A letter to Judy Norsigian of Our Bodies Ourselves
Several days ago I responded to an opinion piece in the Concord (NH) Monitor written by the former Chairwoman of the New Hampshire Midwifery Council, the state organization of direct entry midwives.
I reviewed my 15 reasons for not licensing direct entry midwives:
This is fundamentally a public safety issue. The question: Is it safe to license a second class of midwife with less education and clinical training than any other midwives in the industrialized world? The answer:
1. This is NOT about having midwives in the US. We already have midwives (certified nurse midwives) who are among the best trained midwives in the world.
2. This is about creating a SECOND class of midwives with less education and training.
3. No other country has a second class of midwives.
4. The standards for direct entry midwives, in terms of educational requirements and clinical training, are far below those of any other midwives in the industrialized world.
5. Direct entry midwives are NOT trained for out of hospital birth, since no special training is required. The many taxi drivers, police officers and family members who deliver babies each year could tell you that. The only thing that requires training is dealing with unanticipated complications, and this is precisely what direct entry midwives lack.
6. Direct entry midwives are not "specialists" in out of hospital births. They are restricted to out of hospital births because they are considered unqualified for birth centers or hospitals.
7. Direct entry midwives are not "specialists" in normal birth. Claiming to be a specialist in normal birth makes as much sense as a meteorologist claiming to be a specialist in good weather.
8. Homebirth carries an increased risk of preventable neonatal death in the range of 1-2/1000 ABOVE the neonatal death rate for comparable risk women in the hospital.
9. To date there is not a single study that shows homebirth to be as safe as hospital birth. There are studies that claim to show that, but they do so by comparing low risk women at homebirth with high risk women in the hospital.
10. This is not about "choice". Any woman can choose to have a homebirth. This is about licensing of health care professionals who do not have the necessary education and training.
11. The insurance industry will not write policies for homebirth or charge extraordinary premiums because their data indicate that homebirth carries an unacceptably high incidence of bad outcomes and big payouts.
12. There is no uniformity in direct entry midwifery credentials. There are many different credentials with differing education and training requirements. Direct entry midwives cannot agree among themselves what baseline training is required.
13. Direct entry midwifery credentials were created by direct entry midwives without input from medical or public health sources. These credentials are the "seal of approval" of some DEMs in regard to other DEMs. There is no independent objective basis for these credentials.
14. The Midwives Alliance of North America (MANA), the group that collected the statistics for the BMJ 2005 study, has collected statistics for the years 2001-2006, but refuses to release them to the public. They will only be released to individuals or groups that can prove they will use them for "the benefit of midwifery." The public has a right to know these statistics.
15. There are no statistics at all for long term outcomes of homebirth with direct entry midwives. We have no idea (nor do they) about the incidence of brain damage, oxygen deprivation or birth injuries.
The bottom line is that we already have well educated, well trained, highly competent midwives in the US. We are being asked to accept the licensing of a SECOND class of midwives with less education and less training than any other midwives in the industrialized world.
Today the paper published a Letter to the Editor from Judy Norsigian, the executive editor of Our Bodies Ourselves, in response:
Re the debate about homebirth and certified professional midwives:
The distortions and inaccuracies in Dr. Amy Tuteur's comments on the Monitor website are typical of her many postings at various websites and newspapers. For evidence-based, balanced information, we refer your readers to the items noted at our website, ourbodiesourselves.org, including the new, peer-reviewed report "Evidence-Based Maternity Care: What it is and What it Can Achieve," issued Oct. 8 by the Milbank Memorial Fund, the Reforming States Group, and the Childbirth Connection.
What readers need to fully comprehend is the extent to which documented "best practices" are not followed in many hospitals across the country. That fact alone justifies retention of the option of homebirth with trained, licensed caregivers.
I promptly wrote back:
If there are truly distortions and inaccuracies, it should not be difficult to point them out, yet you could not think of one distortion or inaccuracy to include in your comment. That suggests that you are merely making accusations to change the subject. All the existing scientific evidence shows that homebirth with a direct entry midwife increases the risk of neonatal death. Direct entry midwives (unlike certified nurse midwives) have less education and less training than ANY midwives in the industrialized world.
Your mention of, and inaccurate characterization of "Evidence-Based Maternity Care: What it is and What it Can Achieve," issued Oct. 8 by the Childbirth Connection is telling. First, it does not discuss either homebirth or direct entry midwifery. Second, the title is rather Orwellian since the report is not based on the scientific evidence; it is based on the personal opinions of the activists at the Childbirth Connection. Third, it is not a peer-reviewed journal publication; it is a privately funded and privately produced position paper.
I challenge you, Ms. Norsigian, to provide proof that anything I wrote is either a distortion or inaccuracy, with the scientific citations to back up your claims. Feel free to post it here or on my website Homebirth Debate.
I look forward to her response. Of course, I am not holding my breath. If she is like Henci Goer, Judith Rooks, and Johnson and Daviss, she will find limit herself to casting unfounded aspersions from afar rather than risk debating the issues with me.
Labels: midwifery
New Cochrane study promptly misinterpreted by midwifery advocates
A new study was published by the Cochrane Review this week, and midwifery advocates wasted no time in misunderstanding the results. Midwifery advocates are exulting that the study proves that midwifery care is superior to other models of care. Just one problem: that's not what the study looked at. The study compared midwifery-LED team care with other forms of team care. That's why the name of the study is
Midwife-led versus other models of care for childbearing women.
This incident is instructive on two levels. First, it is an excellent example of why systematic reviews are NOT the gold standard of scientific evidence. Second, it shows how midwifery and "natural" childbirth advocates don't bother to read the scientific papers they cite, don't understand what they say, and promptly disseminate misinformation to others.
First, let's look at what the study was trying to investigate. According to the authors:
Midwife-led care has been defined as care where "the midwife is
the lead professional in the planning, organisation and delivery of care given to a woman from initial booking to the postnatal period". Some antenatal and/or intrapartum and/or postpartum care may be provided in consultation with medical staff as appropriate. Within these models, midwives are ... the lead professional ...
Here's how the authors describe the other models of care that served as the comparison group:
Care is often shared by family doctors and midwives, by obstetricians and midwives, or by providers from all three groups. In some countries ... the midwifery scope of practice is limited to the care of women experiencing uncomplicated pregnancies, while in other countries ... midwives provide care to women who experience medical and obstetric complications in collaboration with medical colleagues. In addition, maternity care in some countries ... is predominantly provided by a midwife but is obstetrician-led, in that the midwife might provide the actual care, but the obstetrician assumes responsibility for the care provided to the woman throughout her pregnancy, intrapartum and postpartum periods.
