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?

 

Margarita Shares Her Story on KATU

Great job, Margarita! I know the reporter didn’t put in everything you told her, but I think your story came across loud and clear, anyway. And kudos to Representative Greenlick. I’m looking forward to seeing what he puts forth this coming legislative session.

And the best comment award goes to Tara, for this:

This tells a good portion of her story but leaves out some of the most chilling details. The “midwives” Darby Partner and Laura Tanner looked great and talked a good game but failed to deliver on their promises. But worse than that, their actions were self-serving. This was Darby’s first primary birth and she wasn’t going to have a hospital transport as her first birth. So they in effect, kidnapped Margarita. They took away her phone and forced her friends to leave. M’s husband was in India and was not allowed to talk to her. Her friend called the police multiple times and got no help. So margarita was alone with these charlatans, and in pain and helpless. They actually left her so they would not have to hear her pleas to go the hospital. They didn’t even know enough to tell that they were picking up her heartbeat and not the baby’s. They also did not even have a bulb syringe or knowledge of CPR. They forced her to labor for 8 days with all the warning signs. Meconium in the fluid, post dates etc. They misrepresented themselves and because of the lack of a system that Oregon has there is no way to tell the difference. I saw Darby’s and Laura’s websites myself, they looked legit. Full of pictures of happy mamas and babies and Darby looking like some benevolent mother earth figure. This is why this mother is fighting so hard, so that no one else is duped by fakers like she was. But is goes deeper than that. Natural child birth and homebirth can be wonderful, but there is an undercurrent of sickly sweet lies that has overtaken the NCB world. The blame lies heavily on the false prophets of the community that peddle the most egregious tripe. They spew such platitudes as no woman can grow a baby she can’t birth, and breech is another variation of normal. They employ fearmongering techniques and tell mothers that doctors only want to cut them so they can get to their golf game. They are zealots and they are cult-like in how they maintain rigid control over the content on their sites. Margarita’s own story was deleted from the most popular of these pages. They do not allow dissenting points of view and commenters, myself included, are deleted for raising up a voice of reason. They deny that there is any risk to birth at all and scoff at known complications like pre-eclampsia, previa and gestational diabetes. Worse, they push bunk remedies like garlic vaginal suppositories for group B strep. They viciously cut down any women who have inductions and c/sections and their followers follow suit. It’s common to hear how women who have c sections are selfish and shouldn’t be allowed to have children. They have created an impossible ideal in the name of being “natural” and and any woman that doesn’t follow in this ideal of homebirth, breastfeeding,cloth diapering,not circing, not vaccinating, etc are denounced and verbally flogged by hundreds of women. I’m actually surprised there aren’t more suicides from this, although we hear of a great deal of postpartum depression and difficulties bonding with the children that result from the “failed birth” I personally know a mother that has spent the last year regretting her homebirth transport and feeling like a failure because of it. Is it any wonder that vulnerable mothers go running to midwives? And these saccharine phonies are there with arms wide open promising to give them the birth experience they always wanted and failing them in the 11th hour. There is nothing we can really do to prevent this kind of propaganda from saturating the internet, but there is damn well something we can do about the lying, self-proclaimed “midwives” that exploit a mother’s fears. We need to demand stricter educational standards(25 births, are you kidding me?) mandatory regulations, mandatory licensing, malpractice insurance and the strictest review board that will drop the hammer down on these incompetent wanna-be midwives. You know, what’s really sad? Because these midwives aren’t insured, there isn’t even any civil action that babyloss mothers can seek. They literally get away scott-free. And they go on to harm even more babies and mothers. If they want to be professionals, then they need to be held to professional standards.

Guest Post: What We Say to Loss Moms

Please welcome today’s guest blogger, Martha Reilly, M.D. Dr. Reilly is an Oregon OB/GYN with whom I have recently been corresponding about the state of homebirth in our great state.

