Issues of Midwife Trust?

[ejg123]

So, we had a homebirth and it went beautifully in many ways. But, after our birth we found out that our midwife had not been upfront with us about some of her own beliefs about interventions, standard of care practices, and how these were tied up with her own religious beliefs. We found out a baby had recently died at a birth she attended and there was concern that this was due to her beliefs about intervention and various standards of care. There were so many things we found out about later in terms of informed consent -  despite all the research we had done, we ultimately trusted her to offer us informed consent about a range of things (pelvic exams, acceptable levels of blood loss after birth, vit k supplements after birth, various newborn screening questions, my nutrition/weight during pregnancy, tests during pregnancy, transfer protocols, etc.). In retrospect, I guess I felt awkward asking about or pressuring her for information on so many things that she seemed to find completely unnecessary. She did not have a back-up midwife, but rather a very new apprentice and I somehow trusted her that this was safe, only realizing during the birth how inexperienced her apprentice was. She just always assured me that everything was fine and I trusted her - she had attended many births and had practiced many years.

All of this is to say that we feel so lucky that everything ended up going smoothly, and still retain a sense of joy and awe about our birth going so well in many ways, but we are also very sad and hurt and scared about the whole ordeal and so many places where there could have been complications/where things could have turned out less good.

Mostly, this is to ask for feedback about the standard for establishing backup plans for transfer. We spoke to several midwives that were pretty laissez faire about transfer plans. What is the thinking on how detailed these need to be and the extent to which one must be in touch with the nearest hospital about such plans?
Also, any thoughts on how to trust a midwife again? I know, hard impossible question. But we want to have another homebirth someday but feel worried and like it is all ultimately on our shoulders to figure everything out.

Sigh.

Anyway, thanks for reading and feedback.

[MeepyCat]

I think these are hard questions, and that there are no easy answers.  Ultimately, issues of the kind you describe are what led me not to pursue a homebirth, and what lead me to continue not to recommend that course to others.  IIRC, homebirth midwives are alegal in Massachusetts - neither licensed and regulated, nor forbidden.  That means that there can be very few consequences for an unqualified midwife.  She can mess up and keep practicing by moving, or by not referring potential new clients to speak to people who know clients whose births have not gone well.  On top of that, issues with malpractice insurance mean that homebirth midwives in MA do not partner with doctors in any way at all.  It is ultimately on your shoulders to figure everything out, and there is no professional accountability or transparency.

IMO, since it's not really possible to be in touch with the hospital in advance (unless you're getting shadow care there, and simply not mentioning the midwife), I would want a midwife to say which ER she'd go to, and why.  I'd want her to commit to come with me.  I'd want to know if she'd transferred a patient there before, and I'd want to know how that went.  I'd want her to describe the experience level of herself and her assistants.  I'd want her to tell me what signs and symptoms she would regard as indicating a need to transfer.  I'd want to ask what her experience was with common complications like shoulder dystocia, meconium aspiration, and post-partum hemorrhage.  I, personally, wouldn't feel comfortable with a midwife who didn't ask me to help her make sure that it was safe for me to birth at home - I'd want her to help me schedule a mid-pregnancy ultrasound, for example.

[aidenn]

Our first birth was at a freestanding birth center, so our approach may have been different.

The midwife we had was very up front with all of the information you were asking about.  There was no need to ask.  At our week 12 appointment, for instance, she covered what different prenatal tests were offered, what the tests would detect and their rate of successful detection.  She also goes over who her backup OB is, what the risk factors were for homebirth (like if you are having twins in Florida, you are 'risked out' of homebirth) and at what point they would transfer care.

At week 28, she would cover what her rate of transfer was, for what reasons they typically were, and we went over a transfer of care plan (how things would be billed, how we would get to the hospital, how long she would stay with me and what role she would take on in a hospital situation where she doesn't have delivering rights).

I'm sort of spoiled, I guess, that all of this was offered up front and in a non-persuasive manner.  I don't think there is anything wrong if the information is not volunteered, to ask the sort of questions that MeepyCat is bringing up.

[Marissamom]

Originally Posted by aidenn 

Our first birth was at a freestanding birth center, so our approach may have been different.

