Where is the Leadership: Part I

Part I:  This post will be the first in a two part series.

What does ...

Having your CPM credential revoked by NARM + Multiple dead babies + Larceny & Misrepresentation = for a MI midwife??  

It equals...still practicing without real consequences.  Yep, you read that right, still delivering babies for MI families.  How can this happen?  

The bottom line is that MI has no laws or regulations in place to stop the reckless midwives like this from practicing.  NARM can hold their peer review sessions, make polite suggestions for change, and midwives can stop referring clients to someone they know to be dangerous, but nothing is in place to prevent that person from continuing to practice. Heck, these midwives can even move to another state, and still practice, if the laws in that state don't prevent them from doing so.  (i.e. Michigan = hotbed for midwives who don't like to play by the rules.) 

Case in Point:
Bridgett Ciupka's (former CPM) NARM credential was revoked in 2004.  Yet, four years later, she was the midwife for Ms. Mushin and her baby, Alia Mushin, who died in-utero, while still under Ms. Ciupka's care, after her mother was 4 weeks post-dates. Further concerning events were charges of Larceny and Misrepresentation in 2009, for which she is still on probation, according to current court records According to Metro Midwives and Birth Partners, Bridgett is still practicing in MI.

The scary truth is that this is just one example.  In MI, we currently have OOH midwives who have served probation for wrongful death, who are in the midst of a criminal trial in other states, who have filed bankruptcy repeatedly to avoid civil accountability, and who have numerous deaths and injuries on their invisible records.  We have midwives who have faced criminal charges for the death of mothers and babies, and those who have dodged charges that should have been pressed.  Ironically, these are precisely the midwives leading Michigan's professional organizations for midwives, and the drive for legislation.

What could these particular midwives have to say about all of this?  Well, they say home birth is still safer than hospital birth, that babies die in hospitals too...in fact some babies just aren't meant to live. They say that peer review through NARM is working, despite the fact that it does nothing to prevent dangerous midwives from continuing to practice.   They continue to offer home birth to women who have had three prior cesareans, and brag about their success on FB, despite having lost a mom and baby after a HBAC2 (Home birth after 2 cesareans).  They continue to offer home birth for breech babies and twins, insisting that it's "just a variation of normal".  They tell mothers who have pre-eclamspsia that it is safe to have a home birth, but when she strokes as a result, it's all about the choices she (the mother) made, and nothing about the professional responsibility of the midwife.  

These midwives tell women to trust birth and their bodies, but don't tell them that sometimes women really do need medical help, or when to get it.  They pretend the system is working like a well oiled machine, when in fact they are covering up the truth about what is really happening out there so they can continue selling an ideal that doesn't exist.  It's an ideal that can't exist while the dangerous midwives continue to represent the leadership.  

Don't just take my word for it.  Here are the thoughts from an anonymous midwife who shares the same concerns: 
 
      "My greatest frustration in all of this is that so many of the midwives have become 
      defensive in this state when it comes to discussing regulations and clinical 
      judgement.  When a well-liked midwife acts erroneously, in terms of poor clinical 
      judgement, the first concern seems to be about her as a midwife." 

     "I know midwives who gave up midwifery because of frustration with MMA not 
     wanting to admit that another midwife was incompetent or negligent, because that 
     midwife was also internationally known and well liked.  The view is that if we as 
     midwives censure one bad midwife, we are failing to stick together and will 
     provide fuel for the OBs and others who would like to see midwives disappear. 
     Our censure is seen as a crack in the armor of our united front to promote 
     midwifery as a profession. It is also seen as being disloyal to the sisterhood. I 
     suppose the general feeling is that any of us could make a mistake, and no one 
     wants to be criticized for the care that they provide. Feels to me like insecurity 
     about the perception we would like families and other professionals to have of us." 

