Ask a Midwife: Why don't you risk out for postive GBS clients?

Why does being GBS + (Group B Strep) not qualify a woman to be risked out of home birth?  I know the pill antibiotics are not as effective as the IV antbx. A CNM can give IV antbx at home, but how likely is that? As I understand, the GBS+ status of the mother is only important for the baby's safety. What can you tell me about this? There was a case of a CPM in California who delivered a healthy baby that died a day or so later of GBS sepsis. Very, very tragic. -- Concerned Reader

 

 The most accurate information concerning GBS can be found here: http://www.cdc.gov/groupbstrep/guidelines/new-differences.html. The majority of OOH birthing centers and home birth practices do not risk out women who are GBS carriers. CNMs have prescriptive authority and therefore can order the IV prophylaxis that is recommended for the prevention of GBS.

2010 Guidelines for Prevention of Perinatal Group B Streptococcal (GBS)

CDC - GBS Prevention Guidelines - Changes Since Last Release - Group B Strep

Safer Midwifery added these thoughts to the discussion:

‎

Again, the difference between CNMs and CPMs comes into play here, as does the importance of licensing, regulation, and defined risking out criteria/scope of practice.  Deb O'Connell, our resident midwife on the blog is a CNM, licensed, insured, and uses strict risking out criteria.  She has prescriptive authority.  If CPMs are unlicensed, unregulated, and have no defined scope of practice, they can treat clients with any unproven method they choose.  They don't have an obligation to transfer care or risk out.  I would venture to say that most home birth midwives are not CNMs and therefore do not have prescriptive authority.

Perhaps the difference in care is that the CPM (Certified Professional Midwife) in CA may not have had prescriptive authority, and resorted to her own unproven methods for treating GBS.  I have read stories of mothers whose GBS was treated by putting garlic in their vagina instead  properly being treated for a serious complication and the baby died hours after birth because of pneumonia from GBS.  See Wren's Story.  Garlic is not a substitute for antibiotics.

The problem then lies in the fact that the midwife made the decision to treat her client for GBS when she was unqualified to do so, instead of getting her client the help she needed.  Without the ability to treat GBS properly with prescriptive authority, the midwife should absolutely be risking out her client so she can receive the care she needs, and transferring her to the care of a physician.  Many, many midwives don't risk out at all and consider everything to be a variation of normal.

A CPM would need prescriptive authority in order to safely treat a client for GBS, strict risking out criteria would have to be clearly defined in order to practice safely, transfer of care would have to be seen as necessary to maintain a safe standard of care, and a solid, foundational education must precede all of these points.  Thank you for the excellent question!

 "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.

What We're Seeking: Standards for Education

"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 need for consistent, high standards in the education of all midwives.   

Think about your profession. Are you a plumber? A teacher? A lawyer? Consider the range of qualities among your colleagues.

If you are going to hire a lawyer, do you want to hire a mediocre lawyer who was trained at a questionable school?  A teacher who earned her degree online, but has little experience with children?  Do you want the least qualified economist to make policy for the country? No . . . you want the best person you can find.

That is why there has to be a bar, a high bar by which all members of a given profession must be measured as a minimum standard of education.  In the case of emergency/specialized care, there has to be a significant amount of intensive clinical training and consistently current educational standards to ensure these professionals are adequately prepared when lives are at stake. 

With no standards for education, the danger is that there is no bar.  This is precisely the case for midwives in MI today.  There is a vast spectrum in the training of midwives that spans those that have no formal education whatsoever (literally learning through mail order and watching you tube videos) to those who have advance practice nursing degrees...and everything in between.  Not only is it nearly impossible to sort the mediocre from the highly qualified, it's down right dangerous to consider that the person calling herself "midwife" could lack the essential skills necessary to keep women and babies safe during birth.  Hiring a competent midwife is confounding to the consumer when there is no minimum standard for the education, training, and skills she possesses.   

When we hired a midwife we made too many dangerous assumptions, one being that anyone who called herself a midwife was educated and competent, a trained expert in birth.  While this might be true for some Michigan midwives, it certainly is NOT true for all of them.  How can consumers know with certainty that who they are hiring has at least had sound educational training behind them when there are no standards for how midwives earn their title or even standards for how they practice?  

Further complicating things is the fact that the qualities that seem so important to those hiring midwives actually end up being those that matter the least.  Many women want their midwife to be warm, friendly, personable, compassionate - and most are.  Well, those things matter if you are a Kindergarten teacher, or if you work at a coffee shop. But when you board your plane, do you peek into the cockpit and think, "Wow, I hope he is friendly!" No. You look at the pilot and think to yourself, "I hope he knows how to fly this plane and keep all of us safe."  

