Neonatal Mortality Part 1: "Babies Die in Hospitals Too!"

(This will be a two part post, the latter specifically focused on the populations served and what data says about the outcomes, as stratified by birth attendant for both hospital and out-of-hospital birth.)


Midwife (to a mother whose baby didn't survive out-of-hospital birth):  "I'm sorry your baby didn't make it.  Babies die in hospitals too.  You know, some babies just aren't meant to live.  You could always try again.  Come have another baby with us someday.  We did everything we could, there just wasn't anything we could have done differently."   

Yes, babies do die in hospitals, but there's a little more to it than the statement implies.  Sometimes everything possible was done to save a baby's life, and other times errors are made, regardless of place of birth.  The difference is that in one environment (hospitals) there are protocols, review processes, oversight, regulation, insurance, and the opportunity for accountability...and in the other (out-of-hospital birth) there is not.  The purpose of oversight, review processes, insurance, and regulation becomes abundantly clear.  I'd like to look more deeply at the context and implication of the statement, "Babies die in hospitals too," to gain a more complete perspective.

Let's focus first, on how hospitals are accredited and what precisely happens when a baby dies from complications at birth in a hospital setting.

Our focus is Sparrow Hospital in Lansing, MI, because that is the hospital we know best.  Sparrow is accredited by the Joint Commission, an organization that has accredited hospitals for more than 60 years and today it accredits approximately 4,168 hospitals nationwide. Approximately 82 percent of the nation's hospitals are currently accredited by The Joint Commission.  Listed on a document entitled, Facts about Hospital Accreditation, are statements explaining why hospitals seek Joint Commission accreditation.  Here are just a few:

• Helps organize and strengthen patient safety efforts.
• Improves risk management and risk reduction.
• May reduce liability insurance costs.
• Provides education on good practices to improve business operations.
• Provides professional advice and counsel, enhancing staff education.
• Provides a customized, intensive review.
• Provides a framework for organizational structure and management.
• May fulfill regulatory requirements in select states.

Sparrow also applies for and has achieved many other notable recognitions that can be found at http://www.sparrow.org/recognitions.  Not mentioned there, but relevant to our discussion specifically related to obstetrics, is the MHA Keystone OB study.

     
     "MHA Keystone: OB focuses on eliminating preventable harm to mothers giving birth  
      and their newborn babies in Michigan hospitals. The collaborative integrates    
      evidence-based clinical and science-of-safety interventions that, together, support a 
      culture of safety to prevent harmful outcomes. Strategies are incorporated to prevent
      fetal and maternal harm due to complications of labor induction and management of the 
      second stage of labor. The collaborative aims to reduce the number of birth injuries from 
      the current estimate of three injuries for every 1,000 births in the United States, and  
      aligns with Gov. Rick Snyder’s “dashboard” priority to reduce infant mortality."

Sparrow was one of the 8 hospitals chosen to participate in the MHA Keystone OB pilot study in 2008, and then continued in the large prospective trial that started in 2010 and is ongoing.  When asked about this initiative, the chief obstetrician at Sparrow, Dr. Molly Guerin says, "Data is starting to come in and looks excellent.  The commitment to avoiding preventable harm is job number one at Sparrow.  We are not perfect but we strive for perfection at all times."  I then asked Dr. Guerin a series of follow up questions.  Here is our dialogue: 

Me: What happens when a baby does die in a hospital? 

Dr. Guerin: "At Sparrow Hospital, specific review processes and protocols are in place for any death, including babies.  Nationwide the Joint Commission on Accreditations of Hospitals mandates reporting of and investigation of "sentinel events", which are events that result in harm or risk of harm to hospitalized patients, including moms and babies. (See their website http://www.jointcommission.org/sentinel_event.aspx)

When we have a sentinel event we do a Root Cause Analysis, which is a specific framework for identifying systems and individual causes of these harms, and make appropriate changes if issues are identified.  Sparrow is fully JACOH accredited, is randomly inspected, and has passed all inspections in full." 

Me: Does Sparrow Hospital report doctors whom they suspect have acted negligently?

Dr. Guerin: "We have taken action against individual physicians in the 22 years I have been here, and those physicians are no longer on our staff. Because these issues are part of Peer Review they are confidential. Certain changes in status of hospital privileges are reported to the State of Michigan and also to the National Practitioner Data Bank." 

Me: Dr. Guerin, am I right in pointing out that what you have stated are the steps Sparrow takes upon themselves to report questionable circumstances?  What can the patients do in terms of reporting questionable care?  

Dr. Guerin:  "Patients can report complaints to the Risk Management Department directly at Sparrow.  These complaints are taken very seriously.  The can also report adverse care, and negligence to Licensing and Regulatory Affairs to request a state investigation.  Patients can  file a lawsuit if they feel negligent circumstances have occurred that have not been resolved by other means."  

Conversely, let's briefly look at what happens when a baby dies in home birth or at a freestanding birth center.  You could report you concerns to NARM, but their process for "complaints" is a peer review, essentially group therapy for when you have had a bad outcome among your colleagues.  Nothing gets submitted to NARM from those peer reviews and none of the "recommendations" are required changes in practice.  I've heard it described as, "Fight Club with all the oaths of silence."  When MANA and NARM were approached about how many midwives in MI have had disciplinary action taken or credentials revoked, they would not disclose the information.  In fact, they couldn't even tell us how many CPMs were certified and working in MI.  I guess it's true that midwives do police midwives, just not very safely, effectively, transparently, or responsibly.  