In other words, this study compared two different models of team care.
This study did not compare midwife care to doctor care. Virtually every woman in both arms of the study was cared for by midwives AND doctors. The study only looked at the role of the midwife within the team.
Let's look at the problems within the study itself. As I mentioned above, systematic reviews are not the gold standard of scientific evidence. That's because they depend entirely on what studies are included, and which are excluded. How did the authors determine which studies to include in this review?
Our search strategy identified ... 31 studies for potential inclusion. Of those, we included 11 trials involving 12,276 randomised women in total ... Included studies were conducted in the public health systems in Australia, Canada, New Zealand and the United Kingdom with variations in model of care, risk status of participating women and practice settings...
Seven studies compared a midwife-led model of care to a shared model of care, three studies compared a midwife-led model of care to medical-led models of care and one study compared midwife-led care with various options of standard care including medical-led care and shared care.
Note that not a single study compared midwife care with doctor care.
How did the authors decide that only 11 of the 31 studies should be included, and the other 20 excluded? The authors never say. This review contains 130 pages of text and tables, and as far as I can determine, the authors offer no justification or even explanation for their decision to use only 11 of the 31 studies. It seems that they simply picked the studies they liked and excluded the ones they didn't like.
I'm rather surprised that the editors of the Cochrane Review were willing to accept this review. It conclusions are essentially useless because studies were included and excluded on an arbitrary basis, and the 11 studies that were included had wide variations in the comparison group. So this study tells us nothing about anything.
The bottom line is that is a poorly done study that is designed to compare midwife led team care with other forms of team care. Did it show that midwife-led care is superior to other forms of team care? The authors think that it did, but that may be simply because the data selection was biased.
One point, though, is undeniable. The study NEVER compared midwife care to doctor care. Therefore, midwifery advocates who are exulting that the study shows that midwife care is superior are only demonstrating that they never even bothered to read the study.
Labels: midwifery
Irony
I suspect that the ultimate irony of the campaign to promote homebirth and license direct entry midwives will be to bring about the demise of direct entry midwifery.
Direct entry midwives and their supporters have successfully tried to confuse American women on two critical points:
1. Homebirth is KNOWN to increase the neonatal death rate
2. American DEMs are grossly undereducated and undertrained compared to ANY other midwives in the industrialized world.
The effort to license DEMs has already let to the national government's collecting statistics on homebirth with a DEM. The first large data set already shows that homebirth with a DEM triples the rate of neonatal death compared to low risk hospital birth. This is consistent with all the existing scientific evidence on homebirth. Homebirth advocates will no longer be able to pretend to themselves or others that homebirth is safe.
MANA, the trade union for DEMs, has been successful up until now at confusing people about the education and training of DEMs. They created their own certification ("CPM") which is so close to CNM (certified nurse midwife) as to create confusion. Homebirth advocates routinely cite the practice of midwifery in European countries like the Netherlands, without bothering to explain the American DEMs are nothing like Dutch midwives and would never be considered qualified in the Netherlands. Dutch midwives, like ALL other midwives in the industrialized world are hospital trained with extensive experience in managing complications. In contrast American DEMs never have any hospital training and receive degrees from correspondence courses.
Homebirth advocates are shrilly and falsely decrying the AMA's attempt to "outlaw" homebirth when the AMA is simply asking for acknowledgement of the facts. Homebirth is not as safe as hospital birth and American DEMs do not meet the standards for midwives anywhere else in the industrialized world.
MANA, the DEM trade organization, may continue to withhold the 7 years of safety statistics it has collected, but soon it won't matter. The government is now involved and the truth can no longer be suppressed.
Labels: midwifery
DEMs on postdates: doubly wrong
DEMs like to tell mothers that the baby "knows" when to be born. In other words, whenever labor starts, it's the right time. Therefore, going beyond 42 weeks of pregnancy is not a problem. The 2003 and 2004 Linked Birth Infant Death Statistics
data set shows that DEMs are doubly wrong. Postdates babies attended by a DEM at home have an appalling rate of neonatal death. In addition, since DEMs fail to refer their postdates patients for inductions, they have a higher proportion of postdates pregnancies among their patients.
These statistics show that DEM attended postdates homebirths have more than TRIPLE the neonatal death rate of MD attended postdates hospital births (all risk groups) and more than 500% higher neonatal death rate than comparable risk CNM attended postdates hospital births.
There are a number of conclusions to be drawn from this data:
The neonatal mortality rate for postdates in the hospital (CNM or MD) is virtually the same as the mortality rate for term pregnancies, suggesting that both CNMs and MDs are appropriately managing the increased risk of postdates.
In contrast, DEM attended postdates homebirths have more than double the neonatal mortality rate of DEM attended term homebirths, indicating that DEMs are not capable of managing the complications that are more likely to arise in postdates labors.
The neonatal mortality rate of 2.43 at DEM attended postdates homebirths is appallingly high, which is consistent with the fact that DEMs lack basic knowledge about the risks of postdates, and lack basic knowledge and training managing complications. Keep in mind that the mortality rate of 2.43/1000 is almost certainly lower than the true rate since patients who were transferred to the hospital for complications that occurred in labor are counted in the hospital group, not in the DEM homebirth group.
Postdates hospital births represent 6.9% and 8.8% of MD and CNM hospital births respectively. In contrast, postdates births represent 10.5% of DEM attended homebirths. DEMs are allowing a greater proportion of patients to go postdates without referring them for induction.
The fact that DEMs lack the most basic knowledge about the risks of postdates pregnancy leads them to be doubly wrong. First, they are not capable of properly managing postdates complications at home. Second, because they don't understand the risks of postdates, they allow more of their patients to go postdates, increasing the number of women who are likely to have complications at home.
We always come back to the same place with DEM attended homebirth: Ignorance and incompetence lead to an increased risk of neonatal death.
Labels: midwifery
It's not about you
Morag, of Mama Mid(Wife) Madness, has read my recent post and written an open letter entitled I have no fight with you (now cached
here) in response.
I am a student midwife, and I am human, and as a person I feel savaged and hurt by your attacks. I have done nothing to deserve such unbridled hostility.
From the title to the last paragraph it demonstrates one of my most common criticisms to direct entry midwives: "It's not about you. It's about the patients!"
Let's look at this from HER point of view. The patient hired your preceptor to support her and to manage any unanticipated complications of labor. One of those unanticipated complications occurred, a life threatening complication at that, and your preceptor handled it all wrong. She made not one, not two, but at least 4 serious errors in judgment, any one of which could have led to the death of the patient, and may have led to permanent injury of the patient (it is too early to know yet).
