Batshittery Redux: Sisterhood Before Safety

Ever since I wrote the post This is Batshittery, I remain appalled and aghast at the continued support the homebirth community offers to killer midwives. At the time, I received several comments along the lines of, “Don’t lump us together with those extremists!” or “They really aren’t getting THAT much support.” Unfortunately, the more I observe this horrifying phenomenon, the more I believe that it simply isn’t the case. These midwives have large numbers of supporters, including the leaders of the natural birth movement, and these advocates are putting the cause before the lives and health of women and babies.

Lisa Barrett has presided over five deaths in four years. Even if she were attending 100 births a year (which I’m sure she isn’t), this would be a shockingly high and inappropriate death rate. She revels in her maverick status and her website is full of birth stories which showcase her questionable judgment. Is she being called out by members of the homebirth community? No, but there are TWO facebook groups (Including one brilliantly named “I support Lisa Barrett and That’s Final“) with more than 1600 members showing their support and raising money for her. She was also a featured speaker at this year’s Trust Birth conference.

But there are no facebook groups raising money for her victims.

If Lisa Barrett were an isolated incident, maybe I could be convinced it’s just a few supporters showing their cultish devotion. But it isn’t. Not only did she take on a 43-year-old first-time mother (in an of itself a high-risk situation) with a breech presentation, whose baby ultimately died and preside over the death of a twin shortly after birth, Karen Carr also told a hemorrhaging mother who was being transported not to tell the hospital about the drugs she’d administered. This behavior is unconscionable for a midwife. In spite of the behavior, however, Karen Carr has more than 1500 supporters sending her money in the Legal Defense Fund for Karen Carr, CPM Facebook community and a whole bunch of people showed up to protest at her hearings.

But no one is raising money for her victims.

Sara and Jarad Snyder’s son Magnus died at the hands of midwives at the Greenhouse Birth Center in Michigan. In spite of the fact that the midwives carry no malpractice insurance, the Snyders managed to find an attorney to take their case, and they are suing. Are any homebirth advocates raising funds to assist them with their legal bills? Hardly. There are homebirth advocates, however, banding together with the midwives to raise money for their legal assistance. In fact, the leader of the natural birth movement, Ina May Gaskin herself, is lending her support to these midwives. You can’t get more mainstream (when it comes to NCBers, at least) than that. Other supporters include Barbara Harper of Waterbirth International; Peggy O’Mara, former publisher and editor of Mothering magazine and Mothering.com mogul; Jennifer Block, author of Pushed; and Geradine Simkins, president of MANA.

And the latest batshittery? At a birth center in Idaho, there were three infant deaths between October 11, 2010 and August 9, 2011. That’s THREE DEATHS IN LESS THAN A YEAR (side note: 2010 and 2011 are going to be banner years for CPMs. I can hardly wait for the CDC numbers to come out.). In one case, they neglected to clamp the cord before they cut it. In another, they took on a mother with Type 1 diabetes, a situation that many obstetricians will refer to a MFM and then neglected to transfer when the baby’s heart rate dipped dangerously low. When paramedics were eventually called, the midwife delayed them in reaching the mother. And finally, they allowed a woman to push for more than 10 hours after discovering meconium in her amniotic fluid. After these deaths, was there an outcry? Were there facebook groups created to raise money for these stricken families? No, but there was an outcry that the midwives are being investigated.

And we can’t forget Clarebeth Loprinzi, who abandoned a woman for hours with her placenta still in her uterus and who’s license was finally revoked years later after yet another infant death. Midwifery Today, the banner publication for homebirth, is hawking “educational” recordings she made with Anita Rojas, another midwife involved in Oregon infant deaths.

Then there’s Gloria LeMayAlison OsbornEvelyn MulhanAmy Medwin. Diane Goslin. Janet Fraser.

I’m sorry, but it looks like you homebirth supporters who find this bizarre phenomenon distressing are actually in the minority. The people who are supporting these mavericks are making a statement, “It is more important to make homebirth look good than to make it safe for women and babies.” But in reality, this blind devotion isn’t even serving your purpose. As homebirth becomes more mainstream and these bad midwives continue to practice, they will be hurting more and more families. More attorneys will take on civil suits.  More legislators will be appalled. More arrests will be made. Why not pull your support now and throw the bums out?

Friday Fallacies: The Hospital Is Just Minutes Away

Anytime you come across someone defending homebirth, you’re going to hear that you can always transfer in case of an emergency. It comes up in almost every thread where someone mentions qualms — be it their own, their partner’s or their mother-in-law’s — about giving birth at home.
etc., etc., etc. This sentiment is all over the internet.
The problem with birth, however, is that when things go wrong, they go very, very wrong. And it can happen quickly. Cord accidents, uterine rupture, placental abruption, hemorrhage…all can occur in a matter of minutes, and all can be deadly.

There are plenty of problems with the “The hospital is only minutes away!” platitude with which all these women are comforting their worried family members.

One is the idea that being “ten minutes” from a hospital means that you can go from realizing there’s a problem to having the baby out and alive in ten minutes. This scenario is certainly realistic. IF YOU’RE ALREADY IN THE HOSPITAL. The hospital where I volunteer as a doula can perform a stat c-section in eight minutes.

If you’re having a homebirth, however, it simply isn’t going to happen. Let’s assume you got lucky and managed to hire a midwife who is not only competent enough to recognize a serious emergent situation and recommend a transfer in a timely fashion, but has a relationship with a hospital where they trust her judgement (read: this is a CNM). This midwife must also have accurate and complete records and bring the chart with her to the hospital. Now, this seems like a no-brainer, but ask these women or any number of L&D nurses that I know, and you will learn that it is sadly uncommon. But I digress.

