Why There is No Excuse for Midwives to Work Without Insurance

Jade Jymson, who does a little blogging over at the Mama Tao, has written today’s guest post for us.

Since I started writing about the state of midwifery in the US, I have come across many reasons why Natural Childbirth Advocates ™ feel that midwives should not have to or are not able to carry insurance. A few of the main reasons are as follows:

  • Why should midwives have to carry insurance when it just means that you want to sue them? Or: We are too litigation happy when all we think about is money when something goes wrong. Or: Money is not going to bring your baby back.

 

 

Let’s start at the beginning, shall we?

Why should midwives have to carry insurance when it just means that you want to sue them? Or: We are too litigation happy when all we think about is money when something goes wrong. Or: Money is not going to bring your baby back.

 We all have to carry insurance. I have insurance on both of my cars. Even though I have never been in a wreck, if I should hit someone, I know I would never be able to pay to have their car fixed out of my own pocket. I buy insurance so that I know I can afford to pay for repairs done to others property. If you break something that belongs to someone else, you should have to pay.

In cases like Zen’s we see that the midwives have done serious damage to these people and their lives. Zen’s mother was told to push for over 6 hours because the midwife was sure she could see the baby’s head. It turned out to be a blood clot on her bladder. His mother still needs serious surgery to repair the damage done to her body, but the midwife was not insured. Why should Zen’s mother have to pay to repair the damage herself?

But then again, why should I care? It’s not like I have to pay for it. But hold on a second…what about Sam’s parents? What if Sam’s parents were not able to pay his hospital bills? In such cases almost all children qualify for Medicaid.  And what is Medicaid? Why it’s a free insurance paid for by tax payers. When the midwife is not able to pay for her mistakes, we all end up paying for them.

There are no companies willing to offer insurance to CPMs

This is simply not true. Contemporary Insurance Services specifically offers insurance to CPMs and CNMs who attend homebirths. In the past week, we requested a quote for a midwife in California with 3 years of experience and a clean record, and they were perfectly willing to insure her. Not only that, but they’ll insure her even if she has previous claims against her practice at a rate only 10% higher. And this isn’t the only company, either. It was just the first one that came up after 20 seconds of making sweet love to Google.

Midwives don’t make enough money to pay out the insurance premiums.

While I have to admit, my first thought is to say, “Who cares?” The first rule you learn in freshman economics in high school is that to have a successful business you have to make more money than you spend on whatever is necessary to keep your business running . And running safely, I might add. You don’t get to run a restaurant without being able to afford the supplies to keep your kitchen clean or own a climbing gym if you can’t afford harnesses for your climbers.

Considering that many states allow midwives to work uninsured because of this issue, let’s take a deeper look and see exactly what a midwife’s  finances must look like.

Faith Beltz, the infamous midwife to the Paperella’s, made $4,200 off of Aquila’s tragic birth. That’s right, she made a mistake that led to their daughter’s death and she was still paid for the job. Let’s pretend that all midwives make as much as Beltz does and take only one birth a month.

$4,200(12)=$50,400

Yep. IF a midwife charging what Beltz does only takes 1 birth a month she makes $50,400 a year. But most midwives have more business than that, right? So let’s look at what she would make if she took only two births a month:

$4,200(2)(12)=$100,800

Wow! That is more than most people I know make in a year. Pretty impressive. So how much does this insurance cost anyway? Some of the commenters in the last post keep throwing out numbers like $60,000. If that is true then a midwife might have a problem paying her bills if she only takes one client a month.

To make sure that this $60,000 a year number was correct, we contacted the company mentioned earlier as a CPM who had been working for 3 years and had never made a mistake that resulted in the death or harm of a patient.  This is what they quoted us:

 

Wait? Huh? The payments start out at $13,000 and then rise to $22,132 after 5 years. For then on after the rates stay the same to be insured. The policy pays out $200,000 to $600,000. If we are using Faith Beltz and her $4,200 with one birth a month, she still has $28,268 to live on in the fifth year and beyond. Most midwives don’t have a birth center or an office or a secretary to pay – they have little to no overhead. They don’t even buy the materials they use at your birth; that is part of the homebirth kit you purchase yourself.

$28,000 is not a whole lot of money, but it’s also not chump change. If she did two births a month she’d have $78,668 left over.

But $4,200 only one number and most midwives take more than one birth a month.  If they only take one client a month and can’t pay their insurance, they need to find more clients.

$2000(2)(12)=$48,000=$25,868 Leftover

$3000(2)(12)=$72,000=$49,868 Leftover

Finally , one of our readers  said that the average midwife makes $60,000 per year.  If this is the case then she’d still have $37,868 leftover at the end of the year. Not too shabby.

Again, if midwives have issues making this payment then clearly they have two options, just like every other business in the world. Take more clients or charge more.

If the insurance companies were involved then midwives would no longer be able to take women with VBAC, Breech, GD, GBS and a number of other issues.

I’m going to do something I thought I’d never do. I’m going to talk about something that was said in The Business of Being Born. If I recall, the entire movie they were raving about homebirth and midwife care, but they were always saying one thing I feel is important. Midwifery care should be the norm for LOW RISK WOMEN. You can rant and rave all you want to about how normal breech is and how GD is a myth made up by the man, but in every first world country that uses midwives there is a list of things that risk them out of homebirth. Breech, multiples, large babies, transverse…it goes on and on.

There are situations that should risk people out of homebirth. That does not stop midwives from taking these clients, but they should not be taking them—whatsoever.  If having insurance stops midwives from taking high risk clients, then GOOD —  it makes midwifery and birth safer for all of us.

I am sorry that this means some of you will make the choice to give birth in a hospital because you want a birth attendant, but we’ll never have the true numbers about the safety of homebirth until midwives stop seeing clients that should never have been homebirth candidates to begin with.

56 Responses to Why There is No Excuse for Midwives to Work Without Insurance
  1. liz p
    September 7, 2011 | 8:09 am

    best.post.ever!!!!! three cheers!!

  2. Emily
    September 7, 2011 | 8:12 am

    EXCELLENT POST, MamaTao!!

  3. Bambi C
    September 7, 2011 | 8:29 am

    The anti-insurance rhetoric is beyond old. It’s just a way of saying “I’m dangerous, please trust me”.

  4. Rebecca
    September 7, 2011 | 8:41 am

    Thank you, Jade. This is an excellent post. There is just no excuse for homebirth midwives to work uninsured.