Did the patient deserve to be treated wrong? No! Is it acceptable to ignore that the patient's life was further endangered because your preceptor did not know what she is doing? No! Is it acceptable to pretend that this did not happen and allow this woman to go out and do it again in the future when it might actually kill someone? No!
You, of course, are not necessarily in a position to know what was done wrong, but you SHOULD find out; at a minimum, someone should tell you. You should not walk away from that incident believing that it was handled correctly or that it is the way that you should handle it in the future. The fact that you wrote about it the way that you did indicates that you took away precisely the wrong lessons from what could have been an excellent teachable moment. This is one of the serious deficiencies of the preceptor system in direct entry midwifery. If your preceptor is incompetent, you will learn to be incompetent, too. Morag, you need to know and you deserve to know that your preceptor did everything wrong.
I do not set out to hurt your feelings, but frankly, when it comes to taking responsibility for the life and death of others, your feelings shouldn't even be involved. The mere idea that you would refuse to read my criticism because you might not like it is frightening in the extreme. If your feelings are going to be hurt by learning something that you don't like, you should find another line of work. It is your OBLIGATION to read and learn from any relevant criticism. If you cannot intellectually defend what you or your preceptor are doing, then you need to study more, read more, learn more.
Morag continues:
I have no idea what it is you are trying to prove, only that you will ultimately be unsuccessful.
I think it is pretty obvious by now what I am trying to prove. I am trying to show that direct entry midwives are grossly undereducated and grossly undertrained. They are dangerous and they should not be providing care to anyone. Unfortunately, I have more than enough examples to draw on to make my case.
I have done you no wrong. Please leave me alone.
I have no fight with you.
How do you know you have done no wrong? Did you even bother to investigate the specific errors that I pointed out? Don't you owe it to this patient and to future patients to learn to do the right thing, not just one of a few things that you know how to do? Morag, it is not about you, and you are committing a very serious error if you think it is. It is about the patient. Her wellbeing must come before your feelings. That is your ethical obligation and you cannot meet it if you refuse to learn from what happened.
Labels: midwifery
Reverberations
Kneelingwoman's post about midwifery education continues to reverberate around the web. Comments to her post and to Navelgazing Midwife's similar post range from supportive to "disappointed" to spluttering indignation. Kneelingwoman
continues the conversation by asking some very important questions:
Why don't we want to know what women want? Why do we keep going to conferences and paying out a ridiculous amount of money to stand in a circle, sing and hold hands with the "ya ya sisterhood" and then flatly reject the idea that we should create a midwifery that actually serves women according to their needs in birth instead of what need to provide? Why are we so afraid to grow and change? Why does the very idea that the reason midwifery isn't reaching more women that there is something about it and us that doesn't resonate with the majority not addressed more seriously?
Why? I'll offer a very simple answer. Homebirth midwifery is about the midwives, not the patients. Not every single DEM feels this way, but the structure of the profession makes it obvious that it is the needs of the midwife that comes first.
When you think about it, it explains a lot.
"Why don't we want to know what women want?"
They don't want to know because they are not interested. The overwhelming majority of women are looking for something very different than what most DEMs are interested in giving. They want healthcare providers who are up to date with the latest medical information and who can provide the safest possible care. DEMs want a friendship and bonding over shared philosophical views.
"Why do we keep going to conferences and paying out a ridiculous amount of money to stand in a circle, sing and hold hands with the "ya ya sisterhood" and then flatly reject the idea that we should create a midwifery that actually serves women according to their needs in birth instead of what need to provide?"
Why? Because the conferences are designed around the needs of DEMs and they want to attended conferences that are nothing more than echo chambers for the views they already hold.
"Why are we so afraid to grow and change?"
Growing and changing means confronting the very serious deficiencies of homebirth midwifery education and training. The concept of growing and changing implies that there is actually something more to know than "trusting" birth. Growing and changing means responding to the needs of others, rather than determining who you will care for by whether they meet your needs. Growing and changing implies standards and standards are anathema to those who are undertrained.
"Why does the very idea that the reason midwifery isn't reaching more women that there is something about it and us that doesn't resonate with the majority not addressed more seriously?"
Most DEMs are not interested in reaching more women. They are not interested in providing healthcare. They do not want to try to meet diverse needs of women with different ethnic, cultural, economic and educational backgrounds. They want relationships with women who will echo back DEMs' flattering views of themselves, not patients who question, who disagree and who are non-compliant.
I suspect that both Kneelingwoman and Navelgazing Midwife are correct that direct entry midwifery is on its way out because legislators and consumers will discover just how uneducated and untrained DEMs are. Yet the lack of education and training is not just the problem, it is a symptom of the larger problem. It is virtually impossible to create a profession around the notion that you don't have to do anything more than "trust" that everything will work out fine. In an age when teachers are required to have masters degrees, it is simply not possible to maintain that attending births requires little more than a high school education. Finally, and perhaps most important, the fundamental reality is that most women view midwives as healthcare providers, not new friends. They are not looking for the relationship that DEMs want to give; they are not looking for friends at all; they are looking for professional health care.
Labels: midwifery, philosophy
Homebirth ignorance 101
Ignorance is the foundation of homebirth advocacy so it is no suprise to find homebirth advocates spreading misinformation across the web. Trying to correct it would take the full 24 hours of each day. However, every now and then there is a post so profoundly ignorant that it deserves special mention. Apprentice Midwife proudly posted this collection of mistruths, half truths and outright deceptions,
Top Ten Childbirth Myths and it was enthusiastically picked up and circulated among the homebirth community. It seems that no one bothered to check whether any of it was true. They simply believed it because they liked it.
Pointing out all the false and absurd statements would make for a post that is far too long, but I will highlight my personal favorites:
Before cesareans, women were dying all the time in childbirth."
It's amazing how many times this is brought up. People have brought this up to me not only about c-sections, but about home birthing, unassisted birthing, and whatever birthing when it's not in the hospital. Women, go google the reason for maternal deaths in childbirth from generations ago. What you will find is NOT that women died from childbirth itself - because if that were the case, the human race would have died off long ago. Women - and babies - were dying from disease, NOT childbirth itself. ... women were wearing corsets from before puberty, and this was causing malformations in their pelvis. How many modern women do YOU know of that have been wearing a very tightly laced corset from the time they were, say 13?
Actually, before cesareans women WERE dying all the time in childbirth. C-sections became safe enough to perform routinely less than a century ago. Before that time women were dying at a much higher rate than now. How much higher? Not double, not triple, not even 10 times higher. Before C-sections women died at a rate 100 TIMES HIGHER than today. Almost 1% of women died in childbirth. That would translate to approximately 40,000 maternal deaths per year, each and every year. So, yes, before cesareans women WERE dying all the time.