You will have to get to the ER somehow. If you’ve called EMS, it will probably take them a minimum ten minutes to get to your house, five to ten minutes to grab you, load you in and get the hell out, and another ten minutes to get to the ER. Hopefully the paramedics have called in to let them know what to expect and the OBs are racing to the ER to meet you. If you don’t call an ambulance, it might take less time to get to the hospital (or not, seeing that your laboring body probably isn’t moving too quickly), but you don’t have the call ahead or stabilization the paramedics could provide.

Once you’ve arrived, an entire team flocks to you, hooking up monitors and placing IVs, all while trying to get the appropriate details. Since you’ve had all your care at home, the hospital has no records; if you had been laboring in the hospital, the history and physical notes, progress notes, labs (you’re going to need your blood typed and crossed for surgery), and IV sites WOULD ALREADY BE DONE. If you are dehydrated from laboring for an extended period of time or from an attempt to induce your labor using castor oil, they will have a hard time inserting the IV, which could cost precious minutes. They will use a portable ultrasound to check the baby unless the head (or body, as in the Lucian Kolberstein and Henry Bizzell cases) is out, in which case they will attempt to get the baby out or head straight for the OR. Even the very best and most efficient team is going to take an additional ten minutes after you show up in the ER to have you prepped and in the OR for an emergency cesarean, and that’s with rapid intubation and general anesthesia. The BEST CASE scenario is 30-45 minutes, not the eight it would take if you were already there.

Now, this scenario only applies if you happen to live in an area with a large teaching hospital and on-call OBs 24/7. What happens when the closest hospital is a smaller community hospital? More than likely, the only doctor there is going to be an ER doctor, not an obstetrician. The OB will have to be called in, as an ER doctor isn’t going to perform a cesarean unless you are dead and your baby is still alive, and may live up to 30 minutes away from the hospital. If the ER doctor is able to deliver your baby — which he hasn’t done since med school — he or she may be the only doctor at the hospital, so the focus will be split between you and your child. He or she may not have intubated an neonate since med school, either. He or she may not be required to have a neonatal resuscitation certification. By the time the OB and pediatrician arrive, an hour may have passed since your midwife first realized you were in desperate need of a transfer.

Do you want to go for an hour without breathing? What makes you think your baby does?

What OHLA Doesn’t Know Could Hurt You

I heard a nasty rumor for the third time yesterday: that the Legacy hospital system and Legacy Emmanual in particular have an unwritten policy of refusing to report sentinel events resulting from homebirth transfers and that they discourage their nursing and medical staff from doing so as well. Now, the first time I hear a rumor, I can ignore it. The second time it sticks in the back of my mind. And the third time? I start to think there may be something to it. Obviously I haven’t substantiated it, but when I hear something from three different people? Someone with sharper sleuthing skills than me needs to look into this.

Let’s take a step back for a minute. The history of reporting negative outcomes that end up at hospitals in Oregon has been fraught with drama. In 2010, a group of Portland midwives decided they didn’t want their bad outcomes reported and sued OHSU, a large Portland hospital, for reporting and their own licensing agency, OHLA, for investigating the reports.  Apparently these midwives are not big fans of having their inappropriate care of laboring women exposed. And apparently they don’t want to be held accountable for poor outcomes like health care workers in hospitals are.

See, hospitals are overseen by the Joint Commission, which mandates that all sentinel event outcomes (death, severe morbidity, transfusion, hemorrhage, etc.) require an investigation. Any outcome meeting certain criteria triggers intense scrutiny, evaluation, and assessment to determine if it was preventable or if standards need to be changed. The hospital system requires and ensures a thorough investigation to establish if there are systemic problems, problems with a specific practitioner, or problems with a policy or protocol that needs to be changed. ANY sentinel event results in multiple layers of meetings and discussions designed to prevent a recurrence. Not only that, in the hospital, no one works alone — there are many eyes watching each patient, which can seem intrusive, but this is part of what keeps women and babies safe and holds care providers accountable.

Where is that reflection and accountability for licensed midwives in Oregon? It simply doesn’t exist. And the only way that the Board of Direct Entry Midwifery and OHLA know of poor outcomes is if they are reported by hospitals, medical professionals, or other community members.

Back to the lawsuit.  If you google it, you can come up with all sorts of midwifery propaganda alleging that the big bad hospital is trying to put the tiny helpless midwives out of business. In reality,  the case was eventually settled with no wrongdoing found on the part of OHLA or OHSU. In any case, the argument that doctors are reporting for monetary gain is ridiculous. Homebirth accounts for a mere 1% of births overall, and HBACs and home breech births, which were the apparent basis for the lawsuit, account for even less than that. More likely, medical staff report such outcomes for the same reason any sane person would do so: they have a goal to keep  women and babies in the state of Oregon safe.

Not only that, but healthcare workers are mandated by law (Oregon HB 2059) to report “unprofessional conduct,” which means

conduct unbecoming a licensee or detrimental to thebest interests of the public, including conduct contrary to recognized standards of ethics ofthe licensee’s profession or conduct that endangers the health, safety or welfare of a patientor client.

And there are legal repercussions for not reporting! The same house bill requires that

(5) A licensee who fails to report prohibited or unprofessional conduct as required by subsection (2) of this section or the licensees conviction or arrest as required by subsection (3) of this section is subject to discipline by the board responsible for the licensee.

