Tuesday, December 18, 2012

Keeping Our Children Safe

It is with a heavy heart that this post comes to exist.  In the wake of one of the most violent attacks on children in my lifetime, the shootings at Shady Hook Elementary in Newtown, CT, I struggle with the rest of our grief-stricken country to understand something that cannot be understood in a simple moment.  I am a parent, a teacher, and someone who knows too well the grief of losing a child...yet I cannot fathom what these families are enduring. 

You may wonder why this topic would appear on a blog advocating for safer practices in midwifery.  The reason comes in understanding that whether the threats and challenges we face as parents on a given day are mental health, gun control, drunk driving, unexpected illness, issues of neglect, poverty, or unsafe birth practices, we all aim to keep our children as safe as we possibly can.  Addressing the gaping disparities on a given issue is something we must do, no matter how daunting the task. 

In moments of tragedy we find more common ground.  We search for answers.  We contemplate change.  We look for inspiration to lead us forward out of a dark and dismal reality.  It is in the midst of that search that I would like to share excerpts from President Obama's Memorial speech given this weekend for the families of Newtown, CT.  His speech addresses a context different from ours, but the message is one that holds meaning for every danger that puts children in harm's way.  It is the message of inspiration, love, and a call to action to do everything we can to protect our children, that is most relevant here. It is the urgent message to be a better, more responsible culture of people than we are today, that I hope we all can hear.

     "...this job of keeping our children safe, and teaching them well, is something we can 
      only do together, with the help of friends and neighbors, the help of a community, and 
      the help of a nation.  And in that way, we come to realize that we bear a responsibility 
      for every child because we’re counting on everybody else to help look after ours; that 
      we’re all parents; that they’re all our children.  This is our first task -- caring for our 
      children.  It’s our first job.  If we don’t get that right, we don’t get anything right. 
     That’s how, as a society, we will be judged.
     And by that measure, can we truly say, as a nation, that we are meeting our  
     obligations? Can we honestly say that we’re doing enough to keep our children -- all of 
     them -- safe from harm? Can we claim, as a nation, that we’re all together there, 
     letting them know that they are loved, and teaching them to love in return? Can we 
     say that we’re truly doing enough to give all the children of this country the chance 
     they deserve to live out their lives in happiness and with purpose?
     I’ve been reflecting on this the last few days, and if we’re honest with ourselves, the  
     answer is no. We’re not doing enough.  And we will have to change.

     We can’t tolerate this anymore. These tragedies must end. And to end them, we must 
      change. We will be told that the causes of such violence are complex, and that is true. 
      No single law -- no set of laws can eliminate evil from the world, or prevent every 
      senseless act of violence in our society.
      But that can’t be an excuse for inaction. Surely, we can do better than this. If there is 
      even one step we can take to save another child, or another parent...then surely we 
      have an obligation to try.
       There’s only one thing we can be sure of, and that is the love that we have -- for our 
      children, for our families, for each other. The warmth of a small child’s embrace -- 
      that is true. The memories we have of them, the joy that they bring, the wonder we see 
      through their eyes, that fierce and boundless love we feel for them, a love that takes us 
      out of ourselves, and binds us to something larger -- we know that’s what matters. We 
      know we’re always doing right when we’re taking care of them, when we’re teaching 
      them well, when we’re showing acts of kindness. We don’t go wrong when we do that.
      That’s what we can be sure of.  And that’s what you, the people of Newtown, have 
      reminded us.  That’s how you’ve inspired us.  You remind us what matters.  And that’s 
      what should drive us forward in everything we do, for as long as God sees fit to keep 
     us on this Earth."

     ~ President Barack Obama

And so I ask you dear readers, are we doing enough to keep all of our children safe?  Are we giving every child the chance they deserve to live their lives?  These great responsibilities our President speaks of start with birth, and move forward with our children as they grow.  We know too many tragedies that can and should be prevented.  The issues surrounding midwifery and out of hospital birth are complex, and represent only one of the issues that pose far too many unnecessary risks to our children.  Should the daunting complexities of issues like these prevent us from healthy conversations about improving safety, from taking action to do our best to prevent he preventable?  As the President said, "Do we not have an obligation to try?"   

To the families of Newtown, Connecticut, your children represent a love and light that will lead this country forward to a better version of itself in ways we cannot yet see.  They have touched many lives already, inspiring people to do better, for and by others.   As the president accurately stated, "You remind us of what matters."  

If I can offer one hope, it is that this country begins to see the larger issues that are putting our children in harm's way.  We must find a way through the complexities to address each and every one of these issues appropriately.  We can do better, and our children deserve better.  