Do pregnant women deserve nurturing and compassion?  Sure, but not at the sacrifice of safety and the utmost competence.  These are women and babies we're talking about here, life and potentially deadly events.  How can MI allow anyone to call herself a midwife with no standards for education or training?    

Safer Midwifery for Michigan is advocating for clearly defined, higher standards for the education of ALL midwives. 

Birth Center at Sparrow Hospital?

Dear Readers,

We've started a petition (see right column) asking for a collaborative care model for the women in the Lansing (MI) area.  We're striving to bring excellence in nurse midwifery and obstetrics together in the safest possible setting.  We know there is much that both professions can offer one another in the name of best practices.  Anyone who supports the idea of collaborative care as an exemplary model of maternity care can sign.

Research has shown that collaborative care reduces cesarean rates, improves outcomes, decreases interventions, and increases satisfaction.  All other major cities in Michigan offer collaborative care models.  Lansing women deserve better options that represent best practices in maternity care!

Please sign our petition and tell Sparrow Hospital that we need a birth center that would:

* Create a place where professionals nurture mothers and babies
* Bring excellence in obstetrics and nurse midwifery together
* Hold safety & patient care in the highest regard

If you feel compelled, you will have the option to leave a comment when you sign about why you feel this is an important issue.  The more feedback through signatures and comments the better the message will be understood.  You can also "share" this petition on your Facebook wall by "liking" it when you visit the URL to sign.  Let's start improving options for women in MI, starting with Lansing. 

Please sign, please share. 

Sincerely,
Safer Midwifery for Michigan


What is Collaborative Care?

Ask an OB: Delayed Cord Clamping

"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 are your thoughts on delayed cord clamping?

The main issue for cord clamping is iron stores in the newborn. Blood flows from the placenta into the baby for up to 2 – 3 minutes after birth, and then ceases. Clamping the cord early (less than 30 seconds) deprives the baby of this extra blood. This extra blood can be thought of as an “iron transfusion” for the baby, which lasts about 3 months. Because breast fed babies are more prone to iron deficiency, this may be mother nature’s way of protecting the baby from anemia (Timing of umbilical cord clamping: effect on iron endowment of the newborn and later iron status Volume 69, Issue Supplement s1, pages S30–S36, November 2011.) 

In the US today where most babies take a vitamin and iron supplement, the benefit of delayed cord clamping (2 – 3 minutes) is probably not as important as it was in times past.

Ask a Midwife: Should midwives carry malpractice insurance?

"Ask a midwife" is a weekly series with Deb O'Connell, CNM, MS. If you have a question for her, please share it with us here. 

My midwife says malpractice insurance is too expensive and that she doesn't have access to it.  Should I only hire a midwife who carries malpractice insurance?   -- Lansing mom

We live in a litigenous society and we live in a country where medical malpractice is standard for all health care professionals.  Medical malpractice for midwives is important because it protects both the consumer and midwife.  

Most providers carry it for below reasons:

1. Protection of private assets should they be sued

2. Allows them to contract with the major 3rd party insurers (BCBS, Cigna, etc)

Consumers rely on it because should there be a claim where the provider is found to be at fault, it provides compensation to the family that has been affected. Consumers also see it as a “professional standard” for their health care provider because it tells consumers the professional they hire has met minimum standards for training, licensing, scope of practice, and professional development in order to be licensed & insured.

Some excuses midwives have given regarding malpractice insurance include:

• “I can’t afford it.” - it depends ...she might not be able to afford it...however, a licensed midwife (CPM or CNM) can get a medical malpractice policy for as little as $4000 a year.  

• “It’s not available.” - not true.  There are insurers that will give medical malpractice insurance to midwives (and a couple that specialize in midwifery medical malpractice products).

• “I can’t provide care to women in poverty because after paying for the high cost of medical malpractice insurance, I'll have to raise my rates.” - This statement is ridiculous.  Carrying medical malpractice insurance has absolutely nothing to do with caring for women in poverty, in fact, the opposite is true - Medicaid providers are expected to carry medical malpractice.

Midwives are required to be licensed in the state they are practicing in order to obtain medical malpractice insurance, likely because holding a license establishes a minimum standard for education, scope of practice, and reporting of outcomes.  (Although, I must note that this isn't true in all legislation that comes forth for licensing midwives.  It should be the standard.)

It’s a sticky subject...and many providers (physicians, midwives, physical therapists, chiropractors, etc. ) wish they didn’t “have to” carry medical malpractice, but the bottom line is...it’s the standard in our country and it’s expected by the consumer.  It is the only responsible way to practice midwifery, knowing lives are at stake. 

What is a Collaborative Care Model?

