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?

58 thoughts on “What’s My Agenda?

  1. EXACTLY! three cheers! i also am not against homebirth- but for a SAFER homebirth! a system that offers the best chance for babies and mamas to make it out alive and unharmed. and i will fight with all my grit to get it.
    Aquila is worth it!

  2. Agreed! Hopefully this makes it clear, but sadly I don’t think it will :(. I came across this debate just a few months ago and to me it couldn’t have been any more clear what this group wants to happen. However, I guess some are so clouded by their own agenda that they can’t see that this is really what’s in the best interest for all. It’s not about making anyone the villain it’s about making everyone safe.

  3. Very well said. I’m really impressed with your goals, and how clearly you communicated them.
    The trust-birth midwives have two choices in how to respond.
    1. Double-down: “If I get malpractice insurance and outcome reporting, Birth will know that I don’t entirely trust ‘her’, and my stats will go way down. I’m 100% successful only if no one makes me report outcomes. Observer bias or something.”
    2. Broaden the Crazy: “To anyone who really cares about women, this is a thinly-veiled plot to outlaw homebirth. And VBAC. And vaginal birth completely. Can’t you see? If we can’t do homebirths with no oversight, even your hospital births will get worse.
    “They will outlaw doulas, too. An army of extra-mean people from your past will be there for vaginal exams during every contractions. It’ll be like ‘This is Your Life’, but only the mean people.”

    I’m predicting #2…

  4. I am of the opinion that the CPM should be abolished. Make the CM an option in more states. CMs and CNMs should be the only available options for midwifery.

    • Indeed. If midwifery and homebirth advocates are going to keep pointing to systems in other countries, like the Netherlands, as proof of the success of more widely used homebirth (despite the shaky grounds that provides for proof), they also need to buck up and adhere to the much, much higher standards such places have for midwives.

  5. Great goals you’ve got there. If only all your posts were so clear cut & sensible! Alas they’re not, a lot are inflammatory, aggressive, prejudice & irrational. But cheers for this post, it’s nice to know whats ticking behind all the drama.

  6. Great post. I thought the goal of your blog has always been very clear. Many commenters have tried to divert attention from your writing in order to stir up drama for themselves. No matter. And NaturalMamaNZ, I think that’s the most clear-cut backhanded compliment you’ve given yet. Too bad your other comments have been full of propaganda, passive aggression, and misinformation. But cheers on this comment. It’s nice to know that there’s at least one thing you’ve read here that you can understand with your level of reading comprehension.

  7. Thanks for responding! And no, I didn’t think it was clear, that’s why I asked. I do want to find common ground, And it sounds like you do to Heather. Too bad the same can’t be said for your commenters: “broaden the crazy”, “double-down”, “clouded by their own agenda”, because I asked for clarification of agenda so I could see if we could come together? Wow, ok.

    Anyway, in response to your (well-though out and productive) points:

    1. Mandatory Licensure: agreed. This makes sense, and I’m still not sure what the drive for voluntary licensure is.

    2. Risk criteria: I don’t agree on that one. I think our risk criteria in Oregon are appropriate. Even in looking at Astraea’s post, I think there is a misunderstanding of how that’s being practiced. I (and all midwives I know and work with) used OBs as the consults and usually Maternal-Fetal Medicine specialists and NICU docs. I think that they are best qualified to decide if transport is appropriate when a risk factor comes up. Unfortunately, there are lots of lay-people doing armchair analyzing of these risks, who aren’t medical professionals. The non-absolute Oregon risks are set up as “transfer care OR consult with an appropriate care provider”. If a midwife isn’t consulting adequately (or just calling up a buddy midwife to sign off) then it is grounds for complaint already, and she’d have to prove in an inquiry why that person was qualified to consult. We also have to document the consultation, the consulted person’s experience with the risk, our experience with the risk, their recommendation, our recommendation. The parents have to read all this and then decide whether to go with the recommendation or not, and sign their understanding. An example that happened for me recently: I had a client whose baby had faster respirations. Not all the time, but sometimes, in the hours after the birth. No other signs of issues. I called the NICU to consult and see if they thought I should bring her in, and consulted with the NICU doc. The doc said not to bring her in, that as long as her behavior was normal, she was nursing, etc, to just observe. The parents were given that info, and got to decide whether to go with the NICU doc’s recommendation or to bring the baby in anyway. Some of those–even absolutes– are stricter than our area hospital, and I think that’s appeopriate, because as I explain to clients: we’re not in the hospital, so itakes sense to be a bit stricter. One example of that is the BP of 140/90. I’ve had docs confused as to why I’ve brought a client in for that because it’s lower than the BP they’re concerned with in the hospital.
    That is the point of the non-absolute’s: to require appropriate consult and still allow parents to choose the next step.

