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 
      hospitals."

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. 

Ask A Midwife: Risking Out of Home Birth

Dead Breech Babies - Navelgazing Midwife

Magnus's Story

Ask a Midwife: Why don't you risk out for postive GBS clients?

Why does being GBS + (Group B Strep) not qualify a woman to be risked out of home birth?  I know the pill antibiotics are not as effective as the IV antbx. A CNM can give IV antbx at home, but how likely is that? As I understand, the GBS+ status of the mother is only important for the baby's safety. What can you tell me about this? There was a case of a CPM in California who delivered a healthy baby that died a day or so later of GBS sepsis. Very, very tragic. -- Concerned Reader

 

 The most accurate information concerning GBS can be found here: http://www.cdc.gov/groupbstrep/guidelines/new-differences.html. The majority of OOH birthing centers and home birth practices do not risk out women who are GBS carriers. CNMs have prescriptive authority and therefore can order the IV prophylaxis that is recommended for the prevention of GBS.

2010 Guidelines for Prevention of Perinatal Group B Streptococcal (GBS)

CDC - GBS Prevention Guidelines - Changes Since Last Release - Group B Strep

Safer Midwifery added these thoughts to the discussion:

‎

Again, the difference between CNMs and CPMs comes into play here, as does the importance of licensing, regulation, and defined risking out criteria/scope of practice.  Deb O'Connell, our resident midwife on the blog is a CNM, licensed, insured, and uses strict risking out criteria.  She has prescriptive authority.  If CPMs are unlicensed, unregulated, and have no defined scope of practice, they can treat clients with any unproven method they choose.  They don't have an obligation to transfer care or risk out.  I would venture to say that most home birth midwives are not CNMs and therefore do not have prescriptive authority.

Perhaps the difference in care is that the CPM (Certified Professional Midwife) in CA may not have had prescriptive authority, and resorted to her own unproven methods for treating GBS.  I have read stories of mothers whose GBS was treated by putting garlic in their vagina instead  properly being treated for a serious complication and the baby died hours after birth because of pneumonia from GBS.  See Wren's Story.  Garlic is not a substitute for antibiotics.

The problem then lies in the fact that the midwife made the decision to treat her client for GBS when she was unqualified to do so, instead of getting her client the help she needed.  Without the ability to treat GBS properly with prescriptive authority, the midwife should absolutely be risking out her client so she can receive the care she needs, and transferring her to the care of a physician.  Many, many midwives don't risk out at all and consider everything to be a variation of normal.

A CPM would need prescriptive authority in order to safely treat a client for GBS, strict risking out criteria would have to be clearly defined in order to practice safely, transfer of care would have to be seen as necessary to maintain a safe standard of care, and a solid, foundational education must precede all of these points.  Thank you for the excellent question!

 "Ask a midwife" is a write-in series here on the blog. If you have a question for our Certified Nurse Midwife, please share it with us here.

Ask an OB: Crystal ball

"Ask an OB" is a weekly series with Dr. Maude "Molly" Guerin, MC, FACOG. If you have a question for her, please share it with us here. 

How can you make sure you are on the same page, specifically regarding risk, with your midwife/OB? For example, is it appropriate to say, "I would like to do my best to birth this child naturally but if you can tell that the baby may not make it, or I am to blow out my body, that is where I draw the line." How do you draw lines with them? Is this a conversation you should initiate during prenatal classes? Should you say, "I am all for candles and bathtubs, but ultimately I am here for the outcome (i.e., healthy mother and baby) and am willing to sacrifice the process (i.e., uninterrupted birth) to get there. I need you to help me identify when our health is at risk." - Okemos Mom

 

I badly need a crystal ball. When they invent them, I get it first! If I could peer into it and see a 30 hour labor, 4 hours of pushing, a C section, a stay in the Neonatal Intensive Care Unit for the baby and a blood transfusion for you . . . I would do a C section before labor and skip all that! If I could see a baby that comes out and doesn’t breathe, has Apgars of 1 and 4 . . .  I would labor you in the hospital, on continuous monitoring, and do a C section if things looked bad. And you would gladly forgo the “candles and bathtubs,” I’m sure!  If I was worried a VBAC would rupture your uterus with a trial of labor, but could use my crystal ball to see a 3 hour labor, 2 pushes and a happy baby and mom, we wouldn’t even talk about all the bad things that can happen! Unfortunately we don’t have that crystal ball. Therefore you DO NEED to have that conversation with your partner before you decide where to have your baby. Then you need to be explicit with your provider. Here are some examples of ways that you can set clear expectations:

• “We are committed to a natural labor and delivery at almost all costs. We accept some increased risk for low Apgar scores, neonatal seizures, and a long labor – in hopes of reducing our risk of a C section. Unless you have clear incontrovertible evidence that my baby or I WILL have irreversible damage, I want to continue with no intervention and accept the outcome.”