(6) A licensee who fails to report prohibited conduct as required by subsection (2) of this section commits a Class A violation

If this is the case, why would Legacy be declining to report such outcomes to the licensing board? One of my sources gave me a warm and fuzzy reason: if they report, midwives won’t bring potential bad outcomes to the hospital, or they’ll wait until it’s too late to do any good. If they have a policy of non-reporting, it’s actually safer for Portland families. That’s all well and good, though it doesn’t reflect well on Portland homebirth midwives.

Another person I spoke to offered a more sinister explanation. This individual thinks that Legacy is making a lot of money on NICU stays as a result of homebirth transfers, and they’d rather that other area hospitals don’t get that business. It’s true that one stay in the NICU is going to bring in a heck of a lot more money than a whole bunch of successful VBACs. Really? Maybe I’m not cynical enough, but I was shocked to hear that even floated as a scenario. I can’t imagine this could possibly be true.

There’s a third possibility as well: they’re afraid of lawsuits. These midwives have already proven themselves a litigious bunch, and even though no wrongdoing was found in the last lawsuit, I’m sure it cost a pretty penny (In a fantastic irony, legal fees were named as a reason for the need to increase midwifery licensing fees in a recent BDEM meeting. I guess that’s what happens when you sue your own board). No doubt Legacy wants no part of that hot mess.

But does fear absolve them of their duty to their patients and to the public to do the right thing? The LEGAL thing? I don’t think so.

Again, I don’t know if these allegations are true. I’m sure that Legacy has never put such a policy into writing, as it is illegal. However, I just can’t get past the fact that three different people would separately bring it up. If it is true, it is horrifying to me and something needs to change.

 

Henry’s Story: Did Lax Oregon Laws Contribute to His Death?

Last week, KVAL in Eugene did a series on midwifery in Oregon,  highlighting the experiences of Kristine Andrews, Mindy Bizzell, and Margarita Sheikh with homebirth midwives:

 

I applaud these women for their courage and strength to tell their stories in the face of criticism from random strangers and homebirth supporters alike. These are things that we all need to hear, and especially those of us who are considering giving birth at home in Oregon.

Of course, while I commend Beth Ford and KVAL for bringing these stories to light, I understand that it is hard to give them the attention they deserve in a scant two minutes on the evening news.

I discussed Mindy’s story with her, and there were a few things that didn’t make the cut that she wanted to get out there.

10Centimeters: Is there anything that didn’t get said in the KVAL story (or that did get said) that you’d like to highlight?

Mindy: The KVAL reporter didnt note that Henry was in fact frank breech, she reported he was footling breech, which was not the case. She highlighted the fact that we didn’t know the difference between midwife care and hospital care, which just isn’t true — obviously we know the difference; what we were trying to convey was that Tamy Roloff was licensed in the state of WA, and we expected a professional who had a certain degree of education and experience. We inquired about what school she had gone to, we asked how many births she had attended (somewhere in the 300 range). We were not just picking up someone from the street to help us have our baby, we hired someone who had a credential and who was state licensed.

10Centimeters: When did Tamy tell you that Henry was breech? Was it before you left for the hospital? Or not until he was delivering in the car?

Mindy: Tamy told us that Henry was breech after my water broke and there was VAST amounts of thick meconium on the bathroom floor and I asked her to check me internally (because I reached up and checked myself and mistakenly though I felt a cord, which had been my worst fear concerning homebirth, I never imagined that he would be breech and Tamy wouldn’t know.  He was a huge baby — 9lbs — and he had evidently been breech for awhile. She was not competent enough to know or to catch it when she palpitated my stomach at our weekly visits). It was at this point that she told us that protocol dictated we go to the hospital, and that she “didnt like it,” but we would go ahead and go. I remember thinking, “WTF, I WANT to go to the hospital lady!” I had no intention and never had of giving birth to a breech baby at home.

10centimeters: Was there any indication that something might be wrong before labor started? In early labor?

Mindy:  In hindsight I can see that absolutely there were indications he was breech. I called her the night before labor started and specifically told her that I thought he was in a strange position and it did not feel like his head was engaged in my pelvis. She told me outright that “I know you want to hear that something is wrong, but that nothing is wrong, Trust me, I hear this from all my mothers.” We talked for 20 minutes about my fears about his position, which she would later deny to the state investigators (I had to produce phone records to prove it). I was also leaking brown fluid before my water broke, and asked her about it at least two separate times, and she told me that it was “fine and normal.” I showed my husband a third time and told him I thought it was strange but we both trusted Tamy when she said it was normal; we presumed she had seen this before. This was the same brown fluid that covered my hands as Henry was being born in the backseat of our car over the Astoria bridge.

10centimeters: That was one of the things that really stuck out to me about your story. Why on earth would your midwife have you drive from your home in Washington more than 45 minutes to Oregon when there was a hospital just minutes away?

Mindy:  At the time, Tamy did not tell us we were going to Astoria until we were in the car and pulling away.  I thought we were going to the hospital two minutes away from our house. She claimed they “would not take me” and that we had to go to Astoria. My mother had asked her earlier in the house why we didn’t call and ambulance and she told her that an ambulance would have to come all the way from Astoria to pick me up (Which we found out later was a lie.  There are ambulance services all over the peninsula. The WA state investigator said she called on of them and their estimated time for getting to me at my home would have been 2 minutes).