Video, Full Text: President Obama's Speech at Memorial for Connecticut Families

Thursday, December 13, 2012

The Things That Matter Most

I always find myself a bit sentimental around the holidays.  This year is no different.  I thought I'd share a bit of that sentiment with our readers, promising more of our traditional, resource-oriented posts in 2013.  

Part I: 
I used to live snugly under a blanket of naive protection, moving forward in life, fully anticipating all of the great things to come.  A husband, and a family were what I hoped for most.  Being in my early thirties, I had not yet experienced anything in my life that I would call a "tragedy".  There weren't really even many challenges worth mentioning.  

When I met my husband, I learned about love in a way I had not previously understood.  We started a family and that love and understanding again grew.  With my second baby, I fell into the trap of expecting things to go just fine, just like they always had.  Why not hire a midwife?  After all, I had never known anyone who had lost a baby from traumatic delivery.  

Let's just say that blanket of protection disintegrated into thin air.  Left shaken, raw, and rocked to our core, we had no idea how to deal with the loss of our baby.  There was no more security in things being okay.  There was no more "guarantee" that any of us would live another day.  Instead, that naive trust was shattered.  We were afraid, insecure, and not sure what the future would hold.   Sometimes it still feels like we're bracing for the next big blow. 

(You can read more about Magnus's story here.)

Part II: 
Until tragedy touches our lives directly, we cannot appreciate fully the challenges others deal with on a daily basis.  I don't know if it's the season, or just me, but on many occasions, I find myself reading a story or watching a television program in a mess of tears for the heartache with which another family is wrestling.  I'm inspired even further by the strength these families have demonstrated along the way.  

“Wounding and healing are not opposites. They're part of the same thing. It is our wounds that enable us to be compassionate with the wounds of others. It is our limitations that make us kind to the limitations of other people. It is our loneliness that helps us to to find other people or to even know they're alone with an illness.  I think I have served people perfectly with parts of myself I used to be ashamed of." ― Rachel Naomi Remen

This post is dedicated to any family or person who has suffered loss, injury, illness, loneliness, or tragedy of any kind.  My hope is that one day you realize that our wounds have the potential to lead us forward to be better versions of ourselves, and further enable us to reach out to our fellow man in ways that others cannot.  More than ever, I realize how much our compassion is needed in this world.    

I've been reminded of the need for this kind of compassion by the lives of so many friends this year.  A family whose child is valiantly fighting cancer, a family who recently lost a father and husband to a sudden heart attack, a friend enduring the trenches of divorce,  a neighbor whose father suddenly passed away, the family looking for resources to help their injured baby, the family swallowed up by the grief of losing their baby, and so many more.  

I often think about our soldiers too, and how sheltered I feel from the sacrifices they make for us each and every day.  It's not because I don't care, or that I'm not grateful for the daily risks they take on our behalf, but because it's a path (just like all but one of those mentioned above) I haven't walked personally, and therefore cannot fully appreciate.  Somehow though, after having dealt with the unexpected loss of our child, I can relate to the harsh reality of tragedy in a way that I wouldn't have in years past.  

It is in fact a soldier's story that best exemplifies the compassion I'm speaking of this week, a compassion that can erupt from the ashes of the darkest moments that life too often brings.  Shilo Harris is a man who demonstrates beautifully, the opportunity and gratitude that can come from tragedy.  He, and many others have inspired me.  He sums up his attitude in the following quotes: 

"There are no guarantees that we'll be alive tomorrow, or that we'll have the same health we have today, but we can count the blessings we do have."  

“You have to look at everything that God gives you as a gift.  It may not always be the gift that you want, but you have to take what you get sometimes and turn it into something else.  And that’s kind of what I’ve done.”  Shilo Harris

I can't say that I believe that the tragedies we face are gifts.  Shilo is a better person than I.  I can however say, that with the perspective that comes from enduring difficult situations, I can more easily relate to the struggles of others.  And further, with that perspective I can offer compassion in a way that many others cannot.  We can choose to turn life's darkest moments into something else.  There is something profoundly healing to my own being in helping another find their way forward.  What better way to honor a loved one, or heal from the challenges we've faced than by reaching out? 

Final Thoughts: 
We live in a culture filled with doubt.  In the most challenging of moments, I find that this doubt can easily overcome us.  One's faith in the unseen and unknown will go one of two ways in the face of tragedy.  It will a) dissipate, allowing doubt (aka grief, loneliness, sadness, shock, etc) to flood our very being, or b) grow stronger.  There are times in my life when my own faith has been tested beyond measure.  Yet somehow I realized, I never really walked that journey alone.  

