Wednesday, November 21, 2012

Thankful for...

Thanksgiving Eve, 2012...7 months since this blog came to life.  I find myself overwhelmed with gratitude on so many levels, that it's difficult to know where to begin.  At the risk of sounding like an award speech, I'd like to express my thanks to the people who have been on my mind the most in recent weeks and months... 

I'd like to thank our readers, first and foremost, for listening to what we have to share with the world, and working with us to make a difference.  Without you there is no blog, and more importantly, there is not movement toward safer midwifery in this great State (and elsewhere).  Thank you for caring, for reading, for sharing, and for helping others understand the complexity of the issues we address here.  

I'd like to thank the other members of Safer Midwifery's advocacy group.  I'm forever grateful for your insight, your time, and your hard work on making our projects a success.  Without your participation, encouragement, and help, none of the great changes we're witnessing would ever get off the ground.  

I'd like to thank every mother who has suffered loss or injury for sharing her story.  I know personally how difficult that decision can be.  Your courage and strength have honored your babies well, and will work to make a difference for others.  

I'd like to thank every doula, midwife, and apprentice who has reached out to share their own stories and concerns.  Your experiences and insight are the most important in advocating for higher standards within your own profession.  You know first hand what is going on around you.  Having the courage to come forward, share your ideas, and work with us to advocate on behalf of mothers and babies is truly remarkable.  Although your voices are often anonymous, they are being heard. 

I'd like to thank every State official, investigator, lawyer, and legislator who has taken the time to read our letters, take our phone calls, listen to our concerns, meet with us in person, and take action.  You are our leadership.  We are so grateful for the opportunity to communicate our experiences with you to better help you understand the need for better safety measures.  

I'd like to thank every physician & EMT who has had to witness repeated preventable deaths, and worked hard to save lives, even when they could not be saved.  These are also the physicians advocating for natural birth in hospitals, and working to make changes happen so women have safer alternatives.  Thank you for your voices and your actions to improve the state of things on both large and small scales.  

I'd like to thank my extended family, friends, and especially my mom for their love and support.  My mom has been with us ever step of the way, supporting us even when she didn't understand.   She never grows tired of talking when we need to talk, and never tells us we should get over the loss of our son.  You have been the steadfast support person through all of us, even while finding your way through your own grief, and for that we are enormously grateful. 

I'd like to thank my husband for his tireless support, his listening ear, his encouragement, his ideas, his perspective, and his love for every member of our family.   It has not been an easy journey the past year and a half, be I'm proud that we've walked it together every single step of the way.  

I'd like to thank Jonah too for being resilient, patient, and loving...for asking questions, for trying to make sense of things that cannot make sense, and for always finding a way to make me laugh.

And last, but certainly not least, I have to say how grateful I am for Magnus.  It moves me still, to think about how an infant, only on earth for 13 days, can touch so many lives in such profound ways.  What I've learned from Magnus in the past year and a half, is more than I've learned in my previous 32 years put together.  The way I see his love, and our love for him, reaching others is incredible.  He leads us forward.  It's Magnus that helps us realize that life is more than the number of days or years spent on this earth.  It is because of him that we will continue to fight for truth, and safer options in midwifery.  No human being deserves what he went through, but every human being should know his story, and that of so many others.  I am thankful for the friends, the support, the encouragement, and the opportunity to make a difference for other families.  There is no better way to express Magnus's love and life to the world.  

Happy Thanksgiving! 


Monday, November 12, 2012

Why Licensing Alone Won't Make Midwifery Safer

A reader recently asked me to explain our experience with licensed midwives, and the implications of legal scope of practice for CNMs in Michigan. 

"What I find curious about Michigan law is that your midwives were licensed certified nurse midwives. What restrictions pertained to their licenses? Were they operating within the legal scope of practice for nurse-midwives when they attended a planned OOH breech birth? If so, what needs to be remedied so Michigan families can be protected from negligence and malpractice of licensed providers."