So where is the leadership?  The midwives we are talking about here, are not representative of every midwife out there.   Clearly there are midwives who are concerned about what they see in the OOH birth community.  The dangerous midwives are blending in with the rest to unsuspecting mothers, protected by professional midwife organizations who would rather defend people like this to protect their cause, than confront reckless practices to ensure safety.  The voices of mothers sharing their stories of negligent loss, the voices of concerned doulas, apprentices, and fellow midwives, all fall on deaf ears.  It is easier to ignore the problems than to acknowledge and address them.  It would make midwifery look bad to admit there are problems.  

My question is, when will the leadership shift?  When will the ethical midwives who are practicing safely, those that care about this profession and the mothers and babies they serve more than themselves, rise up and change the culture of OOH midwifery today?  It is concerning that the current leadership doesn't see, nor do they have any interest in, addressing these matters.  Furthermore, they are corrupting an entirely new generation of aspiring midwives, instead of doing what is right, and pushing for legislation that would serve to protect them further.  When will our legislators do what is right on this issue?  When will women in this great state demand better, more consistently reliable care? 

This blog is not about smearing midwives.  It is a call to action for the good to rise up and make OOH midwifery what it has the potential to be.  Unethical tactics, dangerous practices, cover ups, and denial won't get any of us anywhere.  How can we effectively improve what is broken if the leadership of OOH midwifery pretends that problems simply don't exist, all for the sake of protecting a "sisterhood."  Who is protecting the mothers and babies? We want leadership that is honest, ethical, and can lead OOH midwifery toward safer practices for MI families. 

**OOH means Out of Hospital Birth, referring to home birth and/or freestanding birth centers

Ask an OB: Fear of Unwanted Interventions

"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.

What do modern OB's really do, as far as all the "unwanted" interventions that the natural childbirth community talks about? ~ Confused Mom

      Q1: Are vulvas really still coated with Betadine? If so, why is this a good practice?

  
A1: Hahaha – that’s funny…no, I haven’t seen that done since 1978

  
Q2. Are women still "forced" (not my experience) to have their feet/legs in stirrups? If so, why? (As a doula, I've seen most dr.s totally ok with different birthing positions but this is not what the ncb community likes to claim).

A2. Stirrups? No, I haven’t seen anyone “forced” into stirrups…not sure how we would manage that. Women tell us how they are most comfortable and we accommodate them. I’ve delivered babies squatting, on their side, sitting, in bed, on the floor, in a Lazy Boy, in the shower, wherever they want to be.

Q3. Is routine separation of infant and mother demanded or only if the infant needs assistance?

A3. Babies are with moms 24/7 at Sparrow Hospital. I’ve actually had complaints from moms who WANTED to send their babies to the nursery and they were told NO, baby stays in your room with you all the time. Sparrow has focused on this for > 10 years, and is now pursuing “Baby Friendly” status, which is a national certification that is quite difficult to achieve.

Q4. What do dr.s think of moms who want low to no interventions, like no IV, no EFM, etc.?

A4. Doctors wonder about the motivation for these requests. Give me your reasons and let’s talk.  Let’s deal with the underlying issues first, then get down to the specific requests.

IV for instance – can we negotiate a heparin lock? That way you can move around freely, and I can have a fighting chance to save your life if you have a post partum hemorrhage. PPH is not uncommon, occurring in up to 5% of deliveries, and when it starts, your blood vessels constrict, making an IV start difficult/impossible. With the blood flow to the placenta at 750 cc per minute, it doesn’t take long to exsanguinate. So when someone refuses a heparin lock, I wonder if she is someone I feel comfortable getting into a possible life and death situation with.  

Monitoring…well if you are low risk and you elect intermittent monitoring instead of continuous monitoring, and are willing to accept Apgars a bit lower, then I can live with that.  For those who worry about being, "Tethered to a bed/not allowed to move around," I'd say you can go anywhere you want to as long as mom and baby are low risk and doing well. 

Q5. Can you address these other NCB claims: shaving the pubic area, routine episiotomies, and routine enemas?  

A5.  

- Shaving the pubic area: hahaha – never have seen that, even in 1975 when I started med school.

- Routine Episiotomies: went out 10 - 15 years ago

- Routine Enemas: last saw one of these about 1979

Sounds like the NCB people you are referring to haven’t been in a hospital since the 1970s!