    One of my friends took her car to a mechanic I recommended. On their diagnostic test drive, the mechanic had a head-on collision and totalled her car. (Accidents are a part of driving, right?) Curiously enough, the mechanic’s insurance covered the cost of the accident!!! Who’da thunk it???

  5. moto_librarian
    September 7, 2011 | 9:45 am

    Of all of the problems inherent in the lay midwifery model of care, the lack of malpractice insurance is perhaps the one that bothers me the most. I grow very tired of these lame excuses for why lay midwives don’t get insurance.

    Lay midwives claim that they are professionals. If they really are, they need to start acting like it. Part of being a responsible care provider is carrying malpractice insurance. Even good care providers can make a mistake, but even a minor one can cause huge medical bills and suffering for a family. An ethical provider wants to help take care of her patients should she make a mistake.

  6. Monica
    September 7, 2011 | 9:48 am

    Every business must carry insurance. Even store owners carry insurance. It protects them, it protects their business, and it protects the consumer. No reason what so ever why a midwife wouldn’t need or want insurance. They are human and can make mistakes and therefore should pay for it. Honestly, I have no idea how these midwives who have killed, seriously injured a baby, or injured the mom can live with themselves. How could they even keep the money they accepted as payment for a birth that went wrong? At the very least a refund is in order if you botch it up. Not to trivialize the loss of a baby, mother, or lifelong injuries with this, but I got a cake once that was poorly done and while I still took the cake I got a complete refund. I used the services, but was an unsatisfied customer and therefore the store owner admitted his mistake and refunded my money. Obviously a midwife has way more responsibility on her hands than a cake decorator and she’s dealing in life or death situations, but the very least she could do is refund her fee when she messes up. Guess that’s admitting guilt and we wouldn’t want to do that. Much easier to blame the parents. I couldn’t look at myself in the mirror if my hands were dirty in that way.

  7. Jessie N.
    September 7, 2011 | 9:50 am

    *applause!*
    Excellent post.

  8. LovleAnjel
    September 7, 2011 | 9:51 am

    Hooray for math! Refusing to get insurance is tantamount to admitting that you refuse to take responsibility for your actions.If my plumber has to be licensed and insured, I sure as hell want a health care provider with the same.

    And…seriously, it’s in the CONTRACT that the client has to stand behind the midwife, regardless of outcome? That is unbelievable.

  9. Mama Tao
    September 7, 2011 | 10:54 am

    What? Crickets? Really? :D

    • Aleah
      September 7, 2011 | 12:02 pm

      They’re trying to come up with a new list of excuses, babe ;).

      But, of course, all a CPM really needs are her hands and heart, amirite?

  10. Christina
    September 7, 2011 | 11:21 am

    Excellent post!

  11. tara
    September 7, 2011 | 11:23 am

    I can’t wait to hear the indignant replies to this brilliant post. Every week I keep saying this one is my favorite, no this one is my favorite, and every week you ladies outdo yourselves! Of course they don’t want insurance, they might have to be held to higher standards. They might not be able to take those risky clients. They might have to give up bragging rights in the Great Hard-core Birth Competition. This post makes it even more clear that lay midwives are in this for themselves.

  12. Stephanie
    September 7, 2011 | 12:02 pm

    The more I see of the financial motivations behind NCB the more it angers me. Great post, Mama Tao.

  13. Mary
    September 7, 2011 | 1:11 pm

    My midwife ‘limited’ herself to 4 clients a month and she said she always had 4 and had a waiting list for if someone ‘chickened out’ (her words. Not ‘risked out’ chickened out).

    At $2500 each that is $120,000 a year in a place where the cost of living allows you to get a 2300 sq ft house in the ‘nice’ part of town for 115k.

    An argument I’ve seen many times is “My midwife works on a sliding scale and provides her services for free to some people! For this reason she cannot afford malpractice insurance!” Well, if my midwife offered a full 50% of her services for free then she’d still have 60k left over, which 2x the median income for my area.

    I bet my OB wishes he could make 60k a year seeing only 4 patients a month without any office overhead or insurance fees! Subtracting the insurance premium you still have a hefty wage for someone that isn’t required to have a real education. It’s certainly more than enough to be a single breadwinner for a family of 4 in my area. “hmm, should I work at Walmart with my vast high school education, or become a midwife? I think I’ll become a midwife, it requires less training.”

    • Rebecca
      September 7, 2011 | 6:38 pm

      If direct-entry midwives were more competent and held to a more rigorous licensing standard, their services would very likely be covered by private and state insurers everywhere. And then they would not need a sliding scale for payment.

  14. Ia
    September 7, 2011 | 1:47 pm

    I am really glad to see that malpractice insurance seems reasonable for midwives to obtain.

    However, I keep getting side tracked away from this subject by your inclusion of “large baby” as something that should risk one out of homebirth. Could you expand on how this would be enforced seeing how fetal measurement techniques are as imprecise as they are. What would be the cut off point for being “allowed” to homebirth? I can definitely see the need to keep breeches, twins and VBACs in the hospital but when you start saying large babies shouldn’t be allowed to be born at home either that really makes me worry that you’re taking things too far and I imagine people being told “oh, well, we think your baby might be 9 lbs, no home birth for you”.

    It looks like in FL, the state that does require malpractice insurance, fetal size is a factor but it wouldn’t be enough alone to risk a woman out of a home birth.

    • Mary
      September 7, 2011 | 2:04 pm

      My guess would be that by ‘large babies’ she means ‘history of macrosmia’ which is associated with increased neonatal morbidity, neonatal injury, maternal injury, and cesarean delivery. Macrosmia can only be accurately diagnosed after delivery, and there is no guarantee that just because you had a 10#, 11# and 12# baby that your 4th won’t be 7.5#, however it’s a reasonable precaution to risk a woman out of home birth if that is her history.

      • Ia
        September 7, 2011 | 2:14 pm

        Yeah, I’m a little biased on the subject since I have had two 10 lb babies with absolutely no issues at all. I don’t think having malpractice insurance would actually risk out women with suspected macrosomnia, seeing how in Florida it only counts as one factor (and you need to have 3 factors or the equivalent to be risked out). But if one of the goals of your movement is to forbid women who have big babies from having home births regardless of the circumstances, that is something that is pretty relevant to me and something I can’t get behind. (If you were just talking about risking out women for GD or for a history of shoulder dystocia, I could agree with that, but not a blanket ban on any home births where the baby might be bigger than 9 lbs.)

