contingency plan is solid. Common and less common emergent and urgent situations must be studied and planned for; backup must be arranged. Staff should be drilled on what to do in case of the most dire situations, they can act quickly and calmly in the face of an actual emergency and the panic it brings. This is a well-accepted principle. It is why we have fire drills in schools and offices. It is why lifeguards must be people who have been trained, and not just any person who knows how to swim. Unfortunately, among many “alternative” healthcare providers, risk planning is looked down upon. It is seen as inviting “negativity.” Some even believe that you can “manifest” good or bad results simply by thinking about them a lot. This is a childish, irrational belief, but unfortunately a common one in the circles of direct entry midwifery. (Childish, literally–remember Mr. Rodgers comforting children that they cannot cause a person to die just by wishing they were dead? That’s magical thinking, a normal developmental stage. We’re supposed to grow out of it.)
But homebirth is truly only as safe as the process used to “risk out” of it (and into obstetrical care in the hospital) is complete, thoughtful, and conservative. The risk assessment protocols for Oregon DEMs have again been changed. You can see how they differ from the 2009 version of the same. The criteria have been tightened up slightly in a few ways, but overall loosened substantially from the original 1993 criteria (see table). The legislators who allowed direct entry midwives to be licensed through the state in the first place approved a far more conservative set of safety guidelines than what is currently in place. These changes–for instance, moving from no VBACs to almost any VBAC; no multiples to most kinds of twins; no malpositioning to any breech and back down to no footling breech–have been put in place by the DEM board, without any outside oversight. What is worth examining in some detail is not just how the Oregon absolute and non-absolute risk criteria have changed, but how they compare to the homebirth systems that are so often held up as examples of why homebirth is safe. We cannot expect to get the same results as the Netherlands, Canada, or New Zealand if we are failing to be as conservative in our safety standards as those nations.
Even a quick scan of the risk criteria by a careful eye shows many problems. For one thing, the list is very brief; many potential serious and common risks are not even weighed or considered. Compare it with the far more comprehensive and methodical list from the British Columbia College of Midwives and the sloppiness and shortcomings of the Oregon list are readily apparent. In almost 20 years, how is it that the board has not managed to come up with something as thorough as the Canadian risk criteria? For another thing, some of the determinations rely upon diagnostic tools or skills that DEMs are unlikely to have on hand–for instance, AIDS in an infant is an absolute risk factor according to the 2009 standards, but HIV is a non-absolute risk factor. How is a midwife to determine the difference on site, without being able to determine viral load, T cell count, or the presence or absence of AIDS-related complications?
“Absolute risk” is a condition that rules out homebirth as a possibility. The patient(s) must be referred out to hospital care immediately. “Non-absolute risk” is much blurrier in meaning. Oregon law only requires that the midwife consult with another professional about the situation and obtain “informed consent” from the patient. Another disturbing contrast with the BC system is that while for many conditions, Canadian midwives must consult with a physician and proceed as advised. Oregon midwives must consult with “another licensed professional” but it need not be a medical doctor. It could be a naturopath, in fact, or even just another midwife. Considering the extreme seriousness of many of the conditions on the non-absolute risk list (ie platelet count below 75,000; persistent unexplained fever over 101; labor at 35 weeks gestation; isoimmunization to blood factors) this is extremely alarming. Other direct entry midwives are no more trained in these high risk situations than the direct entry midwife calling the consult. Naturopaths are often not trained in them either, as they lack the inpatient experience that a licensed MD or DO must have. And the looseness of the law makes this a judgment call where the safety depends entirely on whether your midwife is cautious or reckless. A cautious midwife may choose to take an infant weighing less than 5 lbs or with a “suspected major congenital malformation” to the hospital. A reckless one may call a naturopath who in turn suggests breastfeeding and homeopathy…while a premature or growth-restricted baby slowly dies a preventable death, or major malformations begin to claim an infant’s life even though in a hospital, treatment would be available and effective.