• “We sincerely hope for a low tech, ‘hands-off’ labor and an unassisted vaginal delivery. Please stand by and let us know if you see warning signs of trouble for mom or baby…we would like to discuss options for intervention in that situation, and have a time line for decisions.”

• “We want as close to a 100% guarantee as you can give us that our baby will be under absolutely no stress during labor and delivery. If things aren’t going perfectly we want a C section immediately.” 

Writing your feelings down is always good, too. I would much rather see an essay on your risk tolerance and the strength of your desire for no intervention than the list of “do’s and don’ts” that make up most birth plans. So my advice is yes – please talk talk talk to your provider about risk and how you want to handle certain situations. If your provider has her/his own agenda about these things, you need to know that up front and decide if you can live with that. 

Finally, I find the last sentence of your question critical. “I need you to help me identify when our health is at risk.” Honestly, this is not your job, it is our job. Your job is to be strong, to be thoughtful, to climb the big mountain that is labor. Our job is to be nearby spotting you. When you veer off the safe path, we notice, we shepherd you back. Sometimes we yank you back! “Hey your baby is in trouble – get into the O.R. RIGHT NOW!!”  You shouldn’t have to worry about identifying when your health is at risk, you have a huge job to do just getting through this (it’s called “labor” for a reason!). If you are second guessing your provider and don’t trust that they will be able to “identify when your health is at risk”, you are in the wrong place for care.

You can read more about Dr. Maude "Molly" Guerin, MD, FACOG, right here.

Neonatal Mortality Rates Part 2: Who has the best/worst infant morality rates?

This is the second part of our series on understanding neonatal mortality rates, in which we try to answer two questions: “Which is riskier, hospital or home birth?” and "How does place of birth and birth attendant impact outcomes?"  This post will specifically address mortality rates based on data from Wisconsin’s WISH initiative.*

As out-of-hospital birth advocates are quick to point out when a baby dies on their watch, babies die in hospitals, too. This is true. But does this mean that hospitals are less safe? No! One important reason is that the patient populations for home births and hospital births are vastly different. A hospital takes mothers of every kind: healthy mothers, obese mothers, drug addicts, mothers pregnant with multiples, breech babies, preemies, mothers with heart conditions, mothers with high blood pressure, and mothers with every other kind of complication you can imagine. On the other hand, a midwife practicing outside of the hospital is supposed to take on only normal, low-risk pregnancies. Thus, if the safety of the care itself is the same in both places, we would naturally expect the hospital to have higher neonatal mortality rates, given the high-risk population it serves.

You might be surprised to know that is not the case - at least not in Wisconsin.

The data collected in the WISH database can be stratified in many ways.  For our purposes, we have stratified the data by the type of birth attendant. We’ll try to understand how the specific mortality rates for physicians working in a hospital setting (MDs, in this case) compare to direct entry midwives largely responsible for home birth (DEMs, otherwise known as CPMs). We’ll also consider CNMs and their role, since they deliver in both settings.     

The data collected in Wisconsin and presented in the chart below show that the mortality rate for home births attended by DEMs was 4-5 times higher on average during 2003-2008 despite the low-risk client population they serve! 

When you consider that these data include all comers, with high-risk moms tending to choose hospitals and home birth midwives only taking on low-risk pregnancies, things look pretty bad for the DEMs. There seems to be little doubt that care provided by DEMs is much riskier.  The CNM data, however, are more difficult to assess because CNMs can deliver babies in both settings -- hospital and home.  (Note: CPMs would be listed as DEMs in this data set because they are part of the home birth sub group statistics.) 

So let’s look more closely at the role of CNMs and their mortality rates.  The chart above shows that CNMs have mortality rates on par with or even better than MDs. How is this possible when we read that out-of-hospital birth is 3-4 times more risky? Or when the ACOG (American College of Obstetrics and Gynecology) states that perinatal mortality is higher in out-of-hospital births?