    3. Disclosure: this is part of our licensure already, though not all of it. We do have to disclose training, education, and experience, and as I said if a non-absolute risk comes up we have to disclose experience with said risk, as well as the consulting provider’s experience with said risk. We also disclose that we don’t carry malpractice insurance. I can’t imagine any care provider discloses percentages of poor outcomes, lawsuits filed, etc, but I do disclose my personal rates of hospital transfers, c-sections etc. I think you’re saying for all care providers though, so yes! I would agree to an easily searchable database of that info for maternity care providers.

    5. I would disagree with the immediate suspension, because it’s not practical and not done with other care providers. Maybe if the inquiry could be completed in a timely manner (1 week?) then it could work. Otherwise, we’re leaving women with no care-provider, no continuity, etc, and we know that doesn’t serve the well-being of mothers and babies. If fault is found, then it makes sense to suspend it, but pending that… What about requiring disclosure to clients on that database you were talking about? Or the state sending a letter to all the midwife’s clients saying there’s an investigation pending? That way they’d know and decide for themselves whether to switch care providers in the meantime. I don’t know if that’s the best choice either, just brainstorming here…

    6. I’m assuming you mean if fault is found in those two losses/injuries. If a non-preventable death occurs, this wouldn’t apply, right?

    7. Yes, similar to #4. Sounds great.

    8. This is a big question. As it stands right now, it is prohibitively expensive. Despite various blogs trying to calculate our incomes, for many of us malpractice insurance (if available) would represent half or more of our take-home pay. So at this point, I’m going without. This is risky for us too, since it means client in a lawsuit could be awarded all our assets. We do disclose to clients that we don’t carry it. Not only is it in our written disclosures, but I say it verbally to each one and explain why. What is your opinion on that? If a family knows that filing a malpractice suit won’t be possible, signs something to that, and still chooses a midwife for care, should they be allowed to choose that? Not argumentative, that’s a real question.

    9. I agree, more tracking! Since I think homebirth is being safely practiced by *most* midwives, I’d be glad to have that show in statistics.

    Thanks again for answering sincerely. I think it does look like we have lots of common ground to be able to work together to make homebirth a safe choice for women and babies.

    • I’m guilty of inflammatory language. I apologize. Please mentally replace “Broaden the crazy” with “Expand their position”.

      Skepmidwife-
      Some thoughts:
      (using your numbering)
      2.”Unfortunately, there are lots of lay-people doing armchair analyzing of these risks, who aren’t medical professionals.
      Which medical professionals analyzed the risks, and signed off on this list? One of the arguments I’ve heard for preferring the CPM credential is that many midwives do not want to be medical professionals.
      -I am “skeptical” that a doctor wouldn’t understand why you were following the advice from the national guideline clearinghouse
      http://www.ngc.gov/content.aspx?id=11469 I would think they would respect a midwife for transferring before the baby or mother was in imminent danger.
      Why wouldn’t it make sense, in some situations, to transfer before they have reached the level of concerning a doctor in a hospital?
      If I am concerned about a worsening cough, I would see my family doctor while I could still walk around. Why wait for life-threatening pneumonia?

      5. If a human being dies under your care, you should not attend another birth until you (and everyone else) know why. Personal emergencies happen, you have a backup. This should be so rare that anyone would agree to it– or you have some soul-searching to do.

      8. Please post a detailed, if hypothetical, accounting of how you came to this.

      • Trying to keep to the numbers for clarity…

        2. What you’re saying makes sense, except that the things on the non- absolute list are not always cut and dry. For example, the fast respirations in a newborn: it could mean any number of things. It could be a heart defect, it could be an infection, it could be TTN, etc, etc. It may need treatment, or it may not. Midwives recognize something unusual, and consult, giving the full picture to a professional. The professional in this case took in all the information, and deducted that this symptom most likely was not a condition that needed treatment, but would resolve on it’s own. While it may make sense to you to go to the hospital as a precaution, it doesn’t to most women choosing homebirth.
        The cough is a good example: you would choose to go to the doctor, but someone else might only choose to go in if their cough was accompanied by a fever as well. Someone else would choose to call or email their doctor, if that was an option. Someone else might google symptoms and go with Dr. Google. Everyone’s different, and most women choosing homebirth want to go to the hospital with a problem, not as a precaution. That’s why they’re not there in the first place.