And under current Oregon law? The reckless midwife would be absolutely justified, protected, and in the right. This is sick and wrong.
A number of the conditions Canadian midwives must refer for transfer are on the Oregon non-absolute list, or are not named on the Oregon lists at all. If we are looking to Canada’s outcomes to justify licensed direct entry midwifery in Oregon, why this discrepancy? But the difference is far more jarring and obvious when you compare the Oregon list of standards with that of the Netherlands, the country whose high rate of homebirths and relatively favorable outcome statistics are so often held up as an argument in favor of American direct entry midwife-attended homebirths. Nevermind that Dutch midwives are more like American nurse-midwives than our poorly trained and unregulated “CPMs.” Looking at the very strict, conservative, and comprehensive standards Dutch midwives work under, it is clear that we cannot expect to see Dutch results with our sloppy Oregon risk criteria.
For instance, the first three sections of the Dutch criteria, dealing with medical history and prior pregnancies, has no equivalent in Oregon statutes. The Oregon risk criteria deal almost exclusively with the present pregnancy and conditions that may arise within it. This is a huge oversight, considering the impact that medical history and pre-existing conditions can have upon a pregnancy. I think, because DEMs are trained narrowly in “normal birth”–they are more “birth assisting techs” than true midwives in the sense that Dutch midwife or a nurse-midwife is a midwife–they simply were too ignorant of all the possibilities to think of them for their risk criteria list! For instance, while the Dutch standards address alcohol abuse (common!) and chronic conditions like MS or rheumatoid arthritis, the Oregon standards only tangentially address the latter under the umbrella of “conditions that may need medication,” a non-absolute factor. The Dutch standards require twins and breech babies to be born in a hospital, while the Oregon standards do not. Yet the 1993 Oregon standards were in line with the Dutch standards! Why the change? There have been no scientific breakthroughs validating looser protocols. It seems a clear case of letting the people with a financial interest in increasing their reach (DEMs) have too much oversight over their practice protocols, and not enough legislative moderation imposed to slow them down. The Dutch require hospital transfer after 24 hours of ruptured membranes. The Oregon standards don’t even list that as a non-absolute risk factor–only after 72 hours AND the deadly infection chorioamnionitis has set in must Oregon DEMs transfer under penalty of law. Yet in 1993, the standard was just 72 hours…choreoamnionitis was clearly added in later not to protect patients, but to sweeten the deal for DEMs who feared transferring care and perhaps losing out financially or legally when they did so. Failure to progress in labor–a warning and risk factor for many potential problems such as shoulder dystocia, postpartum hemorrhage, and maternal exhaustion–are risk-out criteria after a set time in Dutch regulations. It was also an absolute risk factor in 1993 Oregon law. Now it is not even a non-absolute risk factor; women in Oregon can continue in labor indefinitely at the hands of a negligent midwife, as poor Margarita Sheikh did and the midwives are accountable to no one for this poor treatment of their patient.
The creeping risk factors in Oregon are in opposition to the findings of scientific evidence. For instance, take late prematurity. Recently, much has been made of the evidence that babies born prior to 39 weeks aren’t really ready. While 34-37 week babies were once thought to be mostly ok, we are now learning that they may face long-term effects in brain development and other aspects of their health. This has been the driving force to reduce elective c-sections that take place too early, inductions before 39 weeks, and other such potentially risky interventions. The Dutch criteria require transfer to hospital care in the case of rupture of membranes prior to 37 weeks. The 1993 Oregon criteria require transfer with rupture of membranes prior to 36 weeks. But the 2009 Oregon criteria don’t require the baby to go to the hospital unless it is THIRTY FOUR weeks. Incredible. Unprecedented. Where are they getting these numbers? After all, a baby of 35 weeks gestation still has a 12% risk of respiratory distress syndrome–compared to the 3.5% risk at 37 weeks or virtually nonexistent risk in a 40 week baby with no other predisposing conditions. (See calculator here.)