To better understand this seemingly conflicting evidence, we asked Deb O’Connell, CNM and home-birth midwife, to answer a few questions: 

Safer Midwifery: Deb, ACOG states that perinatal mortality rates are higher in out-of-hospital births. Is this true? 

Deb: Not exactly. When CNMs are managing out-of-hospital births we have the LOWEST perinatal mortality and morbidity rate in the country. That is actually true regardless of our practice setting, home or hospital.

Safer Midwifery: OK, but you have also said that home birth is not as safe for a baby as being born in a hospital. So I'm a little confused. Can you please explain? I think this can be misread as thinking midwife outcomes are the same or better, when there is so much more to be explained. 

Deb: Sure. The reason that out-of-hospital birth is not as safe for baby (and this not limited to home-birth -- it includes freestanding birth centers) is due to delayed response time for intubation if required.  A CNM who is practicing in an out-of-hospital setting and who is practicing within a strict set of protocols will have roughly the same perinatal outcomes as her counterparts practicing in a hospital setting, and if they are NOT the same or BETTER than she needs to revisit her risk-out criteria.

Safer Midwifery:  Okay, I think I am starting to get it. If I understand correctly, there are really two separate but related issues. For two identical pregnant moms, the risk for out-of-hospital birth will be higher than in the hospital. But high-risk births will tend to go to the hospital, so the patient pool for midwives will be mainly low-risk births. Thus, if we see that outcomes are worse for a midwife practice, we can infer that they are doing something very wrong: either they are delivering poor care to low-risk births, or they are taking on too many high-risk births. Is that right?

Deb: Yes!

Thanks to Deb for helping us think that through! You can see now why things are so confusing. As parents, the number we really want to know when choosing between out-of-hospital and hospital birth is the first one: What's the difference in safety across the two settings for two identical, low-risk pregnant mom? The problem is that we don't see this comparison reflected in the Wisconsin dataset, or in any dataset for that matter. We only see final outcomes that reflect the two confounding effects: higher-risk practice versus lower-risk population.

It appears then that CNMs have comparable mortality rates to doctors when they function under a strict set of risking out criteria.  That being said, for two identical mothers, one giving birth at a hospital and one outside of the hospital, the risk is 3-4 times greater outside the hospital --  and even higher if your CNM is not adhering to  strict risking out criteria. Of course, with poorly trained DEMs or CPMs, the risk of out-of-hospital birth are also likely higher. 

Evaluating the efficiency and relative safety by place of birth & type of birth attendant in Michigan is nearly impossible.  You may have wondered why we used data from Wisconsin for this post.  We were not able to use data from Michigan because as a state we are lacking in our data collection efforts  and reporting outcomes as related to birth.  The type of birth attendant is not included on MI birth certificates, thereby making it impossible to adequately collect data stratified by place and care giver type.   In addition, when midwives aren't required to report their outcomes, data becomes even more vague and consequentially so does proper assessment of outcomes, measures of safety, and relative efficiency.  Michigan needs much revision when it comes to collecting data about birth in order to utilize that data to ultimately improve outcomes for mothers and babies.

*(Wisconsin's Department of Health offers a website/database which gives information about health indicators [measures of health] in Wisconsin. WISH allows policy makers, health professionals, and the public to submit questions [requests for data] and receive answers [tables] over the Internet.)

The hospital is "only" 12 minutes away

When clients at an out-of-hospital birth center ask their midwives, "What would happen if there were an emergency," they are greeted with the calming notion that, "The hospital is only 12 minutes away."  Women are often reassured that a short ambulance ride somehow means that care is close enough to feel comfortable when embarking upon out-of-hospital birth.

When you stop and think about this, there is so much more to responding in the event of an emergency than the length of the ride from one driveway to another.  What conveniently is not discussed is

• The time it takes for a decision to be made to transfer, when concerns are in fact recognized
• The time it takes for a mom's request to transfer to be taken seriously instead of "buying more time" with stall tactics
• The time it takes for the ambulance to be called
• The time or day and day of the week and how that impacts traffic flow
• The time it takes for the ambulance to drive to the birth center
• The time it takes  for EMTs to assess the situation and respond accordingly
• The time it takes to load 
• The time it takes to stabilize a baby who isn't breathing for transfer
• Insert Drive Time Here (12 minutes)
• The time it takes for the hospital staff to assess the patient in need and make a plan for moving forward, sometimes having no records on hand
• The time it takes for strangers to fill out paperwork
• The time it takes for new care to effectively take shape with a resolution achieved  
• EMTs do excellent work, but they are not an RNICU or labor and delivery team.  
  