One of the most curious features of homebirth loss stories on the web and elsewhere is the closing remark, most often seen on Mothering.com, that “the doctor said this would have happened in the hospital too.”  Some examples  (all are taken from publicly accessible blogs):

  • A healthy mother labors with very painful contractions at home and, when the baby’s heart rate drops into the eighties, is taken to the hospital where a complete placental abruption is discovered and she undergoes emergency cesarean, but baby is born dead and mom nearly dies from the complications of the abruption
  •  Breech/breech twins are delivered at home,  with a particularly traumatic birth of the second (described in harrowing detail by the father) resulting in a depressed skull fracture. A mom is transported when the fetal heart rate drops and delivered by emergency cesarean, with the infant in for brain surgery and a long NICU stay.
  • A HBA2C with several hours of painful labor and no progress which ends in uterine rupture, the death of the baby, and near-death of the mother.
  • A twin birth with placental abruption before the delivery of the second twin, resulting in the death of that baby.
In all these stories, the narrator takes time out to report that the doctors said that birthing in the hospital would not have prevented the complication. The father of the twins goes one further and insists that he was told by his daughter’s neurosurgeon that a hospital birth would have killed her. This is the moment when, reading these narratives, I mutter, “Yeah, right.”

 

Where does this idea come from, this certainty that what happened at home would have happened anywhere?  Why is it such a fixed idea?  As an obstetrician who has received many homebirth transports, I’ve had way too much time to ponder these questions.

 

Some of the blame lies in the rather fixed and rigid belief systems of homebirth adherents. Birth, they say, is inherently safe, and most birth complications and almost all cesareans are the result of unnecessary intervention, so nothing bad, nothing really bad, can happen at home.  When a birth goes awry, they simply accept the (to me) astonishing concept that it would have happened anywhere.

 

More blame can be placed at the feet of unscrupulous midwives, who have the ear and the trust of the mom, and are busily promoting the idea that the baby’s death was inevitable from the start of the transport all the way to the baby’s gravesite and beyond.    But it’s not just a lack of scruples that leads them to take this stance: many non-medical midwives (such as Certified Professional Midwives) are woefully undertrained and understand the mechanisms leading to intrapartum death poorly.

 

Sometimes this trope results from timing of the narrative. Particularly on Mothering, the posts are often made within days of the baby’s death.  When I read homebirth loss blogs I am particularly interested in the understanding that parents develop over time as they wrestle with their child’s death.  Many parents (and I am thinking in particular of Wren’s and Aquila’s and Mary’s) devastating realizations about the choices they made, but only after months have passed.

 

What about doctors, though?   What information given to parents leads them to report that “the doctor said this would have happened in the hospital?”
To understand what might be going on in the hospital, you have to understand what really happens at an emergency homebirth transport.  We usually get a call that a mother is coming, but very little detail.  Arrival is chaotic. Often the midwife has brought the mother separately from her family and support team. Frequently the records have been “forgotten” or are coming in a second car.  We encourage our local midwives to explain what is happening to us, but in emergencies we are doing this at the same time we are drawing blood, establishing IVs, placing fetal monitors, and performing ultrasound. One of the special challenges in these moments is that homebirth patients many times don’t trust doctors, so we need to establish rapport with them at the same time we are acting as quickly as possible. Since the mother is often exhausted and frightened, it’s a very tense situation.

 

Another challenge is that the midwife’s report of her patient’s labor is often not reliable. There is some outright lying, but most of the problem lies in concepts that are, to put it kindly, different from the model of care we use. A typical report is that “fetal heart tones were strong,”  that is, until they weren’t. Well, thanks, but no thanks. “Strong” has no meaning in the realm of fetal monitoring. Fetal heart tones are either fast or slow, present or absent. The details that I want from fetal monitoring, the ones that REALLY matter (accels, decels, variability) are not discernible without electronic fetal monitoring.  So “strong” is useless information.  Additionally, many midwives don’t recognize, or don’t recognize the seriousness of certain factors (meconium, prolonged rupture of membranes, post-datism), so these might be left out of their story altogether.  Sometimes these factors are present, but explained away, such as the time one of my own patients transferred to a homebirth midwife and then was transported back at 43+ weeks with a stalled labor AND meconium. Her far-past due date was airily brushed away as being an “unsure” due date, even though she’d had a six-week ultrasound.   Some (to us hospital providers) basic information is often missing: some midwives don’t believe in vaginal exams and will allow moms to push based on urge alone, many don’t check temperature or blood pressure regularly.