These are great questions!  First, I should explain that our birth occurred at a freestanding birth center, attended by two Nurse Midwives (CNMs), and two Certified Professional Midwives (CPMs).  Many wonder why we advocate for higher educational standards or licensing when we had CNMs present at our birth.  The answer is that licensing is only one piece of the puzzle in improving safety and outcomes for out-of-hospital birth.  Two of our midwives were licensed, which implies that there are factors that impact safety outside of holding a license.  If this kind of disastrous care can happen with licensed professionals, we need to look more carefully at the practices and expectations of these professionals. 

One of the strongest influences is philosophy, that which a given midwife believes about birth, assessment, and risk.  Does a given midwife believe that birth all costs?  Does she believe that birth is natural, normal, in all cases?  Does she believe that cesarean or intervention is the worst scenario, even more so than death or injury?  Does she believe that some babies aren't meant to live?  Does she believe in assessing risk and risking out?  Does she value assessments to determine risk?  Does she believe that babies don't grow too big? This is difficult to measure, but perhaps has the greatest direct impact on practice.  

Philosophy is not something that can be mandated.  What can be mandated are the assessments and criteria by which we measure risk, who holds a license, and what their minimum standard for education should be.  We can ensure that only low-risk pregnancies are taken on outside the hospital, and that proper assessment is done to evaluate that risk.  This is what many other states and countries are doing, and they're doing it with more qualified, highly trained, professional midwives.

The reader's second question refers to limitations on a CNMs license or scope of practice.  I don't have all the answers to this, but I can do my best to explain what I do know.  There is no law (that I am aware of) that defines a midwife's scope of practice.  The Public Health code simply states that a Nurse Midwife is considered an Advanced Practice Nurse.  It does not detail in any way their scope of practice.  I believe the caveat is that it defers to ACNM as the credentialing body, therefore relying on their standards for scope of practice.  That's the only sense I can make of it at this juncture.  We were told that we couldn't press criminal charges because there were no laws in our state about midwifery.  The state investigation is still ongoing, but the expert witness who reviewed our case did determine that it violated the public health code in some way.  I don't know the specifics yet.  When sanctions have been determined in 2-3 months, by the Attorney General, we can request the documentation that will tell us more.  It's difficult to discern exactly what a CNMs legal "scope of practice" really is in MI because it is not part of MI law directly, at least not that I can find.  (Please comment if I'm misunderstanding this!)

There are no restrictions to out-of-hospital birth practices in MI.  It is legal for a "midwife" to take on any kind or birth, risky or not in our state.  There is no law for what assessments should be done, or guidelines for situations that are simply too risky.  There is no law about what informed consent has to include.  There are no minimum standards for education, meaning anyone can call herself a midwife...even someone who has filed for bankruptcy multiple times over wrongful death, someone who has previously settled out of court for wrongful death, someone who has been convicted of larceny, someone who has had their credentials revoked, and someone who has done time for criminal charges.  Where do these examples come from??  Michigan midwives.  No, not all midwives are felons or have faced civil charges, but too many are.  I don't think anyone on this planet can argue with the fact that this is unacceptable.

Another enormous pitfall of our state leaders is that we collect no reliable data on safety and outcomes of out-of-hospital birth.  This too has to change if we are to effectively analyze safety before we offer up a license, as two dangerous bills (SB 1310 and HB 5070) in MI currently propose.  Legislators have to know who it is they are licensing.  Mothers deserve to know who they are hiring.  The curtain must be pulled back, and the midwives who are practicing responsibly need to take a stand on improving their own profession. 

What has to change to make out-of-hospital birth a safer option?  Our state leaders must first gain awareness, see the need for change, and then implement law that includes ALL of the following components in conjunction with one another:

a) Minimum standards for education (International Standards (which includes some CPMs), CM, or CNM)
b) Mandatory licensing for anyone who calls herself, or advertises a "midwife"
c) Defined scope of practice for midwives
d) Defined assessments and transfer of care protocols for risking out
e) Criteria for informed consent (including disclosure of insurance)
f) Mandatory reporting outcomes

As demonstrated by the death of our son, licensing alone is not enough.  

Note:  We currently have a group of MI midwives working on revisions for a document that would thoroughly explain credentials and scope of practice.  We will share soon! 

