WHAT?? You would still VBAC with 99% chance of uterine rupture?

 

Oh, and before I get all the comments about how I’m shoving all NCBers in the same box…she may be the only one who would VBAC unassisted with a 99% chance of uterine rupture, but she sure isn’t the only one who thinks scientific evidence is bunk.

The good folk at Unhindered Living

Birth Without Fear

 Jette Clausen

 

All over the forums at MDC 

 

 

 

 

 

 

 

 

What’s My Agenda?

Forced c-sections for all!! Muahahahahahahahahahaha!

That was a joke for those of you who are humor impaired. What is true is that I have an agenda. Top of the list? Safer mamas and babies.

I’m writing about this for two reasons. First of all, someone in the Fed Up Facebook group posted one of the ACNM Objectives for Healthy People 2020 and asked the Skeptical OB to write a blog post about how we can increase physiologic birth in hospitals:

 

 

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

 

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

 

 

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

 

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

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

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

As far as what I hope to achieve…

I don’t necessarily want to have the CPM credential abolished, as many of my readers do, but I do think it’s redundant with the existence of the CM (A CM is a direct entry midwife with the same midwifery training and examination as a CNM but no nursing, currently only legal in New York and Rhode Island). If it’s going to stick around, it needs to require a minimum of a Bachelor’s degree from an actual accredited university (i.e., not Birthingway, Aviva Institute, National College of Midwifery, etc.), with the same science courses BSNs are required to take and pass with a B or better. If every CPM had the education that graduates from Bastyr have, I might be satisfied. I also want the NARM to reflect the same level of difficulty and accuracy as the AMCB exam (that CNMs and CMs take). If the requirements for a CPM aren’t changed/made more stringent, then I do want the credential abolished and would be happy to make the Certified Midwife (CM) a national certification.

Other things I’m working for:

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

What changes do YOU think will make childbirth safer?

The Game of Risk

Astraea blogs about midwifery in Oregon and shares her own homebirth horror story over at Oregon Homebirth Reality Check. We felt this recent post of hers was so important that we arranged for it to be be re-posted here as a guest post. You can read the original post here.

Any plan is arguably only as safe as its contingency plan is solid. Common and less common emergent and urgent situations must be studied and planned for; backup must be arranged. Staff should be drilled on what to do in case of the most dire situations, they can act quickly and calmly in the face of an actual emergency and the panic it brings. This is a well-accepted principle. It is why we have fire drills in schools and offices. It is why lifeguards must be people who have been trained, and not just any person who knows how to swim. Unfortunately, among many “alternative” healthcare providers, risk planning is looked down upon. It is seen as inviting “negativity.” Some even believe that you can “manifest” good or bad results simply by thinking about them a lot. This is a childish, irrational belief, but unfortunately a common one in the circles of direct entry midwifery. (Childish, literally–remember Mr. Rodgers comforting children that they cannot cause a person to die just by wishing they were dead? That’s magical thinking, a normal developmental stage. We’re supposed to grow out of it.)
But homebirth is truly only as safe as the process used to “risk out” of it (and into obstetrical care in the hospital) is complete, thoughtful, and conservative. The risk assessment protocols for Oregon DEMs have again been changed. You can see how they differ from the 2009 version of the same. The criteria have been tightened up slightly in a few ways, but overall loosened substantially from the original 1993 criteria (see table). The legislators who allowed direct entry midwives to be licensed through the state in the first place approved a far more conservative set of safety guidelines than what is currently in place. These changes–for instance, moving from no VBACs to almost any VBAC; no multiples to most kinds of twins; no malpositioning to any breech and back down to no footling breech–have been put in place by the DEM board, without any outside oversight. What is worth examining in some detail is not just how the Oregon absolute and non-absolute risk criteria have changed, but how they compare to the homebirth systems that are so often held up as examples of why homebirth is safe. We cannot expect to get the same results as the Netherlands, Canada, or New Zealand if we are failing to be as conservative in our safety standards as those nations.

 

 

Even a quick scan of the risk criteria by a careful eye shows many problems. For one thing, the list is very brief; many potential serious and common risks are not even weighed or considered. Compare it with the far more comprehensive and methodical list from the British Columbia College of Midwives and the sloppiness and shortcomings of the Oregon list are readily apparent. In almost 20 years, how is it that the board has not managed to come up with something as thorough as the Canadian risk criteria? For another thing, some of the determinations rely upon diagnostic tools or skills that DEMs are unlikely to have on hand–for instance, AIDS in an infant is an absolute risk factor according to the 2009 standards, but HIV is a non-absolute risk factor. How is a midwife to determine the difference on site, without being able to determine viral load, T cell count, or the presence or absence of AIDS-related complications?