I've come to recently understand something new, from a beloved children's holiday movie.  I think this little collection of thoughts will speak to many of you who have endured difficult events in your lives: 
"Sometimes seeing is believing, but believing is knowing the things you cannot see, are real...The things that matter most are the things we cannot see."  - Polar Express

And so I've spent a lot of time thinking about all of this, spinning it around in my head like a potter's wheel.  These are the things I've come up with that matter most to me...those things we cannot see, but know to be real: 

Faith in something bigger than ourselves (Namely God)

When I think about our son, who left this earth far too early, I am instantly filled with love.  I can't see him with my eyes, but I sure know this list of words to be far more real than I ever imagined because of him.  That in itself is a gift, a gift I intend to share with others who need it most.  I hope many of you who have walked darker paths, will find peace in your hearts this holiday season knowing you are not alone.  I hope that you will someday see your experience as an opportunity to reach out to another, and remind others that often the things that matter most are those we cannot see.  I invite you to make your own list of what matters most to you.  Thank you my dear Magnus for helping me "see" more clearly than ever, and for helping me find a way to share it with others.     

Happy Holidays!

From our Hearts to Yours, 

The Families of Safer Midwifery for Michigan

Tuesday, December 4, 2012

The Complicated Task of Choosing a SAFE Midwife

What I didn't know in choosing a midwife to attend the birth of our baby, was how critical it would be to choose a "safe" midwife.  I didn't understand the vast differences in philosophy, education, or practices that exist within one profession.  If nothing else, I want every other mother out there to understand there is a difference, and enormous difference, and that just because someone calls herself a "midwife" does not mean she practices safely. 

It is important to me that our readers understand that there is no standard for the use of the term "midwife".  It means a million and one different things, especially in a state like MI, that has no regulations or defined scope of practice that is consistent among "midwives".  In MI, this spectrum ranges from CNMs, midwives with advanced degrees, most of whom practice in a hospital setting with a license and insurance...to lay midwives who have learned apprentice style, with no formal education whatsoever.  We have many midwives practicing responsibly and safely, most (not all) of whom also happen to be practicing in a hospital.  I have met a few midwives in our state who practice outside the hospital setting, who take risking out and safety very seriously.  Unfortunately, they are hard to find, and even more difficult for a consumer to identify. 

For this reason, I find it necessary to discuss these variances, so that women can better choose a care giver.  This can only be the beginning to this discussion because it is complicated.  It makes sense to start with the questions: How do we identify different types of midwives?  How do their practices differ from other midwives?  What does "certified" mean, and how much weight does it hold?  Who is licensed in MI?  What are the minimum educational requirements?  Why does all of this matter? 

I want to start by first dividing midwives as an entire group, into two groups, those that practice according to scope of practice, and those that live on the "extremist fringe".  The latter refers to those midwives who knowingly take risks for philosophical and religious reasons.  These midwives are the  most difficult to identify because their philosophies in practice take precedence over credentials.   

The philosophical boundary that defines the extremist fringe is blurry.  This news reel from Indiana exemplifies the group I'm referring to.  There are less extremist versions of this kind of midwife, those that still trust birth at all costs, religion or not.  For some, adhering to trusting birth is the religion.  These are the midwives I would define as being on the "extremist fringe" of midwifery.  This is not all midwives, it's not even the majority, but it is a prevalent concern.  Especially if you're shopping for an out-of-hospital midwife. 

Controversy surrounds the trend of home birth 

The article below talks about how those choosing, or encouraging risky births outside the hospital are "chipping away at choice from the other direction".   The author's audience is to the "radical birthers", from the perspective of someone who home birthed herself.

Dangerous home-birthers Spoil it for the rest of us

How do we identify midwives that function on the extremist fringe?  This is difficult.  The most obvious hint comes in the language they use (not in their credential):
  • "Trust birth" 
  • "Your body was made to do this"
  • "You can't grow a baby too big for your body to birth"
  • "...(insert high risk situation here)...is just a variation of normal"
  • Gestational Diabetes Screening, Ultrasounds,  (other important assessments) are not proven to be useful or safe

How do their practices differ from other midwives?  These practices differ greatly from other midwives.  Midwives who are practicing within a defined scope of practice are adequately assessing women for risk factors, treating them appropriately, and risking out.  They appreciate that not every pregnancy or clinical condition is appropriate for out-of-hospital birth.  They value the mother and baby's safety above anything else.  These midwives value natural childbirth, and the beauty of it, but will not sacrifice your safety if a clinical situation arises.  These midwives have the skills, knowledge, and training to monitor risk factors.  They recognize that sometimes women need help, and work to get them the help they need, whether the mother "chooses" it or not.  What is murky, is that some midwives believe they have these skills, or tell mothers that this is how they practice, when in fact they do not.  So what's a mother to do? 

