Tuesday, February 5, 2013

Where is the Leadership: Part 2

Part 2: This is the second in a two part series addressing lacking leadership for Michigan's out-of-hospital midwives. Today's focus reflects on the politics of appropriate legislation.
Some of Michigan's out-of-hospital midwives are using loss stories to push legislation, and they're doing it under the disguise of caring about safety.  The truth, as demonstrated by the very bills they are lobbying for, is that safety is not the focus.  Protecting midwives is the goal, as is obtaining reimbursement from state funded programs like Medicaid.  

The following series of quotes come from Kate Mazzara, CPM, who is the current leadership at the Michigan Midwives Association.  She is referencing the death of baby Alia Mushin, as a case that indicates the need for licensing in our state for CPMs.   
(All of Kate's quotes are taken from the above linked article)

      “We want to be licensed because we want to make sure there’s a standard of care. 

      That consumers are protected,” said Kate Mazzara. 

The bills currently proposed to license CPMs in Michigan, (HB 5070, SB 1310) wouldn't change one thing about the standard of care.  Instead, they propose to use the standards set forth by the North American Registry of Midwives, which are EXACTLY the same "standards" by which CPMs currently work under.  Let me just remind readers that there really aren't any standards for practice, no risking out criteria, and a (only recently) high school diploma required as the minimum standard for education held by NARM, the credentialing body for CPMs.  Furthermore, these "standards" do nothing to "protect consumers or families". 

If the goal was truly about safety and protecting consumers, the bill would clearly define a MI midwife only as a licensed individual, set an appropriate minimum for educational training, require midwives to report outcomes, require state-issued informed consent (particularly regarding insurance), and propose specific criteria for risking out, to ensure that all OOH births were truly low-risk women.  As it stands, NONE of those elements are included.   

      “I want to make sure that these moms and babies are birthing in a safe way, and 

      the midwifery model of care has been shown to be an extremely safe option for 
      families, but there should be that safety mechanism to which midwives can be held  
     accountable,” said Mazzara.  Kate Mazzara is a Certified Professional Midwife, 
     and as a member of the Michigan Midwives Association, she’s trying to get 
     Lansing to pass a law to license midwives. Twenty-five other states already do 
     that, and a licensing board would then be able to hear complaints, and take 
     action against midwives if problems arise."

First of all, I'm not sure how anyone can honestly proclaim, "the midwifery model of care has been show to be an extremely safe option for families," when there is absolutely NO ONE collecting data on outcomes in the state of MI for OOH births.   There is literally no evidence to support this claim, unless you are hijacking data that demonstrates CNMs, in hospitals have the best outcomes.  This is a very different group of midwives than those pushing for this legislation.  In fact, I wonder how many current CPMs would even qualify for licensing if data had been collected on their outcomes for the last 15 years, and if accountability had been a larger part of practices.  

 The people who have voluntarily reported infant deaths and injuries to our advocacy group in the State of MI, clearly demonstrate an alarming rate of deaths and injuries in the out-of-hospital birth sector, and this is only a tiny fraction of the out-of-hospital births taking place in our state.  Any responsible legislator would require that the evidence demonstrating safety actually be collected before handing these "professionals" a license.

Kate is accurate about one thing, there is currently no effective mechanism currently in place to which OOH midwives are held accountable.  We do however, already have a licensing board, called the Board of Nursing, which just so happens to be presently chaired by a midwife.   This board currently provides the oversight for CNMs, regardless of place of practice.  If a minimum standard for education for midwives were to be established in order to earn a state-issued license, then this board could easily provide the balanced oversight needed to license non-nurse midwives, and effectively protect the people. At present, anyone can call herself a midwife in MI, and consequently, the board can only offer oversight for those who choose to be licensed by meeting the educational requirements.  Higher standards in education, mandatory licensing to practice midwifery, and a balanced board to provide oversight = safety for consumer.  (Same low standards, no risking out criteria, and a biased board protecting themselves = a recipe for disaster.)

In stark contradiction to safety measures, proposed legislation in Michigan (that the Michigan Midwives Association supports and lobbies for), not only aims to license CPMs, but also establishes an entirely new board for the oversight of OOH midwives.  They propose to establish a Board of Midwifery, composed primarily of CPMs, to replace the current Board of Nursing. Why the need for a new board if midwives are already represented on the Board of Nursing?  Well, it's much like peer review.  If you have a board of colleagues willing to cover for you, (instead of a balanced board of birth professionals) then the "cause" and the "sisterhood" can be more easily protected.  

Let me give you a personal example.  We filed a complaint with the State of MI, regarding the death of our infant son in 2011.  The Board of Nursing approved our complaint for investigation.  The State then thoroughly investigated our case, consulted experts in the field of midwifery, and determined that the Public Health Code had indeed been violated.  They then turned it over to the Attorney General for further review.  The Attorney General agreed that the Public Health Code had been violated, and officially filed what's called an "administrative complaint", including a range of possible sanctions for the actions of the two licensed midwives involved.  The next step in the process is a conference at which the AG and the midwives, in which they have to agree upon sanctions, which THEN have to be approved by the Board of Nursing.  If the Board does not agree, the sanctions don't take place.  If they cannot reach an agreement, the State will hold a hearing, at which we would testify.  The judge would suggest sanctions yet again, but they still have to be approved by the Board of Nursing. 

The point?  All accountability rests on the effectiveness of the board responsible for ethical oversight.  No ethics = no accountability. 

