Many of our blog readers have followed our personal story, and have periodically asked for updates. For those who are new here, you can learn more about Magnus's birth here, and subsequent ripple effects here. There were many important facts that surfaced in the months after Magnus's death, that helped us see that his birth, and death were preventable. We knew things were very wrong, and we knew that we had to stand up for our family, for our son's right to be alive.
This began a journey toward seeking accountability. With no clear resource, or way forward we did four things:
a) Filed a civil lawsuit with a medical malpractice attorney
b) Filed an allegation with the State of MI (for the two licensed nurse midwives involved)
c) Reported our case to the police, asking for criminal ivestigation
d) Filed an allegation with the North American Registry of Midwives (for the unlicensed
CPM involved)
I'd like to take a moment to update our readers on how things are going, and most importantly to share with the public that the State has officially filed an "Administrative Complaint". I'll explain what that means momentarily.
Civil Case
Our civil lawsuit is continuing for only one of the three midwives involved. All of the midwives filed bankruptcy to avoid civil accountability, as did the "business" known as The Greenhouse Birth Center. Apparently this is common strategy among midwives, as it puts and "automatic stay" on the civil case, AND the civil case gets dropped as a result of bankruptcy...if the family pursuing accountability doesn't pay thousands of dollars to fight against it in bankruptcy court. We had to decide where to put our money and time, and could "object" formally to only one of three filings because it is so expensive. Hence, one midwife of the three will still have to deal with us in civil proceedings.
We're grateful that we were able to find a civil lawyer to represent us from the start. That is not the case for many families I know. When midwives don't carry malpractice insurance, many lawyers won't touch a case because they will never be paid for the countless hours they spend on that case. And, as you can see, many families cannot afford to object to the games midwives play to avoid accountability.
Criminal Investigation
Many of you know, the police investigation was turned over to the county prosecutor, who told us there are no laws in MI for midwives, meaning they can't charge for something that doesn't exist. They also don't take cases they don't think they can win, even if they believe a crime has been committed. The analogy given was that if drunk driving weren't illegal, then they couldn't prosecute if there weren't laws against it. For us, that turned out to be a dead end, at least for now.
NARM
As soon as a civil lawsuit is filed, NARM then stops the process of reviewing allegations of negligence. Why? Who knows? Apparently they look to someone else, namely the court to hold their "professionals" accountable. So again, this went nowhere.
The State of Michigan
The State has conducted an investigation, and turned our case over to the Attorney General's office for review. After they completed their review, they determined that the Public Health Code was indeed violated, and there by filed an "Administrative Complaint". Evidence of this decision can be found by anyone who visits www.michigan.gov, and verifies a license for Clarice Winkler or Shelie Ross. (Links below)
Clarice Winkler, CNM
Shelie Ross, CNM
(Note: The only reason you can verify a license for these two midwives is b/c they are CNMs, licensed by the state of MI. There is NO database to check a CPMs history of discipline or outcomes.)
(Another Note: The tricky part is that several licenses are listed for each midwife. Clarice Winkler's complaint and former probation, are listed under her "nursing license", NOT her midwife license. Shelie Ross's complaint is listed under her midwife license.)
Where things go from here is anyone's guess. A conference will be held to see if the Attorney General and the midwives can agree upon appropriate sanctions, that potential sanctions have to be approved by the Board of Nursing. If they cannot agree, then we go to a state hearing, for sanctions to again be determined...and again, proposed sanctions have to be approved by the Board of Nursing. This is why a balanced board of oversight is so critically important. At this point, we're just grateful that the state is carefully looking at this situation, and trying to hold at least some of the people involved, accountable for their actions.
The frustrating piece is that each and every one of these midwives is STILL delivering babies, nearly two years after Magnus's death. Other babies have died. Other babies have been injured in that time, yet they still continue to practice without consequence. It has taken nearly two years for the government to post that there is a complaint in process, and I wonder how many mothers even know where to find that information before they hire these midwives.
And furthermore, even if the state decided tomorrow to revoke their licenses...they can STILL deliver babies in MI. How? Well, you see, there are no laws that say you have to be a licensed midwife in MI. Hell, there are no laws that even define what a midwife is in MI.
So, with a professional organization (NARM) that doesn't hold its member accountable, a civil system that rarely works for these cases, and a state that has no laws, accountability is all but extinct. MI is a perfect hide out for any midwife who wants to fly under the radar. It's a scary place for OOH birth, and what gets me the most is that it doesn't have to be that way. We could have a much, much safer set of guidlines and practices that would offer families OOH birth options, with safety at the forefront. We could have measures of accountability, and standards for education. Instead MI is a hotbed for anyone who wants to call herself "midwife" and market her "services" to an unsuspecting public.
Why MI families aren't demanding better options and higher standards for OOH birth? That I can't answer. Perhaps it is because it is so difficult to actually know what is going on behind the scenes. Perhaps it is too difficult for those who had good outcomes in OOH birth to consider the risks they took/escaped, or to even fathom the idea that things aren't quite right until you personally experience the "other side". There is no real, or honest transparency in OOH birth. There is however, a lot of marketing, play on fear, and outright indoctrination going on. Michigan families deserve better options.
Thursday, February 28, 2013
Wednesday, February 27, 2013
What does "progress" mean to you?
What does "progress" mean to you? For the Safer Midwifery for Michigan team, progress means respecting birth, valuing safe choices, and improving outcomes. We want to build a resource that enables families anywhere to make the safest choices possible. Help us make a difference by supporting our campaign.
31 Days left to make your contribution to a better birth resource!
31 Days left to make your contribution to a better birth resource!
Monday, February 25, 2013
It's Here!!! The Safer Midwifery for Michigan Website Initiative!!!
Please visit our Indie Go-go Campaign Page to learn about this project and some of the ways that you can help. We will update you on our campaign progress right here on the blog each Thursday. You can also find more frequent updates on Facebook and Twitter.
Here's a little video preview to learn more about why this project matters:
The best way to support this effort is to spread the word. You can share the campaign itself on Facebook or send it to your friends and family through email. We need your help. Please share like hotcakes, let those you care about know why this matters to you, and keep your contacts updated on our progress.