        • liz p
          September 8, 2011 | 6:37 am

          ^ i agree with you- having had 2 previous 10 pound babies does not sound like a risk factor to me. now, having a history of GD with 11, 12 pound babies and maybe some shoulder dystocia thrown in there? > not a homebirth candidate…

  15. Mama Tao
    September 7, 2011 | 2:14 pm

    Yes, I am certianly not qualified to say what is and what is not high risk. When I think of large babies I do not usually think of 9 pounders as both my kids were a hair shy themselves. History of macrosmia may work but I think the entire conversation would be better left up to people who could say how high that risk is. I’d imagine that the NHS and Canada have guildlines for homebirth that you could look at to get an idea of what things might risk out a woman for high risk.

  16. Anonoregonian
    September 7, 2011 | 3:05 pm

    They don’t want malpractice insurance for two simple reasons:

    1. They don’t want to pay money for something so unfun, they’d rather spend it on fun stuff and stuff that helps them make more money (ie fancy office furniture and hip advertising). This is also known as immaturity and irresponsibility, like a teen who doesn’t insure his hot car because he wants to be able to afford detailing and a tricked out stereo system.

    2. They know that the insurance co would make them pay for their reckless practices. Pure greed.

    As it is, they take the money eagerly and then let the state pick up the tab for their recklessness and errors. Such as the $150k+ care my third daughter needed because of a mistake my midwife made in the previous pregnancy:

    http://oregonmidwifereviews.blogspot.com/2011/09/because-of-midwifes-negligence-she-had.html

    That midwife OWNS the $1.1 million Victorian mansion her birth center operates out of. She is somehow making mortgage payments on that thing, plus recently remodeled it and redecorated it. She employs a sprawling staff and they do a LOT of births. She has to be pretty comfortable. But she makes clients sign a sheet swearing they won’t sue her and that she has no malpractice insurance.

    What do we call it when someone has a mansion, a nice car, nice clothes, fancy furniture and artwork, high end electronics, but refuses to buy insurance or pay other necessary bills? Irresponsible, immature, greedy, and disgusting. Well, that’s what this is when midwives do it too.

    • Mary
      September 7, 2011 | 5:22 pm

      I was completely unaware that home birth midwives wouldn’t have malpractice insurance. I thought they were bonified medical workers that simply weren’t given access to an extensive formulary list. Shows what I knew.

      I just looked up the info for the local CPM run ‘birth center’ aka house with 2 large bath tubs. In 2010 they had 102 births with their ‘birth package’ costing $3995 (which is $1000 more than my OB!). That amounts to $407,490!!

      They employ 2 midwives, an assistant midwife/massage therapist, and a receptionist. The receptionist likely makes less than 20k a year given their ‘hours of operation’ and the going wages of the area. So even if you gave the receptionist 40k a year, spent 60k on insurance, you’d have $300,000 to split between 3 people, only one of whom has a college education (the massage therapist was an RN at one time).

      It’s likely that given the year of the purchase and the size and location of the home their ‘birth center’ is run out of, the house likely cost $100,000. They may have spent $50,000 remodeling and furnishing it. Bump it up to 200k for the hell of it. Yearly payment on a 200k loan around here is less than 25k.

      Oh those poor poor midwives only making $90,000 a year gross. Poor poor disadvantaged midwives.

      These people are cleaning up and leaving tax payers and families to deal with their disasters. Lovely.

      • Mama Tao
        September 7, 2011 | 5:56 pm

        You and so many otehrs. I was appaled when I found out. Even the “What to Expect..” book , hated by all of NCB does not talk about CPMs like they are as about as good at taking care of business as the guy who sells papers at the intersection.

      • Anonoregonian
        September 7, 2011 | 6:29 pm

        The two biggest birth centers in Portland have expanded massively over the last 6 years. Andaluz opened a second location–purchasing an $800,000+ house in downtown Portland in 2008 and lavishly remodeling and decorating it. Alma went from the original two founding partners to 4 midwives to now 5 midwives PLUS 5 “junior” midwives (not counting the scads of apprentices who rotate through). Their building is the one that is valued at $1.1 million. They rent out portions to other crunchy tenants, too. Their current “new babies” section online shows close to 100 infants, though no dates are shown so I don’t know how far back that goes. At one of my last appointments there before they dropped me, Laura was bragging about dropping $4k on a hot tub. Part of what allows these businesses to expand so wildly even in a time of economic crisis and hardship for most of America is their use of the unpaid labor of apprentice midwives.

        Meanwhile the secretary at Andaluz posts prolifically on the Portland community on LiveJournal. She talks about how she makes just over minimum wage and basically has no benefits and is on call. Her car is always breaking down and she pleads with the LJ community to help her figure out what to do since she has no cash. So these people are not only failing to responsibly purchase insurance for their businesses, they are paying their very few paid employees a shameful pittance, less than I was paid working at the mall when I was 19 years old.

        Greed greed greed greed greed.

        • Ia
          September 7, 2011 | 6:34 pm

          Could this person who works at Andaluz get into trouble if the midwives read your comment? I wonder if that should be edited out.

          • Anonoregonian
            September 7, 2011 | 6:44 pm

            I doubt she’d get in trouble. She talked about a patient online once and only got a stern reminder about HIPAA from Gallardo. That was more than 2 years ago and she still has her job. Honestly if they fired her it might be an act of mercy. At least McDonald’s employees aren’t on call 24/7.

          • Anonoregonian
            September 7, 2011 | 6:44 pm

            (I should say, I know she got the what-for because…wait for it…she wrote about it in a public LJ post.)

    • Ia
      September 7, 2011 | 10:19 pm

      Wait, why couldn’t you sue this midwife? I would think a lawyer would be more attracted by the $1.1 million house plus whatever other assets she’s accrued on her $100,000 a year salary than they would be by an insurance plan that would only pay out a max of $200,000.

      Has anyone tried explaining it like this to a lawyer? “Yeah, they don’t have malpractice insurance but they own a million dollar house!” All it would take would be for them to start losing their fancy birthing centers and they would be lining up for the malpractice insurance.

      Everyone seems to have the idea that malpractice insurance is about protecting your patients, but really, it’s about protecting your assets.