Safer Midwifery for Michigan is excited to announce our new project called Collaborative Care Initiative!   Collaborative Care Initiative (CCI) is a project aimed at offering safer options for women in the greater Lansing area who value a natural birth experience.  We are working toward establishing a model of maternity care that brings excellence in obstetrics and nurse midwifery together in the safest setting possible, Sparrow Hospital.  Women deserve to be nurtured, accurately educated, informed, supported, and most importantly safe during all phases of maternity care, including prenatal, intrapartum, and postpartum phases.  We are aiming for balance in understanding and promoting the inherent value in natural birth, with a staff that can genuinely support it, and simultaneously cultivate an appreciation for the fact that birth doesn’t always work as we plan.  In the event of the latter, we aim to have seamless transfer of care with obstetricians that are experts when birth deviates from being normal or safe.    

Collaborative care represents best practices according to research.  When done well, outcomes have been shown to improve, cesarean rates to decrease, interventions decrease, and greater satisfaction for mothers was reported.  ACOG and ACNM have issued a joint statement advocating for collaborative care models:

“Health care is most effective when it occurs in a system that facilitates communication across care settings and among providers,” according to the joint statement. “Ob-gyns and CNMs/CMs are experts in their respective fields of practice and are educated, trained, and licensed, independent providers who may collaborate with each other based on the needs of their patients. Quality of care is enhanced by collegial relationships characterized by mutual respect and trust, as well as professional responsibility and accountability.”

Effective collaborative care offers both responsible education and appropriate options in a safe environment. Without these options, women seeking a birth with less intervention are turning to unqualified, unregulated, misinformed, fundamentalist midwives and putting their lives at risk in out of hospital birth.  We must find a way to offer more competent, responsible care as people who have concern for the welfare of those in our community.  

Boston Globe recently posted an article entitled, "What Women Want in the Delivery Room". 

Here are examples from our readers of excellence in Collaborative Care from around the country

(Note: We are not officially "recommending" any of these facilities as they represent the opinions of our readers only at this point.  We hope to research more in the near future on this subject to make further recommendations.) 

U of M Von Voigtlander Women’s Hospital & Birth Center

Family Beginnings Birthing Center

Sutter Maternity Center of Santa Cruz

OHSU Center for Women's Health

Shenandoah Women's Healthcare

Bon Secours Hampton Roads Health Systems

Westshore Midwifery Services

Women's Contemporary Health Care

Professionals for Women's Health

UNT Obstetrics and Gynecolcogy

ACOG and ACNM's Award Winning Collaborative Care Models

Collaborative Care is the best model for maternity care! Nurturing, Supportive, SAFE.  Greater Lansing needs collaborative care, women and babies deserve better options.  

Help us make a change!  

Write a letter to Dennis Swan, CEO at Sparrow Hospital

Petition coming soon!

Ask an OB: Does Mother Nature really know best?

"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. 

Why do doctors get nervous and want to induce women when they are overdue? Doesn’t Mother Nature know when the best time is? -- Skeptical Mom

Most of the time, she does. My three boys were 14, 12, and 10 days overdue – I had no non-stress tests, no ultrasounds, no discussion of induction, even though my blood pressure was high – and everyone lived!  My how times have changed in the last 30 years. The problem is that stillbirth does become more common as pregnancy advances, dramatically after 42 weeks – it’s 17 times higher after 42 weeks than it is at your due date. That being said, the chances are good that your baby will be fine even at 42 weeks – look at these numbers:

Completed Weeks	Stillbirth/10,000 births
37	2.4
38	3.6
39	4.0
40	2.6
41	9.4
>42	34.7

Obstetrics & Gynecology, VOL. 103, NO. 1, JANUARY 2004

So in today’s world, we like to get people delivered before 42 weeks. Usually once you pass your due date we are checking the amniotic fluid by doing a quick ultrasound once a week – this helps us know the placenta is still working well. Also doing a non-stress test by putting you on the monitor for 20 minutes twice a week helps us know the baby is doing well. These tests are not perfect, and our data on them is always being updated, but currently they are the standard of care and recommended by the American College of Obstetrics and Gynecology.

Here is a meta-analysis of studies on the management of post-dates pregnancy by the highly respected Cochrane Group:

Selection criteria

Randomised and quasi-randomised trials of interventions involving the intention to induce labour at a specified gestational age.

Main results

Twenty-six trials of variable quality were included. There were four trials of routine early pregnancy ultrasound, two of nipple stimulation, nineteen of routine versus selective induction of labour and one of antenatal fetal monitoring. Routine early pregnancy ultrasound reduced the incidence of post-term pregnancy (odds ratio 0.68, 95% confidence interval 0.57 to 0.82). Breast and nipple stimulation at term did not affect the incidence of post-term pregnancy (odds ratio 0.52, 95% confidence interval 0.28 to 0.96). Routine induction of labour reduced perinatal mortality (odds ratio 0.20, 95% confidence interval 0.06 to 0.70). This benefit is due to the effect of induction of labour after 41 weeks. Routine induction of labour had no effect on caesarean section.

