Is HB5070 for Safer Midwifery?

With much debate in recent months about proposed legislation that would regulate Michigan midwives, the question of safety remains paramount.  We've written numerous times on this blog about HB 5070 and all of the reasons why it would do more harm than good.  I'd like to address the difference between legislation that will directly protect midwives versus legislation that would directly protect consumers, people, mothers, & families.  (And can I just briefly note, it's not the midwives who are losing their lives in these situations.) 

I have to start then with why non-nurse midwives (CPMs in this case) would want to be licensed through the state in the first place, and further why Representative Ed McBroom would support the notion. For midwives, the key components of having a state issued license is that they can then be reimbursed for medicaid.  For some bizarre reason, they also think this will prevent them from being charged in the criminal court system.  I don't see that connection, because license or not, gross negligence is gross negligence...manslaughter is manslaughter...and practicing medicine without a license is practicing medicine without a license.  A state issued license doesn't protect anyone from criminal charges, whether you believe they are warranted or not.  The third reason non-nurse midwives would like a license is that it would earn them status in some circles, on par with that of holding the same license and practice rights as nurse midwives.  

Let me just point out that nurse midwives have a bachelors degree in nursing and have gone to at least two years of graduate school in midwifery.  They are advanced practice nurses, with extensive clinical training, scope of practice guidelines, and on and on.  Non-nurse midwives however are "educated" in a variety of ways, most not earning a degree of any kind and learning midwifery "apprentice" style.  The exception are Certified Midwives, those who have a bachelors degree in something other than nursing, then attend graduate school for midwifery.  HB 5070 does not address licensing for these midwives to my knowledge.  

What then about Representative McBroom's motivation?  I'm not sure if it's really motivation as much as a lifestyle choice for him.  He comes from a farming family in the rural Upper Peninsula, where there is an extreme shortage of OBs on hand.  His mother had her babies at home, and he and his wife have successfully had their four babies at home, one being breech, and the most recent arrived just this summer.  I think he sees a need for licensed midwives and competent caregivers to serve the women of rural Michigan.  While I agree with the idea, our definition of "competent" differs slightly.  I'll remind readers that two of the four midwives present at our out of hospital birth were nurse midwives, and it still ended in disaster.  This issue is about more than education and licensing.  For that reason, there are several guidelines that need to be added to this bill if the primary goal is to improve safety for those that choose out of hospital birth.  I also think there are many details that need to be addressed and deleted from this bill in the way it is presently written. 

The point of this bill should be to offer licensed, competent, accountable midwifery services for families in MI, with safety at the forefront.  The good news is that Representative McBroom plans to revise his bill for resubmission this fall.  Here are Safer Midwifery for Michigan's suggestions for what would actually preserve choice as to where to have your baby, but would provide appropriate guidelines to help those who do choose out of hospital birth to do so as safely as possible:  (Note, these guidelines are on par with Canada and Europe, but a far cry from the low expectations for midwifery education and practices in the US, particularly MI.) 

1) Licensing:  A license should determine who can use the term "midwife".  Earning a license should define "midwife" as a licensed professional with a specific body of skills and knowledge according to minimum standards for education, and a defined scope of practice. 

2) Minimum Standards for Education: Establishing minimum standards for education is critical to improving consistency in quality of care, and ensuring that those who are advertising themselves as professionals have met a minimum standard for training.  International standards (CNM or a CM as the non-nursing alternative) should be the absolute minimum acceptable education and training for any licensed midwife. 

3) Defined Scope of Practice: Define scope of practice for out of hospital birth, as attending only low-risk births, and further specify the proper steps to screen, evaluate, and risk out any woman whose pregnancy becomes high risk.  The board providing oversight should promulgate risking out criteria and transfer of care protocols, thereby defining "high risk".   

4) Report Outcomes: Mandate that all out of hospital midwives report their outcomes to the state, even in the event of hospital transfer. 