        5. Should this be the same for doctors? If it’s during a surgery, should it be the surgeon or anesthesiologist or resident etc who is temporarily suspended? It’s not, so why should that be different for midwives?

        8. Hypothetical accounting below!

    • You should call the two major Portland birth centers on the carpet, then, because I know the whole reason they keep NDs close/in-house is for non-absolute consults. Naturopaths are not qualified to treat or even DISCUSS isoimmunization with a patient but Andaluz summoned Ed Hoffman-Smith to the consult. Because he would tell them what they wanted to hear.

      They have NDs do vacuum deliveries.

      They have NDs “consult” about compromised infants, and do laceration repairs.

      Because NDs will tell them what they want to hear. You scratch my back, I scratch yours…together we protect each other’s profits at the expense of the safety of those we supposedly serve.

      A DEM has a lot of nerve talking about “armchair” anything, honestly.

      • Hm, as far as I know neither birth center has an in- house ND. We do have relationships with NDs because many of our clients see them for primary care–not because we use them for obstetric consult! I hear you (over and over) saying an ND was consulted for your high-risk situation. This was how many years ago? Found anyone else yet with a similar complaint? This seems like it may have been an isolated incident. Sorry that you feel so wronged and feel like you have no recourse, I really am. But that doesn’t mean that’s what every midwife is doing in every high risk situation.

        What proof do you have about any of these other ND stories. The ND vacuum rumor has been going around for years, and the midwifery community was horrified to hear someone might be using a vacuum out of the hospital. Who is using one? What midwife called an ND in to use a vacuum?

        Who consulted an ND about a compromised infant or called one in to do a repair? Sounds like rumors to me.

    • Also if you have worked in Oregon any length of time you know that “complaints” are a cruel joke for consumers who have been maimed, had their infants killed, and had their future fertility nixed by DEMs. Your board wouldn’t remove a license from Pol freaking Pot, let alone a negligent midwife.

      • Mama Tao, I did read your post And that’s what I was basing my statement on.
        So, hypothetical numbers: midwives make around $1000 per birth, after taxes. That’s the per-birth salary of birth center midwives in Oregon. Home birth midwives make a bit more, around $1500. I’ll break that down because I know it may spark controversy. Average cash price of a homebirth in Oregon is $3500. Most practices will discount that if it’s paid before 36 weeks, so now about $2900. $1500 to the midwife. 500-1000 to the assistant midwife. The other 400 would go to expenses: office rentals, equipment, etc. More if she has to pay a back-up because of an illness or a vacation. This is a flat fee, including all prenatal and postpartum care. Full-time out-of-hospital mideifery is considered 4 births a month. 44 births a month (one month off a year, we hope) at 1500 is 66000, before taxes. Now, that’s if you have a full practice, font take any Medicare clients (total OHP pays is $1700) and all of your clients pay in full. Also, if you don’t transfer their care for a pregnancy risk, having counted on that birth for an upcoming month that now will be short.
        I don’t know how to calculate the take home part, but again hypothetically- 44,000? And that’s optimistic.
        In your chart I see that by the fifth year, the premiums are over 20,000. Close to half the take-home pay.
        And yes, a midwife could take more clients per month to cover that better, or stop accepting Medicaid or charge more for births. But, taking many more clients than that would start a safety question, and also a sustainability question. 4 births is already a lot when you are on call full-time… I don’t think this discussion is over, and am still open to it: it just isn’t feasible for most midwives right n
        Also, I haven’t seen the other part of my comment addressed: our clients

        • The other part: as we don’t carry ins right now, and clients are disclosed that and choose to hire us- is that a choice they are allowed to make for themselves?

          • The problem with the rounding game, is that the differences add up:
            If it’s $3500 for a birth, but if you pay early, it’s $2900? What’s the % of medicaid patients?
            $3500 $2900
            Assistant $500 $1000
            Expenses $100/birth $400/birth
            48 b/year $139,200 $72,000
            44 b/year $127,600 $66,000
            40 b/year $116,000 $60,000

            No one wants to pay for insurance. No one thinks they need it, until they need it. You don’t get it to protect yourself, you get it protect your clients. I imagine it could be a selling point.