      • Mama Tao
        September 8, 2011 | 9:23 am

        As a group, 10 women from Fed Up contacted 100 lawyers each in reguards to Liz’s case. That is over 1000 in the state of Texas. Most did not even reply. Out of the four or five who did one man was most kind to call me. He told me that the average wrongful death suit cost over $100,000 and without insurance money there was no way anyone was going to take our case. I don’t believe they can go after homes and buildings. I guess it’s for the same reason that if I hit someone with my car they can’t come after my home. Plus, it’s easy as pie to switch the name of the property to the midwife who is not under litigation. Or just to have both names on it. They can’t go after it if it does not totally belong to the midwife being sued. You also have to rememebr that many of them don’t have birthing centers.

        I HAVE however though about trying to get them on tax evasion.

  17. Staceyjw
    September 7, 2011 | 8:17 pm

    Many MWs do more than a few births a month- Faith Beltz the negligent MW told me they see 4-6 a month, minimum, and that this is low because they try not to overbook. Her fees are $4,200, or $3,500 if you pay cash up front (who wants to bet this isn’t reported to taxes?

    There is NO EXCUSE for not having insurance. None. Can you imagine am OB, or even an electrician, saying “well, I cannot afford it, so Im not gonna bother!” This would never be acceptable, why is it ok for MWs?

    Worst part of it is that they knowingly choose not to get insurance, because they know full well that without it, no one will be able to sue them unless they pay out of pocket to do it. They like not being held accountable, they like not worrying about lawsuits and a history of malpractice someone might find. If you don’t believe me, just hang out on some of their groups, they even share advice on how to get patients to like you too much to sue you. Even when you kill.

    • Anonoregonian
      September 7, 2011 | 9:26 pm

      Stacey if you have links or caps of that “friendly advice,” you know I’d love if you would email it to me. Thanks.

  18. bobbie
    September 8, 2011 | 5:40 am

    $200,000 is a drop in the bucket if anything happens though.

    Anyone who delivers babies typically gets $1 million/$3 million.

    In that sense, real malpractice insurance it may be unaffordable or unavailable. If so, it should tell women this “profession” causes does harm than good.

    “Businesses” can be considered fraudulent operations if they collect fees upfront, but don’t reserve enough assets to cover potential liability, later. Shoe fits, I think.

    Also, check on-line to see who really owns the assets (whose name they are in). There may be a shell game going on there. If so, they may be violating Safe Habors or other health care law by using it without paying market-rate rent to the entity or person whose name is on it.

    Lastly, please note that the average insurance reimbursement for birth for a doctor AND hospital is about the same as these people charge. The doctor only gets half. They seem to be able to afford real insurance.

    • Mama Tao
      September 8, 2011 | 9:26 am

      While I agree it’s not a lot, it certianly better than having none. It would enable them to be sued and I believe that if the bad apples were held accountable, then only the very best and safest CPMs would rise to the top.

      I totally agree with everything else!

    • bobbie
      September 10, 2011 | 6:58 am

      I don’t know that, in practical terms, it enables them to be held accountable that much more than no insurance. It could actually be worse, because, like licensing, it gives the false impression of being a medical professional.

      The typical CPM disaster is a poorer woman who in some way chose this model and provider, often because they didn’t do as much as the hospital. Often the baby dies.

      In most states, death does’t justify much in the way of damages. In the best cases, they have to estimate the value of the child’s lost wages. They do that based on the poor Mediciad parents’ income. Plus, that will be knocked down or even out if can be proven (or really just insinuated enough to get a jury to beleive) that the patient elected the extra risks and was informed. Simply electing homebirth makes many juries think “well what did she expect?” The potential damages may not be anything. Medical costs of survivors often have to be repaid to insurance.

      OB Malpractice cases cost about $100,000 to pursue. No lawyer is plunking down $100,000 for even the maximum potential gain of $200,000. You forget, when they have insurance, they have insurance lawyers. They will appeal appeal appeal to make it difficult for the other side to collect and thus get them to settle for less.

      You definately need huge assets, because forcing them to fork them over or pay up, even after liability is established in court, is an entire separate and very very difficult procedure.

      And there is virtually no such thing as paying out of pocket for a malpractice lawyer. Those with the expertise won’t waste their time on an hourly arrangement when they can get much better compensation than anyone could pay, for a victim with multiple adequately insured defendants, with a known income and losses, and where there’s no doubt that the medical model was chosen by the patients and the providers were supposed to be operating in it.

      Remember the couple featured on the Today Show a while back? Affluent and alleging mostly fraud, not malpractice. And fraud is not covered. Doing nothing is midwives so-called standard of care. They spared her a c-section! What more could you ask for !! Claiming it was as good if not better than the hospital route, that they do exactly the same as doctors in the same situation, that you can’t be worse off, is what midwives can be charged with.

      You may be able to lobby the state to pursue state supported brain damaged survivor cases in the service of Medicaid reimbursment. That’s really all you have.

      Usually things like that are done by charging them for licenses to fund an essentially state run malpractice program as supplemental insurance and requiring private primary coverage.

      And again, we’ve come full circle. This amount for meaningful insurance would be more than a CPM makes, and basically acts as a mathematical proof that shows they are a menace and shouldn’t be permitted to practice in the first place!

      • Mama Tao
        September 10, 2011 | 3:58 pm

        I don’t want CPMs to be legal anyway. A requirement of insurence might just be the thing that ends them. However, I was trying to bust up the myths that everyone seems to have about insurence and midwives, mainly that they were not able to be insured and that they were poor. They are anything but poor.

        I do not however think taht most HBer are poor. $4000 cash upfront is a lot to come up with , I don’t know any low encome famlies who have that laying around.

        • Ia
          September 10, 2011 | 11:57 pm

          Ok, then I think my initial feeling that you all wanted to make homebirth illegal, if not in theory than in practice, was the correct one.

          You certainly have a right to your opinion, but I think you all should just be more honest about it, rather than all this, “but we just want women to have informed choices!” No, you don’t, you want women to make the choices that you think they should make.

          • Heather
            September 11, 2011 | 9:08 am

            No, that’s not right either. Once again, you are reading what you want to hear when one of us says something and you disagree. She said CPMs, not homebirth.

            I would love women to make informed choices, but I don’t care that much about it. What I do care about is making it illegal for birth junkies with little-to-no education (like many CPMs )to claim to be midwives and scam women into paying them to attend their high-risk births. I know they’ll continue to attend births anyway, because that’s what they do now where they *are* illegal. However, when they continue to kill babies, I want them jailed and fined into oblivion instead of getting of scot free as is currently the case. I also want women to have financial recourse and be at least partially compensated for homebirth disasters, because as it is, they are paying for funerals out-of-pocket and forgoing counseling for their living children who witnessed the death of their sibling because they can’t afford it while midwives are “judgement proof.”