Moreover, this statement betrays ignorance of evolution and population dynamics in addition to ignorance about childbirth. High death rates of mothers and babies in childbirth are perfectly compatible with even explosive population growth. For example, the miscarriage rate is approximately 20% and we're still here.
"I had to be induced because they found low fluid."
The modern route of action for this is completely backwards. Amniotic fluid is the baby's urine. If you're not drinking enough water, the baby is not able to process the amniotic fluid. When low fluid is found via u/s ( which, by the way....WHY is an u/s being done in the first place? ) the practice is SUPPOSED to be to have the woman go home, drink a gallon of water, and have the fluid levels re-checked by a *different* technician ...
Yes, amniotic fluid is the baby's urine, but if it is low, it is a sign that the baby is no longer receiving adequate support through the placenta. The first symptom is decreased amniotic fluid, the second symptom is decreased growth (intrauterine growth retardation), the third symptom is death of the baby. This is a classic example of the way that homebirth advocates "reason" by false analogy. If an adult is dehydrated, he will produce less urine. Amniotic fluid is fetal urine. If there is less fetal urine it must mean that the baby is dehydrated, right? Wrong!
How about this gem?
"I pushed for hours and my baby would not come out. I NEEDED a c-section."
... Did you begin pushing when you felt the unbearable urge to push - or did you push when and how they told you to? ("Okay, you're 10cm, you can begin pushing now.....1-2-3-4-5..." It's called "purple pushing") This is a HUGE factor in women who push for hours. Instead of laboring the baby all the way down, they begin pushing as soon as they hit 10, whether they feel the urge or not. Your body WILL labor the baby down. Sometimes women are at 10cm for a few hours before feeling that urge. THAT'S OKAY! Think about it this way. If you knew you were going to have to poop sometime soon, would you go ahead and sit on the toilet and begin trying to push the bowel movement out? What would happen if you did this? Wouldn't you be there forever, and eventually end up hurting yourself? Or would you wait for the urge to pass a bowel movement first? Another thing to note....in a bowel movement, which is not much different than the physiological process of birth, you are sitting. You are not lying in bed. Try pooping while lying in bed, instead of sitting upright.
This is "reasoning" from inanity. A baby is just like a bowel movement, right? Wrong! A baby is approximately 100 times larger, it is in the vagina, not the rectum, it is being pushed by a combination of uterine muscle and voluntary muscles of the pelvis, in contrast to a bowel movement which is pushed by peristalsis of the large intestine.
This also demonstrates the classic contrariness of homebirth advocacy. Whatever the data shows, ignore it and claim the opposite. Hence homebirth advocates insist that women can control the contraction of the uterus during the first stage by affirmations, emotions and environment, not understanding that the uterus is an involuntary muscle, and is NOT under a woman's control. Then they turn around and insist that pushing, which CAN be affected by maternal factors, and DOES involve voluntary muscles, is not under a woman's control.
Apprentice Midwife has shown us once again that most of what homebirth advocates think they "know" is factually false. They proudly spread mistruths, half truths and outright lies to each other, without a clue that they have absolutely no idea what they are talking about.
Labels: midwifery
Respecting the nature of birth
Kneelingwoman has written an amazing post on the nature of birth,
Into the Wild...:
... We live in a country where we are safe, well fed, clothed, educated and have every possible option available to us. We don't believe that anything can really hurt us because most of us have never had to face "nature" raw and threatening to overpower us. We think our technologies and education protect us; but they don't. Not from nature; not from birth. We have to approach birth; especially birth at home, as though we are headed out into the Alaskan wilderness... If I want to go out into the bush, I'll probably seek out the advice of a seasoned wilderness survival expert; someone who has been there and faced some of the potential perils. I'm going to take notes and I'm going to believe him when he tells me that there are Grizzly's out there and there are things you don't do around Grizzly's. I'm not going to tell him that I'm sure he's seen a Grizzly but he's never seen MY Grizzly.....
Be sure to read the whole post. It's terrific.
Labels: midwifery
Why reality wins again
In
Reality wins again, I wrote about Navelgazing Midwife's post
The Myth of the Vertex. In it, I drew attention to Navelgazing Midwife's change of heart about some previously deeply held beliefs. Why did she change her mind? In a word, "experience". Here are several quotes that illustrate the point:
Then, with more experience, I woke up and figured out I couldn’t help if I didn’t monitor the mom and baby. It’s not like I’ll do vaginal exams that aren’t warranted or intrude in women’s space, but there are minimums that I feel are necessary for competent care and I no longer will compromise on that belief...
... I was wrong and I wonder why so many women see every care provider as a threat...
... Sometimes emergencies happen and someone has to be trusted to take care of them. Sometimes births need help and someone has to be there to give it. And take the liability for it, too.
Navelgazing Midwife has implicitly acknowledged two important points: experience is critical to becoming a safe and competent practitioner, and she did not have enough experience during her training to understand that her personal beliefs were wrong. She is not the first direct entry midwife to discover this. I have written about it before:
In Licensed Lay Midwifery and the Medical Model of Childbirth (Sociology of Health & Illness, Vol 7 Issue 1 p 36, March 1985), authors Weitz and Sullivan intensively interviewed 27 of the first 29 women who became licensed in Arizona. They investigated the role of experience in the midwives' attitude toward the "medical model" of childbirth:
The experiences of these licensed midwives, however, have created in them a greater awareness that childbirth can become a medical problem. As the total number of babies delivered by each midwife has grown over the years, they have gained greater exposure to the potential hazards of childbirth. One midwife, for example, when asked if her feelings about the responsibility of being a midwife had changed over time, responded:
'I think I've become more aware of it with every birth I do. I think that when I first started it was like a game and I wasn't really thinking that much about it and now I think it's come to be a major thing. Part of the reason for that is the fact that I'm a licensed midwife, and that I operate under a lot of regulations. If something goes wrong, it's my head that goes on the chopping block.'
Although the midwives are restricted by state rules and regulations - as well as by their own desires - to working with a 'low-risk' population, a few of the babies they have delivered were physically depressed, traumatized, deformed or stillborn. Similarly, some clients failed to progress during labor, tore, or hemorrhaged. In the first four years of the reactivated licensure system, 14 per cent of mothers were transferred to a hospital before delivery. Of those who delivered at home, 15 per cent of mothers and 3 per cent of newborns required postpartum outpatient care and 3 per cent of mothers and 2 per cent of babies required postpartum hospitalization. Thus, while the typical delivery confirms the midwives' definition of childbirth as a natural, healthy process, they increasingly see the potential for medical problems to arise...