“Absolute risk” is a condition that rules out homebirth as a possibility. The patient(s) must be referred out to hospital care immediately. “Non-absolute risk” is much blurrier in meaning. Oregon law only requires that the midwife consult with another professional about the situation and obtain “informed consent” from the patient. Another disturbing contrast with the BC system is that while for many conditions, Canadian midwives must consult with a physician and proceed as advised. Oregon midwives must consult with “another licensed professional” but it need not be a medical doctor. It could be a naturopath, in fact, or even just another midwife. Considering the extreme seriousness of many of the conditions on the non-absolute risk list (ie platelet count below 75,000; persistent unexplained fever over 101; labor at 35 weeks gestation; isoimmunization to blood factors) this is extremely alarming. Other direct entry midwives are no more trained in these high risk situations than the direct entry midwife calling the consult. Naturopaths are often not trained in them either, as they lack the inpatient experience that a licensed MD or DO must have. And the looseness of the law makes this a judgment call where the safety depends entirely on whether your midwife is cautious or reckless. A cautious midwife may choose to take an infant weighing less than 5 lbs or with a “suspected major congenital malformation” to the hospital. A reckless one may call a naturopath who in turn suggests breastfeeding and homeopathy…while a premature or growth-restricted baby slowly dies a preventable death, or major malformations begin to claim an infant’s life even though in a hospital, treatment would be available and effective.

And under current Oregon law? The reckless midwife would be absolutely justified, protected, and in the right. This is sick and wrong.

A number of the conditions Canadian midwives must refer for transfer are on the Oregon non-absolute list, or are not named on the Oregon lists at all. If we are looking to Canada’s outcomes to justify licensed direct entry midwifery in Oregon, why this discrepancy? But the difference is far more jarring and obvious when you compare the Oregon list of standards with that of the Netherlands, the country whose high rate of homebirths and relatively favorable outcome statistics are so often held up as an argument in favor of American direct entry midwife-attended homebirths. Nevermind that Dutch midwives are more like American nurse-midwives than our poorly trained and unregulated “CPMs.” Looking at the very strict, conservative, and comprehensive standards Dutch midwives work under, it is clear that we cannot expect to see Dutch results with our sloppy Oregon risk criteria.

For instance, the first three sections of the Dutch criteria, dealing with medical history and prior pregnancies, has no equivalent in Oregon statutes. The Oregon risk criteria deal almost exclusively with the present pregnancy and conditions that may arise within it. This is a huge oversight, considering the impact that medical history and pre-existing conditions can have upon a pregnancy. I think, because DEMs are trained narrowly in “normal birth”–they are more “birth assisting techs” than true midwives in the sense that Dutch midwife or a nurse-midwife is a midwife–they simply were too ignorant of all the possibilities to think of them for their risk criteria list! For instance, while the Dutch standards address alcohol abuse (common!) and chronic conditions like MS or rheumatoid arthritis, the Oregon standards only tangentially address the latter under the umbrella of “conditions that may need medication,” a non-absolute factor. The Dutch standards require twins and breech babies to be born in a hospital, while the Oregon standards do not. Yet the 1993 Oregon standards were in line with the Dutch standards! Why the change? There have been no scientific breakthroughs validating looser protocols. It seems a clear case of letting the people with a financial interest in increasing their reach (DEMs) have too much oversight over their practice protocols, and not enough legislative moderation imposed to slow them down. The Dutch require hospital transfer after 24 hours of ruptured membranes. The Oregon standards don’t even list that as a non-absolute risk factor–only after 72 hours AND the deadly infection chorioamnionitis has set in must Oregon DEMs transfer under penalty of law. Yet in 1993, the standard was just 72 hours…choreoamnionitis was clearly added in later not to protect patients, but to sweeten the deal for DEMs who feared transferring care and perhaps losing out financially or legally when they did so. Failure to progress in labor–a warning and risk factor for many potential problems such as shoulder dystocia, postpartum hemorrhage, and maternal exhaustion–are risk-out criteria after a set time in Dutch regulations. It was also an absolute risk factor in 1993 Oregon law. Now it is not even a non-absolute risk factor; women in Oregon can continue in labor indefinitely at the hands of a negligent midwife, as poor Margarita Sheikh did and the midwives are accountable to no one for this poor treatment of their patient.

The creeping risk factors in Oregon are in opposition to the findings of scientific evidence. For instance, take late prematurity. Recently, much has been made of the evidence that babies born prior to 39 weeks aren’t really ready. While 34-37 week babies were once thought to be mostly ok, we are now learning that they may face long-term effects in brain development and other aspects of their health. This has been the driving force to reduce elective c-sections that take place too early, inductions before 39 weeks, and other such potentially risky interventions. The Dutch criteria require transfer to hospital care in the case of rupture of membranes prior to 37 weeks. The 1993 Oregon criteria require transfer with rupture of membranes prior to 36 weeks. But the 2009 Oregon criteria don’t require the baby to go to the hospital unless it is THIRTY FOUR weeks. Incredible. Unprecedented. Where are they getting these numbers? After all, a baby of 35 weeks gestation still has a 12%  risk of respiratory distress syndrome–compared to the 3.5% risk at 37 weeks or virtually nonexistent risk in a 40 week baby with no other predisposing conditions. (See calculator here.)