What justifies these reckless Oregon protocols? And where will the creeping upwards in high risk stop? Will 33 weeks at home be argued for next time the criteria are reviewed? After all, stunt “midwife” Lisa Barrett in Australia is all for it–don’t let the fact that she’s being investigated by the coroner disturb you too much. (Warning, link contains nudity and graphic birth scene, not to mention appalling and nauseating stupidity and disregard for human life and limb.)
In fact while I find the Oregon protocols ignorant and lacking when it comes to the health of the mother, it is in regards to the well-being of the infant that I find them the most alarming and disgusting. To get perspective on what other homebirth-friendly areas allow in this regard, I compared the protocols to NICU or Level II admission standards in New Zealand. It seems a safe assumption that if New Zealand professionals, who are used to midwifery care and homebirth being integrated into their maternal care system, think a baby should be in the NICU or SCBU as I think they call the step-down units over there, a baby with the same condition in an Oregon home should be headed for the hospital.
On admission to level 3 in NZ, I found two questionable equivalents on the Oregon list. Since OR does not require transport for a Coombs positive (it’s non-absolute–so call your favorite naturopath to see what kind of sage to burn) Oregon DEMs cannot know if a baby needs an exchange transfusion or not. They cannot diagnose polycythemia or anemia, either, two other indications for exchange, and are likely to dismiss jaundice as “physiologic.” Also, since DEMs are not required to transport a baby who needed PPV at birth so long as eventually he perks up to an APGAR of 7 by 10 minutes of age, that baby will not be monitored in Oregon as he would be in New Zealand. Dangerous, since respiration isn’t a given and can decline without warning in neonates if it was shaky to start with (as too many homebirth loss parents know).
For admission to level II (“feeder grower” as some may know such units here) NZ guidelines require it for infants under 5 lbs 8 oz. Oregon midwives must only consult that friendly naturopath or her buddy midwife even if an infant is under 5 lbs. 36 weekers go to level II to get checked out in NZ; in Oregon, you call your naturopath if you’ve got a 34 weeker. Respiratory distress for an hour sends you to get a look over in level II by NZ standards; in OR you can be grunting and tachypnic and in distress for more than 2 hours before your midwife is required to take you in. Signs of bowel obstruction are considered by NZ guidelines, but not by OR. Metabolic problems get you a doctor’s exam in New Zealand, in Oregon your midwife must only call a friend to validate her less-than-informed opinion of your condition. A NICU doc must look over New Zealand babies with major malformations; Oregon babies suffering the same pain merit only a quick chat over the phone with another professional.
All I can say is, it really seems better to be a newborn in New Zealand than to be born at home in Oregon. It sounds a lot safer to be a NZ baby, and it sounds like the adults in charge of their midwifery boards and government are thinking a lot more of their needs and comfort and right to not be left suffering at the whims of a midwife who either doesn’t know any better or is too arrogant to throw in the towel and ask for help.
All this shows one thing with incredible clarity: Oregon direct entry midwives are not doing a good or responsible job regulating themselves. They are taking advantage of the relative autonomy granted them by the state to put in place an ever-upward-creeping standard of allowed high risk pregnancies and births that they can attend and profit from. Like a game of “Risk,” DEMs have claimed one continent of risky births and are on their way to claiming more–until they win, and Oregon citizens lose. This is done without any heed to scientific evidence or global homebirth standards. And it is done with callous and cruel disregard to the safety of Oregon newborns and their mothers and families. The Oregon legislature must act immediately to put this game of risk to a halt. As a stop-gap, the original 1993 standards, approved by Gov. Barbara Roberts, should be put back into place. And then, a panel of experts should review the standards of care in nations like the Netherlands, the UK, Canada, New Zealand, and Japan; the scientific literature; and the track records of Oregon DEMs and come up with a comprehensive safety plan that serves mothers and babies and NOT simply the needs or wants of direct entry midwives and their high-paid Oregon Midwifery Council lobbyist, or “birth activists.” The panel of experts may contain DEMs, but it must also include MDs and/or DOs, nurse midwives, OB nurses, and public health statistics experts. The safety of Oregon families is worth a REAL effort, not this shoddy, incomplete, ever-loosening current “risk criteria” in place today.