We can start with gaining a better understanding of three components: 1) know the dynamics: that not all midwives are the same, or believe the same about birth and risk, 2) learn about different credentials for midwives, and 3) fully understand the laws in your state (in this case MI) surrounding midwifery, and how that impacts your care...particularly in the event of a bad outcome.  For this reason, I find it necessary to provide a resource that explains the various types of midwives, and their educational background.  Let's look more closely at the various types of midwives.  This can help move our thinking forward in understanding how to find a safe care giver.  (We are also working on a blog post that articulates and explains MI's current laws and their impact, in conjunction with scope of practice.  Will post soon!) 

Types of Midwives doc.

Why do a particular midwife's philosophical position and credentials matter?  The problem is that once a midwife steps outside a regulated situation, such as a hospital, there is little consistency in how midwives practice or adhere to any scope.  Practices are purely individual, making it difficult for mothers to depend upon credentials alone.  Understanding that midwives, within a widely varied profession, differ drastically in philosophical beliefs, and further, that those beliefs directly impact practice and safety, is vital.  Being a "certified midwife" doesn't mean a thing.  It's a term used to sound professional, but when we examine educational training and consider the impact of philosophical differences, we see that the term is meaningless.  

The "Types of Midwives" document presents an ideal, a black and white snapshot based upon credentials alone.  It does not take into account philosophy or beliefs about midwifery and birth.   Filtering those aspects is even more difficult.  It is very possible to hire a CNM or a CM (the most educated type of midwife), who delivers outside the hospital, but resides philosophically in that "extremist fringe".  It is also possible, albeit rare, to hire an out-of-hospital midwife, who functions within a well-defined scope of practice, and risks out appropriately. 

I think the key, from a mother's perspective, is seeking a care provider, and interviewing him/her from the standpoint of safety, credentials, and practices, rather than focusing so heavily on the experience itself.  It means seriously considering the fact that even a normal, low-risk pregnancy can be disastrous in a moment's time, and having access to medical assistance can mean the difference between life and death.  It means accepting that the "experience" matters, but the experience should always be trumped by safety.  If you find yourself interviewing a midwife who tells you birth is inherently safe, that you were made to do it, that you can't grow a baby too big, and that high risk is a variation of normal...well, keep looking, because "safety" is not the priority. 

Women need to understand that hiring a midwife can mean many things, and who you hire, will greatly impact your safety.  When we set out looking for more personal care, I did not fully understand the dynamic within midwifery today.  Nor did I understand the fundamental differences in practice among various midwives in our state and country.  This is vitally important information to grapple with, before considering any midwife for your care. 

Wednesday, November 21, 2012

Thankful for...

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

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

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

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

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

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

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

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

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

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

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

Happy Thanksgiving! 


Monday, November 12, 2012

Why Licensing Alone Won't Make Midwifery Safer

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday, November 6, 2012

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

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

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

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

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

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

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

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

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

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

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

For more:
The Importance of Defining Risk

Tuesday, October 30, 2012

Coming Soon!

Dear Readers,
We haven't forgotten about you, or the need to blog regularly.  We're working to create some documents that will be useful to you, and to mothers who are considering midwifery as an option.  As you can imagine, this process takes time.  We want it to be well done, and to fully consult with MI midwives so that the information we present is accurate, credible, and useful.  We have a few meaty posts coming up, but would like to include the completed documents before we share them with you.  

Some of the topics we'll be addressing include:
  • Choose A Midwife Safely 
  • Midwives: Credentials, Educational Training, & Scope of Practice
  • Routine Assessments During Pregnancy:  What's Necessary & Why
  • Examining Current MI Midwifery Laws & How They Impact Care
** We are open to other ideas or suggestions from midwives or families about information you think women need to have, that would better help them make more informed decisions.  Our primary focus is developing tools that support safe options.  Women need to know who they are hiring, what their strengths & limitations are as professionals, what to expect during sound prenatal care, and how the laws impact their care with a midwife so that they can make a genuinely informed decision. Feel free to suggest your ideas in the comments below.  

** If you are a midwife in MI (or elsewhere) who would like to help develop this kind of content, we'd love to hear from you!   Please contact us.
We're also working heavily on a surprise project that will be announced in the next couple of weeks.  Thank you for your patience and stay tuned!  Big things coming soon.


The Safer Midwifery for MI Team

Tuesday, October 23, 2012

Checks and Balances

I originally sought the care of midwives because I wanted more personal care.  I didn't like the fact that our OB's office had 10 doctors, each of whom we would meet during the course of our prenatal care, but none of which I felt really knew us.  We had no idea who would show up at the birth, and I was worried about how they would care for us if they didn't know us.  Our first baby was born naturally, vaginally, and without issue in the hospital, with a doctor we didn't know too well.  He treated us with kindness and respect, and ultimately did many things to keep me, and my baby safe. 