            I would LOVE it if the only homebirths that happened were low-risk women attended by midwives with CNM-equivalent training. I would prefer CNM-only training–because one of the ingredients in a safe homebirth is the ability for the midwife to transfer seamlessly with the midwife continuing to provide care in the hospital–but I know that’s unlikely to happen. I can dream, though. In addition, if there are real standards for homebirth midwives and protocols to follow, ala Canada (where there has been what I think is a legit study showing homebirth to be reasonably safe under THEIR conditions), it will enable “the system” to eliminate even those well-trained midwives who are practicing unsafely and not following protocol.

          • Ia
            September 11, 2011 | 4:50 pm

            I know she said CPM. I assumed that it goes without saying that if only CNMs could do home birth then home birth would be unavailable to the majority of women who wanted to have one, seeing how only 2% of CNMs do homebirths.

          • Mary
            September 11, 2011 | 5:34 pm

            So your argument is that CPMs need to be legal because without CPMs there won’t be home birth? No other country in the first world has such a shitty uneducated class of midwives, yet home birth appears to be readily available in Canada, Netherlands, etc.

            Sorry if I don’t shed any tears over a bunch of no nothing wanna be medical providers without insurance being forced to go back to school to get a real education and insurance before they attend to women. The solution to the problem of there not being enough midwives to do home births isn’t to just let a group of people call themselves midwives and have at it.

            You may not think women and babies deserve competant, educated, insured healthcare providers, but we do.

          • bobbie
            September 12, 2011 | 9:58 am

            No, it would not make homebirth illegal. It would simply take away the facades that trick people into thinking the government has researched this and is presenting it to the public as equal to the hospital. Then, almost no one would sign up.

            As in, if she needed the hospital of course this lady would give up 2 grand and send her, because you know the state will have big trouble and malpractice in store for her if she needed.

            Take away use of now medical titles like Midwife, medicaid/insurance, and licensing and voila! Do the same thing as before. Then the lady knows she is freebirthing with a doula or support person.

            She is not fooled into thinking she is choosing a health professional that will first and foremost screen her out of homebirth and transfer her out to higher level options when needed, knows how to monitor.

            If CPMs don’t have any takers for their business without fraud and deception, who cares?

            It doesn’t make homebirth illegal, or even homebirth with these women who claim to know something. It simply makes (really enforces) the fraud to get their money and unknowningly risk their lives, illegal.

          • Ia
            September 12, 2011 | 10:20 am

            Bobbie, you said in your first response that meaningful malpractice insurance would cost more than a CPM would make. Following that logic, a law requiring CPMs to have meaningful malpractice insurance would be the same in practice as a law outlawing CPMs all together. And a law outlawing CPMs would have the effect of making homebirth unaccessible to most women since very few CNMs do homebirths (2%).

            It would be like if you were having an abortion discussion with a prolife person and they were all “but I don’t want to make abortion illegal! I just want to take away doctors’ licenses to perform them and take away all funding for poor people to obtain abortions…but they can still go to the back alley abortion providers, so it’s still legal!” No, that wouldn’t count as abortion being legal, so I don’t know why homebirth should count as legal under similar circumstances.

          • bobbie
            September 13, 2011 | 7:18 am

            “Bobbie, you said in your first response that meaningful malpractice insurance would cost more than a CPM would make. Following that logic, a law requiring CPMs to have meaningful malpractice insurance would be the same in practice as a law outlawing CPMs all together.”

            CPMs are the ones who ultimately control the affordability. It’s so expensive relative to what they make, because they are so darned bad! They cost the insurance company so much in pay-outs. And because so few people want them and will pay very little for them!

            The root cause is their own worthlessness in normal situations and their periodic extreme destructiveness in abnormal ones.

            Societies’ unwillingness to keep paying oodles and oodles of money to pay for the often taxpayer dependant victims and therefore restrict it legally is not an affront to people’s freedoms. Victims end up in the despised hospitals who, by law, must treat them without regards to ability to pay.

            Midwives sense of entitlement to public or other people’s money to subsidize their ‘play doctor’ scam is the affront to freedom, here.

            An no, it isn’t up to the public to support your career and a lifetime of support for the people who will be disabled. It’s not up to a private hospital and doctors to provide free care for your preventable harm. It’s not up to the public to give up its public health restrictions and pay for your career!

            And no it isn’t the same as law forbiding CPMs. They can get better and the malpractice would go down. People can become convinced of the wonders of CPM birth and pay more for it. Any combination of the two will make it affordable.

            Trying to hide this CPM Professional Welfare Entitlement behind women’s choice and rights etc is just disgusting, and really lame too. It’s so obvious what you are doing.

            “And a law outlawing CPMs would have the effect of making homebirth unaccessible to most women since very few CNMs do homebirths (2%).”

            Bungee jumping without a cord is inaccessible too. Geez, google or call. NONE, I tell you none of the bungee jumping firms will do it. They say their insurance rates would go through the roof as I crashed into river. Actually, I’ve told them if you are low risk, a good swimmer, know how to land, think positive thoughts on the way down the chances of survival are the same as with the cord.

            I guess I will be forced to bungee jump without a cord myself. If I survive, and have no health insurance, but am catastrophically injured, then society will end up paying for me. Truth be told, I am much more restricted here, as people won’t wait for disaster to try to stop me. The attempt will likely attract a crowd and police etc. I call it my freedom to Bungee Jump without the unnecessary restrictions of a cord. Everyone else calls it jumping off a bridge.

            “It would be like if you were having an abortion discussion with a prolife person and they were all “but I don’t want to make abortion illegal! I just want to take away doctors’ licenses to perform them and take away all funding for poor people to obtain abortions…but they can still go to the back alley abortion providers, so it’s still legal!”

            No, it’s like saying doctors who are so bad they can’t get malpractice insurance can’t do them. Which is exactly what it is now.

            “That wouldn’t count as abortion being legal, so I don’t know why homebirth should count as legal under similar circumstances.”

            If we let doctors who were so bad that they couldn’t get malpractice insurance do them, then it would be the same as a coat hanger. So women know and are warned! The only one who would lose out would be the uninsured doctor who wouldn’t get thousands for “treatment” no better than a coathanger. If no doctor can get malpractice insurance for it, then it must be a pretty dangerous procedure.