I honestly think that a big part of Tamy’s decision to go to Astoria was because she felt that she could still deliver the baby, and if she had me in the car on the way to the hospital and the baby was born in the car then she couldn’t have been held liable for trying to do a breech at home. During my pregnancy she had frequently bragged to me about a birth she had done in a car where the baby was born safely, she had clearly felt like a hero and it was a story I heard her tell many times. I think she felt that she had the power to make any baby be born safely, because she had an incredible earth-mother goddess trip where she felt like some kind of all powerful purveyor of birth. She also told me when we got in the car, after I told her that I was needing to push (and she knew full well that Astoria was 45 minutes away), that “well, we’ll just have the baby in the car then”. She really and truly believed she could do it, I don’t think she ever imagined that he would get stuck like that. She told me outright that she had never done a breech birth before after Henry died, but at the time she behaved as though she knew just what she was doing. I trusted her implicitly. This woman had thrown me a belly casting/baby shower party two weeks before. She was a friend, a confidante, and at the time I was in transition, I had no part of my brain available to question her or to wonder at the sense of what was happening. In hindsight it all seems absurd that none of us called an ambulance, but we had really and truly trusted her. We believed that what she told us was the right thing, we even believed her when she said no ambulance would come for me in time and that the local hospital wouldn’t take me (which we found out later was also untrue).


10Centimeters: When I heard your story, my first thought was that you were transported to Oregon because it was against Washington law for your midwife to attend a breech birth and she knew that she could not get in trouble if you delivered in Oregon. Do you think there is any truth to that?
Mindy: It didn’t occur to me, honestly, for the last two years to think that Tamy took us to Astoria to avoid the laws here but now that you said that it is definitely a possibility and it left me reeling. I do think it’s a possibility, but I never would have said that right after Henry was born. My eyes started to open about what kind of person she truly was after we saw the WA state investigators report, how she attempted to make us look bad, claiming we wanted her to “stand in the other room during our birth”, and all of the other lies and half truths she told (and how she omitted the leaking meconium fluid from her charts). The truth is that Tamy was in it to protect Tamy, and no one else. I don’t believe she cared about Henry more than she cared about her own professional career and her own lifestyle. So I suppose in the end I can say it’s a definite possibility that the lack of laws in Oregon influenced her decision, but I also think it was her own God complex, her need to prove any baby can be born at the hands of a midwife.


10Centimeters: Did she say anything else to you after Henry was born?
Mindy: This woman did her very best to brainwash me after Henry’s birth, immediately whisking me out of the hospital, into her own waiting car (a few hours after I had surgery to repair my severe 4th degree tear). She insisted on driving me home, and then insisted on driving me herself to Portland to see Henry (which is 3 1/2 hour drive from Ilwaco where we lived) who was at OHSU in the NICU. During the entire car ride she took great pains to talk to me about what happened and she kept repeating how “we” had done this or that, and how “we had done the best we could” — she was very intent on creating a bond between her and I and refusing any culpability whatsoever. She also repeatedly told me that my inability to urinate at all after his birth was normal and ok — resulting in permanent nerve damage and 2 solid months of catheterization for me. I still cannot urinate normally and frequently experience bouts of painful bladder spasms (the ER took 3100cc’s of urine out of me four days following Henry’s birth).


Mindy, I want to thank you from the bottom of my heart for sharing your story. I know that it can’t be easy. I’m sure that I speak for everyone reading when I tell you that we are so, SO sorry for the tragic loss of your son.


Tamra Roloff, Mindy’s midwife, has had six Washington case investigations against her license: Case #2009-138744, #2009-142066, #2010-145607, #2010-142794, #2010-143829, #2010-143971

OHLA Direct Entry Midwifery Board is a JOKE (and a hazard to your health)

What is the purpose of a board of … whatever? When it comes to licensing boards, it is to protect the public by ensuring basic levels of competency. For example, the Oregon State Board of Nursing, which licenses Certified Nurse-Midwives, says

The Oregon State Board of Nursing safeguards the public’s health and well-being by providing guidance for, and regulation of, entry into the profession, nursing education and continuing safe practice.

The Oregon Medical Board, which licenses MD’s and DO’s,  also has the same mission:

The mission of the Oregon Medical Board is to protect the health, safety, and well being of Oregon citizens by regulating the practice of medicine in a manner that promotes quality care.

In addition to its licensing functions, the Board conducts investigations, imposes disciplinary action, and supports rehabilitation, education, and research to further its legislative mandate to protect the citizens of Oregon. The Oregon Medical Board is also responsible for the scope of practice of First Responders and EMTs.

What does the Oregon Board of Direct Entry Midwifery and the Oregon Health Licensing Agency do? Well, the stated mission of OHLA is

The Oregon Health Licensing Agency (OHLA) protects the health, safety and rights of Oregon consumers by ensuring only qualified applicants are authorized to practice. OHLA establishes, communicates and ensures compliance of regulatory standards for multiple health and related professions.

That, however, is far from the truth when it comes to licensed midwives in the state of Oregon. In reality, the BDEM and OHLA have…

  1.  Failed to remove the license of a midwife who abandoned a woman with a retained placenta.  Seriously? Someone who’s read one book on childbirth knows that a placenta that doesn’t come out within a couple of hours of the birth of the baby is a serious problem. And a midwife who leaves a woman in that situation? Well, that’s a serious problem as well. But apparently the Oregon Board of Direct Entry Midwifery doesn’t think so. When the Board declined to do anything about it, board member Kate Davidson, CNM, resigned in protest, saying in her resignation letter:

 After the Board’s decision not to revoke the license of a midwife who left a patient with a placenta undelivered, I do not feel I can honestly continue to serve and maintain my own personal integrity. I feel this was an egregious act and failure to revoke the license conflicts with the Board’s duty to protect the public.