Midwives' faith in the natural childbirth process is further strained as they learn the difficulties in predicting who among their 'low-risk' clientele will safely deliver at home. Although they express confidence that 90 to 95 per cent of all women can safely deliver unaided, the midwives still fear the risks they take when they cannot completely screen out the other 5 to 10 per cent. Because of this fear, 85 per cent of the midwives refuse to accept potential clients who meet the legally prescribed health requirements but whom they regard as poor candidates for home delivery (e.g., women who have not given birth before, do not intend to breastfeed, or do not seem psychologically prepared for home birth).
In sum, the midwives' initial views about the safety and naturalness of childbirth are being tempered by experience...
One of my primary objections to direct entry midwifery is that the midwives do not have enough clinical experience. This means that they have very limited experience in recognizing impending emergencies and virtually no experience in managing them. Their attitude toward birth and its inherent dangers are based on their personal beliefs, and therefore bears little relationship to reality.
As the above study of midwives shows, the education and training of direct entry midwives reinforces their erroneous beliefs about childbirth. As they acquire more experience, they learn to their chagrin that the chance of complications is higher than they had believed, their ability to predict those complications is not nearly as good as they had believed, and that their view of "naturalness" of childbirth needs to change to accommodate reality.
Labels: midwifery
Reality wins again
Something must have happened, a bad outcome, an angry patient or a lawsuit.
That's the only way I can account for Navelgazing Midwife's blog entry and for a variety of posts she has made on the websites of other homebirth advocates indicating a new outlook on risks of childbirth and the unrealistic expectations of homebirth advocates.
You can judge for yourself by reading her post
The Myth of the Vertex, excerpts of which are quoted below:
There is a belief that if the baby is head down, the baby will come out the vagina. The thought continues that, if the baby didn’t come out the vagina, something was overlooked, someone did something wrong or the woman didn’t try hard enough.
The reality is – none of these beliefs is true.
Sometimes, babies that are head down simply (or complicated-ly) just don’t come out the vagina. It isn’t often, but it happens enough that natural birth advocates really should take a moment to listen.
Navelgazing Midwife goes on to describe her experiences with two recent births, one a face presentation where the baby would have died without a C-section, the other a serious shoulder dystocia that could have led to the death of the baby. Then she offers suprisingly harsh criticism for another homebirth advocate who questioned the judgment of a provider:
In ignorance, for there is no other way to say it but this, [she] says that whenever a doctor or midwife speaks about induction because the baby is getting large, that that is a threat. Only someone who hasn’t struggled with a shoulder dystocia – either in her own vagina OR with one in her hands as a midwife – would say something so amazingly dangerous...
She describes the ways that experience as transformed her:
... [W]hen women came to me and said, "I don’t want you to do anything but sit in another room," I used to obsequiously tell them I would. It is the woman’s birth, after all, right?
Then, with more experience, I woke up and figured out I couldn’t help if I didn’t monitor the mom and baby. It’s not like I’ll do vaginal exams that aren’t warranted or intrude in women’s space, but there are minimums that I feel are necessary for competent care and I no longer will compromise on that belief...
What’s so funny is I used to be one of these women! I think I know where they’re coming from, but whenever I’ve assisted these women, I am fucked beyond repair. I worry I will have my license yanked from me long after the baby turns one year old. I worry about my reputation in the birthing community. One angry woman can make it difficult for awhile. When it was me, I was so pissed at The System, I took it out on everyone. I really didn’t think I could trust anyone at all, so I didn’t. Everyone was suspect. No one wanted me to have the birth I strove to have.
Well, I was wrong and I wonder why so many women see every care provider as a threat...
She expresses thoughts that are more typically expressed by obstetricians.
When I am hired to be someone’s midwife, I am being hired as a consultant. I am being asked to share my experience and knowledge, to utilize my skills – the ones that can save a life. As a consultant, one that differs from an interior designing consultant, I am being asked to take the lives of two people in my hands and to accept the consequences of the outcome whether that is a spritz of champagne or a cell in a prison. I’ve had a long time to adjust my considerations with my practice – and they might change again (I’d be shocked if they didn’t!). I see women as individuals, listen to their needs and concerns and if we both feel we could work together, I’m game to give it a go. If I find a woman lied to me about her medical or obstetric history, if she hides behaviors she doesn’t want me to know about or if she continually jabs at me questioning my concerns with her pregnancy (and all of these have happened in the last 2 years), I’m going to send her on her way. She is a liability I don’t need to take on… a risk to my profession and life.
Labels: midwifery
Dutch midwifery
Homebirth advocates often tout the Netherlands as an example homebirth midwifery in action. They don't realize that Dutch midwifery is nothing like American homebirth midwifery.
A fundamental assumption of American homebirth midwifery is that birth is "not an illness" and complications are rare; neither hospital backup nor emergency transport is arranged in advance. In contrast, the Dutch system assumes that a significant number of high risk situations will develop in advance and during the actual birth. Therefore, strenuous efforts are made to identify potential complications and transfer care to obstetricians. Since it is assumed that serious complications will during attempted homebirths, an elaborate system for transfer of care and physical transfer of the patient to the hospital has been developed.
In a book chapter entitled
Challenging Normality: Dutch Obstetric Science, Raymond De Vries explores the Dutch midwifery system. De Vries is a medical sociologist and a strong proponent of the Dutch system. Nonetheless, he chides American midwifery advocates for misunderstanding and misrepresenting the system.
Perhaps because of its peculiarity, the maternal care system of the Netherlands is often misrepresented... [M]any articles about birth in the Netherlands written by non-Netherlanders contain errors of fact and tone. For example, Mehl-Madrona and Mehl-Madrona, writing in 1993, claim that "over 70 percent of births are still attended by midwives." In fact, midwives attended about 46 percent of births in both 1992 and 1993... [A]t no point in the twentieth century did they attend more than 60 percent of overall Dutch births... In her ethnographically based discussion of the lessons of Dutch obstetrics for Americans, Rothman sets the scene by discussing windmills, tulips, bicycles and Rembrandt, giving her readers over-romanticized pictures of Dutch midwifery and Dutch society. Her description of the Netherlands as a "Mecca for Midwives" and the home of noninterventive obstetrics makes it difficult to believe that Dutch midwives once argued for the right to wield forceps or that Dutch midwives are beginning to outfit their offices with the apparatus for sonograms.
The care of pregnant women in the Netherlands is divided between midwives, obstetricians and general practitioners. Dutch midwifery is highly regulated.
The preference for primary care in Dutch obstetrics rests on a generally accepted screening system for identifying "physiological" and "pathological" pregnancies. The "obstetric indications list"... defines the conditions that require midwives and general practitioners to refer their clients to specialists. The list allows the Dutch to avoid the assumption made in most other industrialized countries that all births are potentially high risk and, therefore, must be monitored by specialists.