            The bottom line is unaffordable malpractice is nothing more than CPMs are falling on their own sword of incompetence and uselessness.

            As said before, the unaffordability of adequate midwifery malpractice is a calculation that proves in cold, hard numbers that midwives, as a whole cause much more harm than good. It means, essentially, the preventable damage and related health costs are more than their payments for the so-called healthcare they are allegedly providing!

            Trying to get out of adequate malpractice insurance is just Midwifery Welfare — taking all the money and bumming the costs, that are even greater than that money they took, off onto someone else.

          • Ia
            September 14, 2011 | 7:08 pm

            Lol, bungee jumping without a cord (so basically committing suicide) is now the exact same thing as giving birth with a CPM? This is like the boob nazis that compare formula to rat poison. I don’t even see how a discussion is possible if you’re going to use such unreasonable analogies.

          • bobbie
            September 15, 2011 | 10:38 am

            “Lol, bungee jumping without a cord (so basically committing suicide) is now the exact same thing as giving birth with a CPM? This is like the boob nazis that compare formula to rat poison. I don’t even see how a discussion is possible if you’re going to use such unreasonable analogies.”

            Next time, I will close caption my jokes for the humor-impaired.

            But, methinks it is not so much you didn’t get the joke, as you need a cover to divert attention because you don’t have a legitimate response to the serious part.

            What “right” do lay midwives have to run a fraudulent business? One that takes the money, but does not pull its own weight. One that takes money but leaves others or the public to pay for the harm they cause? That is what going without adequate malpractice insurance is.

            What “right” do you have to create an industry that often meets the definition of criminal level negligence and avoid responsibility? That what going without adequate insurance is, that (the extreme level of negligence embodied in its practices) is why it is unaffordable.
            http://www.thefreedictionary.com/criminal+negligence

            What right do you have to do things so likely to cause so much harm that it is far more than you would ever be willing or even able to pay in restitution. But you are quite willing to keep collecting the cash as long as society pays for your fall-out?

            Anyone who earns money from an activity has to be able to cover their costs. Those costs include compensating customers, clients, or patients for reasonably foreseeable harms their mistakes might cause.

            http://business-law.freeadvice.com/business-law/trade_regulation/deceptive_acts.htm

            (FTCA is Federal Trade Commission Act)

            “An unfair act or practice under the FTCA is one that cannot reasonably be avoided by the consumer; and causes, or is likely to cause, the consumer some sort of injury. The act or practice by the business will also be either no, or very little, benefit to the consumer.”

            “An act or practice is considered deceptive when it involves a material representation or omission that is reasonably likely to mislead a consumer.”

            And I think if you click on the link, lay midwifery’s picture is next to this.

            Where do lay midwives get the crazy idea it is their right to violate other people’s rights?

            I await your response.

          • Ia
            September 15, 2011 | 3:26 pm

            Bobbie, I have seen no evidence that the majority of midwives are as you describe. There are obviously a few very bad apples out there, but I don’t see any cause to extrapolate the few bad apples and claim that all CPMs are fraudulent, unqualified, etc. Since it is my understanding that most midwives are responsible care providers who transfer to the hospital when the need arises then I find the idea that someone would want to take away my right to birth with a midwife as extremely offensive. This is why I compared it to a debate between a boob nazi and a formula feeder. You’re not going to convince me that CPMs are the medical equivalent of rat poison and it seems pretty clear I’m not going to convince you otherwise either.

            I feel there is a huge misunderstanding of what malpractice insurance is. Malpractice insurance is to protect the medical professional’s assets. It’s not to reimburse anyone who has a bad outcome. If that’s what you want, perhaps you should be arguing for some kind of no fault legal fund instead. I could certainly see the merit in that. The way the current system is set up does encourage the parents to sue when there is a bad outcome, even if it is no one’s fault, which causes premiums to go up for everyone. And it’s not like the baby with CP through no one’s fault is any less deserving of care than the baby who had an irresponsible care provider and ended up with a birth injury.

            You insist that midwives inability to obtain suitable malpractice insurance is proof that what they do is too dangerous. I don’t find that argument convincing because malpractice premiums have more to do with how likely a big settlement is rather than deriving whose fault it is. If a doctor could defend himself better against a lawsuit simply on the basis of having done more interventions, then this alone could explain why his premiums could be less than a homebirth midwife, who would have to battle the perception in court that homebirth is dangerous, even if she had done nothing wrong. Not to mention I don’t even know what data they’re basing their actuarial tables on seeing how there is not much good data out there to evaluate CPMs on in the first place.

            I do still find it kind of hard to believe some midwives are raking in as much as 2.5 million dollars a year and the lawyers absolutely refuse to go after them since they don’t have malpractice insurance. Something doesn’t seem quite right there. Obviously the midwives could cover the cost of the harm they’re doing, it sounds like from what people have said on here that it’s a problem of the lawyers not wanting the hassle (which I don’t entirely get either as the legal profession is overflooded at the moment so are there really so many insurance malpractice cases that there is no need to go after the millionaire midwives?) Something just doesn’t add up there for me.

          • bobbie
            September 17, 2011 | 7:10 am

            “Bobbie, I have seen no evidence that the majority of midwives are as you describe.”

            It doesn’t matter what you see. Insurance companies have large databases that calculate exactly how much harm they do. Even if there is no malpractice insurance, they can follow through and figure out how much damage they caused by increasing other people’s use of their own insurance or public insurance.

            That’s what is wrong with lay midwifery. It is a bunch of inexperienced people making decisions and founding their beliefs on their limited personal experience.

            “I find the idea that someone would want to take away my right to birth with a midwife as extremely offensive”

            I find the idea that someone would try to hide their greediness and utter lack of responsibility by recasting it as some kind of reproductive right extremely offensive. And the transparent attempt demonstrates their clear lack of intelligence.

            “ This is why I compared it to a debate between a boob nazi and a formula feeder. You’re not going to convince me that CPMs are the medical equivalent of rat poison and it seems pretty clear I’m not going to convince you otherwise either.”

            No, it was to avoid addressing the clearly irresponsible and sociopathetic aspects of lay midwifery. With the attempt below, I can see why.

            “I feel there is a huge misunderstanding of what malpractice insurance is”

            Your feelings don’t matter. Insurance covers losses. They calculate the losses, factor in profits and interest, charge a premium done. Period. Got it?.