  

Wouldn't it be more accurate to consider the broader scope of transfer time as "Care to Care" transfer, meaning the time it takes from request or concern to the time it takes to get the help you need?  Let's look at three different real-life transfer events that happened from the Greenhouse Birth Center to Sparrow Hospital in the Lansing area last year.

Client #1 ~ "Non-Emergency" transfer: Mom in pain requests transfer after pushing without
                     progress for 2+ hours.  Baby's heart rate is variable. Midwives stall because she
                     is "so close" but eventually discuss transfer and call an ambulance.

Client #2 ~ "Urgent: transfer:  Mom has been pushing for 4+ hours with no progress.  

                      Baby's heart rate starts to be concerning. 

Client #3 ~ "Emergency" transfer: Baby born without a heartbeat, immediate resuscitation 

                      necessary 

Table: Transfer Time from Birth Center to Hospital for Three Different Families
Stage of Transfer Process	Type of Scenario
	Non-Emergency mom in excruciating pain requests transfer	Urgent baby’s heart rate in labor is concerning	Emergency baby is delivered with no heartbeat
Transfer Requested or Serious Concern Noted until Ambulance Called	30 minutes (initial requests to transfer discounted)	Not Available	4 minutes (from delivery until ambulance called)
Ambulance Called until Ambulance Arrives at Birth Center	3 minutes	2 minutes	2 minutes
Ambulance Arrives at Birth Center until Ambulance Departs for Hospital	5 minutes	8 minutes	16 minutes (attempting to resuscitate baby)
Ambulance Departs for Hospital until Ambulance Arrives at Hospital	12 minutes (no lights or siren)	9 minutes (lights & siren)	11 minutes (lights & siren)
Ambulance Arrives at Hospital until Care is Effectively Transferred	60+ minutes (epidural given and mom resting)	15 minutes (pain meds given and evaluations in progress)	14 minutes (RNICU team still resuscitating)
TOTAL TIME: Care to Care	approx 2 hours	34 minutes	41 minutes (baby has a heartbeat, prognosis grim)

In the most emergent scenario (third column), you're looking at 41 minutes from the time a baby is born without a heartbeat to the time he has been "resuscitated".  41 MINUTES!  How does a baby have any chance at survival after 41 minutes without a breath?  Furthermore, how does a baby have any chance at survival after 12 minutes without a breath, even if the claims made were true?

Purposefully minimizing the estimated time it takes to effectively transfer a mom or baby in crisis is abhorrent.  Midwives who practice out-of-hospital birth need to be frank with clients about the fact that emergencies do come up in an instant that require immediate medical attention, and that when they do, there is little that can be done to avert it.  By proximity alone, you're putting yourself at risk.  I would have appreciated a frank conversation about this instead of being told that, 'They know what to look for and how to get help in plenty of time, that the hospital is only 12 minutes away and the ambulance is across the street."    

10 cm Blog ~  Friday Fallacy: The hospital is just minutes away.
Lansing State Journal ~ "How far is too far in a birth emergency?"

Lansing State Journal: "Homebirth movement raises questions of acceptable risk..."

The Lansing State Journal has spent 3 months researching birth in Michigan.  Reporter Louise Knott Ahern did countless hours of research and interviews to compile a comprehensive piece about midwifery in the state of Michigan.  The article considers everything from philosophy, to birth options, and safety.  

You can pick up a print copy of the Lansing State Journal today, Sunday, June 3rd, or you can find all the articles, videos, and more at:

"Lawsuit brings home birth movement into the spotlight"

"Home birth movement raises questions of acceptable risk" 

"Who cares how the baby gets here?" 

"How far is too far in a birth emergency?"  

"Where do hospitals fit in with 'normal and natural' birth?"

"Birth Center's practices under scrutiny since March lawsuit"  

"Read local birth stories and share your own" 

(Notes: Be sure to check out the links on the left and right of the article too for extensive resources, interviews, birth stories, and more.  If you start getting pop up boxes asking you for a subscription, just clear your browser's cache.)  