If anyone reading here would like to add our campaign widget to their blog or website for the next 30 days to help us spread the word, you can find the code required right under the Share this campaign section on the campaign home page. Please get in touch if you have questions about how to get things working. We thank you in advance for this great gesture of support!
Many, many thanks from our hearts to yours for supporting this much needed resource!
Thursday, February 21, 2013
Big Announcement: Building A Resource
After 10 months of writing this blog, many women from across the country have contacted us with concerning stories that happened to them, to family members, to colleagues. It has become very clear that families need better resources, more accurate information, and improved support when it comes to considering out of hospital birth.
Introducing our Website Project!
We'd like to help with that by designing a whiz-bang, professional website that will serve the public in a variety of ways. One of the main purposes of the website will be to help women learn about their options, what they mean, who to consider hiring, risk factors, and address the central issues in choosing OOH birth. We want families to have accurate information on a wide variety of related topics that will enable them to make the most informed decisions possible about how and where to give birth.
Another component of our website will be to offer support to families who have received questionable care. If you suspect negligence, where can you turn for help? If you have a baby in the RNICU, or have lost a baby, what kinds of support networks are available for you? We want to house resources in one place that will help families navigate already trying times and get the help they need.
The third major component to our website project will be a section devoted to legislation and how it will potentially impact your care for the immediate and long-term future. We'll have information about current laws related to midwifery, bill reviews, contact information for legislators, and more, to help you have a voice on this important issue. This section will initially be tailored to MI law, but we are open to inviting contributors who would like to provide this information from across the country.
The website project has many more features, but we thought just introducing the overview would be a good start. We want this project to be exemplary, credible, and professional. We are employing perspectives from families, midwives, doulas, and doctors in the creation of this great resource. We can't do it alone. We need your help. Keep reading to learn more!
Action Plan
➨ Raise money for the project via Indie Go-Go Fundraiser
We are going to use Indie-Go-Go to run a campaign to fund this project.
➨ Build the website and work on content
We are going to work with Artemis Solutions Group, a local web design company.
➨ Publish the website and go live!
How You Can Help
1) Watch for the Indie-Go-Go Campaign to be announced on MONDAY! Share it with everyone you know. Consider making a donation of any size. Every penny helps us move toward our goal of offering better resources for families considering out of hospital birth.
2) Share our campaign updates on your FB page, twitter, and email friends and family.
3) Visit the new website often. Share it. Recommend it to friends. Read the blog to stay up to date on current events.
Thank you!
Introducing our Website Project!
We'd like to help with that by designing a whiz-bang, professional website that will serve the public in a variety of ways. One of the main purposes of the website will be to help women learn about their options, what they mean, who to consider hiring, risk factors, and address the central issues in choosing OOH birth. We want families to have accurate information on a wide variety of related topics that will enable them to make the most informed decisions possible about how and where to give birth.
Another component of our website will be to offer support to families who have received questionable care. If you suspect negligence, where can you turn for help? If you have a baby in the RNICU, or have lost a baby, what kinds of support networks are available for you? We want to house resources in one place that will help families navigate already trying times and get the help they need.
The third major component to our website project will be a section devoted to legislation and how it will potentially impact your care for the immediate and long-term future. We'll have information about current laws related to midwifery, bill reviews, contact information for legislators, and more, to help you have a voice on this important issue. This section will initially be tailored to MI law, but we are open to inviting contributors who would like to provide this information from across the country.
The website project has many more features, but we thought just introducing the overview would be a good start. We want this project to be exemplary, credible, and professional. We are employing perspectives from families, midwives, doulas, and doctors in the creation of this great resource. We can't do it alone. We need your help. Keep reading to learn more!
Action Plan
➨ Raise money for the project via Indie Go-Go Fundraiser
We are going to use Indie-Go-Go to run a campaign to fund this project.
➨ Build the website and work on content
We are going to work with Artemis Solutions Group, a local web design company.
➨ Publish the website and go live!
How You Can Help
1) Watch for the Indie-Go-Go Campaign to be announced on MONDAY! Share it with everyone you know. Consider making a donation of any size. Every penny helps us move toward our goal of offering better resources for families considering out of hospital birth.
2) Share our campaign updates on your FB page, twitter, and email friends and family.
3) Visit the new website often. Share it. Recommend it to friends. Read the blog to stay up to date on current events.
Thank you!
Tuesday, February 19, 2013
Why is OOH Birth Risky Business?
If your midwife told you the truth about the "true emergencies" that can creep up during labor and delivery, you may think twice before you choose to pursue your dream home birth. The point of this post is not to scare you away from home birth, nor is it meant to scare you heading into labor. The point is to be honest about what can and does come up during labor and delivery, so that women can make a fully informed choice about where to have their babies.
Safer Midwifery for Michigan is advocating for women to have a safer options in out of hospital birth, but we're honest that if this is truly a choice that a woman is to make, she deserves to be informed that OOH birth is inherently riskier than being in a hospital. If a midwife only tells a mother how her body was made to give birth, that babies know when/how to be born, and that if she (the mother) believes/tries hard enough, things will be fine...she is very much misleading her client.
Instead, what every midwife should be telling every mother is to appreciate the beauty of birth, but to also know it doesn't go perfectly for every mother who "opens herself up to let birth happen". For too many of mothers, the result is devastating when they convince themselves the chances of things going wrong are slim, and it won't happen to them. Mothers deserve to know the truth, no matter how scary it is, because that is the only way they can make an informed choice about where to have their babies. Ignoring the risks, and pretending that birth is always natural, and peaceful, is misleading and wrong. Filling a mother's head full of fear and lies about what awaits them if they go to a hospital, is also maliciously wrong.
In any birth, regardless of location, "true emergencies" come up in an instant. "True emergencies" are those that cannot always be detected ahead of time, but need immediate medical attention. (Note: Immediate in this case does not mean an ambulance ride to a hospital that is "only" minutes away.)
