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?

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.

 

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.

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.

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.