However, implicit within the guidelines is the understanding that many births can and will become high risk and that provision must be made for quick efficient transfer of care. Moreover, although the midwife makes the determination of need for referral, the required indications have been clearly spelled out.
A recent paper in the BJOG describes the system in greater detail. According to
Evaluation of 280 000 cases in Dutch midwifery practices: a descriptive study:
The Dutch obstetric system is well known for its relatively large percentage of planned home deliveries. Approximately 30% of Dutch babies are born at home. This percentage has remained stable over the past 10 years.
The possibility of giving birth at home stems from the organisational model of midwifery care in The Netherlands. A distinction is being made between women with a low risk of pathology and those with a high risk. Early in pregnancy, women enter into the system at the primary care level. Early pregnancy care is primarily being delivered by an independently practising midwife ... If complications occur or threaten to occur, the midwife refers the woman to an obstetrician at the secondary or tertiary care level. Therefore, the woman no longer has the choice of a home birth...
The agreements for collaboration between the professional groups have been specified in the Verloskundig Vademecum (Obstetric Manual). This document includes a list of obstetric indications for referral from primary to secondary care, based on best evidence or on consensus.
The Dutch are particularly cognizant of the need for timely transfer if an emergency should occur during an attempted homebirth. An elaborate transfer strategy has been developed:
A possible disadvantage of referral during home delivery is the time lost in travel to the hospital. The Netherlands is a very densely populated country where the average distance to hospital is relatively short... A local study (Amsterdam) showed that 85% of the urgent obstetric referrals arrived in the hospital within half an hour
after the reporting. We estimate that the time it takes a woman to get to the hospital from her home is, in the majority of women, roughly equal to the time it takes to mobilise the necessary specialists in the hospital. In emergencies at home, the midwife will be able to apply certain remedies themself, such as the administration of an intravenous infusion or the provision of basic life support.
Another substantive difference between Dutch midwifery and American homebirth midwifery is that Dutch midwives are trained in a 4 year program that prepares them to practice in the hospital or in the home. Indeed, women who qualify for midwifery care can pick where they wish to be delivered and they will be delivered by the same midwife regardless of place. Dutch midwives are trained in recognizing and managing complications. American direct entry midwives have little training and no experiencing in recognizing and managing complications.
If the Dutch midwifery system were transplanted to the US, the rate of homebirths would rise, but the women who are currently certified as DEMs would not be qualified to work in the system. They would need years of training to be competent to provide the level of care (in hospital and home) that the Dutch expect. The American DEM philosophy of assuming that complications will not occur will go by the wayside. A strict system of monitoring for risk factors would be introduced and care transferred to obstetricians if those risk factors were identified. The Dutch midwifery system offers care that is highly regulated, depends on risk identification and employs midwives who are medically trained.
Labels: midwifery
Independent midwives will be required to get insurance
Independent midwives in the UK have been practicing without malpractice insurance, and without disclosing this uninsured status to patients. That is changing in response to homebirth complications that leave babies with life long impairment and no compensation.
According to the article
Midwives told to get insured or quit:
Independent midwives - paid for privately by parents to allow them to give birth at home - are under threat because they lack professional indemnity insurance to cover them if things go wrong.
This lack of insurance can have disastrous consequences...
When three-year-old Daisy Anderson was born the nerves in her arm were ripped apart as the midwife pulled her out. Her neck was so badly lacerated she had to have plastic surgery and her mother was also cut and later spent four hours on the operating table.
Daisy has Erb's Palsy - severely limited use of her arm. But when her parents, Victoria and Matt, tried to get compensation for her they were told it was impossible because the midwife was independent - hired outside the NHS.
Like all independent midwives, she was uninsured. Under the Nursing and Midwifery Council rules the Andersons should have been told this - they claim they were not.
The Independent Midwives Association (IMA) say the cost of the insurance is too high and are in negotiation with the NHS to pick up the bill. The government has given them 18 months to obtain cover or stop practising...
The Andersons had no protection and their lawyer lays the blame at the door of the Royal College of Midwives (RCM) for allowing such a situation to go on - for agreeing, for instance, that insurance is recommended but not required.
The college does say independent midwives are required to tell their clients of their insurance status but, in a letter to the Andersons, the RCM's lawyers admitted the college "acknowledged that uninsured midwives could not necessarily be relied on to tell clients they were not insured"...
Indpendent midwives have been practicing without insurance because they cannot afford the premiums. In other words, the amount of money required to cover claims for poor homebirth outcomes, exceeds the amount of money that midwives can afford to pay.
Malpractice insurance serves two purposes. First, it protects the practitioner from huge financial judgments. Equally importantly, it gives patients redress in case of malpractice, and provides financial support to deal with the results of malpractice or poor outcomes. When midwives choose to forgo malpractice insurance, they are depriving patients of important rights, and as such, should be required to inform patients about their lack of protection.
In an effort to preserve their own incomes, independent midwives dispensed with patient protections, and patients are suffering as a result.
Labels: midwifery
Honesty and experience
Navelgazing Midwife has
written honestly about her lack of experience with certain skills:
I suture a couple of times a year. I've done an IV twice in the last 4 years. When I have to check a woman’s vagina, I am nervous that I am going to have to pick up a suture needle and cut through her skin - worried that my skills are going to suck and her vagina isn't going to go back the way it should... I need more practice.
Indeed she had to transfer a patient to the hospital for suturing of a tear:
You see, I had a birth a couple of weeks ago and my mama tore pretty badly. She pushed mightily to get her baby out despite my wholehearted attempts to slow her down; she needed her baby out to feel safe and I don't blame her at all for that - I would have done the same thing. When I looked at her bottom, my first impression was, "This isn’t something I should do," ...
Once at the hospital, two docs came in and opened mom’s vagina up but good and looked hard. They were talking about her as if she wasn’t there (and I’d asked mom already if I could learn and she said yes) and they began pointing to what was her exposed sphincter muscle. I could have just as well been looking at the starry sky and trying to see a constellation for all I didn’t recognize what a sphincter muscle looked like...
I will note, as an aside, the Navelgazing Midwife blamed the patient for her tear; I guess if there's no obstetrician around, the only left to blame is the patient. She also included the obligatory nasty comment about the doctors. Then she contemplated the issue of experience again.
I want to be able to see a tear and know exactly what I am seeing and exactly how to fix it. I want to own those instruments and be able to repair a third degree tear.