 

In short, in an emergency transport we generally operate as if the patient has walked in off the street, since what information we have from the midwife may be limited or unhelpful, and do an independent assessment.  It’s important to remember too that precious time has usually been lost by the time the family makes it to the hospital. Most of these mothers arrive by private car, and sometimes they get stuck in traffic.  A laboring woman, in pain and possibly ill, can be difficult to get dressed and into a vehicle.  Even if someone has dialed 911, sometimes the mother’s preferred birthing place is not easily accessible to the EMTs.

 

Remember that our focus at these times is NOT on the homebirth debate. We are simply trying to do the best by our patients. We are not political animals at these moments.  Most of us are not even ideologically opposed to alternative birthing practices (as long as they do not compromise our notions of safety), no matter what popular midwifery blogs might say.

 

Suppose then that the worst has happened, and that a baby dies. What then? I will never forget my first emergency homebirth transport. It followed what I would later learn was the usual pattern: the call came, mom arrived with two midwives and no records, midwife told a story that made no sense (she claimed the baby had been vertex and “heart tones strong,” but at eight centimeters, the baby had leapt out of the pelvis and turned breech, so she brought mom in).  With some difficulty I got the midwife to step out of the way (she had placed herself between me and “her” patient) and addressed the mother directly.  My ultrasound showed a breech baby.  No heart beat. Mom’s cervix was completely dilated.

 

I’ll leave for another narrative how I had to dissuade the midwife from taking charge of the delivery of what turned out to be a perfect baby girl, who was easily delivered as a vaginal breech, and how I finally had to remove her from the room on the mom’s request (she was “normalizing” the baby’s death by coaching the mom to “join in spirit with the many mothers who have lost their babies in birth, and draw strength from them”), and move on to the topic at hand: what did I say to the mother?

 

What would YOU say?  To this day, I am not certain why that baby died.  I don’t have enough information to go on, really. She certainly was dead on arrival at the hospital, and mom certainly had been laboring at home.  I got calls from people I’d never met who told me the midwife had lied about the due date, that the mother was diabetic and untreated, and so forth.  Why might she have died?  Cord entanglement is common enough with breeches, and this might have been the fault.  Or if she was truly post-dates, the placenta may not have been adequate to support the baby in labor. She was not, by any available measure, diabetic.   Who knows exactly why this baby died?  I surely don’t.  Do I believe this birth was preventable?   Yes, that I do believe. If this baby had been monitored properly, and had been in a place where the changes in her heart rate could be responded to appropriately, she would have made it.

 

Here’s the important thing: the question of whether the baby would have died in the hospital never came up between the mom and me. Then or later. This mother has kept in touch with me over the years, and she came to her own conclusion, that her daughter would be alive today if she’d been in the hospital, and possibly if she’d chosen a different midwife.  I agree.

 

Parents, all parents, want desperately to do right by their children. I have NEVER met a parent who wasn’t trying, to the best of their abilities, to provide what their children need. Mothers always blame themselves when something bad happens to their baby.  In the moments of new grief, when the loss is fresh, I would never add to their burden by blaming them or their choices. My actions are not politically oriented;  I would never be answering their questions with an eye to what might wind up on Mothering or Birth Without Fear.

 

So where does “the doctor said this would have happened in the hospital too” come from?  If a patient asked me why her baby died, I would answer to the best of my knowledge, but my answers would be focused on scientific answers: infection, abruption, meconium aspiration, etc. Keep in mind, “home birth” is not a cause of death.  What causes death is failure to intervene soon enough when bad things are happening.  Three factors make this more likely to lead to death at home:  midwives not well-trained enough to recognize a problem in time to intervene, difficulty and delays in transport, and the tendency to view transport as failure.  While they will never show up on the death certificate, these are the things that kill babies.  The truth is, parents have never phrased their question to me as “If I delivered in the hospital, would this have happened?”  at the time of first hospitalization.  These questions come much later, and the parents usually know the answer by then.

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.