  1. Progressively reduced the number of absolute risk criteria so that Oregon DEMs can attend riskier and riskier births. Between 1993 and 2009, eighteen different criteria were either loosened, reduced to non-absolute criteria, or removed from consideration altogether by the board.  Oregon midwives are now not required to even consult with a medical doctor when an infant is born at home at 35 weeks, much less transfer care.
  2. Refused to discipline midwives whose actions contributed to the death of a child. Case 05-4228 brought before the board was a complaint about a midwife’s management of fetal heart rate which led to fetal demise. According to notes from the board’s meeting on 5/19/2005, the board found that the midwife DID NOT CHECK FETAL HEART TONES APPROPRIATELY but did not discipline the midwife or make her name known to the public.
  3. Ensured that DEMs are not required to provide risk information about homebirth with malpresentations, multiple gestation, VBAC, and postdates.  The disclosures have been required by the legislature, but every time the deadline approaches to implement, OHLA pushes it back.

The Oregon Health Licensing Agency filed temporary administrative rules with the Secretary of State Office on Octoner [sic] 15, 2011, to extend the implementation date to June 1, 2012, which will require each licensed direct entry midwife provide risk information to clients, as published on the agency’s website, regarding out-of-hospital birth, malpresentation birth (breech), multiple gestations (twins), vaginal birth after cesarean (VBAC), and births exceeding 42 weeks gestation (post-dates.)

  1. Allowed multiple members of the board (the chair and vice-chair, in fact) to have a serious conflict of interest. Melissa Cheyney, board chair, is also the director of research for MANA, whose stated goal is “to unify and strengthen the profession of midwifery,” basically a lobbying group for midwives.  Somehow Cheyney and Susan Moray, who is MANA’s press officer (and is also employed as continuing education coordinator by the Oregon Midwifery Council, yet another lobbying organization for Oregon midwives) are allowed to maintain their positions as virtual lobbyists for midwives while running a board that is supposed to be protecting Oregon women from bad midwives.
  2. Hired a private midwife advocacy/lobby group, who has refused to release data to them in the past, to collect safety data on Oregon midwives. That’s right. Starting June 1, 2011, OHLA started requiring Oregon licensed midwives to submit data to Melissa Cheyney’s MANAstats. Totally disregarding the fact that they have requested data from MANA before, and Cheyney denied the request. According to board meeting notes from August, 2010:

Cheyney stated that OHLA requested a state account from the MANA, in order to have the ability to retrieve aggregate data for LDMs in Oregon. Cheyney stated that the MANA board’s official policy is to give state-level accounts to professional organizations as a tool to evaluate areas where more training might be needed for the purpose of self regulation, and to not provide the data to regulatory entities. Cheyney explained that MANA’s policy was generated taking into consideration that MANA is a voluntary database. Cheyney explained that MANA suspected that, due to some state regulatory boards having very hostile relationships with midwives, the quality and quantity of data submitted might be adversely affected if regulatory authorities were provided access. Due to this policy OHLA’s request for a state level account was denied. Cheyney stated that due to multiple requests made by regulatory authorities to MANA for a state-level account, the MANA board decided to re-evaluate this policy. However, based on feedback received from contributors to the MANAstats database expressing concerns, MANA determined that state-level accounts would not be provided to regulatory entities at this time.

  1. Published worthless information about licensees while obfuscating information vital to making a truly informed decision about which midwife to use for a homebirth. Want to know if the midwife you’re considering has ever been disciplined by the board? Well you’re out of luck! For example, Jennifer Gallardo has had at least two final orders (case numbers 00-01 and 02-12) that resulted from cases of fetal or infant demise. What do you find when you look up her license on the OHLA website?

 

Unresolved Disciplinary Action: None. That’s right. OHLA will only tell you if a midwife failed to pay her fine, not whether or not she’s been disciplined. What about a midwife who gave up her license rather than have it revoked? Clare Loprinzi, the midwife who abandoned the woman with the retained placenta, eventually agreed to surrender her license to the board “in lieu of revocation” in 2002 after she was involved in an infant demise in 1999. What does OHLA say about her license?

The same thing it says about midwives who failed to pay their renewal fees. And no mention of case number 99-01, including a “proposed order to revoke license due to unprofessional conduct” which resulted in fetal demise. (an aside, because I don’t have enough hours in the day to detail all that is wrong with OHLA and the OBDEM: Why the f*ck did it take THREE YEARS to take her license away?)

And what about midwives who currently have complaints against their licenses? Shouldn’t the public be aware of that? OHLA doesn’t think so. Adele Rose of Andaluz is currently under investigation for her involvement in a fetal demise in 2010 as well as another 2010 incident. Incidentally, she was given a one month suspension (during which she was allowed to continue practicing as a midwife…) as a result of case 08-5222, which was a VBAC attempt that ended in fetal demise and an emergency hysterectomy. What does a search of her license tell us?

 

Nothing. Not shocking when you consider the rest of this, but it should be.