            Just like when CPMs kill babies and moms with their feelings that anatomy and physiology works a certain way that fits their greedy ambitions. It doesn’t.

            “Malpractice insurance is to protect the medical professional’s assets. It’s not to reimburse anyone who has a bad outcome.”

            Really? So where do your “feelings” tell you a pay-out goes? If not for losses?

            The only reason malpractice could protect one’s assets is if one is responsible for the loss through one’s own actions.

            Insurance for random bad outcomes that protects your own assets, even though you do nothing wrong are things like your own homeowner’s insurance, health insurance, disability insurance.

            The payout goes to the premium payor in those cases. If you pay the premiums the and the insurance’s payout goes to someone else, you made some kind of mistake and have some kind of responsibility. Get it?

            This is basic know-how required to function as an adult. The lack of knowledge is astounding.

            “The way the current system is set up does encourage the parents to sue when there is a bad outcome, even if it is no one’s fault, which causes premiums to go up for everyone.”

            Ridiculous. Malpractice Insurers hire the biggest, meanest, most dishonest lawyers they can find to defend their policy holders against a suit. They are doing their best to get guilty clients off the hook.

            Studies show only 2% of actual victims sue. Studies also show that, based soley on the chart, the provider’s version of event, which may be biased in their favor, the virtually all paid-out cases had strong merit and significant harm. Overall, the research shows much more malpractice is caused then ever gets justice.

            That’s evidence, data, research, facts. Not proclaimations of “feelings” to hide greedy self-serving propaganda.

            “ And it’s not like the baby with CP through no one’s fault is any less deserving of care than the baby who had an irresponsible care provider and ended up with a birth injury. “

            Random victims have their own health insurance or public assistance. See above.

            When someone causes the damage through negligence, especially when they earn their living through it, there’s no discouragement. In fact, there’s an incentive to create more damage than there ever would have been.

            “You insist that midwives inability to obtain suitable malpractice insurance is proof that what they do is too dangerous. I don’t find that argument convincing because malpractice premiums have more to do with how likely a big settlement is rather than deriving whose fault it is.”

            How likely it is that one has to pay a big settlement is related to how dangerous one is!

            It is absurd to insist that insurance companies aren’t out to avoid paying out for things not the insured’s fault. That’s why they include hiring a lawyer in the package.

            Your arguments are so unscathed by complexity. One cannot have a big malpractice settlement without fault.

            “ If a doctor could defend himself better against a lawsuit simply on the basis of having done more interventions, then this alone could explain why his premiums could be less”

            If doing interventions is a defense then not doing them is negligence.

            “than a homebirth midwife, who would have to battle the perception in court that homebirth is dangerous, even if she had done nothing wrong.”

            It is homebirth parents that have to battle that, not the midwife. Jurors wonder why they signed up as most people think it is very risky.

            “ Not to mention I don’t even know what data they’re basing their actuarial tables on seeing how there is not much good data out there to evaluate CPMs on in the first place.”

            It flows through the victim’s insurance, public or private. see above. It even shows up as upticks in the parents, especially the mother. Even a bit in the siblings. It also comes through on the hospital write-offs for free care.

            The midwifery freeloading is very obvious.

            “I do still find it kind of hard to believe some midwives are raking in as much as 2.5 million dollars a year and the lawyers absolutely refuse to go after them since they don’t have malpractice insurance.”

            I find it hard to believe they are raking in that much.

            That’s like 2 births a day every day of the year at $3500. Most midwives are so unpopular they do a dozen per year. and for less. More like $35,0000. It’s a lot of money for someone who would otherwise be making minimum wage and in a fraction of the time, but a drop in the bucket to the harm they can and do cause.

            “ Something doesn’t seem quite right there. Obviously the midwives could cover the cost of the harm they’re doing,”

            The harm is in the range $10,000,000. Truth be told, adequate insurance of a lay midwife would have to be a policy would have to be really more like 10,000,000/30,000,000 not the 1,000,000/3,000,000 of doctors. Because with a team, more than one person or institution ad therefore policy, might share fault. A lay midwife is solo. And most importantly, docs and hospital premiums are based on the fact they don’t just stand around and cause harm, as their norm.

            So, even your impossible fabricated-to-facilitate-irresponsibility millionaire midwife doesn’t cut it without insurance.

            “ it sounds like from what people have said on here that it’s a problem of the lawyers not wanting the hassle (which I don’t entirely get either as the legal profession is overflooded at the moment so are there really so many insurance malpractice cases that there is no need to go after the millionaire midwives?) Something just doesn’t add up there for me.”

            Since you can’t figure out that 2 births per day with 20 hours of labor average each is impossible no, not just impossible, laughable, I am not surprised things don’t add up for you.

            So, therefore there are really no millionaire midwives who work 40 hours per day 365 days per year. And even if there was it doesn’t pay 10 million to care for an infant for life.

            And you can’t figure out that buying a million dollar isn’t the same as having a million in assets. There’s a mortgage, only the paid off portion is up for grabs, if the value hasn’t sunk. And that is only after another lengthy legal court procedure, it isn’t automatic. And it is not within the realm of malpractice lawyers’ expertise, so they have to hire a lawyer to do it.

            So really your only response to the concern of how irresponsible and fraudulent midwifery is is to invent these impossible imaginary midwives working 40-hours-a-day (not a week, a day) midwives.

          • Ia
            September 17, 2011 | 5:58 pm

            From the tone of your post I can only assume you must have been a victim of a negligent midwife to be this angry. I am truly sorry for whatever harm you have suffered. I’m not going to reply further to any of your arguments. There is plenty I would like to say, but I don’t trust myself to keep it civil with how you rude you were in your response to me, so I’d rather bow out now than risk causing any hurt to someone who has lost a baby. I am not a midwife, if that’s what you think. Just someone who wants a homebirth with my next baby and doesn’t want to see that right taken away from me.

            • Mama Tao
              September 24, 2011 | 12:31 pm

              I can’t force CNMs to do homebirths, but I can do away with their dangerous counterparts , CPMs. If you are saying that CPMs are the only way to have a homebirth then what you are actually saying is that homebirth with a highschool drop out is fine. It’s not. You might want to ask yourself how the other countries manage to have so many hoembirths. There would be many CPMs who do homebirth who would walk the extra mile to deliver as a CNM if we didn’t keep letting people in with such easy standards. If there was an easier way to have gotten my degree and to still be able to work the same job I would have taken it too. Not my problem if CNMs don’t want to deliver you at home.