The midwife we had was very up front with all of the information you were asking about.  There was no need to ask.  At our week 12 appointment, for instance, she covered what different prenatal tests were offered, what the tests would detect and their rate of successful detection.  She also goes over who her backup OB is, what the risk factors were for homebirth (like if you are having twins in Florida, you are 'risked out' of homebirth) and at what point they would transfer care.

At week 28, she would cover what her rate of transfer was, for what reasons they typically were, and we went over a transfer of care plan (how things would be billed, how we would get to the hospital, how long she would stay with me and what role she would take on in a hospital situation where she doesn't have delivering rights).

I'm sort of spoiled, I guess, that all of this was offered up front and in a non-persuasive manner.  I don't think there is anything wrong if the information is not volunteered, to ask the sort of questions that MeepyCat is bringing up.

I feel even more lucky. at our initial interview the midwife handed me a packet with stats on transfers of care for different reasons and outcomes. she also is able to offer all standard testing because in my state midwives are more integrated into the medical community. she also told me right off that she doesn't have a specific backup OB, but has transfered to all the areas hospitals, and usually she calls ahead to see who the OB on call is to know which would be preferable to transfer to. 

[Lady Lilya]

I had a home birth in NY, with a CNM who was legal.  

I already felt so fortunate to be not in a hospital setting, that I didn't wonder about the possibility of declining any tests or exams.  I just let her do what she was used to doing.  She was very well-reputed.

I knew that she and I had some philosophical differences, and I had mistakenly thought that having that all out in the open upfront would mean that when the time came she would know my wishes.  In some cases that was true, but simply by virtue of it being too late for her to go against my wishes at birth time.  (For example, she thought I was a horrible candidate for home birth.  I had no risk factors, but she didn't believe that I had it in my personality to turn my mind off and be in my body.  I knew I could, but couldn't express that to her.  So every visit she strongly insisted that I get a doula.  I didn't, and there was nothing for her to do about it.)  But in other cases she took advantage of the time when I was helpless to push for what she wanted.  (I wanted a male-free birth.  My husband sequestered himself in the most remote part of the house.  She kept going there and trying to get him to come to where I was.)

But really, those things weren't so important in the grand scheme of things.  I can only think of one thing of consequence that I would prefer she do differently, but at the time I just wasn't educated enough about it.  That was suctioning my baby when he was born.  There was a bit of meconium in the fluid that I was slowly leaking all day.  Then after 2 hours of pushing him through the birth canal (where he clearly couldn't have aspirated any) there was some more meconium that had been squeezed out behind him.  I know now that it is not a good idea to suction for that in an otherwise vigorous baby.  But at the time I didn't realize.  

[MsBlack]

Originally Posted by ejg123 

So, we had a homebirth and it went beautifully in many ways. But, after our birth we found out that our midwife had not been upfront with us about some of her own beliefs about interventions, standard of care practices, and how these were tied up with her own religious beliefs. We found out a baby had recently died at a birth she attended and there was concern that this was due to her beliefs about intervention and various standards of care. There were so many things we found out about later in terms of informed consent -  despite all the research we had done, we ultimately trusted her to offer us informed consent about a range of things (pelvic exams, acceptable levels of blood loss after birth, vit k supplements after birth, various newborn screening questions, my nutrition/weight during pregnancy, tests during pregnancy, transfer protocols, etc.). In retrospect, I guess I felt awkward asking about or pressuring her for information on so many things that she seemed to find completely unnecessary. She did not have a back-up midwife, but rather a very new apprentice and I somehow trusted her that this was safe, only realizing during the birth how inexperienced her apprentice was. She just always assured me that everything was fine and I trusted her - she had attended many births and had practiced many years.

All of this is to say that we feel so lucky that everything ended up going smoothly, and still retain a sense of joy and awe about our birth going so well in many ways, but we are also very sad and hurt and scared about the whole ordeal and so many places where there could have been complications/where things could have turned out less good.

Mostly, this is to ask for feedback about the standard for establishing backup plans for transfer. We spoke to several midwives that were pretty laissez faire about transfer plans. What is the thinking on how detailed these need to be and the extent to which one must be in touch with the nearest hospital about such plans?
Also, any thoughts on how to trust a midwife again? I know, hard impossible question. But we want to have another homebirth someday but feel worried and like it is all ultimately on our shoulders to figure everything out.

Sigh.

Anyway, thanks for reading and feedback.