Converesly, our three midwives spent an hour with us at every prenatal appointment.  We knew them intimately, considered them friends.  Hell, we even enjoyed tea and family play with a train table my son still talks about.  The resulting care?  Our baby died because of preventable injuries sustained at birth. 

Are doctors perfect and midwives evil?  Absolutely not.  Could this story easily have been the reverse experience?  Sure.  What then was the difference in care?

I've come to understand that while relationships matter, safety and the checks and balances of a licensend, ethical profession matter more.  While I once complained about long waits, short doctor visits, and too many care givers in a practice, I now see the need for a collaborative approach.  All good care givers need appropriate checks and balances, even midwives.  They need to hear differing viewpoints, to bounce ideas off of one another, and to be held accountable when mistakes are made, in order to funtion in a healthy, balanced way.  I now see the value in the kind of care I once resented...just too little too late. 

Appreciating and assessing risk factors in a client seeking an out of hospital birth is critically important to protecting the safety of that mother and baby.  Midwives often say that birth is normal, safe for low risk women without signs of complication.  The problem lies in the efficiency of how assessents are performed, and even more importantly how they are valued.  Disregarding the importance of assessments, avoiding them altogether, or even failing to risk out appropriately based on the results of such assessments is putting mothers and babies in great danger.  Risks are being taken then, that do not need to be taken.  How is this possible?  There are no checks and balances, no guidelines, no scope of practice for midwives practicing out of hospital birth in MI.  They can take any risks they want, avoid any assessments they choose, and call anything a "variation of normal".  No questions asked. 

If a midwife presents biased information about gestational diabetes testing to a mother, then tells her how great her nutrition habits are, and further expresses a belief that many times the test shows a false positive, why on earth would the client then value that test?  Has she been adequately informed, in a way she can truly make an educated choice for herself and her baby?  Does she know the risks of not doing the test?  Again, there is no standard for what "informed consent" actually means in midwifery. 

Why is this so vitally important for out of hospital birth?  In the event of an emergency due to any complication, a mother or baby in the out of hospital birth environment are at detrimental disadvantages to get the care they need immediately.  Precious minutes cost lives.  If midwives were truly attending only low risk women, results would no doubt improve.  Unfortunately, that's not what's happening.  Instead we have midwives who don't inform clients, who don't value assessments, who don't risk out.  We have midwives who are boasting online about delivering three breech babies in a year, delivering twins, and this is not to mention all of the severe near misses...those situations midwives knowingly take on to "honor a mother's right to out of hospital birth" instead of telling her the safest place in a high risk situation is at the hospital. 

Are midwives capable of implementing appropriate checks and balances?  Sure.  Are they capable of defining appropriate assessments, and adhering to low risk birth in the name of safety?  Sure.  Are midwives able to practice conservatively and collaboratively?  Yes.  The problem is that it isn't happening consistently.  Women and babies deserve a consistent standard of care, and midwives who function within a defined scope of practice.  Families want midiwifery they can rely on and trust.  At present, hiring a midwife in MI is (as I've said many times before) like Russian Roulette. 

This is precisely why we NEED Safer Midwifery in MI!! 

(In Development:  A document is currently being developed in conjunction with exemplary midwives, that lists the appropriate assessments that every midwife should seriously consider with her patient's clinical history.  We'll highlight it here on the blog as soon as it is finished, so women know what to look for in prenatal care.)

Wednesday, October 17, 2012

Introducing "Death Midwives"

What is a "death midwife"? 

     "Just as a birth midwife provides care at the beginning of life, a death midwife
     provides care during the final stages of life. Professional death midwives can offer
     the dying and their family spiritual and emotional comfort, advocate for their
     rights, guide them through paperwork, plan special burial rituals, and act as a
     liaison with funeral homes. Although certification processes are still relatively
     new and not yet standardized, there are a number of options for people interested
     in training and certifying to be a death midwife or, as it sometimes called, death doula."

     "Family-Directed Choice means you have the right to care for your loved one through  
     death at home; and to make educated, informed decisions about the death and dying

After Death Home Care ~ Ann Arbor, MI
     "In 25 years of professional life I have been helping people make empowering choices
     concerning their health care, specifically in women’s health and childbirth. My work
     as a home birth midwife for many years gave me the privilege of working very
     personally with families during a major life transition."
     "Preparing the body for a home funeral: This document is intended for the primary
      person takingthe lead in preparing the body for a wake and his or her helpers."

     "Death is as certain and sacred as birth."

This post feels like a collection of links, and it is.  There isn't much conversation written between the lines, mostly because I'm speechless. 