But maybe this is par for the course when it comes to reporting actions taken against licenses?  I mean, Birth Without Fear is constantly telling us about how hospitals are hiding things from us. Maybe the Oregon Board of Nursing refuses to report actions against their licensees as well? Oh, look. If you go to the OBON website, it has all of the disciplinary actions taken in the last year, complete with details and the area in which the disciplined nurse lives. And if you look up those nursing licenses individually? Those violations are listed on the license with a .pdf of the final order. Nurses, schmurses. Surely the medical board, with those evil doctors who are hiding ALL those terrible hospital outcomes we always hear rumors (but never see any proof!) about on MDC, isn’t telling the public about actions taken against medical licensees!  Nope. They have final orders, current to those handed down LAST WEEK, on their site, complete with names and copies of the order. Not only that, but they have temporary orders taken against doctors who are being investigated listed! And violations are all listed on the medical license look-up as well.

Oregon women who are considering a homebirth should be OUTRAGED at the lack of oversight, protection, and transparency provided by OHLA and the Oregon Board of Direct Entry Midwifery. It is clear that their real agenda is to promote midwifery and not to protect Oregon families, in direct opposition to their stated goal. When are you going to start speaking out?

 

Nine Times Nothing is Still Nothing

Please welcome guest blogger Mrs. W! She is a a health economist, a mom and a modern feminist who lives in British Columbia and blogs at Quality Care for BC Mothers.

The Nine Statements of Consensus from the Home Birth Summit: Nine Times Nothing is Still Nothing

There are substantive and real issues confronting the home birth and obstetric communities in the United States.  Having a summit could have moved things forward, fairly substantially, if they actually took the 9 pre-determined agreed upon consensus statements and used them as starting points, instead of accomplishments – because nothing is accomplished as a result of the statements made.

  •  We uphold the autonomy of all childbearing women…
 Autonomy in the absence of complete and unbiased information is meaningless – there cannot be free informed choice when the information given to women on childbirth is incomplete or biased.  A woman must be informed of the risks and benefits of the choice she is making if she is to be empowered to make the choice that best meets her needs and the needs of her child.  If the autonomy of childbearing women is to be upheld, there must be a consensus on what the real facts of childbirth are, and a commitment to providing that information to women in an unbiased and accessible way.  
  • We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes…

Again a really lovely idea, but, clearly there are substantial barriers to making this a reality in the current system.  In order to collaborate, midwives and OBGYNs need to speak the same language.  In order to collaborate, midwives and OBGYNs would need to hold each other in esteem and respect.  In order to collaborate, they need to facilitate the work of one another.  This means that when a woman who is at risk in labor is transferred to hospital for care, the hospital is prepared for her arrival before hand and the midwife is capable of giving full and appropriate information about the woman and her labor to the OBGYN upon arrival.

  • We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes…

Homebirth as it exists in the US today does not ameliorate disparities in access, delivery of care, or outcomes – it accentuates them.

Women in the US are far more at risk accessing the homebirth system than the hospital birth system.  They are at risk of having a care provider who does not undertake standard and appropriate prenatal care (gestational diabetes testing, group B strep testing, weight and fundal height measurements, and pre-natal ultrasounds).  They are at risk of having a provider who does not have adequate and appropriate education and experience.  They and their babies are at greater risk of death or disability and they are at risk of having a provider who does not carry malpractice insurance and who would be held accountable to a lower standard of care in the event of death or disability.

There will continue to be disparities in access, delivery of care and outcomes seem unavoidable in the current context.

  • All health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice…
This begs the question what is the appropriate standard?  Furthermore, in the absence of legislation, what would be the consequence of failing to meet the standard?
  • We believe that increased participation by consumers … is essential to improving maternity care…
Is this the facilitation of informed joint decision making during the care delivery process?  If so, See number 1.  Or, perhaps more meaningfully, will this mean that consumers would have a way of voicing their concerns and having those concerns heard in much the same way that hospital patients can have a formal review of the care they received?
  • Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings…
See #2.
  • We are committed to improving the current medical liability system …
Another starting point – what medical liability system currently applies to homebirth midwives?  Doesn’t a system need to be in place before it can be improved upon?  Is there an insurer that would take on the risk in the current environment?
  • We envision a compulsory process for the collection of patient … data on key … outcome measures in all birth settings….
So. Data is collected. MANA collects data. Does a $#!T load of good – unless you commit to releasing the data, it means nothing. Data existing does nothing without it being available to be analyzed, actually having it analyzed and releasing the results of that analysis.  Furthermore, there needs to consensus on what data elements are critical and the definitions of those elements – this is essential if the data across birth settings are to be comparable and the data is to be transformed into meaningful information.
  • We … affirm the value of physiologic birth … and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies… 

This seems at odds with valuing patient autonomy, particularly when not all pregnant women giving birth would choose physiologic birth if given complete information to make an informed choice.  Furthermore, valuing the particular process of birth (physiologic, a.k.a. “normal birth”) places form over function – shouldn’t the ultimate goal be healthy moms, healthy babies regardless of delivery method?

 

 

This is Batshittery.

Sorry, but there is no other word that accurately describes what is going on here. “Crazy,” or even “insane” don’t even begin to characterize this phenomenon. What is it?

That homebirth advocates continue to support Lisa Barrett. And every other dangerous midwife out there.

Who is Lisa Barrett? She is an Australian midwife who is currently the subject of a coroner’s inquest. On her website she recounts — with pride — birth stories full of high risk scenarios and obviously questionable judgement, ranging from… twins whom she allowed to deliver more than 48 hours apart (Story comes complete with a google search whereupon she came back to inform the expectant parents that the average time between delivery of twins is FORTY SEVEN DAYS. Even though most reputable sources and common sense report it as being 17 minutes.)… to a 35 weeker who didn’t begin breathing until TEN MINUTES after she was born… to a HBA3C with a previous vertical incision. Pictures of limp, blue babies abound.