In other words, induction of labor after 41 weeks reduced the chances of the baby dying by 80%. And since we never know if your baby is going to be one of the 9966 out of 10,000 who is fine, or be one of the 34 that is not – we want to get you delivered.

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

A Father's Day Wish

A guest post, by Jarad Snyder

In a perfect world I want one wish on Father’s Day.   Of course this wish can’t be something crazy like money or super hero abilities (that one’s for a certain 3 year old.)  I’m talking about something reasonable, feasible, and needed in this country.  While my Father's Day wish could probably have a million uses, this father is going to tip his hat to the mothers in this world.  My wish is that every expectant woman in the United States would receive the highest level of honest, professional maternity care.

Is it too much to ask that your care provider tells you the truth?  You would think that anything to do with a precious, innocent baby would be as honest as it gets, but unfortunately too many families have to deal with the absence of truth.  Again, we’re talking about mothers and babies who crave the truth, yet receive half-truths and even the avoidance of truth.  Since when is it wrong to tell a client or patient that you don’t know all the answers, or that a given situation is outside of your expertise?  When is it okay to delay the transfer of care for the good of a perceived belief?  When is it acceptable for a care giver to lie about events that took place to protect him or herself?  

Whether it’s the first month of pregnancy or the ninth hour of labor, every woman and baby deserves the truth.  They don’t need an ego following a blind philosophy, or an over confident roll of the dice.  It’s fairly simple, you either know what you're doing or you don’t. Being trapped in a dishonest care model is almost impossible to escape.  This is because you’re trusting people whose interests you really don’t understand.  Are they interested in what is truly best for babies, or what’s best for advancing a cause and adhering to established philosophy?  Can and do they recognize the gamble they’re taking with risk?  All the “noise” surrounding maternity care should start with honesty.  It’s pretty simple that what’s best for moms and babies is the truth.  

Now that you know my wish, we should ask every expectant mother what her wish is for her upcoming birth.  Though you might find more "noise" in these wishes, I can guarantee that at its core, rests the image of bringing a healthy baby home.  Any care provider selling an image outside of this one, or practicing in a way that doesn’t do everything  possible to ensure safe, honest care, can’t be trusted and should find a new line of work. 

Why Licensing CPMs Will Not Make Out of Hospital Birth Safe

Licensing CPMs is not a quick fix to improving the safety of out of hospital birth.  Proponents would have you focus on the fact that if licensed, the state is looking after midwives, thereby making out of hospital birth safer. At our own birth, we had two CNMs and two CPMs present and it was still a disaster.  Why?  Becasue the license didn't matter, it was the absence of several other safety guidelines and the actions of the individual midwives that enabled this to happen.  While licensing is part of the picture, there is so much more that MUST be included in any legislation that truly aims at offering women safer options.

House Bill 5070 is a bill that intends to license CPMs in the state of MI.  Not only are there glaring gaps throughout this bill, there are also many self serving elements written into this bill that would actually make out of hospital birth more dangerous for mothers and babies. 

To read about the pitfalls of this bill, you can visit:  Top 10 Reasons HB 5070 Will do More Harm Than Good 

In addition to the absence of critical elements that would actually improve safety of out of hospital birth, this bill proposes two obviously self-serving notions.  The first is the proposal of establishing a new board within the department of Licensing and Regulatory Affairs to serve as oversight for midwives.  This proposed board would be made of only midwives and one citizen.  Other states who have regulations for midwives do have boards, but they are balanced boards, comprised of Obstetricians, Nurses, Pediatricians, and a majority are midwives.  Creating a board of only midwives reeks of the same appalling practices of NARM who claims accountability, but does more to protect themselves than the people they serve.  

The second self-serving notion comes from the words of State Representative Ed McBroom himself as the primary sponsor of this bill.  He claims that the bill will, "Authorize creation of licensing process for midwives, including creation of licensing exam, rules, and standards."   He fails to disclose that ALL of the licensing processes, exams, rules, and standards would be set forth by NARM and NARM alone.  This is an institution that is notorious for protecting themselves and their midwives, with little to no accountability to the families they serve.  This is also the organization that has accepted mail order study and a 350 question multiple choice test as a means to "certification".  Choosing NARM as the lone source in establishing exams, rules, and standards for practice has no place in state legislation.