I see many parallels in language, words like "empowerment, choice, and educated/informed decisions" to that of home birth midwives.  The other glaring parallel is that "certification" is earned in a weekend workshop, but a self-appointed person or group.  18 hours of online learning is also considered sufficient. 

I find it interesting that these folks are even referring to themselves as "death midwives or doulas", and many of them are home birth midwives or doulas in practice.    I suppose at least in this line of work, the clients and families they are serving are knowingly coming to end of life.  It's the irony that gets me.  Thoughts? 

Monday, October 15, 2012

The Greenhouse Birth Center Gets A New Name

Not even two days after closing of the Greenhouse Birth Center, LLC to avoid any consequences in civil court, the same midwives have forged their own new business. Never mind that two of them have filed for bankruptcy to dismiss accountability for wrongful death(s), and they pulled the same move with the business itself. 

Check out Harmonious World Midwifery  (AKA Sage Midwifery)
(Formerly known as the Greenhouse Birth Center in Okemos, MI)

The "Harmonious World" midwives are charging $3,000.00 per birth, but surely can not afford malpractice insurance to protect the families they serve.  Not only have their staff and practices gone without change, their language too remains the same:

      "The midwife is trained to work with normal, healthy pregnancies, thus she is aware       of identifying deviations from normal, healthy pregnancies, and will refer the mother
      to obstetrical care should complications arise."  

The least they could do is tell people the truth!  How about telling women they trust birth...at all costs.  If pregnancy becomes "high risk", they'll just tell you it's a variation of normal anyway.  There are assessments that can be done to evaluate risk, but these midwives will tell you instead how unnecessary those assessments are...leading to severly lacking risking out protocols.  If your baby dies because they didn't inform you of the risks, and they didn't do their jobs...well then the baby just wasn't meant to live.  If they could be honest with women, and if women still chose their care, knowing the truth, at least they are choosing something that they want and believe in. 

Instead, these midwives continue to pretend to be something they are not.  They are feeding women the same false idea that they know what to look for and will get them help if they need it.  Every single infant death and injury over the past two years, is proof that this is nothing more than a false ideal, something to lull mothers into feeling safe when they are not.  It's either a crafty marketing tool to broaden their client base, or denial in recognizing the gap between what they tell people and how they actually practice.   
Indoctrination continues: 

      "Pregnancy and birth can be a normal and empowering process in a family's life." 

...unless you are taken advantage of to advance an agenda, and/or your baby dies because of severe negligence.  How is that empowering?  

      "Thus, I have great faith in the notion that families are to be primary in the role of       
      decision-making for their care." 

This basically means that families are birthing unassisted, and should anything go wrong, the midwife has absolved herself of any, and all responsibility.  It should clearly be understood to mean that you're not paying $3,000.00 for the care of a professional that takes responsibility for your safety.  There is nothing about this relationship that will be fiduciary.  A more accurate description would be: a mother, fed a bunch of lies about how her body can do this, trained to think she will be empowered by her experience, and then left in the dark when it ends in disaster.  Midwives work very hard to craft "informed consent" to alleviate themselves of liability should things go wrong.  They hold workshops on this very topic, as evidenced in recent posts. 

Hey Audra Post, CPM, founder of "Harmonious World".  How many of the 300 babies you had the privilege of delivering died?  How many were injured?  How is it that you are under such financial and legal stress that you have to file for Chapter 7 bankruptcy to avoid a wrongful death lawsuit, but can somehow manage to open a new "business"?  My pregnancy and birth were far from "normal", and you either didn't bother to tell me, or didn't recognize that there was an enormous problem.  The same is true for your CNM "Birth Assistants", Clarice Winkler and Shelie Ross.   

Don't think for one second that the women of this community won't see through this charade ladies.  Families deserve to know the truth about who you are. Your websites, old and new, are full of misleading information.  

Your despicable actions speak for themselves.  You are not destitute.  You are not mourning. You clearly do not have one bit of remorse for the harm you have caused to many families, or you wouldn't still be practicing.  I can say you are strategic, sneaky, and relentless.  I can also say you have cost too many lives.  The kind of people you are continues to be revealed in your own actions.  

Unfortunately the pattern will continue, and it will only be a short matter of time before tragedy strikes again.  When nothing about improving practices takes place, when nothing is learned in retrospect, then the dabalacle continues.  It's like the dog that chases it's tail endlessly, pretending he doesn't hear his owner's call.  He continues in this manner until he (or in this case someone else's baby) falls over dead. 

Nothing, I repeat nothing, is "harmonious" about the way you operate, and nothing about the care women are receiving from your group is "empowering," no matter what you call your "business". 