            I know it’s impossible to get reimbursed from a moving company who breaks your stuff. Even so, I always hire a bonded/insured one anyway. It lets me know that they consider themselves professionals.

          • Someone asked to do it hypothetically, so I did.

            No answer to the other part?? Women choosing Care providers with full disclosure that they are uninsured. We don’t need the selling point, we’re busy without it 🙂

        • If you can’t make your bills with what you charge you need to have your clients pay more. It’s simply not my fault or the fault of your clients if you can’t run your business in a proper and safe manner that provides security for the familie you serve. Life is like that and any other business owner will tell you the same thing.
          I also think I should add that your insurance would be tax deductible. I am sorry, you can talk all you want but your first goal should be to make enough money to pay your bills. If you don’t you need to close your business.

  8. Oh, just realized I didn’t reply to the first part of your post. It’s not only the out-of-hospital birth community that is trying to minimize interventions. Every study on birth outcome (home or hospital) takes interventions into account, and is one of the aspects being compared. Interventions examined in those studies are listed as:
    Epidural anesthesia
    Episiotomy
    Operative vaginal delivery
    Cesarean delivery
    Do we accept that those interventions lead to an increased risk? Please people, don’t start comparing the risks of those things to the loss of a baby. Nobody is talking about that.
    If we accept those are more risky than a spontaneous vaginal deivery, then it makes sense to want to decrease interventions.
    And, just to pre-empt where I (sadly) know this may go,Studies on the risks of epidurals:
    The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review.
    Leighton BL, Halpern SH
    Am J Obstet Gynecol. 2002;186(5 Suppl Nature):S69.
     
    Mothers given an epidural rather than parenteral opioid labor analgesia report less pain and are more satisfied with their pain relief. Analgesic method does not affect fetal oxygenation, neonatal pH, or 5-minute Apgar scores; however, neonates whose mothers received parenteral opioids require naloxone and have low 1-minute Apgar scores more frequently than do neonates whose mothers received epidural analgesia. Epidural labor analgesia does not affect the incidence of cesarean delivery, instrumented vaginal delivery for dystocia, or new-onset long-term back pain. Epidural analgesia is associated with longer second-stage labor, more frequent oxytocin augmentation, hypotension, and maternal fever (particularly among women who shiver) but not with longer first-stage labor. Analgesic method does not affect lactation success. Epidural use and urinary incontinence are associated immediately postpartum but not at 3 or 12 months. The mechanisms of these unintended effects need to be determined to improve epidural labor analgesia.

    Epidural analgesia side effects, co-interventions, and care of women during childbirth: a systematic review.
    Mayberry LJ, Clemmens D, De A
    Am J Obstet Gynecol. 2002;186(5 Suppl Nature):S81.
     
    The purpose of this article is to profile research findings targeting the intrapartum care implications of the most common side effects and co-interventions that go along with the use of epidural analgesia during labor. Randomized, controlled trials published in English from 1990 to 2000 that addressed each of the targeted side effects and 3 specified co-interventions were evaluated for inclusion in this report. Side effects such as pruritus, nausea, and hypotension during labor are common, but they are usually mild and necessitate treatment infrequently. However, even with the advent of newer low-dose epidurals, the extent of impaired motor ability remains variable across studies. The incidence of “walking” epidurals during labor is likely to be complicated by multiple factors, including individual patient desires, safety considerations, and hospital policies. In response to risks for a decrease in uterine contractions that could prolong labor, oxytocin augmentation is likely to be administered after epidural analgesia. The use of “delayed” pushing may be an effective way to minimize the risk for difficult deliveries. Upright positioning even when confined to bed may be advantageous and desirable to women; however, additional research to determine actual outcome benefits with epidurals is needed. Implications forfurther research linked to epidural analgesia also include informed consent, modification of caregiving procedures, and staffing/cost.

    This one discusses both operative vaginal delivery and c-sections.

    Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study.
    Murphy DJ, Liebling RE, Verity L, Swingler R, Patel R
    Lancet. 2001;358(9289):1203.
     