A more subtle advantage that this bill brings is that the newly licensed midwives would be eligible for insurance reimbursement.  Let's not confuse that with thinking they would carry malpractice insurance as a means to better protect their clients.  It means they'd get paid for the work they do by insurance companies, but wouldn't be bothered by having to adhere to any guidelines or specific scope of practice.

I've heard ridiculous arguments to support this bill, one being that it would serve rural communities in MI.  While the need may be present in rural communities, why would people living there be subject to sub standard care?  Don't wives and daughters of farmers and miners deserve to have highly educated, licensed, insured, accountable midwives too?  If we're truly talking about reforming out of hospital birth, with the goal being to improve safety, then let's get serious about the standards to which we hold all midwives.  A license should stand for something no matter where you live. 

Another argument I recently read on the Greenhouse Birth Center's face book page, was a letter writing campaign that asked supporters to write a letter to their legislators.  The post was explicitly explaining that if we licensed our CPMs it would somehow protect them from criminal charges and prosecution.  Since when does a state license prevent criminal prosecution?  The argument doesn't even make sense.  Anyone can still press charges against a licensed midwife if her actions warrant such action.  How does licensing a CPM prevent her from being prosecuted should she break the law?  This argument makes no sense. 

The critical question we should be asking is who are we proposing that we license and what do we know about their safety and outcomes?  How can we license CPMs without having collected ANY data about their safety record, a thorough analysis of outcomes, why/how these outcomes happened, and furthermore how to improve upon them?  Wouldn't it make more sense to do the homework first before handing CPMs a license?  CPMs could be the most educated, well intentioned people on the planet...or not.  The point is that without specific definition of scope of practice, educational standards, and safety guidelines for out of hospital birth, and actually knowing their outcomes with certainty, what does licensing matter? 

Do women deserve a choice in where to have their babies?

Yes

Do women deserve for those choices to be as safe as possible, educated, insured, responsible, and accountable...no matter where in MI they live?

Yes

Is that the case now?

No

Would HB 5070 improve safety?

No

How then could we improve the safety of out of hospital birth and the practices of the midwives attending them?  What action steps will truly improve safety for mothers who choose out of hospital birth?

* Set Educational Standards allowing only the most highly trained midwives available, with 
   a solid education behind them, clinical practice in handling emergency care, & neonatal   
   resuscitation certification to practice midwifery.

* Allow only licensed midwives to practice.  Licensing is based upon aforementioned 
   educational standards and nothing less.  (Not set forth by NARM).

* Require all midwives to carry malpractice insurance.

* Define a clear scope of practice and limitations for midwives.

* Identify screening measures and "risk out" criteria so that midwives are appropriately 
   assessing risk factors and risking out the clients that would not be good candidates for out 
   of hospital birth, thereby minimizing risk.

* Define protocols for transfer of care and physician consultation.

* Establish consistent informed consent documents to be used state wide.

* Mandate reporting of all outcomes for every midwife so that clear assessments of safety 
   can be determined. 

* Work to develop a system of collaboration between doctors and midwives. 

* Only allow "birth centers" that are licensed facilities through Licensing and Regulatory 
   Affairs and staffed with midwives that meet all of the above criteria. 

I am weary of the deceiving notions proponents of this bill are using to advance their own agenda.  It's time to start having honest, detailed conversations about the fact that out of hospital birth DOES take on an amount of added risk, what those risks are, and what they mean in the end.  It's time to start evaluating outcomes, analyzing preventative measures, and taking action that will actually improve the safety of out of hospital birth.  This bill needs a great deal of revision if it is to be effective and actually serve the mothers and babies of this state well.  Simply handing CPMs a license and cushioning them with a false board and standards set forth by NARM will NOT make out of hospital birth safer, it will make it inherently more dangerous than it already is.

If this post resonates with you, PLEASE take the time to write to your State Representative and Senator to express your concern for HB5070 and the ways it needs to be improved. Legislators listen to their constituents. 

Find Your Legislators 

Example Letter to Legislators

Ask an OB: Crystal ball

"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. 