Wednesday, October 10, 2012

Breech Birth at Home

With many of Michigan's CPMs slated to attend the Breech Birth Coalition's annual conference in Washington D.C. this November, it's time to start talking about breech birth at home.  Women in MI, and elsewhere must be more informed than we were.  When a woman is faced with a breech positioned baby at the end of pregnancy, it's very difficult to really "research" effectively.  It's easy to listen to what a trusted care provider is telling you, and see only through a lens that supports those notions.  Before you consider a vaginal breech delivery outside the hospital, please check out these resources and clarifications. 

We have talked a great deal on this blog about the concerning, variable training for becoming a CPM.  The fact that a midwife, of any credential (CPM/CNM or otherwise), would even consider a delivery as high risk as a breech delivery at home should be an enormous red flag.  No midwife, without an immediate medical facility, and physician presence, is prepared to properly attend a breech birth.  In fact, in other countries like Europe and Canada where midwifery is an integral part of their medical system, there are explicit guidelines for risking out mothers with breech presenting babies from home birth.  It's a very high risk delivery that sometimes needs immediate emergency care and extremely close monitoring.  These countries have determined that screening women to determine who is low risk/high risk, is the most appropriate way to a) keep babies and mothers safe, and b) prevent tragic outcomes.  Research was done directly because of the fact that women in Canada were choosing home birth for breech birth because they didn't feel they had options.  Canada's response can be found here.

     "Women in Canada and abroad are requesting the option of breech vaginal delivery.    
      Will it be obstetricians and gynecologists offering this, or, since many hospitals are not
      offering breech vaginal delivery, will women rely on midwives to do so? Some women    
      with a breech presentation elect to deliver at home because they believe they will be    
      refused a breech vaginal delivery at the hospital. It is urgent that we take on this 
      responsibility and that every hospital in Canada offer safe breech vaginal delivery. We 
      need to meet with our colleagues in midwifery to support their request for breech
      vaginal delivery in hospital and access to consultation with their obstetrician
      colleagues. We cannot condone home breech vaginal delivery; thus, we 
      must offer breech vaginal delivery as a safe alternative in our maternity 

I want to be clear that having a breech presenting baby doesn't mean that mothers in the US, cannot aim for a vaginal delivery in the hospital.  Doctors in the US willing, and with enough experience to attempt a breech trial of labor, are harder to find, but they do exist across the country.  In Canada, they explicitly state that women need to be informed of all risks, and not abandoned should they make a choice that differs from a physician's recommendation.

A "Trial of Labor" for a vaginal breech delivery is very different from automatically scheduling a cesarean.  It's is also very different from a midwife stating, "recent research supports vaginal breech delivery, I could delivery your baby at home...or at our freestanding birth center."  The research she's likely referring to is a 2009 study by the Society of Obstetrics and Gynecology.  If you read this Clinical Practice Guideline, you will quickly learn that this research was explicitly written to take place in a hospital, with an obstetrician, and an operating room present.  

What exactly is a "Trial of Labor" then?  A trial of labor refers to an attempted vaginal breech delivery given very specific safety guidelines.  Those guidelines begin with proper evaluation of candidacy before labor even begins.  An ultrasound is necessary to determine important factors such as baby's estimated weight (no less than 5.5 lbs and no more than 8.8 lbs are considered qualifying), fetal head attitude, cord position, type of breech position, etc before determining if a woman and her baby meet the criteria for a trail of labor.  There are other factors in determining candidacy outlined in the SOGC's research.  If mom and baby meet these criteria, then fully informed consent about the risks of both a cesarean and a vaginal breech delivery must be addressed, and documents that show record of such informed consent are signed.  

The SOGC research further specifies guidelines for managing labor and delivery with a thoroughly experienced physician on hand.  Some of the highlights include immediate pelvic exam upon waters breaking, active pushing in labor should not exceed 60 minutes, and continuous fetal heart monitoring, among others.   Another critical note named in this guideline is for a health care provider current in neonatal resuscitation to be present. 

For more information about the SOGC's recommendations, visit this link to their brochure on the topic for public education.  

If a woman, and her physician, have closely evaluated her candidacy for a vaginal breech trial of labor, then I see no reason not to support that effort inside hospital walls, where emergency care is immediately available.  The notion of CPMs, or anyone else for that matter, attempting this kind of delivery in the home setting is disturbing.  The fact is that area CPMs are attending a conference held by an organization who, as they put it, "...are not medical professionals," but are instead, "well read mothers and families." Their aim is to learn more about delivering breech babies in the home setting, as if there were no other options.    This speaks volumes about their intentions, their misunderstanding of what the medical world can offer, and their lack of appreciation for the risks involved in this kind of delivery.  