Some wonder if doctors & nurses are held accountable at all?  While I recognize this isn't a perfect system, doctors and licensed midwives are more likely to be held accountable than unlicensed midwives with NO system of accountability and NO insurance.  There is good reason for oversight and dangerous consequences without it.  For disciplinary actions taking place over the past 7 years against licensed individuals in MI, visit this link: 

Disciplinary Action Reports (Licensing & Regulatory Affairs for the State of MI)

Negligence is negligence no matter where it happens, in a home or hospital.  The point is that there must be mechanisms in place to hold responsible parties accountable, to consistently review & improve practices taking place.  Babies do die in hospitals, true, but at least there is an immediate system of review, mandated reporting of outcomes, and malpractice insurance as a means of recourse.  In addition, hospitals are licensed facilities, full of licensed professionals, both of which have oversight and opportunity for reporting negligent circumstances. 

A freestanding birth center has no such oversight, as they are not a licensed facility.  A CPM or DEM?  No such regulation exists in MI.  They are not licensed or insured, and they are not mandated to report outcomes.  When a baby dies at a freestanding birth center or at home, it's as if it never happened and there's not a damn thing you can do about it.  There isn't any opportunity for recourse in any way.  While no system is perfect, something is better than nothing.   

                      
10 cm blog ~ "Babies Die in Hospitals Too"

The real reason I chose a birth center

I'd like to welcome a guest post today by a Lansing area mom. Do you have an idea for a post topic? Are you interested in sharing your story? We would love to hear from you. Please get in touch with us here. 

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It took me a year, but I think I am finally able to be honest with myself about why I wanted to have my baby at a birth center.  I didn't chose a birth center because I thought it was safer. Or because I was scared of the hospital. Or because I think natural birth is better than medicated birth. I went to a birth center because I was lonely and I wanted to meet people.  That's the truth. Let me explain.

My husband and I moved to Lansing a little over a year ago from another town in Michigan. We got pregnant and had our first trimester of care out of state. When we came home I felt anxious to start building my social "nest" - surrounding myself with people that would support me through the rest of my pregnancy and into parenthood. With all of my friends and family out of town (and out of state) and no local network of colleagues or acquaintances since I work from home, I felt terribly isolated. The way I saw it, I had about twenty weeks to build a social hub for myself and my baby. How could I do it?

Then I landed on the perfect answer: I could have my baby at the local birth center - Greenhouse Birth Center! Plugging into that community of midwives and families seemed to be the fastest and easiest way to gather support for my motherhood journey. I felt that if I had a hospital birth, I would miss out on a one-time chance to forge meaningful, long-lasting friendships . . . the kind of relationships that build up around powerful, shared life events (like birth). Have you ever heard a woman talk about her hospital "community?" Me neither.

Through our pre-natal care, I did feel that I was building close relationships with the midwives. We talked for hours over the course of our pre-natal visits. They asked me about my Thanksgiving dinner. They met my mom when she was in town. They gave me hugs. We laughed, we cried . . . I figured we were well on our way to being buddies. I didn't have as much interaction with other moms as I had hoped (our birth class was really small) but I figured that would come after our son was born with Mommy & Me classes, breastfeeding support, etc. All in all, I felt very comfortable and welcome at the birth center and that was just what I needed . . . a place to go where everybody knew my name. As my due date approached I felt very confident. Not only was I healthy but I trusted that the close relationships I had been forging with my caregivers over the last 20 weeks would come in super handy during labor. I imagined that the midwives would know exactly what to do and say to help me. I also felt certain that they would support me if and when I needed additional help or asked to go to the hospital. Through all of this, it never occurred to me that we would have anything less than a stellar labor/delivery at Greenhouse Birth Center. After all, I had only ever heard positive things!

Unfortunately, I did not end up having a great experience. I had a frustrating labor and a sloppy hospital transfer. I asked questions during labor and got blank looks. The midwives told me I was completely dilated and encouraged me to push when it was too early. They stalled when I asked to go to the hospital after pushing for three hours then told me that, if I went, I would probably have an emergency c-section (which I didn't). We arrived at the hospital and spent the next 30 minutes answering basic health questions and filling out insurance forms, since we weren't pre-registered. Our midwife came with us but did nothing to assist in the transfer of care. We felt like people off the street. All in all, the midwives were passive and at times downright unprofessional during the time when I most needed guidance and support.  Happily, our care at the hospital was excellent and our son was born healthy. But my carefully laid plans for having the birth center as my social hub post-partem had gone right out the window.

I didn't feel like continuing relationships with the people who had disappointed me. I also felt embarrassed about "failing" and going to the hospital - how could I face other birth center moms with my story? I felt confused and insecure. Those feelings all persist but now, more than anything else, I feel angry at myself for making such an important decision based on my emotional needs. By placing such high value on my social "birth experience" as a woman and a mom, I actually jeopardized what was really important: the health and wellness of our baby. I will always regret that.

I wanted to write this post because I don't think my mindset in choosing an out-of-hospital birth was unique. After all, it seems that most couples these days are raising children far away from their support network of parents, siblings, relatives and friends. Unfortunately, the people that matter most to us - the people we want around during challenging times - are often scattered far and wide. For women, I think this distance is especially difficult during the childbearing year. I know it was for me. But I learned that no matter how lonesome you feel and no matter how much you crave a place to belong, it isn't appropriate to make important decisions about health care based on emotions. I won't be making that mistake twice.