How can you make sure you are on the same page, specifically regarding risk, with your midwife/OB? For example, is it appropriate to say, "I would like to do my best to birth this child naturally but if you can tell that the baby may not make it, or I am to blow out my body, that is where I draw the line." How do you draw lines with them? Is this a conversation you should initiate during prenatal classes? Should you say, "I am all for candles and bathtubs, but ultimately I am here for the outcome (i.e., healthy mother and baby) and am willing to sacrifice the process (i.e., uninterrupted birth) to get there. I need you to help me identify when our health is at risk." - Okemos Mom

 

I badly need a crystal ball. When they invent them, I get it first! If I could peer into it and see a 30 hour labor, 4 hours of pushing, a C section, a stay in the Neonatal Intensive Care Unit for the baby and a blood transfusion for you . . . I would do a C section before labor and skip all that! If I could see a baby that comes out and doesn’t breathe, has Apgars of 1 and 4 . . .  I would labor you in the hospital, on continuous monitoring, and do a C section if things looked bad. And you would gladly forgo the “candles and bathtubs,” I’m sure!  If I was worried a VBAC would rupture your uterus with a trial of labor, but could use my crystal ball to see a 3 hour labor, 2 pushes and a happy baby and mom, we wouldn’t even talk about all the bad things that can happen! Unfortunately we don’t have that crystal ball. Therefore you DO NEED to have that conversation with your partner before you decide where to have your baby. Then you need to be explicit with your provider. Here are some examples of ways that you can set clear expectations:

• “We are committed to a natural labor and delivery at almost all costs. We accept some increased risk for low Apgar scores, neonatal seizures, and a long labor – in hopes of reducing our risk of a C section. Unless you have clear incontrovertible evidence that my baby or I WILL have irreversible damage, I want to continue with no intervention and accept the outcome.”

• “We sincerely hope for a low tech, ‘hands-off’ labor and an unassisted vaginal delivery. Please stand by and let us know if you see warning signs of trouble for mom or baby…we would like to discuss options for intervention in that situation, and have a time line for decisions.”

• “We want as close to a 100% guarantee as you can give us that our baby will be under absolutely no stress during labor and delivery. If things aren’t going perfectly we want a C section immediately.” 

Writing your feelings down is always good, too. I would much rather see an essay on your risk tolerance and the strength of your desire for no intervention than the list of “do’s and don’ts” that make up most birth plans. So my advice is yes – please talk talk talk to your provider about risk and how you want to handle certain situations. If your provider has her/his own agenda about these things, you need to know that up front and decide if you can live with that. 

Finally, I find the last sentence of your question critical. “I need you to help me identify when our health is at risk.” Honestly, this is not your job, it is our job. Your job is to be strong, to be thoughtful, to climb the big mountain that is labor. Our job is to be nearby spotting you. When you veer off the safe path, we notice, we shepherd you back. Sometimes we yank you back! “Hey your baby is in trouble – get into the O.R. RIGHT NOW!!”  You shouldn’t have to worry about identifying when your health is at risk, you have a huge job to do just getting through this (it’s called “labor” for a reason!). If you are second guessing your provider and don’t trust that they will be able to “identify when your health is at risk”, you are in the wrong place for care.

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

Portrait of Michigan Midwives

Hiring a "midwife" who practices outside a hospital can mean many things in Michigan:

She may or may not be licensed

She may or may not have clinical training

She may or may not have a high school diploma or college degree

She may or may not be certified in neonatal resuscitation

She may or may not carry malpractice insurance

She may or may not report her outcomes to the state of Michigan, or anyone else

She may or may not have had previous, preventable infant deaths or birth injuries

She may or may not have strict "risk out" criteria and truly take on only low-risk clients

She may or may not carry and use prescription medications illegally

She may or may not effectively evaluate and appreciate risks

She may or may not believe in "high risk" as being more than a variation of normal 

She may or may not transfer your care before it's too late

She will not have all of the tools, medications, resources, and skills at her finger tips to resuscitate your baby if he or she needs it.    

Furthermore, given a bad outcome, poor decisions, inadequate skills, mistakes made, red flags missed or flat out ignored, you may or may not be able to hold your midwife accountable...most likely not when there are not standards or regulations by which to do so.  

Midwifery can be done responsibly and ethically.  Collaborative care is happening in many parts of our country, even some cities in MI.  The problem is, that without a defined scope of practice, you don't know what you're getting when you step outside a hospital and into the hands of a midwife.  

Links:

Lansing State Journal Article: "Home birth movement raises questions of acceptable risk..." 

Freestanding Birth Centers: Common myths revealed

Ask A Midwife:  How do I pick a good midwife? 

The importance of defining risk

Considering out of hospital birth?  Questions to ask your midwife

Neonatal Mortality Rates Part 2: Who has the best/worst infant morality rates?

This is the second part of our series on understanding neonatal mortality rates, in which we try to answer two questions: “Which is riskier, hospital or home birth?” and "How does place of birth and birth attendant impact outcomes?"  This post will specifically address mortality rates based on data from Wisconsin’s WISH initiative.*

As out-of-hospital birth advocates are quick to point out when a baby dies on their watch, babies die in hospitals, too. This is true. But does this mean that hospitals are less safe? No! One important reason is that the patient populations for home births and hospital births are vastly different. A hospital takes mothers of every kind: healthy mothers, obese mothers, drug addicts, mothers pregnant with multiples, breech babies, preemies, mothers with heart conditions, mothers with high blood pressure, and mothers with every other kind of complication you can imagine. On the other hand, a midwife practicing outside of the hospital is supposed to take on only normal, low-risk pregnancies. Thus, if the safety of the care itself is the same in both places, we would naturally expect the hospital to have higher neonatal mortality rates, given the high-risk population it serves.