Tuesday, November 6, 2012

What We're Seeking: Safety Protocols for Out of Hospital Birth

Out-of-hospital birth should be an option for low risk pregnancies, and it should be practiced within a defined scope of practice, by educated, licensed care providers.  Some of the major problems with this, lie in the fact that MI has no guidelines for defining low-risk versus high-risk, for defining scope of practice for midwives practicing outside the hospital, or for establishing standards for minimum education/training for the midwives practicing in this setting.  In order for out-of-hospital birth to be a reliable option for women, these critical components of safe care must change.

Women deserve to know about risks up front.  They also deserve to be appropriately monitored and screened in the name of "preventable" trauma. 

Does out-of-hospital birth carry more risks than a birth in the hospital setting?
Yes, by proximity aloneNot to mention the direct impact of the skill set of a given care provider.  In MI "midwife" can mean a million different things. 

Do care givers practicing outside the hospital (or anywhere for that matter) have a responsibility to acknowledge and appreciate their limitations?
Yes.  This is even more important for those serving women and babies outside the hospital since risks are higher.

Women need to understand that a cesarean is not the worst case scenario, that a dead or injured baby is far, far worse.  Risk matters.  It's evaluated for a reason, and should be a respected.  Any ethical care giver that gives one iota about the safety of the mother and baby she is "serving", would value risks, and the assessments that come along with that to ensure that every precaution is being taken to protect mom and baby from harm, preventable harm. 

In many other countries, all midwives are minimally trained, educated and function by International Midwifery StandardsThey also have established absolute and non-absolute criteria that every midwife uses to determine risk, and thereby evaluate the safety of a given set of circumstances.  Take a moment to view the link above that lists many complications and clinical scenarios in which a midwife must either consult with a physician, or in severe circumstances, risk her client out for obstetrical care.  The link compares Dutch home birth standards to Oregon's mandated standards.

Let me be very clear that Michigan has NO such mandates for transfer of care.  We have NO absolute or non-absolute criteria that out-of-hospital midwives use to consistently evaluate and risk out in dangerous situations.  We have NO protocols for transfer of care or consultation.  This is what makes out of hospital birth infinitely more dangerous in our state.  The worst part?  It doesn't have to be this way.  We don't have to reinvent the wheel, we just need to be responsible about the care we are offering women.  We need to function as professionals with standards, and consistent guidelines for practice.  We need to prevent the preventable, and folks, that is not happening here. 

If my family had lived in the Netherlands or Canada, our breech presenting baby would have been risked out or given a "trial of labor" in the hospital, with our midwife and physician present.  If I had lived in Florida, Arizona, Oregon (or others), we would have risked out, likely ending with a cesarean and a living baby boy.  In MI, with no protocols for transfer of care?  Well, our midwives could tell us, and do whatever they wanted.  The result?  Our baby died in a botched, out-of-hospital breech delivery with midwives who didn't know what they were doing.  No evaluation or explanation of risk.  No informed consent.  No suggestions that we consult with a physician.  No physician or emergency staff on site.  No consequences for their actions since there are no mandates to which they are expected to adhere.

Instead?  We were sold on lies and misrepresentations of how great it would be for us, and for our baby, by the people we trusted most.  After all, "birth works" right?  "We were made to do this."  "Moms know how to give birth, and babies know how to be born."  You've heard it all before, sorry to be redundant.  My point is that midwives here can preach whatever they want, and abide by no rules.  It's a toxic concoction, and a disgraceful abuse of what midwifery was intended to be.  Out-of-hospital birth in Michigan is not being practiced safely.  Babies are dying and being injured that don't need to be, and wouldn't be if we lived across state lines, or if we simply had appropriate guidelines.   I still ask myself every single day, "How can this happen in today's world?"  "Why are people allowed to practice so recklessly?"  And these practices continue...

If out-of-hospital birth is to be as safe as it can be, then we need to define parameters for this kind of care.  Who attends these births, and what should their training be minimally?  What defines "low-risk" versus "high risk" and how should it be evaluated?  What clinical situations would make out-of-hospital birth a dangerous prospect?  How can out-of-hospital birth be safer?  What should absolute and non-absoulute criteria be for Michigan?  Why is the expectation anything less that out-of-hospital birth being as safe as possible for Michigan families?  Michigan mothers must expect more, and Michigan midwives must do better. 

For more:
The Importance of Defining Risk