On her site, she also claims 20 years of experience “within the system” and :

I am experienced in all types of birth and this includes birthing at home with babies in a breech position, twins and birth after caesarean. Anyone who believes they want and need this service should be entitled to get it.

So what does all this experience include and why is she facing a coroner’s inquest? It’s not because THE MAN is after her. It’s not because, as she claims in her plea for money at the top of her page, “the authorities are trying to censure homebirth via its most vocal advocates.”  It’s not “another witch hunt of a sister midwife.”

No, it is because this is a woman has attended at least four birth-related deaths since 2007. These are spectacularly horrific numbers, and who knows if they’re even complete. As much as homebirth advocates love to parrot the phrase, it just isn’t true that “babies die in the hospital, too.” Yes, they die of anencephaly or heart defects, but it is unbelievably RARE for babies who were perfectly healthy before labor started to come out dead or dying. But somehow, in Lisa’s case, they do. The first two deaths were HBACs and the last two were twin births.

  • Tate Spencer-Koch, born in July of 2007,  suffered a shoulder dystocia for more than 20 minutes and was unresponsive by the time she was finally delivered. The ambulance officers testified in court that Lisa hindered their attempts to get the baby into the ambulance and to the hospital.
  • In April 2009, Jahli Jean Hobbs was breech, became stuck, and was eventually born when Gemma Noone, A DOULA who was not supposed to have a role in the delivery at all, freed her arm, enabling her head to be delivered, but she was not responsive. It was all too late for little Jahli Jean.
  • In July 2011, Lisa attended the homebirth and death of an unnamed twin in Western Australia, which — in an amazing coincidence –also happens to be where Annie Bourgault lives.
  • On October 9, 2011, Lisa crammed with the mother and lifeless twin into the front seat of a car (Do they not have emergency transport in Australia? Or, perhaps, was it that she does not want ambulance officers testifying at the next inquest…) when complications arose after the home delivery of a first twin; the second twin was later declared dead at the hospital.
After the death of Spencer-Koch, Lisa attempted to argue  in the Australian High Court that the infant was never, in fact, a live  human being, and thus not deserving of a coronial inquest. The court disagreed and the inquest began. Throughout the hearings, Lisa continued to trumpet her contempt for the system and her victims by tweeting from the courtroom, including the chillingly ironic:
Yep. October 6.  Three days before the fourth death. Looks like “normal service” resumed all too quickly. Actually, Lisa has been for the past several months attending births outside of the law. Earlier this year, she handed in her registration because she no longer wanted to work as a midwife, giving the excuse that she was not happy with moves last year to increase regulation of midwives. However, since relinquishing her registration, she has attended more than twenty births, including the last two deaths. She claims she is only acting as a consultant and advocate, but she is still advertising her midwifery services on the Maternity Coalition website, on the Bellybelly breech birth page for practitioners “who are skilled and experienced with vaginal breech birth” (apparently having a doula deliver a mostly-dead baby counts as experience), on the Essential Baby midwives page, and on Birth Matters.

Yet, in spite of her blatant recklessness and disregard for human life, the homebirth and midwifery community continues to support Lisa Barrett.  We have the 1400 strong  “I Support Lisa Barrett and That’s Final” facebook page, complete with the idiotic slogan “Freedom is in Peril. Defend it with all your Might.” These women are depositing money into her bank account. She also hosted a movie fundraiser night, where 60 people bought tickets at $25 each, and additional people made donations, in an effort to support her legal battle.

This phenomenon is not unique to Lisa Barrett, either. Karen Carr is a midwife who said after the death of a breech infant under her care, “The baby’s position wasn’t the problem, the problem was that the baby’s head became stuck.” She is also a midwife who practiced illegally in both the states of Virginia and Maryland, and who was prosecuted after two deaths and a case of severe brain damage, all within a years time. She recklessly accepted the care of a 43-year-old first time mom with breech positioning and tragedy resulted. But does the homebirth community condemn her recklessness? NO! She is hailed as a hero and the community is raising money for her “defence.” I don’t see anyone raising money for her victims, though.

What about Amy Medwin? Amy presided over the death of an infant in North Carolina, where CPMs are illegal. She is blatantly flouting the judges’ orders and continues to attend births, posting about them on her open facebook page. She too has bunches of acolytes supporting her and paying her legal bills.

And then there’s the great-grandmother of them all, self-taught Gloria LeMay. According to the College of Midwives of British Columbia, LeMay has had myriads of complaints against her, including several deaths; has been given a permanent injunction against practicing midwifery; has even GONE TO PRISON; but continues to flout the law and attend births. Has she been censored by the homebirth community? Of course not! In fact, she is teaching online midwifery courses which have enthusiastic reviews all over the (Oh, look! It’s Lisa Barrett endorsing Gloria LeMay!) internet.

WAKE UP, PEOPLE! If you truly wanted homebirth to be safe,  you’d be outraged at the outrageous behavior some of these so-called midwives exhibit. It’s not a matter of a woman’s “personal choice.” Any woman can have her baby at home with whomever she wants to attend. It’s a matter of who gets to give themselves the authority that comes with the title of midwife and use that title to profit.  And sorry, no matter how much you may protest to the contrary, calling yourself a midwife does indeed impart some semblance of authority. Do those of you who practice safe midwifery really want to be lumped in the same group with these mavericks who take risks with other peoples’ lives? I sure wouldn’t. Any other profession would be banding together to throw the bums out rather than circling the wagons around them. Is this an indication of the real values behind the culture of homebirth? That the advancement of lay midwifery is more important than the safety of women and babies? It is MIND BOGGLING to me that not only is no one speaking out against this egregious behavior, and in fact, they’re all throwing their support behind it.