I can practice suturing on a pillow until I am blue in the face, but until I see dozens/hundreds of torn vaginas, I am just not going to have that (what I call) Helen Keller moment (that moment when spelling w-a-t-e-r in the hand a thousand times suddenly MEANS "water" in all its forms). Until I feel that needle and thread going through the flesh myself, it isn’t going to connect completely and I won’t be the as wonderful a midwife as I want to be.
Same with IV’s. I can do them when I have to. I can start one in an emergency if I have to, but I shudder when I think about having to and I don’t want to be afraid of any skill I want to be able to do with aplomb. I want to be strong and sure-footed and jab the arm with the same body memory I have for poking a baby’s foot. And I can never get enough practice in a homebirth practice, even when practicing on family and friends. I need volume...
I agree completely with her assessment and am impressed with her honesty. However, it raises very serious questions. She sutures only a few times a year, and worries that she cannot do it properly. She probably sees even fewer shoulder dystocias each year, has done fewer expert resuscitations (perhaps none), and sees fewer emergencies of all kinds. So if she can't even suture with the experience she has, and she has less experience with emergencies (which are even harder to manage), how will she be able to handle an emergency? How can she represent herself as someone who can safely manage an emergency, when she knows, if she is honest with herself, that she doesn't have nearly enough experience?
The is the crux of the problem with homebirth. If there is an emergency, the direct entry midwife will not have enough experience handling it, and the baby has a dramatically increased chance of dying because of that. How can that possibly be acceptable? Shouldn't direct entry midwives be obligated to share that information with their patients? Doesn't honesty require a direct entry midwife to explicitly inform her patients: "I don't have much experience with emergencies, so if something goes seriously wrong, your baby will be in terrible danger"?
Labels: midwifery
Who has the right to criticize?
Direct entry midwives spend an inordinate amount of time criticizing doctors and "medwives". Yet they do nothing to improve patient care or outcomes. Do they have a right to criticize if they are doing nothing to solve existing problems?
I'm not talking about the legal right to criticize. Obviously, they are free to say whatever they want about modern obstetrics, doctors and CNMs. I am asking about their moral rights and moral obligations.
What function is their criticism supposed to perform? Clearly, it is a means of expressing their frustration that things are not to their liking. Also, it is a means of advertising themselves and their beliefs. Ostensibly, criticism of the existing practice of medicine is meant to improve care for people, but direct entry midwives appear to feel they have no obligation to patients who do not share their philosophy. Unlike doctors and CNMs who are ethically obligated to provide care to everyone and to attempt to meet patient needs whether they agree with them or not, direct entry midwives never consider or mention women who do not agree except to criticize them, too.
Most importantly, direct entry midwives make no effort to improve anything. Take the C-section rate, for example. They are shrill in their condemnation of the C-section rate, yet I have never heard even one remotely practical suggestion from them for reducing the rate. "There are too many unnecessary C-sections," they say. Okay, if that's how they feel, they should tell us speficially which ones are the unnecessary ones. What tests or techniques are we to use to limit C-sections to only those that are necessary? Do those tests or techniques actually work to lower the C-section rate without raising the neonatal mortality rate? They don't know and they don't care; they don't even give it any thought.
So here's my question: if you never make any effort to devise improvements in obstetric care, if you never make any effort to lower mortality rates, if you research nothing, and if you refuse to have anything to do with any patient who isn't just like you, do you have any right to criticize the obstetricians, CNMs and midwives who are constantly working, assessing and changing in an effort to improve outcomes?
Labels: midwifery
Whatever the scientific evidence shows, do the opposite.
One of the hallmarks of homebirth advocacy is defiance. The classic homebirth prescription is to review the evidence, then ignore it and advocate the opposite. All the while, homebirth advocates congratulate themselves for solving complex medical problems WITHOUT DOING ANY RESEARCH. Homebirth advocates consider themselves so smart that they don't need to do any research; they can just learn about the current recommendations and do the opposite.
Take the issue of diet in pregnancy. There are some pregnancy complications that can be modified by diet and there are other pregnancy complications that cannot be modified by diet. Gestational diabetes, a form of insulin resistance, leads to a variety of pregnancy complications including stillbirth. Diet and exercise are extremely effective in reducing blood sugar, and in reducing the need for more aggressive treatment like insulin injections. So what do homebirth advocates have to say on the subject? Henci Goer claims that the
standard management of gestational diabetes is useless.
On the other hand, a great deal of research has been done on the role of diet in pre-eclampsia, and there is no evidence that pre-eclampsia can be averted or modified by diet. So what do homebirth advocates have to say on the subject? You guessed it. They recommend diet (specifically the
Brewer diet) to prevent or limit the severity of pre-eclampsia.
It would be amusing if it were not so serious. So much of homebirth advocacy is simple defiance. If obstetricians or scientists show that something works, insist that it doesn't. If they show that something doesn't work, insist that it does. Don't worry about not having any evidence, and don't worry about issuing harmful recommendations that may hurt babies and mothers. Evidently, those issues pale in comparison to the righteousness and self satisfaction that come from defying authority.
Labels: midwifery
Midwives' skills criticized after baby dies
Do you notice a tragically recurring theme here?
From today's
Belfast Telegraph:
A coroner has criticised the skills of midwives who he said could have saved the life of a newborn baby boy if they had acted earlier...
Paul was born in Antrim Area Hospital "in poor condition" with the umbilical cord wrapped three times around his neck. Attempts to resuscitate him were unsuccessful.
He was transferred to the Neonatal Unit, but died four days later from Ischaemic brain injury...
The inquest revealed that during labour the midwives failed to spot a drop in the baby's heart rate through the cardiotocograph (CTG)...
Mr Leckey said: "If fetal heart traces had been interpreted correctly and medical assistance sought promptly, opportunities existed for the earlier delivery of the baby... Earlier intervention would have improved the chances of survival."
Within the past month there have been newspaper reports of 4 preventable perinatal deaths. The deaths differ in location, attendant, and in precipitating cause, but they are united by the same themes: all four involved failure to recognize or manage complications in a timely fashion; all four could have been averted with a C-section; in all 4 cases, had a C-section been done early and resulted in a healthy baby, the C-section would have appeared in retrospect to have been "unnecessary". In other words, had the attendants practiced "defensive medicine", those babies would have had a much higher chance of survival.
The consequences to the parents are devastating, but the consequences to the attendants are quite serious as well. In all four cases the attendants have been the focus of public investigations, public censure, and potential loss of license. I can assure you that none of them can use the high C-section rate as a defense in administrative hearings, disciplinary hearings or a court of law. I can assure you that none of the parents are comforted to know that they won't have to worry about VBAC (one woman actually had a C-section AND lost her baby). Newspaper accounts have indicated that none of the parents have taken the position that "sometimes babies die".