5) Malpractice Insurance:  Require out of hospital midwives to carry medical malpractice insurance, like their in-hospital counterparts.  If they are licensed, it's affordable.  (Or, at the very least, the board providing oversight should draft a state-wide informed consent document that discloses whether or not a midwife carries malpractice insurance, as many other states do.) 

6) Define "Birthing Center": Every "birth center" in MI should be required to be a licensed facility, and responsible for hiring only licensed midwives as defined above.  

7) Establish a "Balanced" Board:  Establish a balanced board within Licensing and Regulatory Affairs that includes majority midwives, OBs, family practice doctors, and citizens to establish practice guidelines, collect data on outcomes, and review cases of questionable care for out of hospital birth is critical in establishing fair and balanced oversight. 

I do think it's possible to write legislation that both, protects midwives and the families they serve.  SB 1208 is the closest we've come to that, despite differences of opinion.  I hope that Representative McBroom can thoughtfully hear the stories of families that have been put in harm's way, and revise his bill thoroughly.  Michigan's families deserve competent, accountable care, no matter what part of MI is their home.  This isn't just about choice, it's about having safe choices.  Legislation must do more than protect midwives, it must protect and serve the people of this great state. 

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?"

Are freestanding birth centers "safer" than hospitals?

Expectant Mother: I've been hearing rumors of several infant deaths in your care over the past couple of years and a baby who is currently in the RNICU fighting for its life.  Should I be worried? 

Local Freestanding Birth Center: Here is an updated stat sheet (shows "data" through 2010, even though it's half-way through 2012).  Having your baby at our birth center is still safer than the hospital.  

Expectant Mother:  Really, safer than the hospital?  

Local Freestanding Birth Center: "Freestanding birth centers have demonstrated superior safety.  Safe and satisfying outcomes include significantly lower cesarean rates than the nation-wide average of 32%."  "Birth is as safe as life gets."  

I feel compelled to address some of the myths women are being told in our own community.  The first is noting that safety should be defined as much, much more than whether or not you have a cesarean.  The way your baby is born has nothing to do with whether the labor & delivery was "safe".  What matters most is whether you both come through the experience alive.  

Safety is defined by Merriam-Webster dictionary as, "the condition of being protected from, or unlikely to cause danger, risk, or injury."  Ignoring risk factors, inviting clients to opt out of assessments that would determine risk,  and pretending that risks don't exist during childbirth, is not what I would consider safe.  Implying that having a cesarean is the enemy, a danger to be avoided, or that having one is "un-safe" creates a fear in expectant mothers that shouldn't be perpetuated.  Consider for example a mother who ends up needing a cesarean for reasons that couldn't be avoided in order to keep her baby safe.  Her first thoughts would be about how dangerous it is for her and baby instead of understanding its necessity.  A planned, pre-term cesarean without medical conditions is one thing, a cesarean that saves lives is another.  Using statistics as scare tactics and without context is unethical.    

I would also note that having a "satisfying" birth has nothing to do with safety.  Approaching birth with the priority being about the "experience" instead of the safety of babies and mothers is absurd.  While I believe that everything should be done that possibly can be done to ensure the experience is positive, ultimately the safety of the baby matters more.  It is not acceptable to sacrifice safety for a satisfying experience, rather the two should work together with an understanding that sometimes safety takes the driver's seat.  The mother I mentioned in the previous paragraph who had to have a cesarean, deserves to know her baby was born just the way he or she needed to be and to be no less satisfied because of it.  When cesareans are made out to be the standard by which we measure safety, we have a real conflict of interest on our hands.   