I'm not sure what you're getting at...

So, you had a fine homebirth with an experienced mw and an inexperienced assistant, right?  And after that, you discovered some things about the mw that made you 'worry in retrospect'....worry about what could have happened if the birth had not gone so well, and you had needed to transfer--and has made you consider whether you'd hire her again for another birth...?  And this is what bothers you:

"But, after our birth we found out that our midwife had not been upfront with us about some of her own beliefs about interventions, standard of care practices, and how these were tied up with her own religious beliefs. We found out a baby had recently died at a birth she attended and there was concern that this was due to her beliefs about intervention and various standards of care."

I guess this part is hard for me to understand.  I can't help but read between the lines, as it were...seems that a baby died and some people are saying that this death may have been medically prevented, and there is speculation that the mw's religious beliefs dictated that she NOT obtain timely and sufficient medical care...?  Is that about right?

So did you find out that she "had not been upfront...about some of her own beliefs about interventions" by talking with her--or only by hearing the story of a baby's death from other people?

I don't know...I wasn't there at your prenatals, your birth, or the dead baby's birth...but it kind of sounds basically like you are saying that you had a great birth but now you're not sure your mw agrees with you about enough important things.  And you're not sure now, because of speculations that abound concerning another family's loss.

I don't know--was she really 'not upfront' with you...or did you not make your own beliefs and preferences clear?  Seems to me that in a situation like MAs, there is a great opportunity to get the care you want, because the mws are not constrained by the medical model of care/safety, as imposed by law.  Seems to me that you could certainly find mws who agree that the med model IS the best of the best, and would necessarily automatically transfer your care in certain situations (or whenever you say so).  Seems you can also find mws who have other beliefs.  It can be hard to answer every question to clients...especially if they don't ask.  But it is not so hard for families to state their own beliefs/preferences when interviewing a mw.  Maybe you made assumptions?  It is SO easy to do--not criticizing you at all--it seems to happen quite a bit.  I know for myself, I try really hard to be upfront, but I'm also on the watch during the course of care for those assumptions--to try to set things straight if needed, before the birth.  I'm usually pretty successful...but then, not always because some assumptions are so deep.  Our collective cultural beliefs about birth and health care are so ingrained! 

Anyway...rambling here, sorry...2 things:

1.  When a death or other problem arises at a homebirth, there is most always a lot of speculation about why it happened, whether it could have been prevented by more timely med care, and whether the mw was both honest and competent enough.  Sometimes, a mw does fail somehow in her duty; some mws are not as honest about stuff as they should be (IMO) about their beliefs, skills, protocols.  And sometimes, stuff happens at birth that cannot be predicted or prevented even by the best, most honest mw.  And we tend not to have the same speculations about med birth because of that underlying assumption that 'all was done that could have been done'--even though doctors are just as likely as mws to have areas of incompetence or dishonesty (we're ALL human), and even though med care frequently causes needless problems for moms/babies and sometimes med care even causes death directly.  I suggest that perhaps the rumor/speculation is getting to you, and it might help to understand that your feelings now are being influenced too much by all that. 

2.  In future, just be sure to tell your mw what YOUR beliefs/preferences are, when it comes to medical care, transfer, etc.  Maybe if you do so, you would find that your mw doesn't really suit you as well as you thought.  Maybe you will find that she does. 

[MegBoz]

Originally Posted by ejg123 

We spoke to several midwives that were pretty laissez faire about transfer plans. What is the thinking on how detailed these need to be and the extent to which one must be in touch with the nearest hospital about such plans?

Well, when you say "transfer plans" - do you mean decisions on WHEN to transfer, or WHERE to go and HOW to establish a relationship with the hospital? or all of the above?

As for the former, I know there are many straightforward reasons - such as cord prolapse, prematurity, and then not quite as "straightforward" issues like non-reassuring FHT (fetal heart tones), which I'd have to trust my MW to make a judgment call on. That's one issue where I trust her training & experience. I didn't ask her to give me a run down on precisely what sort of decels, at what point in time, would warrant transfer. But if she says she's "concerned" - then I'd transfer.