Placental Abruption
Uterine Rupture (Primary)
Uterine Rupture (HBAC ~ Story coming soon)
Uterine Rupture (VBAC @ hospital)
Cord Prolapse
Shoulder Dystocia
Post Partum Hemorrhage
Neonatal GBS Sepsis
Vasa Previa
Amniotic Embolism
I think the lacking transparency in what can go wrong, is largely why so many loss moms feel as though they have been duped, swindled, fooled, or manipulated. They are only told how great home birth can be, convinced that it is superior because they are "educating" themselves, and told that it is safe. They were not told about "true emergencies" that can come up, or how their lack of immediate care will impact the outcome, likely because the midwife doing the "informing" didn't want to scare her client. The problem lies though, in the fact that a woman cannot possibly make a "choice" to have a home birth, if she does not have all the information she needs to actually make a choice. The illusion that home birth is somehow safer than anything else, regardless of risk factors, is being perpetuated to the most vulnerable... pregnant mothers who only want what is best for their babies.
"But wait a minute, OBs don't tell their patients about everything that can go wrong!" True, often they don't. The difference though, is that an OB is medically and surgically trained, working in a facility equipped to handle those true emergencies at a moment's notice. A home birth midwife is not, yet she is knowingly advertising her services as safe without discucssing accurately those added risks a mother is choosing when she decides to have her baby outside a hospital. It seems to me that midwives have even more of an obligation to be forth coming about increased risks and limitations for addressing emergencies, if they are supporting women in out of hospital birth.
Usually a midwife's informed consent reads VERY general, and that's intentional. It's a blanket "You agree that by having a home birth you are assuming any & all responsibility for the outcome of your birth". They make you sign that it's on you no matter what. Then they don't HAVE to tell you what you don't know, because, "Mama...you should have done your research".
I trusted birth. I believed my body and my baby could do it. I trusted my midwives, and did every bit of homework I could to choose the "right" midwives. Believing it was safe, we chose to have our baby at a freestanding birth center. My baby died. So how does anyone look me in the face and tell me that "birth works"? The truth is we cannot "trust" birth, because it doesn't always magically work. Maybe if midwives told their clients that usually birth works, but sometimes babies die in the end, and we have limited options for how we can help you when an emergency arises, it would be a more accurate statement. It's more about respecting birth, appreciating/assessing risks along the way, and fully understanding that emergencies can and do come up. Where you are birthing your baby matters in an instant, often in a way that cannot be detected ahead of time, and cannot be handled with any kind of fighting chance if you happen to be without immediate medical care.
If you're considering an OOH birth, you have every right to do so. We hope this post has at least helped you better understand that there are risks involved in that choice, and those risks are magnified by the environment in which you choose to birth. No, birth doesn't always end well, no matter where you have your baby, but there are many life saving measures that can and do happen at the hospital, that cannot be done at home no matter how wonderful your midwife might be. It's the preventable deaths and injuries that don't get prevented that make home birth especially risky business.
Please also consider the following links:
Questions to ask your midwife
The Complicated Task of Choosing a Safe Midwife
Checks and Balances
The Delicate Risk Between Assessment & Safety
Routine Care During Pregnancy
The Importance of Defining Risk
Is Your Midwife Insured?
Safer Midwifery for Michigan is advocating for women to have a safer options in out of hospital birth, but we're honest that if this is truly a choice that a woman is to make, she deserves to be informed that OOH birth is inherently riskier than being in a hospital. If a midwife only tells a mother how her body was made to give birth, that babies know when/how to be born, and that if she (the mother) believes/tries hard enough, things will be fine...she is very much misleading her client.
Instead, what every midwife should be telling every mother is to appreciate the beauty of birth, but to also know it doesn't go perfectly for every mother who "opens herself up to let birth happen". For too many of mothers, the result is devastating when they convince themselves the chances of things going wrong are slim, and it won't happen to them. Mothers deserve to know the truth, no matter how scary it is, because that is the only way they can make an informed choice about where to have their babies. Ignoring the risks, and pretending that birth is always natural, and peaceful, is misleading and wrong. Filling a mother's head full of fear and lies about what awaits them if they go to a hospital, is also maliciously wrong.
In any birth, regardless of location, "true emergencies" come up in an instant. "True emergencies" are those that cannot always be detected ahead of time, but need immediate medical attention. (Note: Immediate in this case does not mean an ambulance ride to a hospital that is "only" minutes away.)
Placental Abruption
Uterine Rupture (Primary)
Uterine Rupture (HBAC ~ Story coming soon)
Uterine Rupture (VBAC @ hospital)
Cord Prolapse
Shoulder Dystocia
Post Partum Hemorrhage
Neonatal GBS Sepsis
Vasa Previa
Amniotic Embolism
I think the lacking transparency in what can go wrong, is largely why so many loss moms feel as though they have been duped, swindled, fooled, or manipulated. They are only told how great home birth can be, convinced that it is superior because they are "educating" themselves, and told that it is safe. They were not told about "true emergencies" that can come up, or how their lack of immediate care will impact the outcome, likely because the midwife doing the "informing" didn't want to scare her client. The problem lies though, in the fact that a woman cannot possibly make a "choice" to have a home birth, if she does not have all the information she needs to actually make a choice. The illusion that home birth is somehow safer than anything else, regardless of risk factors, is being perpetuated to the most vulnerable... pregnant mothers who only want what is best for their babies.
"But wait a minute, OBs don't tell their patients about everything that can go wrong!" True, often they don't. The difference though, is that an OB is medically and surgically trained, working in a facility equipped to handle those true emergencies at a moment's notice. A home birth midwife is not, yet she is knowingly advertising her services as safe without discucssing accurately those added risks a mother is choosing when she decides to have her baby outside a hospital. It seems to me that midwives have even more of an obligation to be forth coming about increased risks and limitations for addressing emergencies, if they are supporting women in out of hospital birth.
Usually a midwife's informed consent reads VERY general, and that's intentional. It's a blanket "You agree that by having a home birth you are assuming any & all responsibility for the outcome of your birth". They make you sign that it's on you no matter what. Then they don't HAVE to tell you what you don't know, because, "Mama...you should have done your research".