So I ask critics of the high C-section rate:
Which are the unnecessary C-sections?
If you can't even tell me which ones are unnecessary after the fact, how on earth are we supposed to know which ones are unnecessary before the fact?
How "trustworthy" was birth in these circumstances?
Where is the tolerance for the type II errors that are inevitable when you don't practice defensive medicine?
Which message is the public sending: "A few perinatal deaths are acceptable as the consequence of lowering the C-section rate." OR "Any perinatal death that might have been prevented with a C-section is totally unacceptable and will result in public investigation and public censure."?
Which parents accepted the death of their child with fatalism?
Labels: midwifery, neonatal mortality
Midwives announce plan to ignore coroner's recommendations
According to the
Gazette:
Quebec's midwives are planning no changes in the short term to the way they deliver babies, despite a coroner's report that calls for an overhaul of their practice.
Coroner Paul Dionne recommended the Quebec Order of Midwives significantly improve the training of midwifery to respond better to high-risk births after what he described as the "preventable" death of a baby boy in Montreal last year...
Dominique Porret, president of the Quebec Order of Midwives, insisted yesterday there is no need to follow the coroner's recommendations because they are already in place...
"It's not that we haven't responded to the recommendations," she added, after being grilled by reporters at a news conference on what the Order intends to do in light of the report.
"Nothing will change, in the sense that we are already doing our very best to ensure the safety of mothers, babies and their families..."
Last year, midwives delivered 1,453 babies, and no complaints were lodged with the Order. Porret said there were a few stillbirths - comparable to the rate in hospitals - but could not give a number.
I can't imagine why the midwives' organization would hold a press conference to insist that they are not going to implement the recommendations. It makes them look defensive and is very insensitive to the parents who lost their child. Interestingly, the president of the Quebec Order of Midwives could not or would not reveal the number of deaths that have occured under midwifery care. It is completely inappropriate to withhold that information.
Labels: midwifery, neonatal mortality
Coroner: homebirth midwives' inaction led to baby's death
This story from
CTV.ca illustrates all too clearly why a baby can easily die at a homebirth. The midwives refused to call for assistance during a bradycardia, and (not surprisingly) when they attempted to intubate the lifeless infant, they put the tube in the wrong place. Almost certainly, they had no prior experience with a real infant intubation.
According to the coroner:
The coroner reports that the labour, attended by two midwives, seemed to progress normally until the mother's water was broken. The midwives noticed the presence of meconium in the amniotic fluid -- a life-threatening development.
Rather than calling for emergency help immediately, the midwives continued the birth.
When they later noticed that they had lost the baby's heart rate, they again failed to call for help, nor did they perform an episiotomy to hasten the delivery.
When the baby finally emerged, it was limp, grey and had no heart rate. Only then did the midwives call an ambulance -- a full 12 minutes after they noticed the lack of heartbeat.
While waiting the 10 minutes for help to arrive, they attempted to intubate the baby to suction out the meconium from the baby's lungs. When paramedics arrived, they found that the intubation had been done improperly and the child was declared dead shortly after.
[The coroner] determined in his investigation that the baby likely died less than 15 minutes before its birth. He contends the midwives were competent and knew what was happening, but failed to see the need for help.
Under Quebec law the baby should have been transported to hospital. In fact, the [baby's] home was minutes from Montreal's Maisonneuve Rosemont hospital.
This was a classic set up for a homebirth death. The midwives' elected to do a high risk birth at home. They did not call for backup when they diagnosed fetal distress. It was irrelevant that they were close to the hospital. And, of course, they were incapable of performing a correct neonatal resucitation. This was yet another preventable neonatal death at homebirth.
Labels: homebirth death, midwifery, neonatal mortality
Judge strikes down Missouri midwifery law
According to the
Kansas City Star:
"A judge has struck down a new law that would have allowed certain lay midwives to deliver babies in Missouri without facing the threat of criminal charges.
A Cole County judge declared the midwifery language unconstitutional, saying it went beyond the title and original purpose of the health insurance bill to which it was secretly attached in the final weeks of the legislative session.
Circuit Judge Patricia Joyce issued a permanent injunction barring the midwifery law from taking effect as scheduled Aug. 28. She allowed the rest of the health insurance bill to stand."
As I wrote in a previous post,
Direct Entry Midwifery can only be legalized by lies, the Missouri legislature has repeatedly voted down attempts to license DEMs. So this year, homebirth advocates thought that they would try something new: lying. A legislator slipped the language into a large insurance bill without telling anyone, including his colleagues, about it. For his deception, he lost his chairmanship of the Small Business, Insurance and Industrial Relations Committee.
The case is not over. Mary Ueland, of the Missouri Midwives Association, the main intervenor-defendant in the case, has suggested that the Midwives Association may appeal the decision.
Labels: midwifery
MANA is unethical in withholding its statistics
As we have seen repeatedly, the amount of data on homebirth is sparse, and most of the studies are poorly done and biased. Even so, the existing scientific evidence shows that homebirth has an excess rate of preventable neonatal death. There is not enough evidence to draw any conclusions regarding maternal mortality.
There is, however, a repository of statistical information that dwarfs all the existing scientific information, even when it is added all together. That repository is the MANA (Midwives' Alliance of North America) collection of statistics for all registered midwives from 2001-2006 and continuing up through the present. The database probably contains somewhere in the range of 30,000 deliveries, perhaps more. We know that the data is available because MANA is offering it to pre-approved individuals who sign confidentiality agreements preventing them from sharing the data with anyone else.
I don't know what the data shows, but I'd be willing to bet a lot of money that it shows a significant excess rate of preventable neonatal death, perhaps even higher than 1-2/1000. I wouldn't be suprised, either, if it included maternal deaths. Why do I think the data shows that homebirth is not safe? The issue of licensing of DEMs is being discussed in several states. If the MANA data demonstrated the safety of homebirth, they would release it publically themselves. The fact that they refuse to release it except to pre-approved individuals, and the fact that they require a legal document preventing disclosure suggests that the data will be very harmful to MANA's interests.
MANA does not seem to realize that it has an ethical obligation beyond serving its members and their professional and economic interests. It has an ethical obligation to patients. If MANA is in possession of a large database that demonstrates that homebirth is not safe, and I believe they are, it is unethical for them to withhold that information and to take legal steps to insure that the public does not learn that information.
MANA should release the information immediately, both in print and on the web. Any state agencies contemplating DEM licensure should insist on a release of the information as a prerequisite for even considering the licensure issue.
There is simply no ethical justification for withholding the safety information in the MANA database.
Labels: midwifery, neonatal mortality