    BACKGROUND: A frequent dilemma for obstetricians is how to keep morbidity to a minimum when faced with arrested progress at full dilatation of the cervix. Our aim was to examine maternal and neonatal morbidity associated with vaginal instrumental delivery in theatre and caesarean section, at full dilatation.
    METHODS: We did a prospective cohort study of 393 women, who had term, singleton, liveborn, cephalic pregnancies requiring operative delivery in theatre at full dilatation for 1 year.
    FINDINGS: Factors increasing the likelihood of caesarean section included maternal body-mass index greater than 30 (adjusted odds ratio 2.4, 95% CI 1.2-4.9), neonatal birthweight greater than 4.0 kg (2.3, 1.3-3.8), and occipitoposterior position (2.5, 1.6-3.9). Women undergoing caesarean section were more likely to have a major haemorrhage (>1 L; 2.8, 1.1-7.6) and extended hospital stay (>/=6 days; 3.5, 1.6-7.6) than those with vaginal delivery. Babies delivered by caesarean section were more likely to require admission for intensive care (2.6, 1.2-6.0) but less likely to have trauma (0.4, 0.2-0.7) than babies delivered by forceps. Overall neonatal morbidity was low, but a few babies in each group had serious complications (serious trauma, eight vs three; sepsis, six vs 13; and jaundice, ten vs 12 after vaginal delivery and caesarean section, respectively). Major haemorrhage was less likely after delivery by a skilled obstetrician (0.5, 0.3-0.9).
    INTERPRETATION: The data lend support to an aim to deliver women vaginally, unless there are clear signs of cephalopelvic disproportion, and underline the importance of skilled obstetricians supervising complex operative deliveries.
    erative delivery and c-sections:

    Obviously, don’t go by abstracts alone, that’s why I posted the full citation, but there are lots more where those came from. I’m just hoping to head off at the pass any arguments that those interventions don’t carry more risk than vaginal births. And please: we are not talking about life-saving c-sections.The World Health Organization recommends that the c-section rate be no higher than 10-15%; anything above that and we’re generally not talking about life-saving surgery
    Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study.
    Murphy DJ, Liebling RE, Verity L, Swingler R, Patel R
    Lancet. 2001;358(9289):1203.
     
    BACKGROUND: A frequent dilemma for obstetricians is how to keep morbidity to a minimum when faced with arrested progress at full dilatation of the cervix. Our aim was to examine maternal and neonatal morbidity associated with vaginal instrumental delivery in theatre and caesarean section, at full dilatation.
    METHODS: We did a prospective cohort study of 393 women, who had term, singleton, liveborn, cephalic pregnancies requiring operative delivery in theatre at full dilatation for 1 year.
    FINDINGS: Factors increasing the likelihood of caesarean section included maternal body-mass index greater than 30 (adjusted odds ratio 2.4, 95% CI 1.2-4.9), neonatal birthweight greater than 4.0 kg (2.3, 1.3-3.8), and occipitoposterior position (2.5, 1.6-3.9). Women undergoing caesarean section were more likely to have a major haemorrhage (>1 L; 2.8, 1.1-7.6) and extended hospital stay (>/=6 days; 3.5, 1.6-7.6) than those with vaginal delivery. Babies delivered by caesarean section were more likely to require admission for intensive care (2.6, 1.2-6.0) but less likely to have trauma (0.4, 0.2-0.7) than babies delivered by forceps. Overall neonatal morbidity was low, but a few babies in each group had serious complications (serious trauma, eight vs three; sepsis, six vs 13; and jaundice, ten vs 12 after vaginal delivery and caesarean section, respectively). Major haemorrhage was less likely after delivery by a skilled obstetrician (0.5, 0.3-0.9).
    INTERPRETATION: The data lend support to an aim to deliver women vaginally, unless there are clear signs of cephalopelvic disproportion, and underline the importance of skilled obstetricians supervising complex operative deliveries.

  9. Oops, sorry for the article posted twice. It’s hard to do this on a phone! Anyway, my point being that if we accept (the medical community’s) supposition that intervention increases risk, it makes sense to minimize it- to support your goal of healthy moms and babies. The WHO (world health organization) recommends a c-section rate no higher than 10-15%, so anything above that may not be for life-saving purposes.
    OBVIOUSLY not talking about life-saving surgery.

  10. SkepticalMidwife, I am very pleased to see constructive dialogue here in what is so important an issue for Oregon. I also look forward to what Heather has to say, but I do just want to say one thing about the risk of injury from interventions such as Epidural anesthesia, Episiotomy, Operative vaginal delivery, and Cesarean delivery. Of course they have risk, which is why nobody does them out of the blue.

    For example, having your car door being pulled open by the jaws of life and being pried out, versus having Patrick Dempsey in a tuxedo and monocle extend his arm and gracefully raise you out of the car and to your feet, will be associated with morbidity. BUT the first one only happens in the presence of worse circumstances, where such intervention has been shown to be the best way to minimize morbidity in those circumstances, and the second one had better never happen to my wife. Are you reading this, Honey? Absolutely no opera with Patrick Dempsey!