What We're Seeking: Informed Consent & "Choice"

"What We're Seeking" is a bi-weekly series that expands upon Safer Midwifery for Michigan's statement of purpose.  This week's post examines the issue of informed consent as a means for making an informed choice.

Midwives and their clients are proponents of "educating" themselves and making "informed" decisions about the care they receive.  Women often feel "empowered" by making choices for themselves instead of inviting a physician to do so for them.  This brings me to the question, what does it mean to truly make an informed choice?  In order for someone to make an informed choice, giving their consent, they must first have some body of information on which to base their decision.  The word choice indicates that they are choosing between at least two options.

The aforementioned definition would imply that midwives offer clients balanced research, information that supports multiple perspectives, and then the client decides what is best for her without influence of fear or mantra.  In order to achieve the goal of making an informed choice a client also assumes that the research being presented by her midwife is credible, evidence-based, and in tact (meaning it hasn't been manipulated to influence her in a particular direction).    

After establishing a clear understanding of what informed decision making entails, lets look at the opposite end of the spectrum, indoctrination and brainwashing behavior. 

A) Indoctrination: 

1. To instruct in a body of doctrine or principles.

2. To imbue with a partisan or ideological point of view.

(Synonyms: brainwashing, schooling, training, inculcation, ingraining, instilling)

B) Brainwashing:

1. Intensive, forcible indoctrination, usually political or religious, aimed at destroying a person's basic convictions and attitudes and replacing them with an alternative set of fixed beliefs.

2. The application of a concentrated means of persuasion, such as an advertising campaign or repeated suggestion, in order to develop a specific belief or motivation.

(Synonyms: indoctrination, conditioning, persuasion, re-education, manipulation)

Now it's time for you to decide.  Below are a few scenarios for your consideration.  Each is based on real life experiences with out-of-hospital midwives in MI.  Read each one and determine in your own opinion if you think it represents informed choice or indoctrination.

Scenario I:  

The biggest decision a mother makes is where to have her baby.  When considering the options, every mother looking at out-of hospital birth asks the question, "Is it safe to have my baby outside the hospital?"  When touring a freestanding birth center early in pregnancy, here's how the conversation went for one MI mom ~

Client: Is it safe to have our baby here?

MW: Birth is as safe as life gets.  Your body was made to do this and women have been giving birth for centuries.  Birth centers aren't for everyone.  We screen our clients carefully and only take on low risk women with normal pregnancies.  In addition, we have attended hundreds of births.  We know how to spot trouble and get you the help you need in plenty of time.

Client: What if something goes wrong? 

MW:  The hospital is only 12 minutes away should you need to transfer care.  We transfer moms often and for a variety of reasons.    

Client: Have you had adverse outcomes before? 

MW: We did deliver one baby who we knew wasn't fit for life outside the womb.  There are no guarantees and babies do die in hospitals too.  Having your baby at our birth center is safer than the hospital, who has a cesarean rate of 32%.

Client: What does the birth center model offer in comparison to the hospital?  How do the two differ?

MW: The hospital staff does not know how to support natural childbirth because they don't often see it anymore.  They are bound in practice by limitations that insurance companies require of them, like not letting you eat during labor, tying you to a bed with an electronic fetal heart monitor, and giving you IV medications.  In a hospital, you are subject to the doctor's protocols and decision making, and much more likely to receive unnecessary interventions.  At the birth center, babies are born gently, in comfortable rooms, and in birthing tubs.  Your instincts guide you, no one is telling you when to push or how to move.  You can eat and move freely and let labor progress naturally.  

Comments:  What evidence-based information was given to inform the client from Scenario I?  The only fact I can find is the cesarean rate for the local hospital.  Were there any risks discussed for either option? How can this client have made an informed choice when she was only told about all the wonders Natural Child Birth & what the birth center has to offer, but none of the specific risks?  To say that, "There are no guarantees, they only take low risk clients, they transfer to the hospital and that the hospital is only 12 minutes away," is not an explanation of risk, they are marketing statements.  There is no talk whatsoever about those risks that come up in an instant during birth that can't be avoided, the potential for harm when those situations arise outside a hospital, or the benefits that modern obstetrics can offer in certain situations.  There is no discussion about what would constitute high-risk.  There is however a lot of implicit philosophy already starting to be suggested as superior.  With NO discussion of risks involved, how can this client make an "informed" choice about where to have her baby safely?

Scenario II: Approaching 20 weeks, a midwife asks her client if she'd like to have a 20 week ultrasound.

Client:  Is there a reason to have an ultrasound other than finding out the gender? 

MW: It's really up to you.  There's no reason to have to do an ultrasound.  In fact there aren't really enough studies to know if ultrasound technology is 100% safe for babies in utero. 

Client: Well we don't want to know the gender and I guess if there's no reason to do one, why take the risk? 

MW: Here's our waiver form to decline an ultrasound if it isn't something you want to do.  The choice is yours.

Comments: Again, influence of opinion or sharing evidence-based data?  Does this conversation show balanced information that would lead a mother to make and "informed" choice? Does signing a waiver mean she's been "informed"?

Scenario III:  A birth center client is asked if she would like to do the typical Gestational Diabetes Screening, after all the choice is hers to make.  The midwife gives her client a piece of paper to read over that explains what Gestational Diabetes is, who is at risk, and how to avoid/treat it.