I trusted birth. I believed my body and my baby could do it. I trusted my midwives, and did every bit of homework I could to choose the "right" midwives. Believing it was safe, we chose to have our baby at a freestanding birth center. My baby died. So how does anyone look me in the face and tell me that "birth works"? The truth is we cannot "trust" birth, because it doesn't always magically work. Maybe if midwives told their clients that usually birth works, but sometimes babies die in the end, and we have limited options for how we can help you when an emergency arises, it would be a more accurate statement. It's more about respecting birth, appreciating/assessing risks along the way, and fully understanding that emergencies can and do come up. Where you are birthing your baby matters in an instant, often in a way that cannot be detected ahead of time, and cannot be handled with any kind of fighting chance if you happen to be without immediate medical care.
If you're considering an OOH birth, you have every right to do so. We hope this post has at least helped you better understand that there are risks involved in that choice, and those risks are magnified by the environment in which you choose to birth. No, birth doesn't always end well, no matter where you have your baby, but there are many life saving measures that can and do happen at the hospital, that cannot be done at home no matter how wonderful your midwife might be. It's the preventable deaths and injuries that don't get prevented that make home birth especially risky business.
Please also consider the following links:
Questions to ask your midwife
The Complicated Task of Choosing a Safe Midwife
Checks and Balances
The Delicate Risk Between Assessment & Safety
Routine Care During Pregnancy
The Importance of Defining Risk
Is Your Midwife Insured?
Tuesday, February 12, 2013
Five Surprising Things You Should Know About the Birth Center Study
If you're involved with midwifery at all, you may have heard about a study that was recently published in the Journal of Midwifery and Women's Health. Outcomes of Care in Birth Centers: Demonstration of a Durable Model has been touted as a "Landmark Study" confirming the safety and cost-effectiveness of birth centers in the US. We read the study, and found some interesting details that many people are not aware of. We support out of out-of-hospital birth attended by licensed, qualified midwives. We expect out-of-hospital providers to adhere to standards that make midwifery safer. This study, on the surface, appears to confirm that, but we would like you to know some things that we think you should know.
1) It doesn't demonstrate a reduction in c-section rates
This study did not actually compare two groups of expecting women and determine a cause and effect relationship. If the study had done this - they could provide some evidence to support the statement that giving birth in a midwife-led birth center lowers the c-section rate. The study was a descriptive study - one where they examined one group of women, in this case, low-risk women giving birth at birth centers, and described the results. The reported c-section rate was about 6% in this study. A better comparison group (even though it still doesn't prove anything) would be to women giving birth with CNMs in hospitals. The ACNM tracks this data, and in 2010, the estimated c-section rate for CNM-attended births in the hospital was between 9-10.7%.
Comparing a 6% c-section rate with a 10% c-section isn't that compelling.
2) It doesn't describe outcomes for most US birth centers
The AABC estimates that there are approximately 248 freestanding birth centers in the US. This study was restricted to birth centers that had CABC accreditation, or those birth centers that agreed to abide by the same standards as accredited birth centers. Only 79 birth centers from 33 states contributed data to this study. The publicity surrounding this study make broad claims about the safety of "birth centers."
Nowhere in the article did it discuss the estimated number of births that occurred in the known 248 birth centers during the same period, their standards of practice, or their outcomes.
The authors of the article weakly acknowledge that these results pertain only to those birth centers that follow the standards set forth by the AABC. But they gloss over the fact that an overwhelming majority of birth centers (~80%) in the US are not accredited, and have no impetus to follow these standards.
If less than a third of the birth centers contributed data to this study, and only about 20% of birth centers are accredited, how do we know if these good outcomes can be extrapolated to all birth centers?
A side-note for our Michigan readers: Greenhouse Birth Center is/was an AABC member. How do you think their "access to continuing education and support" as an AABC member influenced their practices?
3) It doesn't even describe outcomes for the practices included in the study (since homebirths were excluded)
There were only 35 home births included in the 3 year study with 15,574 births in 79 midwifery practices. Many birth centers offer home birth as well as birth center birth. The study says that only data from precipitous or unplanned home births were included. This makes sense, because 35 births is a considerably small percentage of births considering the size of the study, and the number of practices participating. So there must have been many more births in these practices - but they weren't counted because they were planned home births.
Would inclusion of the home birth data change the results? Did exclusion of the planned home births allow the "prohibited" (VBAmCs, twins, breech, post-dates) births to occur with the practice, but outside of the birth center?
4) It not only includes data from dicey places like The Birth Place in Taylor, Michigan. But also from birth centers that list services on their websites that were explicitly restricted by the study:
Examples:
CABC accredited center recommending the client transfer to "The Farm" for a vaginal breech birth:
CABC accredited center offering twins and breech deliveries:
CABC accredited center suggests a breech delivery to her birth center client with a breech because accreditation doesn't allow it to occur at the birth center:
We didn't go through the entire list of birth centers. Just a few. But we were surprised at how quickly we could find that multiple midwifery practices openly advertised these high-risk birth services.
For comparison, we'd like to show you an example of an accredited birth center that CLEARLY STATES that they abide by the CABC standards:
5) The "top notch" findings are only applicable if the birth centers follow strict standards
From the examples above, it's hard to know how many of the birth centers in the US, let alone those that participated in the study, are abiding by their own standards. And that's a shame. Because at Safer Midwifery, we believe there should be safe options for women wanting OOH births. We believe the standards set forth by the AABC and required for CABC accreditation are good standards. And we recognize that many accredited birth centers do follow these standards and provide excellent and safe care to their clients. But we're disappointed that they these standards appear to be so easily flouted and that families are left to figure out themselves whether their birth centers are truly safe.
Reference:
Stapleton, S. R., Osborne, C. and Illuzzi, J. (2013), Outcomes of Care in Birth Centers: Demonstration of a Durable Model. Journal of Midwifery & Women’s Health, 58: 3–14. doi: 10.1111/jmwh.12003
1) It doesn't demonstrate a reduction in c-section rates
This study did not actually compare two groups of expecting women and determine a cause and effect relationship. If the study had done this - they could provide some evidence to support the statement that giving birth in a midwife-led birth center lowers the c-section rate. The study was a descriptive study - one where they examined one group of women, in this case, low-risk women giving birth at birth centers, and described the results. The reported c-section rate was about 6% in this study. A better comparison group (even though it still doesn't prove anything) would be to women giving birth with CNMs in hospitals. The ACNM tracks this data, and in 2010, the estimated c-section rate for CNM-attended births in the hospital was between 9-10.7%.