Jade Jymson, who does a little blogging over at the Mama Tao, has written today’s guest post for us.
Since I started writing about the state of midwifery in the US, I have come across many reasons why Natural Childbirth Advocates ™ feel that midwives should not have to or are not able to carry insurance. A few of the main reasons are as follows:
Let’s start at the beginning, shall we?
Why should midwives have to carry insurance when it just means that you want to sue them? Or: We are too litigation happy when all we think about is money when something goes wrong. Or: Money is not going to bring your baby back.
We all have to carry insurance. I have insurance on both of my cars. Even though I have never been in a wreck, if I should hit someone, I know I would never be able to pay to have their car fixed out of my own pocket. I buy insurance so that I know I can afford to pay for repairs done to others property. If you break something that belongs to someone else, you should have to pay.
In cases like Zen’s we see that the midwives have done serious damage to these people and their lives. Zen’s mother was told to push for over 6 hours because the midwife was sure she could see the baby’s head. It turned out to be a blood clot on her bladder. His mother still needs serious surgery to repair the damage done to her body, but the midwife was not insured. Why should Zen’s mother have to pay to repair the damage herself?
But then again, why should I care? It’s not like I have to pay for it. But hold on a second…what about Sam’s parents? What if Sam’s parents were not able to pay his hospital bills? In such cases almost all children qualify for Medicaid. And what is Medicaid? Why it’s a free insurance paid for by tax payers. When the midwife is not able to pay for her mistakes, we all end up paying for them.
There are no companies willing to offer insurance to CPMs
This is simply not true. Contemporary Insurance Services specifically offers insurance to CPMs and CNMs who attend homebirths. In the past week, we requested a quote for a midwife in California with 3 years of experience and a clean record, and they were perfectly willing to insure her. Not only that, but they’ll insure her even if she has previous claims against her practice at a rate only 10% higher. And this isn’t the only company, either. It was just the first one that came up after 20 seconds of making sweet love to Google.
Midwives don’t make enough money to pay out the insurance premiums.
While I have to admit, my first thought is to say, “Who cares?” The first rule you learn in freshman economics in high school is that to have a successful business you have to make more money than you spend on whatever is necessary to keep your business running . And running safely, I might add. You don’t get to run a restaurant without being able to afford the supplies to keep your kitchen clean or own a climbing gym if you can’t afford harnesses for your climbers.
Considering that many states allow midwives to work uninsured because of this issue, let’s take a deeper look and see exactly what a midwife’s finances must look like.
Faith Beltz, the infamous midwife to the Paperella’s, made $4,200 off of Aquila’s tragic birth. That’s right, she made a mistake that led to their daughter’s death and she was still paid for the job. Let’s pretend that all midwives make as much as Beltz does and take only one birth a month.
Yep. IF a midwife charging what Beltz does only takes 1 birth a month she makes $50,400 a year. But most midwives have more business than that, right? So let’s look at what she would make if she took only two births a month:
Wow! That is more than most people I know make in a year. Pretty impressive. So how much does this insurance cost anyway? Some of the commenters in the last post keep throwing out numbers like $60,000. If that is true then a midwife might have a problem paying her bills if she only takes one client a month.
To make sure that this $60,000 a year number was correct, we contacted the company mentioned earlier as a CPM who had been working for 3 years and had never made a mistake that resulted in the death or harm of a patient. This is what they quoted us:
Wait? Huh? The payments start out at $13,000 and then rise to $22,132 after 5 years. For then on after the rates stay the same to be insured. The policy pays out $200,000 to $600,000. If we are using Faith Beltz and her $4,200 with one birth a month, she still has $28,268 to live on in the fifth year and beyond. Most midwives don’t have a birth center or an office or a secretary to pay – they have little to no overhead. They don’t even buy the materials they use at your birth; that is part of the homebirth kit you purchase yourself.