Client: Is this testing necessary? 

MW: Considering your nutritional habits, I don't see any reason to be concerned.  You can have the testing done if you want to. (Note: this particular client of average weight and height, has gained 40 pounds already, by 24 weeks gestation)

Client: What would happen if the test came back as concerning? 

MW: You would have to monitor your diet more closely and with appropriate effort your baby will be fine.   
Client: What are the concerns about having a baby with gestational diabetes?  

MW: The babies are generally larger, but you body won't grow a baby too big for you to birth.  Being labeled as having Gestational Diabetes increases your chances of having lots of interventions and a c-section.  Here is our waiver form if you decide to decline testing. The choice is yours.

Comments:  Influenced or Informed?

In any of these scenarios, was evidence based information given from multiple perspectives?  Was information given without biased influence?  You can't make a choice about something with only partial information and NO explanation of risks involved.  You also can't make a clear choice about something when you're being subtly indoctrinated to think a certain way about birth.  Bear in mind too, that this subtle indoctrination is coming from the very people you have come to trust, when you come through the door each week for you hour long appointment, greeted with a long hug from a supposed friend, and offered a glass of pregnancy tea.  

The goal of all those caring for pregnant women should be to teach them about birth so that they can fully engage in the journey, rather than to indoctrinate them in a narrow set of beliefs. The key to making an informed choice is first having all the information necessary to consider and decide upon. It's being informed of all of the risks on both sides of an issue.  To be "educated" is to have information from multiple perspectives, not just one point of view.  Indoctrination and brainwashing are not synonymous with education.  Ladies you are not making "educated choices", the choices are being instilled in you, made for you, with carefully presented statements of untruth and a side dish of fear about how awful the hospital will be.     

Establishing standards for the practice of midwifery in Michigan is exactly what women deserve in order to have the opportunity to make an actual, informed choice.  In our current state of severely lacking regulation in MI, how can anyone make a choice about even selecting a midwife to attend a birth, when there is no way to know her number of infant deaths, injuries, complaints filed against her, desertions, transfers, etc.?  If there is no standard for education and scope of practice choosing a midwife is like trying to pick a needle out of a haystack, a haystack loaded with needles, and hoping you don't get pricked in the process.  Making an educated, informed choice about your care is nearly impossible within the current midwife model in Michigan. Time for change.   

For further reading on this topic, visit:  Deconstructing Informed Consent

Ask an OB: Holy leg pain, Batman!

"Ask an OB" is a weekly series with Dr. Maude "Molly" Guerin, MC, FACOG. If you have a question for her, please share it with us here. 

I experienced terrible, shooting pain down both of my legs during my labor. It was much worse than the pain of contractions. I had never heard of this before and it caught me totally off guard. Is this normal? Is there anything I can do to avoid leg pain in future labors? - Michigan Mom

Hard to say without more details on the shooting pain…. did it intensify with contractions or was it constant? Did it disappear at delivery or did it persist? Did it radiate up into your uterus, your lower back, or down into your calves? The nerves that carry pain sensations from the thighs and the uterus overlap, especially in later labor, and it sounds like your pain got worse as labor progressed. If it was constant (intensity between contractions just as severe as during contractions), then I suspect the baby was lying on some nerves. If the pain intensified during contractions and faded back a tiny bit between contractions, I suspect this was part of contraction (uterine) pain. 

 “Labor” is serious work and it really hurts. Is there a single woman out there who felt her FIRST labor was not as bad as she thought it would be? Personally I thought it was the most intense physical feeling I’d ever experienced. Eventually rewarding and exhilarating, but WAY more painful than I imagined. The good news is that subsequent labors are so easy you want to burst out laughing when it’s done. So don’t let a (first) painful labor stand in the way of another baby. I invariably tell first-time moms, “you never have to deliver your first baby again, the rest of your labors are your reward for the hard work you did today.”

You can read more about Dr. Maude "Molly" Guerin, MD, FACOG, right here. 

We'll see you there!

  

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We wish you a long, restful Memorial Day weekend. See you on Monday!

The Roots of Dogma: Ina May's Religion & the Midwives Who Follow

dog·ma  n. 

1. A doctrine or a corpus of doctrines relating to matters such as morality and faith, set forth in an authoritative manner by a church.

2. An authoritative principle, belief, or statement of ideas or opinion, especially one considered to be absolutely true.

dog·mat·ic  adj.

1. Relating to, characteristic of, or resulting from dogma.

2. Characterized by an authoritative, arrogant assertion of unproved or unprovable principles

After reading the recent article in the New York Times about Ina May Gaskin and her battle for home birth, it all makes sense.  Now I know exactly where the dogma started.  

As I read the article, I learned more about who Ina May Gaskin is on a human level.  It seems to me that her perception of birth is much like a religion.  Her followers even reference her as a "saint" and feverishly distribute copies of "Spiritual Midwifery" to expectant mothers.  Apparently, being a saint these days means that you were involved in a four-person marriage, are proud of doing LSD and attending workshops to process your acid trip, and that you preach to the masses about just how safe birth really is without having any real education, medical training, or reported data to back it up.  The roots of Gaskin's movement are most clearly articulated with this sentence: "The participants in the caravan settled in Summertown, Tenn., in 1971. They took a vow of poverty and veganism and lived communally. Birth was a revered 'sacrament.'"  