    In situations where no elevated risk is indicated, obviously forceps or the jaws of life, or other method and its associated risk of morbidity, is an unnecessarily harmful rescue. In discussions of which method of getting a baby out alive and uninjured and a mother alive and uninjured are preferable, though, it is important to speak of them in terms of their potential to mitigate total risk of morbidity and mortality.

    • I totally agree Gabriel! And as an out-of-hospital midwife, I’m very glad to go to the hospital for those interventions when needed. What I meant was, continuing to insure that they are being used when needed, and not becoming standard protocol.
      Maybe episiotomy is a better example: episiotomy can be life-saving for a baby in distress. Cutting an episiotomy can hasten delivery, which we can all agree can be not only necessary, but crucial. It used to be believed that they also decreased the risk of other tears, and doing them minimized perineal trauma. Research has shown that that benefit doesnt exist, and in fact can lead to worse tears sometimes because of the extension if the cut. Current practice protocols in many hospitals in most states still include routine episiotomy.

      So: we all would agree that episiotomy should be done to save a baby’s life, and that the evidence doesn’t support it being done for other reasons.

      I think we can also use that example to have an interesting debate about women’s choice. What if, given the evidence, and no fetal distress, a woman chooses a routine episiotomy. Do you do it?

      • If “current practice protocols in many hospitals in most states still include routine episiotomy,” then they are not following ACOG’s current recommendation: http://www.acog.org/from_home/publications/press_releases/nr03-31-06-2.cfm. I don’t think that’s true, though. It certainly isn’t true in the hospitals where I have doula’d in the last two years in both Ohio and in Oregon. In more than 30 vaginal births, I have never seen one episiotomy performed.

        • I’ve seen three in Portland hospitals, all three to facilitate forceps. That wouldn’t be considered routine though. I agree that they’re not routine in the hospitals in Portland.

          I’m not sure we can find published info on this; it’s more anecdata. A good friend just had a hospital birth in Florida. She wanted to be in the hospital, and wanted a natural birth if possible, but was open to necessary interventions. She interviewed 18 OBs and only found one who didn’t perform routine episiotomies. After calling some docs in NY where she’s originally from, several said the same thing. She asked her friends out of state and found the same thing, in different proportions.

  11. Had a nice little quick phone discussion with a charge nurse at a Portland area NICU. She said if a homebirth midwife calls with concern about a baby, the neonatologist will tell her to BRING THAT BABY IN. They will have to examine the baby in ER to know what’s up. They would not tell her to keep that baby at home. That’s what I suspected.

    Someone is being less than 100% factual about her spotless “consultation” practices.

    • Well, now it’s just a she-said/she-said situation. Did you pose as a midwife when calling the charge nurse? Did you give her a name and practice name and actually speak to a doc who you’ve met, and have a good relationship with? Did you give her the delivery information, baby’s APGAR at birth and how the baby has been doing during the past 4 hours of observation? Because that’s how I do it. The docs I work with are people I’ve met, have working relationships with, and know me when I call. There’s no way you can call and talk to a charge nurse and get the same info. It’s clear that whoever you spoke to was misinformed for another reason as well- we don’t go to the ER, we go straight to NICU, as per the hospital’s request.
      And what possible motivation could I have to lie? I’ve been clear that I’m here to find common ground and promote safe and healthy moms and babies. If I am concerned enough about a baby to call a NICU doc, it’s because I have a clinical concern. In this particular case, I was actually recommending transport, and the doc didn’t- so the parents had those two opinions to decide between.
      Who used the term “spotless consultation practices”? I consult the appropriate person. For a baby, it’s the NICU. For a mother, it may be an OB, a hospital-based CNM, an OB or MFM, depending on what the issue is. I’ve personally only used an ND for anemia consults, and that’s only because I think their training in herbs and vitamins can help with anemia, in my experience. I can’t imagine consulting with them on an obstetric issue, or being able to defend that choice if a complaint was filed.

  12. Anoregonian, maybe the average caliber of home birth midwife in Ohio is higher, and there’s more professional trust there.

    I can understand a charge nurse in a Portland NICU just wanting the baby to come in, with voluntary licensing there and all of the incidents that they see as a result.