You might be surprised to know that is not the case - at least not in Wisconsin.

The data collected in the WISH database can be stratified in many ways.  For our purposes, we have stratified the data by the type of birth attendant. We’ll try to understand how the specific mortality rates for physicians working in a hospital setting (MDs, in this case) compare to direct entry midwives largely responsible for home birth (DEMs, otherwise known as CPMs). We’ll also consider CNMs and their role, since they deliver in both settings.     

The data collected in Wisconsin and presented in the chart below show that the mortality rate for home births attended by DEMs was 4-5 times higher on average during 2003-2008 despite the low-risk client population they serve! 

When you consider that these data include all comers, with high-risk moms tending to choose hospitals and home birth midwives only taking on low-risk pregnancies, things look pretty bad for the DEMs. There seems to be little doubt that care provided by DEMs is much riskier.  The CNM data, however, are more difficult to assess because CNMs can deliver babies in both settings -- hospital and home.  (Note: CPMs would be listed as DEMs in this data set because they are part of the home birth sub group statistics.) 

So let’s look more closely at the role of CNMs and their mortality rates.  The chart above shows that CNMs have mortality rates on par with or even better than MDs. How is this possible when we read that out-of-hospital birth is 3-4 times more risky? Or when the ACOG (American College of Obstetrics and Gynecology) states that perinatal mortality is higher in out-of-hospital births?

To better understand this seemingly conflicting evidence, we asked Deb O’Connell, CNM and home-birth midwife, to answer a few questions: 

Safer Midwifery: Deb, ACOG states that perinatal mortality rates are higher in out-of-hospital births. Is this true? 

Deb: Not exactly. When CNMs are managing out-of-hospital births we have the LOWEST perinatal mortality and morbidity rate in the country. That is actually true regardless of our practice setting, home or hospital.

Safer Midwifery: OK, but you have also said that home birth is not as safe for a baby as being born in a hospital. So I'm a little confused. Can you please explain? I think this can be misread as thinking midwife outcomes are the same or better, when there is so much more to be explained. 

Deb: Sure. The reason that out-of-hospital birth is not as safe for baby (and this not limited to home-birth -- it includes freestanding birth centers) is due to delayed response time for intubation if required.  A CNM who is practicing in an out-of-hospital setting and who is practicing within a strict set of protocols will have roughly the same perinatal outcomes as her counterparts practicing in a hospital setting, and if they are NOT the same or BETTER than she needs to revisit her risk-out criteria.

Safer Midwifery:  Okay, I think I am starting to get it. If I understand correctly, there are really two separate but related issues. For two identical pregnant moms, the risk for out-of-hospital birth will be higher than in the hospital. But high-risk births will tend to go to the hospital, so the patient pool for midwives will be mainly low-risk births. Thus, if we see that outcomes are worse for a midwife practice, we can infer that they are doing something very wrong: either they are delivering poor care to low-risk births, or they are taking on too many high-risk births. Is that right?

Deb: Yes!

Thanks to Deb for helping us think that through! You can see now why things are so confusing. As parents, the number we really want to know when choosing between out-of-hospital and hospital birth is the first one: What's the difference in safety across the two settings for two identical, low-risk pregnant mom? The problem is that we don't see this comparison reflected in the Wisconsin dataset, or in any dataset for that matter. We only see final outcomes that reflect the two confounding effects: higher-risk practice versus lower-risk population.

It appears then that CNMs have comparable mortality rates to doctors when they function under a strict set of risking out criteria.  That being said, for two identical mothers, one giving birth at a hospital and one outside of the hospital, the risk is 3-4 times greater outside the hospital --  and even higher if your CNM is not adhering to  strict risking out criteria. Of course, with poorly trained DEMs or CPMs, the risk of out-of-hospital birth are also likely higher. 

Evaluating the efficiency and relative safety by place of birth & type of birth attendant in Michigan is nearly impossible.  You may have wondered why we used data from Wisconsin for this post.  We were not able to use data from Michigan because as a state we are lacking in our data collection efforts  and reporting outcomes as related to birth.  The type of birth attendant is not included on MI birth certificates, thereby making it impossible to adequately collect data stratified by place and care giver type.   In addition, when midwives aren't required to report their outcomes, data becomes even more vague and consequentially so does proper assessment of outcomes, measures of safety, and relative efficiency.  Michigan needs much revision when it comes to collecting data about birth in order to utilize that data to ultimately improve outcomes for mothers and babies.