What justifies these reckless Oregon protocols? And where will the creeping upwards in high risk stop? Will 33 weeks at home be argued for next time the criteria are reviewed? After all, stunt “midwife” Lisa Barrett in Australia is all for it–don’t let the fact that she’s being investigated by the coroner disturb you too much. (Warning, link contains nudity and graphic birth scene, not to mention appalling and nauseating stupidity and disregard for human life and limb.)

In fact while I find the Oregon protocols ignorant and lacking when it comes to the health of the mother, it is in regards to the well-being of the infant that I find them the most alarming and disgusting. To get perspective on what other homebirth-friendly areas allow in this regard, I compared the protocols to NICU or Level II admission standards in New Zealand. It seems a safe assumption that if New Zealand professionals, who are used to midwifery care and homebirth being integrated into their maternal care system, think a baby should be in the NICU or SCBU as I think they call the step-down units over there, a baby with the same condition in an Oregon home should be headed for the hospital.

On admission to level 3 in NZ, I found two questionable equivalents on the Oregon list. Since OR does not require transport for a Coombs positive (it’s non-absolute–so call your favorite naturopath to see what kind of sage to burn) Oregon DEMs cannot know if a baby needs an exchange transfusion or not. They cannot diagnose polycythemia or anemia, either, two other indications for exchange, and are likely to dismiss jaundice as “physiologic.” Also, since DEMs are not required to transport a baby who needed PPV at birth so long as eventually he perks up to an APGAR of 7 by 10 minutes of age, that baby will not be monitored in Oregon as he would be in New Zealand. Dangerous, since respiration isn’t a given and can decline without warning in neonates if it was shaky to start with (as too many homebirth loss parents know).

For admission to level II (“feeder grower” as some may know such units here) NZ guidelines require it for infants under 5 lbs 8 oz. Oregon midwives must only consult that friendly naturopath or her buddy midwife even if an infant is under 5 lbs. 36 weekers go to level II to get checked out in NZ; in Oregon, you call your naturopath if you’ve got a 34 weeker. Respiratory distress for an hour sends you to get a look over in level II by NZ standards; in OR you can be grunting and tachypnic and in distress for more than 2 hours before your midwife is required to take you in. Signs of bowel obstruction are considered by NZ guidelines, but not by OR. Metabolic problems get you a doctor’s exam in New Zealand, in Oregon your midwife must only call a friend to validate her less-than-informed opinion of your condition. A NICU doc must look over New Zealand babies with major malformations; Oregon babies suffering the same pain merit only a quick chat over the phone with another professional.

All I can say is, it really seems better to be a newborn in New Zealand than to be born at home in Oregon. It sounds a lot safer to be a NZ baby, and it sounds like the adults in charge of their midwifery boards and government are thinking a lot more of their needs and comfort and right to not be left suffering at the whims of a midwife who either doesn’t know any better or is too arrogant to throw in the towel and ask for help.

All this shows one thing with incredible clarity: Oregon direct entry midwives are not doing a good or responsible job regulating themselves. They are taking advantage of the relative autonomy granted them by the state to put in place an ever-upward-creeping standard of allowed high risk pregnancies and births that they can attend and profit from. Like a game of “Risk,” DEMs have claimed one continent of risky births and are on their way to claiming more–until they win, and Oregon citizens lose. This is done without any heed to scientific evidence or global homebirth standards. And it is done with callous and cruel disregard to the safety of Oregon newborns and their mothers and families. The Oregon legislature must act immediately to put this game of risk to a halt. As a stop-gap, the original 1993 standards, approved by Gov. Barbara Roberts, should be put back into place. And then, a panel of experts should review the standards of care in nations like the Netherlands, the UK, Canada, New Zealand, and Japan; the scientific literature; and the track records of Oregon DEMs and come up with a comprehensive safety plan that serves mothers and babies and NOT simply the needs or wants of direct entry midwives and their high-paid Oregon Midwifery Council lobbyist, or “birth activists.” The panel of experts may contain DEMs, but it must also include MDs and/or DOs, nurse midwives, OB nurses, and public health statistics experts. The safety of Oregon families is worth a REAL effort, not this shoddy, incomplete, ever-loosening current “risk criteria” in place today.

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

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

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

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

Here are the numbers from 37 weeks on:

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

 

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

 

 

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

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

 

 

 

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

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

 

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

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

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

Just to Clarify…

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

 

What are we for?

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