Comparing a 6% c-section rate with a 10% c-section isn't that compelling.
2) It doesn't describe outcomes for most US birth centers
The AABC estimates that there are approximately 248 freestanding birth centers in the US. This study was restricted to birth centers that had CABC accreditation, or those birth centers that agreed to abide by the same standards as accredited birth centers. Only 79 birth centers from 33 states contributed data to this study. The publicity surrounding this study make broad claims about the safety of "birth centers."
Nowhere in the article did it discuss the estimated number of births that occurred in the known 248 birth centers during the same period, their standards of practice, or their outcomes.
The authors of the article weakly acknowledge that these results pertain only to those birth centers that follow the standards set forth by the AABC. But they gloss over the fact that an overwhelming majority of birth centers (~80%) in the US are not accredited, and have no impetus to follow these standards.
"The birth centers contributing data to the AABC UDS may have been different from those birth centers not contributing data. The study birth centers are AABC members and thus have access to continuing education activities and support the organization's model and Standards for Birth Centers. This potential difference means that the findings may not be generalizable to all birth centers."
If less than a third of the birth centers contributed data to this study, and only about 20% of birth centers are accredited, how do we know if these good outcomes can be extrapolated to all birth centers?
A side-note for our Michigan readers: Greenhouse Birth Center is/was an AABC member. How do you think their "access to continuing education and support" as an AABC member influenced their practices?
3) It doesn't even describe outcomes for the practices included in the study (since homebirths were excluded)
There were only 35 home births included in the 3 year study with 15,574 births in 79 midwifery practices. Many birth centers offer home birth as well as birth center birth. The study says that only data from precipitous or unplanned home births were included. This makes sense, because 35 births is a considerably small percentage of births considering the size of the study, and the number of practices participating. So there must have been many more births in these practices - but they weren't counted because they were planned home births.
Would inclusion of the home birth data change the results? Did exclusion of the planned home births allow the "prohibited" (VBAmCs, twins, breech, post-dates) births to occur with the practice, but outside of the birth center?
4) It not only includes data from dicey places like The Birth Place in Taylor, Michigan. But also from birth centers that list services on their websites that were explicitly restricted by the study:
Examples:
CABC accredited center recommending the client transfer to "The Farm" for a vaginal breech birth:
"The Birth Center wasn’t allowed to do breech births, so that meant that after preparing for months for a natural birth, we were looking at an automatic C-section. That just wasn’t acceptable to us, not without looking at our options."
"It was a very frustrating and stressful week, but luckily my midwives at the Birth Center recommended that I call the Farm Midwifery Center"
CABC accredited center offering twins and breech deliveries:
"Our midwives are experienced with twins and breeches. We ask that our clients wanting a twin and/or breech birth be well informed on the risks & benefits. We fully support women in their choice of how and with whom to birth their baby. For more information about breech birth studies and abstracts see our resources section."
CABC accredited center suggests a breech delivery to her birth center client with a breech because accreditation doesn't allow it to occur at the birth center:
"Because of the accreditation process for the birth center, we could not deliver a breech baby there. Because the current recommendations from ACOG are to c-section for breech presentation, we did not want to deliver at our local hospital and have an automatic c-section. So [the midwife] asked us to think about whether or not we would like a home birth."AABC study participating birth center (currently applying for accreditation) midwife moonlights with other area midwives to attend an OOH breech birth.
"I was privileged to help another midwife ... the birth of [a] seventh baby.... This was [the mother's] 7th home birth, but their first to come out breech!AABC study participating birth center loses ability to practice after a string of newborn deaths.
I was asked to come and help, but things went very smoothly and their was very little for me to do. I am so happy to have gotten to be part of this joyous birth. All my best wishes to a wonderful family!"
"The midwives acted in “serious, unprofessional” ways and broke the rules of their profession, the Board of Midwifery said. It suspended the Goodwins in the spring, after claims that the women acted wrongly while overseeing births."
"State investigators said the Goodwins delivered babies with dangerously low heartbeats, interfered with emergency hospital transfers, failed to send a woman to the hospital when she had persistent vomiting and diarrhea, and allowed a baby’s umbilical cord to hemorrhage blood."
We didn't go through the entire list of birth centers. Just a few. But we were surprised at how quickly we could find that multiple midwifery practices openly advertised these high-risk birth services.
For comparison, we'd like to show you an example of an accredited birth center that CLEARLY STATES that they abide by the CABC standards:
"[T]here are some very strict guidelines that risk women out of birthing at our birth center such as: Twins, breech presentation, labor before 37 weeks gestation, labor after 42 weeks gestation, certain medical conditions including but not limited to insulin dependent diabetes.. These are conditions that are best cared for in the hospital setting."From our internet research, unless a birth center specifically makes a statement like the one above, that "certain conditions are best cared for in the hospital setting" we're dubious about whether or not those birth centers will appropriately risk out their high-risk clients.
5) The "top notch" findings are only applicable if the birth centers follow strict standards
From the examples above, it's hard to know how many of the birth centers in the US, let alone those that participated in the study, are abiding by their own standards. And that's a shame. Because at Safer Midwifery, we believe there should be safe options for women wanting OOH births. We believe the standards set forth by the AABC and required for CABC accreditation are good standards. And we recognize that many accredited birth centers do follow these standards and provide excellent and safe care to their clients. But we're disappointed that they these standards appear to be so easily flouted and that families are left to figure out themselves whether their birth centers are truly safe.
Reference:
Stapleton, S. R., Osborne, C. and Illuzzi, J. (2013), Outcomes of Care in Birth Centers: Demonstration of a Durable Model. Journal of Midwifery & Women’s Health, 58: 3–14. doi: 10.1111/jmwh.12003
Thursday, February 7, 2013
Ask an OB: Rural Maternity Care
"Ask an OB" is our blog series with Dr. Maude "Molly" Gurein, MC, FACOG. If you have a question you'd like to ask her, please share it with us here.
Midwives like to talk about how they serve the rural population of MI, those folks that are 200 miles from the nearest hospital. Is this an issue that OBs are discussing? Is there a shortage of OB access for rural MI? If so, what are some potential solutions that are safe?
