What’s My Agenda?

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:

 

 

I think that the goal of hospitals, doctors, midwives, and nurses should be improved outcomes and not necessarily less intervention. If there is evidence that less intervention improves outcomes, then, sure, we should strive for that. In some cases, such as elective induction before 39 weeks, I think that is the case. Overall, however, I think many of the poor outcomes in the US are unrelated to levels of intervention. It is true that the US has poorer outcomes than some countries in Europe. However, some of those European nations have both lower mortality rates AND higher rates of intervention *cough* Italy *cough*, so I’m not sure there’s even a correlation with rate of intervention and better outcomes. I do think that, in any case, experience should come after outcome on the importance scale.

 

The other reason I’m writing this is that I came across a comment from an older post on this blog, to which I’d neglected to reply:

 

 

I hope that my response to her makes my agenda when it comes to homebirth a little more clear:

 

First of all, it is true that I am *STILL* using the wonder database. It would be great if there were only RCTs regarding birth outcomes, but it’s impossible to do and get the numbers needed to show anything real. You have to have tens of thousands of births in order to show a pattern — anything less and the death numbers could be a fluke.

It is also true that many of the women who post here have been harmed because of an out-of-hospital birth with a CPM and they have not only been censored and shouted down by the natural birth community, but also ridiculed because of their experience. This blog does serve as an outlet for them in some ways.

I not against homebirth with a CNM. I believe that in certain situations (truly low risk woman, proper screening and precautions taken, location close to hospital in case of transfer), the risk approaches that of a hospital birth with an OB.

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:

  1.  Mandatory Licensure. Those practicing midwifery without a license should be subject to criminal and civil liability and actively prosecuted. No turning a blind eye as is currently happening, even in states where lay midwifery is illegal.
  2. Adoption of something similar to the Netherlands Obstetric Protocols for Antepartum, Intrapartum, and Maternal Postpartum Risk Assessment for homebirth in the US. While the Netherlands numbers aren’t the best, their homebirth numbers are certainly better than ours. Adopting their protocols will give homebirth midwives a solid guideline to safely serve women and families and restrict them to the low risk births in which they are trained and specialize. Those who choose to attend high risk births in violation of these regulations should be subject to supervision and/or suspension and if appropriate (ie in the case of a death as a result of their violation), civil and criminal liability.
  3. Adoption of an Infant Postpartum Risk Assessment Tool. The Netherlands protocols do not include comprehensive risk assessment for neonates, so such a tool could be composed by a team of GPs, OB/GYNs, pediatricians, and neonatal nurse practitioners.
  4. Disclosure…of training level, numbers of births attended, numbers and percentages of poor outcomes with comparison to national rates, complaints filed, malpractice lawsuits filed and settled — for all maternity care providers
  5. Immediate Suspension of the license or required supervision of any CPM involved in a maternal or infant death or major injury, pending investigation. Midwives involved in fatalities and major morbidity must be investigated and must stop practicing until it is determined that they are safe practitioners.
  6. Permanent Revocation of any CPM license after a second fatality or major injury if it has not already been revoked. A midwife might have one unlucky accident in the number of births that homebirth midwives typically attend, but a pattern of incompetence, recklessness, or negligence must not be tolerated. Once a practitioner has reached 750 births, the number of deaths allowed before suspension could be increased.
  7. Publicly Available Information about each maternity care provider’s record in a reliable online search tool. Patients must be able to see if their provider has had malpractice suits, complaints in the last 10 years, disciplinary actions, suspensions, or other indicators of poor performance.
  8. Malpractice Insurance for all CPMs and Birth Centers. Malpractice insurance is simply part of the cost of doing business as a healthcare provider. It protects consumers and the State from shouldering the costs of mistakes.
  9. Better Tracking and Public Availability of mortality and morbidity statistics.  If CPM is going to be a legitimate credential, it needs to be listed as a choice on birth certificate data. There must also be a spot for “planned homebirth” so that hospitals don’t get the blame for transfers that end in a death they could not have prevented by the time it arrived. Morbidity data is not currently collected and it needs to be.
So there you have it. My agenda is not to make homebirth illegal.  I have no naive illusions that if all I hope for comes to pass, the Gloria LeMay’s of the world will suddenly stop taking on risky clients and hiding in the closet when the sh*t hits the fan. If you spend enough time on MDC, it is pretty clear that there is no shortage of lay midwives willing to deliver footling breech post-dates twins being carried by over-40 moms in states where they are currently illegal. I do not support prosecuting parents for making risky choices that end in disaster. I do, however, support the prosecution of those who call themselves midwives and do the same. My desire is that women have the information they need to make the appropriate decisions for themselves and their babies, and that midwives are held accountable for their actions.

What changes do YOU think will make childbirth safer?

Just to Clarify…

We here at 10centimeters aren’t against natural birth. Several of us have even had one. We’re not even against homebirth, given the right woman and the right midwife! We support women who choose to give birth without pain relief, women who choose c-sections, women who can’t have children, women who adopt children, and women who choose not to have children at all.  What we don’t support is the way the way the leaders of the natural birth movement try to shame women into having a very specific kind of birth using misinformation, half-truths, and occasionally outright lies. We also don’t support sanctimommies bashing women for their choices. We, however, DO NOT CARE how any individual chooses to give birth.

 

What are we for?

  • Better training and stricter clinical standards for homebirth midwives in the US
  • Mandatory malpractice insurance for all homebirth midwives
  • Mandatory reporting of outcomes and better recording (i.e., no planned homebirth transfers counted in hospital stats, no unintentional homebirths counted in planned homebirth stats)
  • Real evidence-based maternity care, with the understanding that science/medicine changes practices as the body of evidence changes
  • Open and honest discussion without stifling one viewpoint under the guise of not wanting to scare people or being “supportive”