  13. I would add to Gabriel’s point-
    Not only are the ‘interventions’ required because of the situation justifies the risk of adverse effects,
    but the “adverse effects” in those studies are not necessarily caused by the ‘intervention’. They are correlated, but we all know that isn’t enough to prove that one causes another (don’t make me say it!).

    Augmentation and induction are associated with c/section, but they do not cause fetal distress. The same conditions that contribute to fetal distress can contribute to stalled labor. Long labors correlate to epidural which is associated with pitocin which is associated with c/section…Which one causes another? Is there one common cause? You are not going to find research that says that epidurals cause problems, because it’s just not known. None of this is known at this point.

    There is widespread agreement that the simplest, safest delivery is best. There is no widespread agreement that we should try to lower our rate of ‘intervention’.

    • Hi All,

      Going to bow out of comments now because the bickering is not constructive, and my whole point in asking the original comment was to see if we could meet in the middle somewhere.

      I see that there are some places we meet and others we don’t, and maybe won’t! Thanks for posting my comment and taking the time to answer, and I appreciate that most people commenting are here to work towards safer moms and babies.

      I will explore points you’ve brought up and see if they make sense for my practice and the families I serve. 🙂

  14. About 5 and 6…
    I have no idea what the actual rates are, but I’d be worried about these on statistical grounds. The problem here is that although it would be nice to have all babies live, not all of them will, and that isn’t always the midwife’s fault, even if she does everything right.

    Imagine that the rate of a “safe” midwife is 1/1000, and the rate of an “unsafe” one is twice that. Twice as many dead babies is bad, right?

    If our theoretical midwife attends 40 births per year (the person above supposed 44; I’m rounding) then there’s about an 0.038 chance that she’ll have a baby die on her. After ten years of midwifing, that grows to 0.268. That’s one in four midwives. Even in one year, that’s close to 4 out of every hundred midwives who are going through an inquiry. Unless inquiries are very short and very cheap, that’s a hell of a risk to take. I disagree that this is so incredibly rare.

    At two deaths, assuming a ten year career, the rate for our theoretical “good” midwife is 0.054, or a little over 5 per hundred. If our theoretical midwives practice for 20 years, that goes up to 14 per hundred.

    The real problem is the power of this test. Over 20 years of service, “bad” midwives are only two and a half times more likely to see two or more deaths than “good” ones. If you up it to, say, 4 deaths, that goes up to 8.7 times more likely — which is a little more like it, in my opinion.

    You see, people do make mistakes, and studies have repeatedly shown that people are really bad at metacognition. It’s very easy to look back and say that, in retrospect, there were signs that something was wrong. The real question is not “were there signs that were missed”, it’s “were the signs missed as a result of incompetence? What is the chance of these signs being missed under a reasonable level of competence and care? Is the evidence powerful enough in favor of incompetence to conclude incompetence?” and that’s very difficult for humans to answer, especially in a situation with high emotional content — like the death of a child.

    If competent people dominate the field (which one would hope they would) and the chance of a competent person facing inquiry is even moderately large (relatively speaking), most of the people facing inquiry will be competent. This can lead to undesirable outcomes in a real-world scenario. The problem is to balance the necessary specificity (the ability to clear midwives who are not at fault in a reasonably economical manner) with the necessary sensitivity (the ability to correctly identify problem midwives and take action).

    As a statistician, a few nice, pretty solutions come to mind, but I doubt any would be adopted. One method would be to use some sort of actuarial calculations based on an objective birth risk metric and number of births attended to “weight” deaths. Another would be to track midwives’ full statistics and use on-line updating to produce “risk metrics” for them, and begin inquiries when the risk metrics reach some minimum threshold — after all, ideally you’d like to pull an incompetent midwife from service before she kills a child, not after. One advantage of this system would be the ability to concurrently track increases/decreases in overall systemic risk. Of course, none of these would ever actually happen in real life; it’s just a statistician’s pipe dream… (unless you work for Kaiser Permanente, in which case they might become reality. Full digital records are a beautiful, amazing thing to statisticians.)

    • I realized there’s another reading of your original #6. It can be read as speaking of pulling midwives when they reached 2 deaths, period, end of story.

      In that case, life gets… pretty bad for our good midwives. If a “good” midwife has 1/1000 chance of a baby dying on her, about 19 out of every 100 “good” midwives will have their licenses pulled before they reach 20 years of service. 6 out a hundred will have them pulled before 10 years. It only takes about 45 months to reach a rate of 1 in 100.