Dr. Amy weighs in on the subject too on the Skeptical OB Blog: 

"Brilliant series on the dangers of home birth"

A full article review by Safer Midwifery for Michigan will be posted tomorrow. 

The Roots of Dogma: Ina May's Religion & the Midwives Who Follow

dog·ma  n. 

1. A doctrine or a corpus of doctrines relating to matters such as morality and faith, set forth in an authoritative manner by a church.

2. An authoritative principle, belief, or statement of ideas or opinion, especially one considered to be absolutely true.

dog·mat·ic  adj.

1. Relating to, characteristic of, or resulting from dogma.

2. Characterized by an authoritative, arrogant assertion of unproved or unprovable principles

After reading the recent article in the New York Times about Ina May Gaskin and her battle for home birth, it all makes sense.  Now I know exactly where the dogma started.  

As I read the article, I learned more about who Ina May Gaskin is on a human level.  It seems to me that her perception of birth is much like a religion.  Her followers even reference her as a "saint" and feverishly distribute copies of "Spiritual Midwifery" to expectant mothers.  Apparently, being a saint these days means that you were involved in a four-person marriage, are proud of doing LSD and attending workshops to process your acid trip, and that you preach to the masses about just how safe birth really is without having any real education, medical training, or reported data to back it up.  The roots of Gaskin's movement are most clearly articulated with this sentence: "The participants in the caravan settled in Summertown, Tenn., in 1971. They took a vow of poverty and veganism and lived communally. Birth was a revered 'sacrament.'"  

Do women have a right to choose any religion they please?  Sure they do.  Do they also have a right to know whom they are following?  Absolutely. But (and this is a big "but") when a mom hires a CPM or a lay midwife to attend her birth, does she fully understand the dogma at the root of that woman's practice?  I don't think so. And this is the big problem that I see.

When a woman seeks the care of a midwife, someone who is posing as a professional caregiver, the expectation is that they operate under certain professional parameters, religion aside.  I have to believe that most women do not understand the dynamics of who it is they are hiring or how the the extremist nature of the "root" philosophy will impact the care she receives.  I know I didn't.  I was looking for a more personal model of care and thought birth to be an intimate experience.  I liked knowing exactly who would attend our birth and that our midwife would be present for the duration.  I thought midwives to be a safe, reliable, professional option...part of our health care system (as some are).  Surely it must be safe if they are running freestanding birth centers in the middle of reputable suburbs.

So what went wrong?  How did we end up in the hands of midwives who were so far from the professionals, the people we thought them to be?  What I didn't understand is the vast spectrum in philosophy that resides within the practice called "midwifery."  I wasn't looking for religion and I didn't knowingly volunteer my baby for sacrifice at the altar to advance anyone's cause, yet somehow that's exactly what happened.  Blind religious faith masked as natural childbirth and sold on a communal platter.  Some might call it a cult as in this post from 10 cm, The Cult of Natural Childbirth.  I must admit, in retrospect, much of this parallel seems eerily familiar.  Especially after reading about where the dogma started and after personally experiencing the backlash from the NCB community after speaking out about our experiences.           

What bothers me most is that the "Big Push" for midwives is aimed at the general population. Women are brought into the care of extremist midwives with specific selling points and marketing tactics that make birth sound alluring and empowering. There is no honest discussion of the real risks involved.  Ina May is a good saleswoman - she has already successfully marketed her cause across the country, with 27 states now licensing CPMs (who are directly trained and credentialed from Ina May's organizations, MANA and NARM).

How is this happening when most don't fully realize just how extreme the founder's roots really are?  How can someone earn a license to attend life and potentially deadly events without an education?   How are these women earning the privilege of attending our births with no oversight or accountability whatsoever?  Dogma cannot be allowed to influence maternity care.  Best practices must be defined, standards of care established, reporting outcomes required.  I hope we can reach women in MI and help them understand the complexity of this issue before Michigan makes the same detrimental mistake. Please visit:  Top 10 Reasons Why HB5070 Would do More Harm Than Good.

Every woman has the right to know exactly where this movement is coming from and what it's all about. They also have the right to know how many families it has adversely affected through infant loss and injury, BUT unfortunately, without regulation to require reporting outcomes, we don't have that data. We just have small voices fighting to be heard.  To read more about some of those small voices, visit: Hurt by Homebirth

Click here for Another reader's review of the NYT article .