$28,000 is not a whole lot of money, but it’s also not chump change. If she did two births a month she’d have $78,668 left over.
But $4,200 only one number and most midwives take more than one birth a month. If they only take one client a month and can’t pay their insurance, they need to find more clients.
Finally , one of our readers said that the average midwife makes $60,000 per year. If this is the case then she’d still have $37,868 leftover at the end of the year. Not too shabby.
Again, if midwives have issues making this payment then clearly they have two options, just like every other business in the world. Take more clients or charge more.
If the insurance companies were involved then midwives would no longer be able to take women with VBAC, Breech, GD, GBS and a number of other issues.
I’m going to do something I thought I’d never do. I’m going to talk about something that was said in The Business of Being Born. If I recall, the entire movie they were raving about homebirth and midwife care, but they were always saying one thing I feel is important. Midwifery care should be the norm for LOW RISK WOMEN. You can rant and rave all you want to about how normal breech is and how GD is a myth made up by the man, but in every first world country that uses midwives there is a list of things that risk them out of homebirth. Breech, multiples, large babies, transverse…it goes on and on.
There are situations that should risk people out of homebirth. That does not stop midwives from taking these clients, but they should not be taking them—whatsoever. If having insurance stops midwives from taking high risk clients, then GOOD — it makes midwifery and birth safer for all of us.
I am sorry that this means some of you will make the choice to give birth in a hospital because you want a birth attendant, but we’ll never have the true numbers about the safety of homebirth until midwives stop seeing clients that should never have been homebirth candidates to begin with.
A favorite argument in the anti-hospital contingent is that the US infant mortality rate is SO BAD, that it is worse than “third world” countries.
There are many things wrong with the above argument, not the least of which is that the US “has more infant mortality than most other countries, including 3rd world.” You’d think maybe this was one lone internet warrior, but the argument is everywhere.
My favorite part is that both of these women claim that anyone who doesn’t accept what they say just hasn’t done the research. Anyone want a drink?
Before I say anything else, let me mention that “third world” is an outdated term, and we now use “developing countries” to describe, well, developing countries. But, as I often do on this blog, I digress.
There are two things wrong with this argument. First, it simply isn’t true. The US infant mortality rate, while higher than it should be, in my opinion, is nowhere near the rates of developing nations. Let’s have a look at this map:
Huh. Would you look at that. We’re in the same basic category as all of Europe, Japan, South Korea, Australia…
A graph is a little more your style? Well, here you go:
Again, there is always improvement to be made when it comes to any kind of mortality, and the US rate is higher than many developed nations (The WHO says the American rate is a 5, and countries like Canada, the UK, New Zealand, and Ireland, are a 4 and many Scandinavian countries are a 3. Countries like Poland and Hungary are a 6.), but the United States is nothing like a “third world” country when it comes to infant mortality. We’re far lower than the world average.
The other — larger — problem with this argument, is that infant mortality is not a measure of maternity care, it is a measure of pediatric care. It covers babies from birth through a year of age. The correct statistic to use is perinatal mortality, which is through 27 days of life. So how does US perinatal mortality measure up?
Have a gander. I used the data from the list of countries that the World Bank considers “high income or developed” to make my graph (I left out Trinidad and Tobago, as the World Bank has given them an asterisk and their PMR is significantly higher than all other nations on the list including, of course, the United States):
The US has numbers equal to or better than 18 of the 31 nations, including Great Britain, France, Finland, Denmark, the Netherlands, etc. In the category of perinatal mortality, the US does much better in comparison to the rest of the developed world than they do with infant mortality. Again, there is always room for improvement when it comes to death rates, but it is a flat out lie that the United States is on par with developing nations in this regard.