Do women have a right to choose any religion they please?  Sure they do.  Do they also have a right to know whom they are following?  Absolutely. But (and this is a big "but") when a mom hires a CPM or a lay midwife to attend her birth, does she fully understand the dogma at the root of that woman's practice?  I don't think so. And this is the big problem that I see.

When a woman seeks the care of a midwife, someone who is posing as a professional caregiver, the expectation is that they operate under certain professional parameters, religion aside.  I have to believe that most women do not understand the dynamics of who it is they are hiring or how the the extremist nature of the "root" philosophy will impact the care she receives.  I know I didn't.  I was looking for a more personal model of care and thought birth to be an intimate experience.  I liked knowing exactly who would attend our birth and that our midwife would be present for the duration.  I thought midwives to be a safe, reliable, professional option...part of our health care system (as some are).  Surely it must be safe if they are running freestanding birth centers in the middle of reputable suburbs.

So what went wrong?  How did we end up in the hands of midwives who were so far from the professionals, the people we thought them to be?  What I didn't understand is the vast spectrum in philosophy that resides within the practice called "midwifery."  I wasn't looking for religion and I didn't knowingly volunteer my baby for sacrifice at the altar to advance anyone's cause, yet somehow that's exactly what happened.  Blind religious faith masked as natural childbirth and sold on a communal platter.  Some might call it a cult as in this post from 10 cm, The Cult of Natural Childbirth.  I must admit, in retrospect, much of this parallel seems eerily familiar.  Especially after reading about where the dogma started and after personally experiencing the backlash from the NCB community after speaking out about our experiences.           

What bothers me most is that the "Big Push" for midwives is aimed at the general population. Women are brought into the care of extremist midwives with specific selling points and marketing tactics that make birth sound alluring and empowering. There is no honest discussion of the real risks involved.  Ina May is a good saleswoman - she has already successfully marketed her cause across the country, with 27 states now licensing CPMs (who are directly trained and credentialed from Ina May's organizations, MANA and NARM).

How is this happening when most don't fully realize just how extreme the founder's roots really are?  How can someone earn a license to attend life and potentially deadly events without an education?   How are these women earning the privilege of attending our births with no oversight or accountability whatsoever?  Dogma cannot be allowed to influence maternity care.  Best practices must be defined, standards of care established, reporting outcomes required.  I hope we can reach women in MI and help them understand the complexity of this issue before Michigan makes the same detrimental mistake. Please visit:  Top 10 Reasons Why HB5070 Would do More Harm Than Good.

Every woman has the right to know exactly where this movement is coming from and what it's all about. They also have the right to know how many families it has adversely affected through infant loss and injury, BUT unfortunately, without regulation to require reporting outcomes, we don't have that data. We just have small voices fighting to be heard.  To read more about some of those small voices, visit: Hurt by Homebirth

Click here for Another reader's review of the NYT article .

To read more about dogma in midwifery visit: 

N.A.R.M ~ No Accountability, Renegade Midwifery

The "Whistleblower Midwife" & More

Midwife Masquerade: What Does Your Midwife Believe? 

Midwife Masquerade: Denial

Should my midwife be my friend?

When Our Baby Died

Freestanding Birth Centers ~ Common Myths Revealed 
The Hypocrisy of Midwifery

The Hypocrisy of Midwifery

I'm growing weary of the hypocrisy that permeates much of midwifery and the accompanying NCB (Natural Child Birth) advocates that can't see the forest through the trees, despite their own great experiences. Those who "sell" natural childbirth say that it is safe and put it on a pedestal. But when a baby dies, they quickly change their tune and say that it was the parents "choice."  Never mind that the risks were never part of the conversation from the start, at least not in an honest way.

How is it that midwives can claim that home birth is safe - as safe as life gets, safer than the hospital - BUT the minute a baby dies the mantra shifts dramatically to place responsibility on the parents as having made the "choice?"  

Dear midwife, ...Wait a minute, I thought you said it was safe?  Isn't that the "choice" I made, choosing something safe, the educated choice that was better for me, for my baby?  I don't remember making a choice to put my baby's life at greater risk?  Did we talk about risks?  I don't remember talking about them, but I do remember talking about how close the hospital was, how sure you were that you could spot trouble with plenty of time, how we are born to do this and babies know how to be born, how you've been delivering babies for 30 years with a spotless record.  I remember choosing you because you told me this was safer for me and for my baby.  I remember all the awful things you taught me about what the hospital and doctors would do to me if we went there.  

I remember you telling me that a breech baby is just a variation of normal, that they tend to fall out.  I remember you telling me that you were confident in delivering him, that we didn't need another, more experienced midwife to be here.  I remember you telling me that recent research supports vaginal breech delivery and that we were good candidates for said delivery.  I remember you telling me you watched a video once on breech birth, was it Ina May's from 1980?  I remember you teaching me to trust birth, and building a relationship in which I would trust you, and I did.  Turns out that trust is exactly what blurred my rational thought.  Our baby never came home.   I trusted you to know what you were doing and to tell me the truth about risks involved so I could make a "choice".  

Instead, the choice people speak of was taken from me, by intentionally manipulating information and conveniently avoiding conversations about real risks involved.  Perhaps I should coin the phrase "choice rape" here. 