Midwives like to talk about how they serve the rural population of MI, those folks that are 200 miles from the nearest hospital. Is this an issue that OBs are discussing? Is there a shortage of OB access for rural MI? If so, what are some potential solutions that are safe?
Yes there is a shortage, the causes and solutions are complex. Until we change the whole structure of how we provide medical care in our country, this will remain an issue. Are untrained providers, with no access to immediate emergency care “better than nothing”? That’s a tough one.
I wonder what our readers think about this...
Tuesday, February 5, 2013
Where is the Leadership: Part 2
Part 2: This is the second in a two part series addressing lacking leadership for Michigan's out-of-hospital midwives. Today's focus reflects on the politics of appropriate legislation.
Some of Michigan's out-of-hospital midwives are using loss stories to push legislation, and they're doing it under the disguise of caring about safety. The truth, as demonstrated by the very bills they are lobbying for, is that safety is not the focus. Protecting midwives is the goal, as is obtaining reimbursement from state funded programs like Medicaid.
The following series of quotes come from Kate Mazzara, CPM, who is the current leadership at the Michigan Midwives Association. She is referencing the death of baby Alia Mushin, as a case that indicates the need for licensing in our state for CPMs.
(All of Kate's quotes are taken from the above linked article)
“We want to be licensed because we want to make sure there’s a standard of care.
That consumers are protected,” said Kate Mazzara.
The bills currently proposed to license CPMs in Michigan, (HB 5070, SB 1310) wouldn't change one thing about the standard of care. Instead, they propose to use the standards set forth by the North American Registry of Midwives, which are EXACTLY the same "standards" by which CPMs currently work under. Let me just remind readers that there really aren't any standards for practice, no risking out criteria, and a (only recently) high school diploma required as the minimum standard for education held by NARM, the credentialing body for CPMs. Furthermore, these "standards" do nothing to "protect consumers or families".
If the goal was truly about safety and protecting consumers, the bill would clearly define a MI midwife only as a licensed individual, set an appropriate minimum for educational training, require midwives to report outcomes, require state-issued informed consent (particularly regarding insurance), and propose specific criteria for risking out, to ensure that all OOH births were truly low-risk women. As it stands, NONE of those elements are included.
“I want to make sure that these moms and babies are birthing in a safe way, and
the midwifery model of care has been shown to be an extremely safe option for
families, but there should be that safety mechanism to which midwives can be held
accountable,” said Mazzara. Kate Mazzara is a Certified Professional Midwife,
and as a member of the Michigan Midwives Association, she’s trying to get
Lansing to pass a law to license midwives. Twenty-five other states already do
that, and a licensing board would then be able to hear complaints, and take
action against midwives if problems arise."
First of all, I'm not sure how anyone can honestly proclaim, "the midwifery model of care has been show to be an extremely safe option for families," when there is absolutely NO ONE collecting data on outcomes in the state of MI for OOH births. There is literally no evidence to support this claim, unless you are hijacking data that demonstrates CNMs, in hospitals have the best outcomes. This is a very different group of midwives than those pushing for this legislation. In fact, I wonder how many current CPMs would even qualify for licensing if data had been collected on their outcomes for the last 15 years, and if accountability had been a larger part of practices.
The people who have voluntarily reported infant deaths and injuries to our advocacy group in the State of MI, clearly demonstrate an alarming rate of deaths and injuries in the out-of-hospital birth sector, and this is only a tiny fraction of the out-of-hospital births taking place in our state. Any responsible legislator would require that the evidence demonstrating safety actually be collected before handing these "professionals" a license.
Kate is accurate about one thing, there is currently no effective mechanism currently in place to which OOH midwives are held accountable. We do however, already have a licensing board, called the Board of Nursing, which just so happens to be presently chaired by a midwife. This board currently provides the oversight for CNMs, regardless of place of practice. If a minimum standard for education for midwives were to be established in order to earn a state-issued license, then this board could easily provide the balanced oversight needed to license non-nurse midwives, and effectively protect the people. At present, anyone can call herself a midwife in MI, and consequently, the board can only offer oversight for those who choose to be licensed by meeting the educational requirements. Higher standards in education, mandatory licensing to practice midwifery, and a balanced board to provide oversight = safety for consumer. (Same low standards, no risking out criteria, and a biased board protecting themselves = a recipe for disaster.)
In stark contradiction to safety measures, proposed legislation in Michigan (that the Michigan Midwives Association supports and lobbies for), not only aims to license CPMs, but also establishes an entirely new board for the oversight of OOH midwives. They propose to establish a Board of Midwifery, composed primarily of CPMs, to replace the current Board of Nursing. Why the need for a new board if midwives are already represented on the Board of Nursing? Well, it's much like peer review. If you have a board of colleagues willing to cover for you, (instead of a balanced board of birth professionals) then the "cause" and the "sisterhood" can be more easily protected.
Let me give you a personal example. We filed a complaint with the State of MI, regarding the death of our infant son in 2011. The Board of Nursing approved our complaint for investigation. The State then thoroughly investigated our case, consulted experts in the field of midwifery, and determined that the Public Health Code had indeed been violated. They then turned it over to the Attorney General for further review. The Attorney General agreed that the Public Health Code had been violated, and officially filed what's called an "administrative complaint", including a range of possible sanctions for the actions of the two licensed midwives involved. The next step in the process is a conference at which the AG and the midwives, in which they have to agree upon sanctions, which THEN have to be approved by the Board of Nursing. If the Board does not agree, the sanctions don't take place. If they cannot reach an agreement, the State will hold a hearing, at which we would testify. The judge would suggest sanctions yet again, but they still have to be approved by the Board of Nursing.
The point? All accountability rests on the effectiveness of the board responsible for ethical oversight. No ethics = no accountability.
If our state establishes a Board of Midwifery, run by CPMs, there will be no opportunity for accountability. Our case likely would have never even been investigated had this been the case. The current process for reviewing cases in the OOH birth community is called Peer Review. Despite our complaint also being filed with the North American Registry of Midwives, no peer review was ever done, nor were any consequences whatsoever put into place. A Board of Midwifery will serve to protect midwives, just as the current peer review process does. It will not protect the families they serve in any way, shape or form. How do I know this? I've seen it time and time again in states across the US who have established Boards of Midwifery. These boards have dismissed severe cases of negligence, and actively worked to erode safety standards that protected the people.