To read more about dogma in midwifery visit: 

N.A.R.M ~ No Accountability, Renegade Midwifery

The "Whistleblower Midwife" & More

Midwife Masquerade: What Does Your Midwife Believe? 

Midwife Masquerade: Denial

Should my midwife be my friend?

When Our Baby Died

Freestanding Birth Centers ~ Common Myths Revealed 
The Hypocrisy of Midwifery

The Hypocrisy of Midwifery

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

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

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

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

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

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

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

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

Related Posts:

Ask an OB: "Risk Out" Criteria

Midwife Masquerade: Denial

The Importance of Defining Risk

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

Ask a Midwife: "Risk Out" Criteria

What are some "risk out" criteria for home birth? In other words, what are some things that might make a woman (and her midwife) change her mind about pursuing an out-of-hospital birth? -- Grand Rapids mom

As a provider (nurse-midwife) attending home births, one of the biggest challenges I am presented with is informing a woman that she is not (or is no longer) a candidate for a home birth. Why is this a challenge? Because it will disappoint her. One of the “myths” surrounding the natural childbirth community is the idea that having a labor/birth at home is a choice for all healthy women. However, there is often a difference between being “healthy” and meeting a medical criteria for a home birth that will optimize outcome for both mom and fetus/ baby.

A woman can be “healthy” (or have a self-perception of health) and still have a medical/ emotional diagnosis that risks her out of having a home birth. An example would be a woman with a history of seizures, even if the history were a remote one. She would still risk out of having a home birth. Another example would be a mom with a history of having insulin-dependant gestational diabetes with her previous pregnancy. She may be “diabetes-free” currently but her HISTORY of having the insulin-dependent GDM risks her out. Other factors are fetal-related as opposed to maternal-related issues. Malpresentation is the most common fetal related risk factor for a home birth, with breech presentation being the most prevalent at a rate of 2-3% of pregnancies. 

The following is a list of common risk factors that "risk out" a woman from having a home birth in a responsible home birth practice. It is not an exhaustive list but includes many of the issues we have come across while interviewing clients and managing pregnancies within our practice. Many times we will co-manage gals that “risk out” of a home birth with their physician(s) and will provide continuity of care for them in the postpartum period as well as be present for them during the hospital labor/birth. Here is the list:

1	Noncompliance with visits, scheduled screenings, testing during pregnancy
2	History of previous cesarean section
3	Current/History of seizure disorder
4	Current diabetes (and history of Insulin Dependent Gestational Diabetes)
5	Current fetal malpresentation (breech, transverse lie)
6	Placenta Previa or Marginal Previa
7	Current drug and tobacco use
8	Current alcohol dependence
9	Current mental illness that involves thoughts of harming self or others
10	Home that is greater than 30 minutes from a hospital or paramedic station
11	Home that does not have running water, heat and electricity
12	Pre-eclampsia during pregnancy
13	Insulin-Dependent diabetes during pregnancy
14	Fetal anomaly detected during pregnancy that may compromise neonate if born at home (cardiac anomaly, cleft palate, gastroschisis, ect).
15	Pregnancy before 37 weeks
16	Pregnancy after 43 weeks (we require antenatal testing at 41 weeks weekly and if, at 42 weeks, mom wishes to continue plans for a homebirth, she is counseled on increased risk of meconium and the fact that we will no longer manage birth at home once meconium in noted.)
17	Poor support system in place for days after the birth
18	History of postpartum psychosis
19	Multiple gestations (twins, etc.)
20	Fetal demise during pregnancy

The article links below are pertinent to this topic. Please keep in mind that the Committee Opinion from ACOG (American Congress of Obstetricians and Gynecologists) does not reflect the difference between planned home births attended by CNMs and “other midwives”. Unfortunately we are all lumped in together, which is very disappointing since it is clear that Certified Nurse Midwives (CNMs) have the LOWEST neonatal mortality and morbidity rates of ALL providers both in the planned home birth and planned hospital birth settings.

Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ (Canadian Medical Association Journal) September 15, 2009 vol. 181 no. 6-7.  

Planned home birth. Committee Opinion No. 476. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:425–8 

"Ask a midwife" is a write-in series here on the blog. If you have a question for our Certified Nurse Midwife, please share it with us here.