Part of the Problem: Peer Review

This post is written by an anonymous guest writer, a former CPM apprentice who has a unique perspective regarding peer review sessions among midwives:  

Part of the problem with CPMs self-regulating, is that the peer review process does not correct poor practice. Peer review is a process where a CPM cherry picks some friendly home birth midwives, to review a case where there was a complication or bad outcome. Often, there is nothing that comes of it: “Oopsie-daisy, we had a bad outcome, too bad for the parents, and too bad for the baby.  Birth is a safe as life gets.” The CPM who had the bad outcome can document that she had a peer review and all is good.  Back to catching babies.

But another way that peer review fails to ensure safe midwifery is when peer review results in a midwife receiving inappropriate and reckless feedback for her actions at a birth.

 
An example:

Let's say a midwife has a client who is having a normal, low-risk pregnancy. Nothing special about this mom. Everything in the course of her pregnancy has gone uneventfully and right around 40 weeks, she goes into labor. When the midwife checks the client in active labor in her home, she discovers that the baby is breech and informs the mother that she will need to go to the hospital for a c-section delivery. This midwife (rightfully!) made this decision based on:
 
     1) the undiagnosed breech position discovered in labor,
     2) her lack of training in handling breech deliveries,
     3) her license does not allow for attending breech deliveries at home.

She called the back-up hospital and provided information to the OB staff with the information regarding the client. Then she and the client went to the hospital together. This was not an urgent transport. But a necessary one.

She was present and cooperative with the OB staff, provided background information on the client and stayed with the family during the delivery and immediate postpartum recovery. In my mind, she did everything right.

Now midwives don’t like surprises. They don’t like missing a breech presentation. And they don’t like it when a family planning a home birth ends up with a hospital surgical birth. Families have some adjustment as well. And sometimes I think the adjustment to the change-of-birth-plan is harder when the baby is not in any acute distress. An unplanned c-section, even if it was not a true emergency c-section - requires some emotional and mental (not to mention physical) adjustment.

So after this birth, the midwife requested a peer review with another midwife in the area regarding this birth.

And here is the part of the problem:

Upon hearing about this less than ‘homebirth-perfect’ hospital birth, the consulting midwife may criticize the first midwife’s actions:

“You didn’t need to transport that mom for a c-section.” 
“Breech is just a variation of normal.”
“She was still in early labor, you could have called one of us who will attend breech births to come and attend the birth.”
“That mother is probably traumatized by her c-section and the hospital care she received.”
“Your client would have had a much less risky vaginal birth than the c-section.”

And the midwife who’d acted appropriately, within her professional scope of practice, within her personal skill level, and by the rules that govern her license, was now second guessing herself.

And let's say the memory of this ‘peer review’ follows her to her next birth, and her next birth and her next birth. And the next time she has a labor complication - maybe a breech, maybe something else - she may NOT transport her client in labor. She may remember what her peer told her about protecting her client from harm. About hurting women with unnecessary interventions. About not being ‘midwife-enough’ to stick it out at home with women who have complications.

This. Happens. All. The. Time.

Too many midwives see themselves as not only appropriate for low-risk, healthy women, but for women with increased risk, women with breech babies, twin babies, women who have labor complications and prolonged labor, women who have history of surgical deliveries and women with complex health conditions. They minimize complications (low-lying placenta, elevated blood glucose levels, hypertension, gestation beyond 42 weeks), and encourage each other to treat these complications as “variations of normal.” A midwife who appropriately refers women to medical care is often derided by her peers as being a “medwife” or as being “too jumpy” - or told that her actions caused unnecessary harm. 

And they convey this reckless message in peer review. 

This is part of the problem. Peer review is held up by NARM as assuring competence and safety in midwifery care. But unfortunately it allows for unscientific, non-evidence-based recommendations to be perpetuated among midwives.  And this is harmful not only to midwives, but most importantly, to midwifery clients. 

For more about NARM's review process, click here.