Tuesday, January 22, 2013

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.  


  1. Wow....how telling. This again is very helpful and valuable insight into the personal and professional dynamics with home birth midwifery. I am curious, though, if an ob/gyn could comment on how this peer review process happens in hospitals. I think it would be helpful to look at both processes side by side. Things go wrong in hospitals, too, and I'm just curious about that process.

  2. Great Question Laura T. Here is a previous post that touches on this topic. I will ask some OBs to comment in response as well.


  3. Laura T, when I was in training we had monthly peer review conferences where cases with bad outcomes were reviewed by the entire department and the cases were picked apart to see how we could've gotten a better outcome. We were grilled, absolutely grilled. And it was all about outcomes and how to prevent them.

    Now our peer review process is still in place, and our partners/colleagues can be very pointed in their criticisms, but there are two more layers of review. We now have stats kept on us for EVERYTHING. C/S rates, blood loss, compliance with protocols etc, etc. We are not looking only for bad outcomes but for patterns of practice that might signal that someone is acting in a way that might court a bad outcome. In other words, we're trying now not just to evaluate bad outcomes; we're trying to identify patterns that might end in bad outcomes. When we do have a bad outcome, we often will have a Root Cause Analysis where every bit of a case is picked apart by representatives of every single department, in order to correct problems in our systems.

    It is not enough to look at bad outcomes. Bad outcomes are just the tip of the iceberg. What's underneath them are: system failures, failures to follow protocols, personnel errors, etc. If these are identified and corrected, outcomes improve.
    I hope this answers your question.

  4. "we're trying now not just to evaluate bad outcomes; we're trying to identify patterns that might end in bad outcomes."

    ^ THAT kind of peer review would do OOH midwives a world of good.

  5. Thank you attitude devant for your input. I think that process of identifying potential bad outcomes is excellent; exhausting, but extremely important. It speaks to the integrity and care that supports your medical practice.

  6. That kind of peer review is unlikely to ever happen with most U.S. lay midwives, whether CPM or not, because they have little to NO scientific training, they have no regulation nor do they have any motivation to do this type of soul searching and picking apart of their practices, their guidelines, their scope of practice. They don't WANT that. They don't want "the man" looking over their shoulders and pointing out areas that need improvement. They would rather "go with their intuition" and just "go with the flow" and do "whatever feels right". Midwives like to "trust their gut" and use "women's wisdom". They do NOT appreciate a science-based review of their practice, their infection control, their IV skills (non-existent in many cases)their resuscitation skills, their palpation skills... I could go on and on. They do not want to be judged (as incompetent) nor do they want anyone else telling them how they should do anything. I don't like sounding so fatalistic, but it will have to be mothers who make the change and stop hiring incompetent, poorly trained and under-experienced midwives and make the choice to hire competent, safe CNM's with protocols in place and the ability to seamlessly transfer to hospital when needed.