Things get even uglier when NCB advocates start defending negligent midwives by saying, "Don't take my choice away just because things went wrong for you.  Maybe you should  have done more research and picked a better midwife."  Why is it that in the Natural Child Birth movement, women are continually exhorted to "educate yourself, mama!" and "take responsibility" for your birth? We don't do that with any other aspect of medical care -- we don't tell women take responsibility for their own breast cancer treatment! Plus, to what degree can a person truly educate themselves when their main tool is the trust they have with their care provider (one who claims to be a professional), and frankly, Google?  I am not a researcher, nor am I a physician.  I am a mother who trusted her care givers to be professionally competent & honest in an area that they posed as an expert.

Dear midwife, . . . Why is sharing the truth about adverse care so viciously attacked?  Why does your good experience with a midwife mean you were smarter than me or did better research?  Why does your good experience mean we should excuse situations that weren't handled properly?  Do you not care about the fact that negligence is happening and being brushed under the rug?  Why should we not hold midwives professionally accountable?  Why should they fly under the radar without reporting outcomes, getting a degree, or carrying insurance?  Why is this about hoping you get lucky in whom you choose to attend your birth and not about consistently reliable standards of care & ethical practice? Why does asking for midwifery to improve its practice, be accountable, and function in a way that is professionally safe, somehow threatening to a woman's choice?  Holding midwives accountable is about doing the right thing, about making negligence known, and ensuring bad things don't happen to other families, not about taking away anyone's choice!   Why wouldn't we aim to improve midwifery if it really has something to offer?   

The hypocrisy has to stop.  Either out-of-hospital birth is safe, or it's not.   
A midwife is either ethical and responsible 100% of the time, or she's not.  Women are being educated about real risks or they are not.  
We're either making a truly informed "choice" or we're not.  
Midwifery is a profession of highly educated professionals, functioning on behalf of the safety and a well-being of mothers and babies...or it's not.     

Related Posts:

Ask an OB: "Risk Out" Criteria

Midwife Masquerade: Denial

The Importance of Defining Risk

Considering Out-Of-Hospital Birth?  Questions to ask your midwife.

"Midwife Fairies & Elves"

After hearing stories of CPMs in Michigan carrying Pitocin and medications like Cytotec that are illegal for they to even posses, I asked Mindy Wolfe, Reformed CPM to write a guest post on this issue.  Thank you Mindy for sharing your insight!   

As you read, please recognize yet another reason why regulation and oversight are needed in the midwifery model of care.

I've always been a huge proponent of using the right tool for the right job.  In out of hospital birth, probably the most common complication that could arise for mother during the postpartum period is hemmorhage.  A postpartum hemmorhage can quickly become a matter of life and death, which I feel negates the option of homeopathic or herbal treatments.  These routes are simply not fast enough.  The right tools for postpartum hemmorhage are Pitocin, Methergine, and Cytotec because they are faster, more universally effective and safer to dose appropriately because they come in standardized units.  I feel it would irresponsible to attempt out of hospital birth without at least Pitocin on hand in case of postpartum hemmorhage.  No one lives close enough to a hospital to transfer for an uncontrolled postpartum hemmorhage.

That much said, even the right tools are unsafe when used inappropriately.  To begin with, drugs cannot be expired, and they have to be properly handled at all times to ensure their efficiency.  Then, the drug has to be administered properly and by the correct route.(meaning any midwife who cannot quickly and without fail start an IV on a dehydrated woman should not be practicing alone).  The drug also has to be given with full knowledge of the woman's condition and the potential, if not absolute, cause for her hemmorhage.  (Does she have heart disease or pre-E?  Is the placenta out and complete, or will you need to do a manual exploration for missing pieces?)  How often can the drug be administered and with what frequency?  What are the potential side effects?  And it is completely essential that any midwife, regardless of her legal status, accompany her client in case of transfer and very clearly explain any drugs she has given, at what time, for what reason and in what amount.  

All of these questions touch on a big part of the reason why physicians spend so much time in school studying chemistry, physiology, microbiology and anatomy. (among other courses) They need to have an intimate knowledge of every bodily process, so that when they purposely attempt to change a physical process gone wrong they know what to expect.  Does any lay midwife have that level of knowledge, in order to use her drugs correctly and safely? I would actually doubt it.

In those states where midwives are practicing without legal protection, how do they obtain their drugs?  The "midwife fairies" are usually online drug companies or their midwife-friend in another state that can obtain those drugs legally.  Even apart from the large legal concerns, this introduces the valid concern that the drugs might not have been handled properly in order to ensure their efficiency and safety.  

In summary, all birthing women should be attended by a competent provider who has legal access to in-date medication that they know how to use safely in case of postpartum hemmorhage.  Any deviation from that presents a significantly increased risk to the birthing woman.

Want to know more?  Here's a link to a NPR article that talks more about the variance in what midwives are and are not allowed to do.  The article refers mostly to medications that midwives are and are not allowed to carry.  States Vary On What They Allow Midwives To Do. 

What medications are midwives allowed to carry in Michigan?  A Nurse Midwife is considered an "advanced practice nurse" and is licensed by the state of Michigan.  Under the supervision of a physician she is allowed to carry and use specific medications.  Michigan Nurses Association: Perscriptive Authority   

A CPM, DEM, or lay midwife however, is not a licensed medical care giver and is NOT permitted to carry any perscriptive medications, period.  It is illegal for them to do so and would be considered grounds for prosecution.  These cases should be reported immediately to the DEA and the local police.  