If our state establishes a Board of Midwifery, run by CPMs, there will be no opportunity for accountability.  Our case likely would have never even been investigated had this been the case.  The current process for reviewing cases in the OOH birth community is called Peer Review.  Despite our complaint also being filed with the North American Registry of Midwives, no peer review was ever done, nor were any consequences whatsoever put into place.  A Board of Midwifery will serve to protect midwives, just as the current peer review process does.  It will not protect the families they serve in any way, shape or form.  How do I know this?  I've seen it time and time again in states across the US who have established Boards of Midwifery.  These boards have dismissed severe cases of negligence, and actively worked to erode safety standards that protected the people.  

Here are a few examples:

First, welcome to the Texas Board of MidwiferyPlease note the laundry list of reckless behavior, and petty consequences being doled out as compensation for lives lost.   To further illustrate the point, read  Liz's Story about the birth of her baby, Aquila.  Then you can visit her blog to read about her "hearing" with the Board of Midwifery for Texas. You can even listen to an audio account of the hearings themselves, where DEMs are actually boo-ing this mother for bringing her case before the board, and telling her, "You know, this won't bring your daughter back, don't you?"   To save you time, let me point out clearly, that the Texas Board of Midwifery decided that an appropriate consequence for Aquila's death would be $500 and six months probation, despite obvious negligence.  
      "Beltz, Faith Midwife 04005 Austin 22 TAC §831.58, 831.65 and 831.131-Related to 
      failure to complete the Informed Choice and disclosure Form required by state law 
      for a client and failure to perform an initial evaluation on client and failed to initiate 
      immediate emergency transfer for chorio-amnionitis. 6 mo Probated Suspension 
      and $500 Administrative Penalty 2/7/11"

Does this seem like accountability, or am I crazy for thinking this consequence is unbelievably lacking for the extremely unprofessional, and incompetent care Liz and Aquila received? This midwife's collective failures resulted in Aquila's death here people!  $500?  Really?   

Next, welcome to the Oregon Board of Midwifery, called the Board of Direct Entry MidwiferyIn 1993, Oregon established a Board of Midwifery to act as the official oversight for LDMs and DEMs in their state.  Licensing in Oregon is still voluntary.  Over the last decade, this board has slowly eroded a number of provisions that were initially aimed at protecting the safety of mothers and babies, and repeatedly ignored negligent actions that have cost lives.  Here is a summary of their appalling actions, as the blog author calls the board, "A joke, and a hazard to your health."  Or you can peruse their "disciplinary actions" for more examples that illustrate paltry actions for severely unprofessional care.

As if that weren't enough, this board has had midwives resign over disagreement about the scarcity of accountability.  Here is a letter of resignation by a CNM in Oregon, after the board refused to revoke a midwife's license for obvious negligence that cost a baby her life.  Even other midwives are uncomfortable with how this board is functioning.   

And to round out Ms. Mazzara's questionable perceptions:  

     "Mazzara and others insist the sad stories are rare, and that home births are a 

      beautiful, natural experience. "

Well Kate, we can't really know just how "rare" the sad stories really are when no one is collecting the data can we?  The sad stories are covered up, or used as leverage.  They become part of the dark webbing that forms the "sisterhood".  A few slip out, but those moms are made to look as though they are crazy, bitter villains.  Try a healthier perspective on for size:
      "I would be much happier if everyone would truly hear what the women who have 
      been hurt are saying.  If we don't do something about the bad midwives, the state 
      will do something for us.  And as midwives, we aren't going to like what that is.  
      Couching important discussions, disguised as women's choice puts the onus on    
      childbearing women rather than on the profession providing care"  
     ~ Anonymous Midwife

What would actually make OOH birth safer?  Legislation that includes all of these: 
  • Defining "midwife" and limiting the practice of midwifery to only those who are licensed
  • Keeping a balanced board as the body of oversight at the state level
  • Gathering data on all OOH birth outcomes
In conclusion, again I ask, "Where is the Leadership?"  Clearly the people lobbying for licensing alone, are confused about what it means to protect consumers instead of themselves.  Time for honest leadership that doesn't use loss stories to promote their own twisted agenda.  Time for transparency in the goals we're really striving for...those that would preserve choice, and improve safety for out-of-hospital birth.  It can be done, with the right leadership. 

Where is the leadership?  Part 1

1 comment:

  1. I'm embarrassed to admit that I once believed in the idea that all birth options had to be preserved and allowed for certified professional midwives to attend. Because of the few women who would opt to birth alone rather than go to the hospital.

    I thought that CPMs would use these liberal rules cautiously, and only take the extreme cases, and risk out most women who wanted extremely risky homebirths. That this allowance would be reserved for only the rarest cases.

    But in my training I found that the door is wide open - that CPMs accept these women who are high risk readily and often. That there is rarely a risk factor too high to exclude from OOH care.

    I thought that CPMs were "professionals" and therefore capable of of professional judgment. I really believed that CPMs - by their own oft-touted philosophy, only attended the births of women who were low-risk.

    The reality was slowly and gradually revealed to me throughout my training. And the more I studied, and experienced the more I realized how many risks were being taken.

    There is still a part of me that is saddened that midwives would be regulated by state laws over their own professional guidelines, standards, and evidence-based practices. Because conceptually, a profession of midwifery that is governed by itself is a very appealing and exciting concept.

    But as you aptly pointed out:

    " there really aren't any standards for practice..."

    And therefore, certified professional midwives only have themselves to blame.