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?

The Game of Risk

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.

No Matter How You Run The Numbers, The Result Remains the Same:

Homebirth, with or without a non-CNM midwife, is more dangerous than giving birth in the hospital.

Keeping in mind that homebirth midwives all claim to work with only low-risk women, lets look at the numbers I posted Friday:

“This Must Be a Joke” rants and raves in the comments of the previous post, calls me biased and stupid, and claims I shouldn’t have used the numbers from 32 weeks on. Other than the insults, she has a point. (I assume she is a she. If not, I apologize profoundly.) So I re-ran the numbers. Several times. Keep in mind that homebirth midwives all claim to work only with low-risk women. If women are having footling breech babies at home, it is only because some CPMs and DEMs lack the education and skill to diagnose the problem ahead of time and are shocked to see feet coming out first down the birth canal.  Or they believe that breech is just a “variation of normal” and low risk enough for birth at home. But I digress. We’ll compare the “other midwife” category (Notice this is midwives who are not CNMs we’re talking about here. There are no women in this category who intended to give birth with their OB at the hospital and somehow ended up giving birth with a midwife in their car on the way instead) with both the hospital numbers that include high risk hospital births — those attended by all hospital caregivers — and those that are only low risk, which are the births attended by CNMs.

Here are the numbers from 37 weeks on:

 hmmm. Looks like homebirth midwives are doing even worse in comparison to the hospital than they were in the 32 weeks-and-beyond numbers. How could that be? Because the 32 week numbers were increasing the hospital death rates! Once the pregnancy approaches term, hospital numbers improve, but it sure looks like the homebirth midwives don’t. Keep in mind, homebirth midwives claim to work only with low-risk women. But wait! These numbers include those babies born before 39 weeks. We all know those are slightly more dangerous than those born after 40 weeks. What happens if you throw out weeks 37 through 39?

 

Even WORSE numbers for homebirth! The homebirth death rate with an other-than-CNM midwife is now virtually TWO TIMES the higher risk hospital numbers, and more than three times the lower-risk CNM numbers. Keep in mind that homebirth midwives claim they work only with low-risk women. But wait, that 42nd week can get dicey! Totally ignoring the fact that most homebirth midwives claim there’s no expiration date on pregnancy, lets just take that out of the numbers. SURELY that must be the problem for homebirth midwives.

 

 

Hmmmm…nope!  While in all three cases above — while their numbers are slightly higher than CNMs working in the hospital — homebirth CNMs have a much more reasonable rate of death than other homebirth midwife death rates, which are yet again twice as high as higher risk hospital rates and more than three times as high as lower risk hospital rates.

Ahhh, but then we have another commentor, NaturalMamaNZ, who takes issue with my numbers. She complains that I have not properly accounted for confounding factors. Fair enough, she could be right. However, a confounding variable in this case would be high risk situations- but it’s quite an anomaly because midwives themselves accept high risk patients — all the while claiming to accept only low risk patients — and create high risk situations (remember, there’s no expiration date on pregnancy…) so there is really no way to seperate that from the data because that would be “cherry picking” good numbers, just like Johnson and Daviss did in NaturalmamaNZ’s favorite study. The data shows what it shows because of the current unregulation of midwifery and the carelessness in their want to accept patients of all levels of risk. Other confounding variables can easily be accounted for by changing the comparison groups to make them more alike. In this case, I changed the search criteria to include the same criteria Johnson and Daviss used – U.S. non-hispanic white neonates of 37 weeks + gestation. I further narrowed the criteria to women between the ages of 25 and 45 attended by the “other midwife” category, in order to remove any higher risk teen moms. I also only included those women with 12 years or more of education, meaning those who are, at a minimum, high school graduates.

 

 

 

WHAT? These numbers are even higher!!! Two times higher than the higher risk hospital births, the ones that include all caregivers, malpresentations, fatal birth defects, and so on,  and MORE THAN THREE times higher than those numbers for the low risk women who deliver with CNMs in the hospital.

But I can hear it now. “This must be a joke” will not stand for the fact that I left women up to age 45 in the group, because we all know they are higher risk. And those numbers include other potential confounders — single mothers, lack of prenatal care, twins, etc., etc. OK. Lets run these numbers, then: non-Hispanic white, singleton, 37 weeks + gestation neonates born to married women ages 25-39 with a minimum 12 years of schooling who started prenatal care before the 7th month of pregnancy. Surely these women — who are the epitome of the woman who hires a homebirth midwife in the US — will have stats that show that homebirth is safe!

 

I’m shocked. SHOCKED. (that’s sarcasm, for those of you who couldn’t tell. By the time I ran these numbers, I had ceased to find any of it shocking. I kept thinking I would be proven wrong with the next set, but alas, it wasn’t the case). These numbers are just as bad. Two times as high for the higher risk hospital births, and three times as high for the lower risk ones.

These numbers are sad. Yes, sad. They represent PREVENTABLE deaths.  Preventable by restricting the kinds of births that homebirth midwives can attend and requiring much higher standards for CPM/DEM education.  Or, better yet, doing away with CPMs and DEMs altogether and requiring a CNM to attend h0mebirths.

(Keep in mind that homebirth midwives claim they work only with low-risk women.)