What We're Seeking: Defining "Birth Center"

"What We're Seeking" is a bi-weekly series that expands upon Safer Midwifery for Michigan's statement of purpose.  This week's post examines more closely, the current state of "birth centers" in Michigan and further indicates improvements Michigan families deserve.

Freestanding birth centers are not currently regulated in any way in the state of Michigan.  I could literally wake up tomorrow, call myself a midwife, and open a "freestanding birth center" in my garage according to current MI laws.  "There are 215 freestanding birth centers in the United States, with more in development. The number of birth centers has increased more than 20% over the past 5 years; they are regulated in 41 states." (American Association of Birth Centers.  http://www.birthcenters.org.  Accessed March 30, 2012)  

What is a birth center?  

The term "birth center" refers to a facility that specifically is designed around birth.  Birth centers are generally more in tune with supporting and nurturing a woman in labor.  In Michigan, we have birth centers that are attached to or affiliated with hospitals.  We also have "freestanding birth centers," which is an entirely different model and a body of absent regulations.

 

What is a" freestanding" birth center?

 A freestanding birth center is one that is not affiliated with a hospital or a physician.  The birth center may have a consulting physician, but this relationship is as your midwife determines a consultation is necessary.  It is not in a capacity of oversight.  Freestanding birth centers are not required by MI law to be licensed as a facility or insured, nor are there any regulations that specify when you should consult a physician.    

How is a birth center different from a hospital?  

A birth center's mission is to support and perceive birth as natural and normal first.  The staff is trained to support women and create an environment that embodies this mission.  You may find options in a birth center that more traditional hospitals don't offer, such as birthing balls, water birth, birthing stools, etc.  A freestanding birth center goes further to offer things like homeopathy, placenta encapsulation, and the freedom to birth without any rules or regulations in place.

Freestanding birth centers do not have emergency medical equipment beyond oxygen.  They cannot intubate or give medications that would be used in a resuscitation circumstance. They do not use Electronic Fetal Heart Monitoring, instead using intermittent Doppler assessments.  Midwives working at a freestanding birth center may or may not be licensed as individual, may or may not carry insurance, and may or may not be trained in NRP (Neonatal Resuscitation Program).  The bottom line is that in the event of an emergency, they are under equipped for life saving measures. 

     

Who works in a birth center?

In a hospital affiliated birth center, you care is primarily with a licensed, nurse midwife.  If at any time during your pregnancy or labor complications arise, your care would shift to that of an obstetrician at the same birth center or hospital.  

In a freestanding birth center, midwives, doulas and other staff run the facility.  Some may be licensed nurse midwives, others certified professional midwives (no license), and other apprentices or lay midwives (also not licensed).  Often times midwives in a freestanding birth center have a physician they will work with to refer clients they determine to have complications.  (Bear in mind that this determination of need is solely at their discretion as there are no regulations.) 

Are birth centers safe?    

This is subject to opinion and definition of "safety".  It is our belief that a birth center affiliated with a hospital is the safest alternative to a hospital birth.  Medical technology and staff are immediately available and they have high standards for education, scope of practice, and review of outcomes.  It seems to be the best collaboration at present, between out of hospital birth and traditional maternity care.  As you will read in many of our other posts, without defined regulations, standards for education, defined scope of practice, and without reporting outcomes, freestanding birth centers vary widely in ethical practices.  This poses great risk in terms of safety.  It's difficult to determine what you're really getting into. 

Are birth centers licensed, insured?

Hospital and physician affiliated birth centers are licensed and insured, as are the nurse midwives who work in these facilities.

Freestanding birth centers may be insured, but many are not as it is not required by law.  Freestanding birth centers are not licensed through the state of Michigan as facilities.  Some of its employees may be licensed as individual professionals if they hold the appropriate credential (CNM), while other employees are not.  There is no requirement for any midwife at a birth center to have a license.

Are birth centers "accredited"?

Some freestanding birth centers are "accredited" by a national third party who supports regulation.  To find out if your birth center is accredited, please visit this link. Click on the "parents" tab and search by zip code.  If the birth center is accredited, it will say so in parenthesis next to the name of the birth center.  (Note: The Greenhouse Birth Center in Okemos is NOT accredited.  In fact there is not an accredited, freestanding birth center anywhere in MI.)   

What actions would improve freestanding birth centers? 

A freestanding birth center is essentially electing home birth in another house with no regulations, no insurance, and no reporting of outcomes.  In order for birth centers to be considered safe, they must be licensed as facilities & individuals, insured, and required to report all out comes. They should also have a board and policies established to review practices regularly, including insight from outside their own practice.  Even if these practices were in place, proximity alone makes them a greater risk to get the help you need in the event of an emergency.  

Ask an OB: Red Flags

"Ask an OB" is a weekly series with Dr. Maude "Molly" Guerin, MC, FACOG. If you have a question for her, please share it with us here.

What signs should midwives be looking for in labor that signal the mother and/or baby need additional help? It seem that other birth attendants (like dads!) would also like to know these signs and help look out for them. -- Lansing area family 

“Needing additional help” falls in to four categories:
1) Baby not tolerating labor
2) Mom exhausted/too painful to continue without medication
3) Labor not progressing as it should, especially if membranes are ruptured
4) Mom's status is concerning  

1.) Baby not tolerating labor
To know this you have to listen to the baby’s heartbeat FREQUENTLY. American College of Obstetrics and Gynecology recommends listening before, during, and after a contraction every 15 minutes in active labor, and every 5 minutes during pushing (which will be almost every push most likely).  Adhering to this standard will find most cases of severe fetal compromise. Subtle, earlier changes that are marked by loss of “variability” without changes in the “rate” of the baby’s heart will not be picked up by this method.   
You can read this article for details. 