*(Wisconsin's Department of Health offers a website/database which gives information about health indicators [measures of health] in Wisconsin. WISH allows policy makers, health professionals, and the public to submit questions [requests for data] and receive answers [tables] over the Internet.)

The hospital is "only" 12 minutes away

When clients at an out-of-hospital birth center ask their midwives, "What would happen if there were an emergency," they are greeted with the calming notion that, "The hospital is only 12 minutes away."  Women are often reassured that a short ambulance ride somehow means that care is close enough to feel comfortable when embarking upon out-of-hospital birth.

When you stop and think about this, there is so much more to responding in the event of an emergency than the length of the ride from one driveway to another.  What conveniently is not discussed is

• The time it takes for a decision to be made to transfer, when concerns are in fact recognized
• The time it takes for a mom's request to transfer to be taken seriously instead of "buying more time" with stall tactics
• The time it takes for the ambulance to be called
• The time or day and day of the week and how that impacts traffic flow
• The time it takes for the ambulance to drive to the birth center
• The time it takes  for EMTs to assess the situation and respond accordingly
• The time it takes to load 
• The time it takes to stabilize a baby who isn't breathing for transfer
• Insert Drive Time Here (12 minutes)
• The time it takes for the hospital staff to assess the patient in need and make a plan for moving forward, sometimes having no records on hand
• The time it takes for strangers to fill out paperwork
• The time it takes for new care to effectively take shape with a resolution achieved  
• EMTs do excellent work, but they are not an RNICU or labor and delivery team.  
  
  

Wouldn't it be more accurate to consider the broader scope of transfer time as "Care to Care" transfer, meaning the time it takes from request or concern to the time it takes to get the help you need?  Let's look at three different real-life transfer events that happened from the Greenhouse Birth Center to Sparrow Hospital in the Lansing area last year.

Client #1 ~ "Non-Emergency" transfer: Mom in pain requests transfer after pushing without
                     progress for 2+ hours.  Baby's heart rate is variable. Midwives stall because she
                     is "so close" but eventually discuss transfer and call an ambulance.

Client #2 ~ "Urgent: transfer:  Mom has been pushing for 4+ hours with no progress.  

                      Baby's heart rate starts to be concerning. 

Client #3 ~ "Emergency" transfer: Baby born without a heartbeat, immediate resuscitation 

                      necessary 

Table: Transfer Time from Birth Center to Hospital for Three Different Families
Stage of Transfer Process	Type of Scenario
	Non-Emergency mom in excruciating pain requests transfer	Urgent baby’s heart rate in labor is concerning	Emergency baby is delivered with no heartbeat
Transfer Requested or Serious Concern Noted until Ambulance Called	30 minutes (initial requests to transfer discounted)	Not Available	4 minutes (from delivery until ambulance called)
Ambulance Called until Ambulance Arrives at Birth Center	3 minutes	2 minutes	2 minutes
Ambulance Arrives at Birth Center until Ambulance Departs for Hospital	5 minutes	8 minutes	16 minutes (attempting to resuscitate baby)
Ambulance Departs for Hospital until Ambulance Arrives at Hospital	12 minutes (no lights or siren)	9 minutes (lights & siren)	11 minutes (lights & siren)
Ambulance Arrives at Hospital until Care is Effectively Transferred	60+ minutes (epidural given and mom resting)	15 minutes (pain meds given and evaluations in progress)	14 minutes (RNICU team still resuscitating)
TOTAL TIME: Care to Care	approx 2 hours	34 minutes	41 minutes (baby has a heartbeat, prognosis grim)

In the most emergent scenario (third column), you're looking at 41 minutes from the time a baby is born without a heartbeat to the time he has been "resuscitated".  41 MINUTES!  How does a baby have any chance at survival after 41 minutes without a breath?  Furthermore, how does a baby have any chance at survival after 12 minutes without a breath, even if the claims made were true?

Purposefully minimizing the estimated time it takes to effectively transfer a mom or baby in crisis is abhorrent.  Midwives who practice out-of-hospital birth need to be frank with clients about the fact that emergencies do come up in an instant that require immediate medical attention, and that when they do, there is little that can be done to avert it.  By proximity alone, you're putting yourself at risk.  I would have appreciated a frank conversation about this instead of being told that, 'They know what to look for and how to get help in plenty of time, that the hospital is only 12 minutes away and the ambulance is across the street."    

10 cm Blog ~  Friday Fallacy: The hospital is just minutes away.
Lansing State Journal ~ "How far is too far in a birth emergency?"