While I appreciate that no major surgery, cesareans included, come without risks, there are many more immediately dangerous circumstances that can come during labor that could cost your baby his life, put him at risk, and place him in a situation that is ultimately not safe at all in a freestanding birth center setting. ACOG President Kenneth L. Noller, MD, MS, states, “Even a normal pregnancy can become high-risk with little or no warning, and serious, sometimes life-threatening complications may arise for the woman and her fetus.”  He noted that shoulder dystocia occurs in one in every 200 births and listed the frequency of other complications:

• prolapsed umbilical cord: 1 in every 200 births
• life-threatening maternal hemorrhage: 1 in 250
• eclamptic seizures: 1 in 500
• uterine inversion: 1 in 700
• Apgar score of 0–3 at 5 minutes: 1 in 100 to 200.

These situations should be considered far more dangerous for your baby than a cesarean, and furthermore should be the foundation for discussions about the safety of out-of-hospital birth and it's relative "safety".  Instead, the birth center in this example is referencing cesarean rates and not addressing the real complications mothers need to be aware of if they are going to be truly "informed" about the risks they are embarking upon by choosing a freestanding birth center.  Neglecting to share the real risks that would define measures by which safety could be adequately assessed is not informed consent, nor is it honest, nor is it honoring the rights of women to make choices for their own well being.  No one can argue that based on proximity alone and immediate access to medical technology, hospital birth has to be considered safer than having a baby farther away...even if it's "only 12 minutes from the hospital".     

I need to state the obvious, of course a freestanding birth center with no medical equipment or medical personnel, is going to have a lower cesarean rate when compared to a hospital.  They are comparing apples to oranges here.  A freestanding birth center doesn't do surgery and would have a cesarean rate of 0%.  A hospital, taking on all kinds of high risk births including breech and delivery of multiples, etc, would of course have a higher cesarean rate in comparison.  Does this mean they are somehow not as safe in overall practices?  The claim doesn't even make sense.  Nothing about the rate of cesarean in either birth center or hospital addresses why a birth center would be safer.  Wouldn't the outcome, a baby and mother who are alive, be a better determining factor of safety, regardless of how the baby is born?  The statement about cesarean rates is nothing more than a distraction, a way to avoid answering the question, a way to influence a woman's feelings about cesarean delivery in a subtle way. 

Mothers also need to understand that a freestanding birth center in Michigan is not a licensed facility and does not report their outcomes to the state or anyone else.  There is no data to support the claim that giving birth outside the hospital is somehow safer than giving birth in the hospital. In fact, when babies who die are transferred to the hospital in an effort to save their lives, they are counted as the hospital's loss, as we learned from personal experience.  There is no body of oversight, no third party checking the "data" on the handouts a birth center distributes, and nothing that gives what is printed on that paper any kind of credibility.  There cannot be evidence to prove the birth center's safety if there is no reported data about outcomes that would directly demonstrate safety margins. 

Studies that have been done to compare safety and mortality rates of out-of-hospital birth to in-hospital birth, consistently show that out-of-hospital birth is 3-4 times more risky.  (See Wisconsin's WISH website)  Another interesting point to be made here is that MANA (Midwife Alliance of North America) did conduct their own study about mortality rates in home birth. When the study was completed, they decided to keep the results private, only issuing the release of their findings to researchers who sign a contract, agreeing to use the information to advance the cause of midwifery.  Hmmm, something to hide? 

A birth center's safety can only be considered "superior" when compared to free or unassisted birth.  You don't want to find yourself in a room with a care giver who views cesarean rates as the defining standard for safety assumptions.  Please make sure you have real conversations about risks and safety before choosing to have your baby outside of a hospital or hospital run birth center.  Are hospital's perfect?  No, but real risks, like your baby not surviving, are even higher when you choose to have your baby at a freestanding birth center.  Make sure you're in the hands of a care provider who is being honest with you about potential complications, risks, and all matters that would impact you or your baby's safety.  It is one thing to be honestly and accurately informed in making choices about where to have your baby, and quite another to make a choice without knowing the truth.        

The Hypocrisy of Midwifery

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

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

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

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

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

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

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

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

Related Posts:

Ask an OB: "Risk Out" Criteria

Midwife Masquerade: Denial

The Importance of Defining Risk

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