Here are a few examples:
First, welcome to the Texas Board of Midwifery. Please note the laundry list of reckless behavior, and petty consequences being doled out as compensation for lives lost. To further illustrate the point, read Liz's Story about the birth of her baby, Aquila. Then you can visit her blog to read about her "hearing" with the Board of Midwifery for Texas. You can even listen to an audio account of the hearings themselves, where DEMs are actually boo-ing this mother for bringing her case before the board, and telling her, "You know, this won't bring your daughter back, don't you?" To save you time, let me point out clearly, that the Texas Board of Midwifery decided that an appropriate consequence for Aquila's death would be $500 and six months probation, despite obvious negligence.
"Beltz, Faith Midwife 04005 Austin 22 TAC §831.58, 831.65 and 831.131-Related to
failure to complete the Informed Choice and disclosure Form required by state law
for a client and failure to perform an initial evaluation on client and failed to initiate
immediate emergency transfer for chorio-amnionitis. 6 mo Probated Suspension
and $500 Administrative Penalty 2/7/11"
Does this seem like accountability, or am I crazy for thinking this consequence is unbelievably lacking for the extremely unprofessional, and incompetent care Liz and Aquila received? This midwife's collective failures resulted in Aquila's death here people! $500? Really?
Next, welcome to the Oregon Board of Midwifery, called the Board of Direct Entry Midwifery. In 1993, Oregon established a Board of Midwifery to act as the official oversight for LDMs and DEMs in their state. Licensing in Oregon is still voluntary. Over the last decade, this board has slowly eroded a number of provisions that were initially aimed at protecting the safety of mothers and babies, and repeatedly ignored negligent actions that have cost lives. Here is a summary of their appalling actions, as the blog author calls the board, "A joke, and a hazard to your health." Or you can peruse their "disciplinary actions" for more examples that illustrate paltry actions for severely unprofessional care.
As if that weren't enough, this board has had midwives resign over disagreement about the scarcity of accountability. Here is a letter of resignation by a CNM in Oregon, after the board refused to revoke a midwife's license for obvious negligence that cost a baby her life. Even other midwives are uncomfortable with how this board is functioning.
And to round out Ms. Mazzara's questionable perceptions:
"Mazzara and others insist the sad stories are rare, and that home births are a
beautiful, natural experience. "
Well Kate, we can't really know just how "rare" the sad stories really are when no one is collecting the data can we? The sad stories are covered up, or used as leverage. They become part of the dark webbing that forms the "sisterhood". A few slip out, but those moms are made to look as though they are crazy, bitter villains. Try a healthier perspective on for size:
"I would be much happier if everyone would truly hear what the women who have
been hurt are saying. If we don't do something about the bad midwives, the state
will do something for us. And as midwives, we aren't going to like what that is.
Couching important discussions, disguised as women's choice puts the onus on
childbearing women rather than on the profession providing care"
~ Anonymous Midwife
What would actually make OOH birth safer? Legislation that includes all of these:
Where is the leadership? Part 1
Some of Michigan's out-of-hospital midwives are using loss stories to push legislation, and they're doing it under the disguise of caring about safety. The truth, as demonstrated by the very bills they are lobbying for, is that safety is not the focus. Protecting midwives is the goal, as is obtaining reimbursement from state funded programs like Medicaid.
The following series of quotes come from Kate Mazzara, CPM, who is the current leadership at the Michigan Midwives Association. She is referencing the death of baby Alia Mushin, as a case that indicates the need for licensing in our state for CPMs.
(All of Kate's quotes are taken from the above linked article)
“We want to be licensed because we want to make sure there’s a standard of care.
That consumers are protected,” said Kate Mazzara.
The bills currently proposed to license CPMs in Michigan, (HB 5070, SB 1310) wouldn't change one thing about the standard of care. Instead, they propose to use the standards set forth by the North American Registry of Midwives, which are EXACTLY the same "standards" by which CPMs currently work under. Let me just remind readers that there really aren't any standards for practice, no risking out criteria, and a (only recently) high school diploma required as the minimum standard for education held by NARM, the credentialing body for CPMs. Furthermore, these "standards" do nothing to "protect consumers or families".
If the goal was truly about safety and protecting consumers, the bill would clearly define a MI midwife only as a licensed individual, set an appropriate minimum for educational training, require midwives to report outcomes, require state-issued informed consent (particularly regarding insurance), and propose specific criteria for risking out, to ensure that all OOH births were truly low-risk women. As it stands, NONE of those elements are included.
“I want to make sure that these moms and babies are birthing in a safe way, and
the midwifery model of care has been shown to be an extremely safe option for
families, but there should be that safety mechanism to which midwives can be held
accountable,” said Mazzara. Kate Mazzara is a Certified Professional Midwife,
and as a member of the Michigan Midwives Association, she’s trying to get
Lansing to pass a law to license midwives. Twenty-five other states already do
that, and a licensing board would then be able to hear complaints, and take
action against midwives if problems arise."
First of all, I'm not sure how anyone can honestly proclaim, "the midwifery model of care has been show to be an extremely safe option for families," when there is absolutely NO ONE collecting data on outcomes in the state of MI for OOH births. There is literally no evidence to support this claim, unless you are hijacking data that demonstrates CNMs, in hospitals have the best outcomes. This is a very different group of midwives than those pushing for this legislation. In fact, I wonder how many current CPMs would even qualify for licensing if data had been collected on their outcomes for the last 15 years, and if accountability had been a larger part of practices.
The people who have voluntarily reported infant deaths and injuries to our advocacy group in the State of MI, clearly demonstrate an alarming rate of deaths and injuries in the out-of-hospital birth sector, and this is only a tiny fraction of the out-of-hospital births taking place in our state. Any responsible legislator would require that the evidence demonstrating safety actually be collected before handing these "professionals" a license.