I sincerely hope that women can sift through the muck, the misinformation, the misguided relationships, and the agendas to see that if a vaginal breech delivery is what you seek, there are safe ways to go about it.  (And that is not outside a hospital)  If you're in the hands of a responsible midwife, who appreciates safety, she'll help you find a physician that will work with you on determining whether a trail of labor in a hospital is a safe option for you.  (If your midwife tells you breech presentation is just a "variation of normal" and she can handle it, find yourself an OB immediately.)  There has been good research on this topic as noted here.  I hope we can learn from Canada to first see that home birth is not a safe way to delivery a breech baby, and second that our hospitals, midwives, and doctors will continue to work together to best serve the women that need them. 

Monday, October 8, 2012

What do MI Midwives Make of Public Outcry for Safer Practices?

What do MI midwives make of public outcry for safer practices?   

Well, they think they are the victims. 

Instead of working to examine and improve practices, the leaders of midwifery in MI are hosting workshops to teach fellow midwives how to protect themselves.

Instead of acknowledging the very real problems that permeate midwifery, and out of hospital birth, they are convening to talk about how to protect themselves by revisiting "informed consent". 

Instead of finding ways to bargain for malpractice insurance that would protect families, they are discussing how to protect their assets.  

     "I just attended an informative workshop at MANA on protecting your assets. 
     We will be sharing information." 
     ~ Patrice Bobier, MI CPM, and MI Midwives Association board member

Instead of hearing the voices of concerned families, doulas, and other midwives, they are choosing to pamper themselves with massages, pedicures, and a good dose of denial.  

Shouldn't the focus be on how to make out-of-hospital birth as safe as it can possibly be?  Shouldn't the conversations be about why and how babies are dying preventable deaths?

 Not according the the Michigan Midwives Association...

The only true statement in this entire advertisement is, "Midwifery in Michigan has seen many crises this past year."  Our definition of "crises" differs greatly.  The real crisis is the number of babies that died or were injured, and the families (not the midwives) mourning the loss of their children under preventable circumstances.   This crisis is further complicated by the dysfunctional and dangerous practices that every midwife attending out-of-hospital birth has seen, but won't admit.  Ignoring these instances, these families, these babies is the crisis.  Pretending there aren't problems, and refusing to address them adequately will lead further down the same self-destructive path.  

If midwives are mourning, it's because the truth is spreading across MI, and women demand safer, more reliable options for out-of-hospital birth.  I'd like to see a workshop that addresses issues of screening for risk, reporting outcomes, educational standards, defining scope of practice, and how to bargain for competitively priced insurance.  The profession of midwifery, as it pertains to out-of-hospital birth, would move forward much more effectively if the leadership could address the issues that are causing the problems, instead of wallowing in self-pity for tragedies that are created by negligent midwives themselves...and then further going to great lengths to deny any responsibility whatsoever.  

Instead, the Michigan Midwives Association continues to support not only negligent midwives, but criminal midwives too.

     "Support midwives who are facing prosecution for doing the everyday work that we 
     do: Ireena Keeslar lives in Indiana, but practices also in Michigan, attending 
     homebirths and births at her freestanding birth center. She was charged with 
     practicing nurse-midwifery without a license and is in the pre-trial stage at this 
     point, with her next court day pending. Her legal expenses are likely to be 
     considerable. You can donate to her cause by sending her paypal at   
     warriormidwife@gmail.com or by writing her a letter of encouragement at 
     7570 E 750 N, Howe, IN, 46746."

It would appear that "warrior" midwives, are even above the law.  Even though the state of Indiana requires a state issued license to deliver babies as a midwife, you can just let it lapse, and your supporters will be asked to support your irresponsible actions by funding your court battles.  Better yet, just come on across the border and set up a birth center in Sturgis, MI because we have no regulations here.  

Where are the midwives that are asking people to contribute money to the families who have to battle in court to hold negligent midwives accountable...midwives who file for bankruptcy multiple times over  wrongful death lawsuits?  Where are the midwives funding medical care and treatment to injured babies across the state, whose injuries are the result of pure negligence?  Why do these families turn to the court system?  Well, because no one else will hold midwives practicing this way accountable, least of all their own professional organizations.  Nope, the mentality is: must protect the sisterhood, must protect the "harassed, sued, interrogated, targeted" midwives because so obviously when a baby dies, it's the midwives who are mourning.  

The focus must shift to protecting families.  

This not a "witch hunt" ladies, it's a call to action.  We want you to step up to the plate, to offer us something better that we can depend on.  We want you to be educated, responsible, professionals who work hard to keep us as safe as you can.  If you are unable to redefine yourselves, to raise your expectations, to better admit your faults along with your successes, to practice ethically & safely, then our state has an obligation to set it's own guidelines to keep people safe.  We want better for Michigan families.