        • Ia
          September 11, 2011 | 9:41 pm

          No, the argument was that I made a reference to them wanting to make home births illegal and they were all “Oh noes we would never want to do such a thing perish the very thought of it!” Whether or not CPMs are qualified yadda yadda is a totally different debate. I just want people to be honest about what they’re trying to accomplish here.

  19. moto_librarian
    September 8, 2011 | 3:39 pm

    So where is the midwife from CA who claims that you can’t get insurance as a CPM? We’re waiting…

  20. tara
    September 9, 2011 | 5:35 am

    Well, I guess they got nothing…

  21. Emily
    September 14, 2011 | 4:01 pm

    Well, Ia certainly gave it a run for the money, but still gave absolutely NO REASON for why midwives should not be absolutely REQUIRED to carry insurance. She even tried to deflect the whole discussion onto a “well you just want ALL homebirth to be illegal” thread. It’s incredibly obvious that they have nothing to say. Medical Professionals (which they’re trying to claim they are) adhere to STANDARDS, and one of those standards is to carry insurance. Get some, and if you can’t, that means that you are not qualified to be a medical care provider. Get over your ego, and go back to school. Real school.

  22. bobbie
    September 20, 2011 | 10:36 am

    “From the tone of your post I can only assume you must have been a victim of a negligent midwife to be this angry. I am truly sorry for whatever harm you have suffered. I’m not going to reply further to any of your arguments. There is plenty I would like to say, but I don’t trust myself to keep it civil with how you rude you were in your response to me, so I’d rather bow out now than risk causing any hurt to someone who has lost a baby. I am not a midwife, if that’s what you think. Just someone who wants a homebirth with my next baby and doesn’t want to see that right taken away from me”

    Have no fear. I have never ever even considered hiring a lay midwife, so you should have no problem continuing.

    Be as rude as you like. We are all willing to put up with that to hear your explanation as to why a group of people should be able to profit from doing something (that’s really nothing) that costs society millions?

    And you are not a midwife, yet….. We all know the multi-level marketing aspects to lay midwifery. Have a few kids with them now. Doula when they are tots. Then, midwife when they are in school.

    That makes ten times more than anything else you can do after ten years out of the work force….so long as society picks up the tab for all the damage it causes to others.

    Please stop hiding behind your fear of hurting our feelings to avoid your obvious lack of legit response to the overwhelming evidence of greed and irresponsibility. It is as transparent as hiding behind some make-believe repro rights to disguise your midwife-2-B profit motives.

    • Ia
      September 21, 2011 | 1:59 pm

      Oh, good, glad to hear you haven’t lost a baby to a midwife. Your reply to me was just so full of emotion and devoid of all logic that I assumed something must have happened to make you that bitter. Are you this black and white on all issues or is it just midwifery? And I am LOLing so hard at at your accusation that I support home birth because I want to some day be able to kill babies myself for profit. Don’t worry, I don’t have any desire to be a doula, even. And then you had to go and throw in a jab at stay at home moms too. I am starting to think you are just out trolling and not even being serious. But just in case you are being serious, here is my response to your previous reply:

      I found your reply to be a better argument for why malpractice insurance should not be required than anything the NCB has come up with. Only 2% of victims of negligent doctors sue? So basically, if the same rate of victims sued their midwives (and if anything it would probably be lower) than the vast majority of negligent midwives will never have a claim filed against them. Even the most egregious examples of midwives that I have seen Dr. Amy highlight only had a handful of victims, so when you’re talking about only 2% of victims suing, how will malpractice insurance have any practical effects? it won’t.

      Also, since statistically the vast majority of midwives would never be sued, this just shows the insurance companies are being full of it when they deny them malpractice insurance at reasonable rates.

      Additionally, I find this thinking that blames midwives for “burdening” society by not carrying malpractice insurance to be problematic because it creates a moral obligation on the part of the parents to sue so that they don’t “burden” society with their “defective” child. That attitude is reprehensible. If your concern is with society having to pay for midwives mistakes, then it only follows you would be concerned about the 98% of parents who are having society pay for the mistakes their doctors made rather than suing malpractice insurance. And maybe you are, but I disagree strongly that there is ever any moral obligation to file a lawsuit.

      Also, the average physician only has two malpractice claims filed against her in her career, which means that there is an average of another 98 additional acts of negligence committed that go unfiled. D: That is really scary. If a doctor works for 30 years, that would be one act of negligence every four months. And you wonder why NCB people want to avoid doctors.

      Some other points:

      Ridiculous. Malpractice Insurers hire the biggest, meanest, most dishonest lawyers they can find to defend their policy holders against a suit. They are doing their best to get guilty clients off the hook.

      You seem to be forgetting that big bad lawyers cost a lot money. The more money the insurance company has to spend on lawyers, the more they have to charge for premiums.

      Random victims have their own health insurance or public assistance.

      And victims of negligence have those things too, so what exactly is your point?

      In fact, there’s an incentive to create more damage than there ever would have been.

      Yeah, it’s a conspiracy. Midwives try extra hard to kill babies when there is no malpractice insurance.

      So, even your impossible fabricated-to-facilitate-irresponsibility millionaire midwife doesn’t cut it without insurance.

      This isn’t something that I fabricated, see here: http://oregonmidwifereviews.blogspot.com/2011/09/mo-money-mo-problems-oregon-midwives.html The assets she talks about should be big enough to entice a lawyer.

  23. NavelgazingMidwife
    October 5, 2011 | 1:11 pm

    Here’s a CA midwife who was fed a load of crap for her entire midwifery career (short as it was), TOLD there was NO insurance company that would insure us and, stupid me, believed it without researching myself. I trusted those that told me such, including the CA Assoc of Midwives. Even my Agreements speak to not being able to get insurance. I am LIVID that I could have and didn’t.

    As I write my own post about this, I have some researching to do… can’t take other folks’ word for things either, you know! So, wait and watch for my own piece on this rather reprehensible lie being perpetuated here in California.

  24. Kiera
    October 6, 2011 | 8:28 am

    I love that you broke down the wording so we can all understand. However, large babies, breech babies, and even twin pregnancies does not automatically mean that it is unsafe to have a homebirth with a midwife. I think it is a situational thing where we have to look at the woman’s history, the pregnancy, and many other factors.

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