      A “bad” midwife will have her license pulled earlier. Over three in a hundred will have theirs pulled after 45 months. 19% will lose them after ten years, and by the time you reach 20 years, almost half will have lost their licenses.

      Problem: again, assume competent midwives dominate. Would you enter a field that required a lot of study (and probably debt) only to have a six percent chance of losing your license before ten years were up? I wouldn’t. You’d get skew towards risk-takers entering the field — the risk adverse would choose a safer career — which I’d argue is exactly what you don’t want in a good midwife!

      If you up it to 4 deaths, only 1% of competent midwives lose their licenses by the end of 20 years of service. A midwife with twice their probability of loss loses hers with 8% probability, and has 1% probability of losing it in the first 10 years. A midwife with four times the chances of a death loses hers with 8% probability in the first 10 years. If you take it up to 10/1000 (which is not an unreasonable guesstimate for some of these midwives in Oregon), that’s 57% of really bad midwives who lose their license in ten years. 14% would lose them in 5 years, and almost 1% in the first two years.

      On the other hand, you still have that 1% of competent midwives who are getting screwed over. Again, the problem is one of weighing sensitivity and specificity.

      • The deaths we are hearing about at not ones where someone made a mistake. They almost always include several of the following elements:
        -mother had one or more conditions that qualified as high risk
        -initial signs of a problem were not correctly recognized by the midwife
        -initial signs of a problem were not correctly addressed/treated by the midwife
        -inadequate assessments of maternal blood pressure, temperature, cervix/dilation
        -inadequate assessments of fetal heart rate
        -failure to adequately assess and treat for GBS and Rh status
        -knowledge deficit as relates to basic infection prevention/sepsis, and meconium aspiration
        -knowledge deficit as relates to timing of human labor, including alteration
        -failure to maintain thorough and accurate records
        -failure to transfer care
        -other knowledge deficit/human anatomy and physiology
        -use of unproven treatment for emerging conditions

        Mistakes are made all the time– even in healthcare, even at home. The vast majority of these don’t cause any serious harm. The ones that do– particularly when they are willful, should be punished.

        The inquiry should be pretty straightforward in the cases of a simple error. In more complicated cases, it’s more complicated. Most midwives will never have one of these. Those that do, owe the families an honest explanation.

  15. “Permanent Revocation of any CPM license after a second fatality or major injury if it has not already been revoked…. Once a practitioner has reached 750 births, the number of deaths allowed before suspension could be increased.”

    I actually agree with pretty much all that you said. I’m partial to homebirth but frankly it would not occur to me to participate in one without a CNM in attendance. I’m all for higher standards all around so that, like the Netherlands, homebirth becomes perceived as safe and reasonable choice for low risk women.

    That said, I’d say #6 is grossly unfair unless you apply to OB/GYNs and hospitals as well. Doctors are not subject to a numbers game where their license is revoked automatically. It is in fact, very difficult to get incompetent doctors out of practice. As long as this numbers based standard was apply equally to *all* birth professionals, I’d be all for it. But for CNM midwifes, only, then no, it’s an unfair standard (and much higher) than for MDs.

  16. “If there is evidence that less intervention improves outcomes, then, sure, we should strive for that.”

    But there is evidence that less intervention can improves outcomes and it comes ironically, from the planned homebirth community with highly trained midwives in attendance.

    I’m not saying it’s the end all be all of evidence, because it’s again based on correlation. There’s no way we can get that gold standard of controls or even a random double-blind study because no mother would willingly give up her right to choose birth environment.

    “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.”

    I’m not sure what experience after outcome means on the importance scale, exactly. Also, *cough*, *cough* the Netherlands. If rate of interventions *don’t* correlate at all with better outcomes then why all the hub-hub against homebirth with CMs? Why bother with this blog?

    I do agree with you that some of the reason of US mortality rates having nothing to do with hospital procedures. The US struggles with large zones of poverty that are not found within the relatively tiny European nation states. I’ve felt for a long time that comparing the entire US to the equivalent of state in Europe was an apples to oranges comparison. The only true comparison would be to say, of the US to all of the EU or Europe.

    I’m not letting US hospitals off the hook entirely, however. They still have some of highest C-section rates in the world, the last time I looked. And for certain, the system could become far more mother/child oriented than it is today.

    “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.”

    It might even be safer if you take into account lower risk of infections and less temptation for the optional/ambiguous interventions that may lead to unnecessary C-sections. I see in this statement bias here that is a mirror reflection of my own. I try to be mindful of mine..

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