Kate is accurate about one thing, there is currently no effective mechanism currently in place to which OOH midwives are held accountable. We do however, already have a licensing board, called the Board of Nursing, which just so happens to be presently chaired by a midwife. This board currently provides the oversight for CNMs, regardless of place of practice. If a minimum standard for education for midwives were to be established in order to earn a state-issued license, then this board could easily provide the balanced oversight needed to license non-nurse midwives, and effectively protect the people. At present, anyone can call herself a midwife in MI, and consequently, the board can only offer oversight for those who choose to be licensed by meeting the educational requirements. Higher standards in education, mandatory licensing to practice midwifery, and a balanced board to provide oversight = safety for consumer. (Same low standards, no risking out criteria, and a biased board protecting themselves = a recipe for disaster.)
In stark contradiction to safety measures, proposed legislation in Michigan (that the Michigan Midwives Association supports and lobbies for), not only aims to license CPMs, but also establishes an entirely new board for the oversight of OOH midwives. They propose to establish a Board of Midwifery, composed primarily of CPMs, to replace the current Board of Nursing. Why the need for a new board if midwives are already represented on the Board of Nursing? Well, it's much like peer review. If you have a board of colleagues willing to cover for you, (instead of a balanced board of birth professionals) then the "cause" and the "sisterhood" can be more easily protected.
Let me give you a personal example. We filed a complaint with the State of MI, regarding the death of our infant son in 2011. The Board of Nursing approved our complaint for investigation. The State then thoroughly investigated our case, consulted experts in the field of midwifery, and determined that the Public Health Code had indeed been violated. They then turned it over to the Attorney General for further review. The Attorney General agreed that the Public Health Code had been violated, and officially filed what's called an "administrative complaint", including a range of possible sanctions for the actions of the two licensed midwives involved. The next step in the process is a conference at which the AG and the midwives, in which they have to agree upon sanctions, which THEN have to be approved by the Board of Nursing. If the Board does not agree, the sanctions don't take place. If they cannot reach an agreement, the State will hold a hearing, at which we would testify. The judge would suggest sanctions yet again, but they still have to be approved by the Board of Nursing.
The point? All accountability rests on the effectiveness of the board responsible for ethical oversight. No ethics = no accountability.
If our state establishes a Board of Midwifery, run by CPMs, there will be no opportunity for accountability. Our case likely would have never even been investigated had this been the case. The current process for reviewing cases in the OOH birth community is called Peer Review. Despite our complaint also being filed with the North American Registry of Midwives, no peer review was ever done, nor were any consequences whatsoever put into place. A Board of Midwifery will serve to protect midwives, just as the current peer review process does. It will not protect the families they serve in any way, shape or form. How do I know this? I've seen it time and time again in states across the US who have established Boards of Midwifery. These boards have dismissed severe cases of negligence, and actively worked to erode safety standards that protected the people.
Here are a few examples:
First, welcome to the Texas Board of Midwifery. Please note the laundry list of reckless behavior, and petty consequences being doled out as compensation for lives lost. To further illustrate the point, read Liz's Story about the birth of her baby, Aquila. Then you can visit her blog to read about her "hearing" with the Board of Midwifery for Texas. You can even listen to an audio account of the hearings themselves, where DEMs are actually boo-ing this mother for bringing her case before the board, and telling her, "You know, this won't bring your daughter back, don't you?" To save you time, let me point out clearly, that the Texas Board of Midwifery decided that an appropriate consequence for Aquila's death would be $500 and six months probation, despite obvious negligence.
"Beltz, Faith Midwife 04005 Austin 22 TAC §831.58, 831.65 and 831.131-Related to
failure to complete the Informed Choice and disclosure Form required by state law
for a client and failure to perform an initial evaluation on client and failed to initiate
immediate emergency transfer for chorio-amnionitis. 6 mo Probated Suspension
and $500 Administrative Penalty 2/7/11"
Does this seem like accountability, or am I crazy for thinking this consequence is unbelievably lacking for the extremely unprofessional, and incompetent care Liz and Aquila received? This midwife's collective failures resulted in Aquila's death here people! $500? Really?
Next, welcome to the Oregon Board of Midwifery, called the Board of Direct Entry Midwifery. In 1993, Oregon established a Board of Midwifery to act as the official oversight for LDMs and DEMs in their state. Licensing in Oregon is still voluntary. Over the last decade, this board has slowly eroded a number of provisions that were initially aimed at protecting the safety of mothers and babies, and repeatedly ignored negligent actions that have cost lives. Here is a summary of their appalling actions, as the blog author calls the board, "A joke, and a hazard to your health." Or you can peruse their "disciplinary actions" for more examples that illustrate paltry actions for severely unprofessional care.
As if that weren't enough, this board has had midwives resign over disagreement about the scarcity of accountability. Here is a letter of resignation by a CNM in Oregon, after the board refused to revoke a midwife's license for obvious negligence that cost a baby her life. Even other midwives are uncomfortable with how this board is functioning.
And to round out Ms. Mazzara's questionable perceptions:
"Mazzara and others insist the sad stories are rare, and that home births are a
beautiful, natural experience. "
Well Kate, we can't really know just how "rare" the sad stories really are when no one is collecting the data can we? The sad stories are covered up, or used as leverage. They become part of the dark webbing that forms the "sisterhood". A few slip out, but those moms are made to look as though they are crazy, bitter villains. Try a healthier perspective on for size:
"I would be much happier if everyone would truly hear what the women who have
been hurt are saying. If we don't do something about the bad midwives, the state
will do something for us. And as midwives, we aren't going to like what that is.
Couching important discussions, disguised as women's choice puts the onus on
childbearing women rather than on the profession providing care"
~ Anonymous Midwife
What would actually make OOH birth safer? Legislation that includes all of these:
- Establishing an appropriate minimum standard for education (International Standards)
- Defining "midwife" and limiting the practice of midwifery to only those who are licensed
- Keeping a balanced board as the body of oversight at the state level
- Gathering data on all OOH birth outcomes
- State-issued informed consent documents, that disclose malpractice insurance among other things (Ex: Wisconsin's Mandatory Informed Consent for every licensed midwife in the state. It's not perfect, but it's so much better than nothing, like we have here in MI. That's another blog post!)
Where is the leadership? Part 1