2) Mom exhausted/too painful to continue without medication

3) Labor not progressing as it should, especially if membranes are rupture
In a “normal” labor, first-time moms will progress about a centimeter an hour during the “active phase” between 4 and 10 cm. The “latent phase”, from 0 to 4 cm can take a lon ger time, up to 24 or even 48 hours. Pushing can take up to 2 hours and be considered normal.  So anything outside this time frame (24 hrs latent phase, 6 hrs active phase, and 2 hrs pushing phase) should be cause for concern. Previous vaginal delivery shortens all these numbers dramatically! Pushing more than 1 hour would be abnormal in someone with a previous vaginal delivery. Many many women will not fit this time frame and be perfectly fine, and we do NOT put women on a timetable in labor! But an alert accoucheur will prick up her ears when these thresholds are crossed and begin to discuss the situation, try to figure out why (baby too big? Labor poor quality? Baby in unusual position?), have Plan B in mind, and do the simple things that can help (hydrate, position change etc). As time goes by and no progress is made, despite best efforts, transfer is a good idea. Frequently pain relief, rest, and augmentation to make contractions better will result in a vaginal delivery. 

4) Mom’s status concerning 
Fever, high pulse rate, excessive pain, high blood pressure, severe headache, blurred
vision can be signs of preeclampsia or infection. Transfer is mandatory if these are suspected. 

You can read more about Dr. Maude "Molly" Guerin, MD, FACOG, right here. 

Ask a Midwife: "Risk Out" Criteria

What are some "risk out" criteria for home birth? In other words, what are some things that might make a woman (and her midwife) change her mind about pursuing an out-of-hospital birth? -- Grand Rapids mom

As a provider (nurse-midwife) attending home births, one of the biggest challenges I am presented with is informing a woman that she is not (or is no longer) a candidate for a home birth. Why is this a challenge? Because it will disappoint her. One of the “myths” surrounding the natural childbirth community is the idea that having a labor/birth at home is a choice for all healthy women. However, there is often a difference between being “healthy” and meeting a medical criteria for a home birth that will optimize outcome for both mom and fetus/ baby.

A woman can be “healthy” (or have a self-perception of health) and still have a medical/ emotional diagnosis that risks her out of having a home birth. An example would be a woman with a history of seizures, even if the history were a remote one. She would still risk out of having a home birth. Another example would be a mom with a history of having insulin-dependant gestational diabetes with her previous pregnancy. She may be “diabetes-free” currently but her HISTORY of having the insulin-dependent GDM risks her out. Other factors are fetal-related as opposed to maternal-related issues. Malpresentation is the most common fetal related risk factor for a home birth, with breech presentation being the most prevalent at a rate of 2-3% of pregnancies. 

The following is a list of common risk factors that "risk out" a woman from having a home birth in a responsible home birth practice. It is not an exhaustive list but includes many of the issues we have come across while interviewing clients and managing pregnancies within our practice. Many times we will co-manage gals that “risk out” of a home birth with their physician(s) and will provide continuity of care for them in the postpartum period as well as be present for them during the hospital labor/birth. Here is the list:

1	Noncompliance with visits, scheduled screenings, testing during pregnancy
2	History of previous cesarean section
3	Current/History of seizure disorder
4	Current diabetes (and history of Insulin Dependent Gestational Diabetes)
5	Current fetal malpresentation (breech, transverse lie)
6	Placenta Previa or Marginal Previa
7	Current drug and tobacco use
8	Current alcohol dependence
9	Current mental illness that involves thoughts of harming self or others
10	Home that is greater than 30 minutes from a hospital or paramedic station
11	Home that does not have running water, heat and electricity
12	Pre-eclampsia during pregnancy
13	Insulin-Dependent diabetes during pregnancy
14	Fetal anomaly detected during pregnancy that may compromise neonate if born at home (cardiac anomaly, cleft palate, gastroschisis, ect).
15	Pregnancy before 37 weeks
16	Pregnancy after 43 weeks (we require antenatal testing at 41 weeks weekly and if, at 42 weeks, mom wishes to continue plans for a homebirth, she is counseled on increased risk of meconium and the fact that we will no longer manage birth at home once meconium in noted.)
17	Poor support system in place for days after the birth
18	History of postpartum psychosis
19	Multiple gestations (twins, etc.)
20	Fetal demise during pregnancy

The article links below are pertinent to this topic. Please keep in mind that the Committee Opinion from ACOG (American Congress of Obstetricians and Gynecologists) does not reflect the difference between planned home births attended by CNMs and “other midwives”. Unfortunately we are all lumped in together, which is very disappointing since it is clear that Certified Nurse Midwives (CNMs) have the LOWEST neonatal mortality and morbidity rates of ALL providers both in the planned home birth and planned hospital birth settings.

Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ (Canadian Medical Association Journal) September 15, 2009 vol. 181 no. 6-7.  

Planned home birth. Committee Opinion No. 476. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:425–8 

"Ask a midwife" is a write-in series here on the blog. If you have a question for our Certified Nurse Midwife, please share it with us here.