Originally Posted by MeepyCat 

I think these are hard questions, and that there are no easy answers.  Ultimately, issues of the kind you describe are what led me not to pursue a homebirth, and what lead me to continue not to recommend that course to others.  IIRC, homebirth midwives are alegal in Massachusetts - neither licensed and regulated, nor forbidden.  That means that there can be very few consequences for an unqualified midwife.  She can mess up and keep practicing by moving, or by not referring potential new clients to speak to people who know clients whose births have not gone well.  On top of that, issues with malpractice insurance mean that homebirth midwives in MA do not partner with doctors in any way at all.  It is ultimately on your shoulders to figure everything out, and there is no professional accountability or transparency.

IMO, since it's not really possible to be in touch with the hospital in advance (unless you're getting shadow care there, and simply not mentioning the midwife), I would want a midwife to say which ER she'd go to, and why.  I'd want her to commit to come with me.  I'd want to know if she'd transferred a patient there before, and I'd want to know how that went.  I'd want her to describe the experience level of herself and her assistants.  I'd want her to tell me what signs and symptoms she would regard as indicating a need to transfer.  I'd want to ask what her experience was with common complications like shoulder dystocia, meconium aspiration, and post-partum hemorrhage.  I, personally, wouldn't feel comfortable with a midwife who didn't ask me to help her make sure that it was safe for me to birth at home - I'd want her to help me schedule a mid-pregnancy ultrasound, for example.

Wow, this post seems written from a state of ignorance on birth in America today.

There is no professional accountabilty or transparency for OBs in America either! OBs could cut episiotomy on every single one of their patients and I believe NY is the only state that legally mandates such data be disclosed to the public. So I'm not quite sure what gives you the idea that legal OBs or legal CNM MWs have "transparency" either!

As far as accountability is concerned, there are tons & tons of stories of docs doing things like cutting an episiotomy AGAINST a woman's consent - and she has no legal recourse because it's considered part of a "standard of care" for a vaginal birth. Her wishes be darned. (& that's just one example - there are lots of other such issues - AROM without even telling a woman, let alone obtaining consent, likewise pumping Pitocin into her IV, VBAC-bans, etc. etc.)

If a doc was guilty of malpractice which did indeed lead to a dead baby, he is even unlikely to be prosecuted because it's so hard to find other OBs who will testify against him. The fact of the matter is simply that there are "very few consequences" for horrible actions on the part of OBs too. Please read, "Born in the USA" by Dr. Marsden Wagner for more on this (He calls it the obstetric "omerta.")

Moving on, I just don't see how it is the MWs responsibility to handle back-up OB care. For one thing, it's just totally impractical. My MW sees clients within a one-hour radius or more of her home. Do you know how many square miles that is? Do you know how many potential transfer hospitals that includes? I live just outside Baltimore city and there are like 6 hospitals for me to chose from within 20-30 min drive! How can I expect her to have working relationships with OBs who have priviledges at ALL of those places? That seems silly to me. Even if she WERE legal (which she's not), I wouldn't expect that.

Establishing a relationship with hospital-care providers, if I so desire, is my responsibility & that seems reasonable to me. It just so happens she DOES know, and have a good relationship with, the CNMs at my transfer-hospital. It also so happens that she encourages clients to establish care with a transfer hospital & maintain a cordial relationship (keep going back for occasional prenatal apts) to help ease the transfer process. It is something we discussed.

Furthermore, many women have 2 transfer hospitals - the absolute closest one in case of a true emergency, but one farther-away that is BETTER in case of transfer for something like maternal exhaustion, wherein it's not a problem to drive the distance. This also seems reasonable to me - just like many many women who birth in hospitals may chose a hospital farther away because they prefer it. Seems to me that is MY CHOICE to make about where I would want to transfer.

It just seems to me like you ladies are putting all the onus on the MW to manage everything with regards to transfer and to have "a backup doc." I personally think it's good that I've made my own choice for which hospital to choose in case of transfer.

Now, granted, I know stories of MWs who, in states where they are illegal or even alegal, will not even GO WITH a mama when she needs to transfer - or will go & claim to be the doula, leaving mama to have to say she had no prenatal care (and, therefore, leaving her at risk for hostility from the hospital staff & maybe even CPS calls!) that would bother me, which is why I asked my MW. Not only does she NOT hide who she is, she personally knows several of the MWs who practice at my transfer-hospital.

All of this aside, we know the medical community is hostile to HB. HB with a CNM is legal here in Maryland, but yet one hospital in Baltimore is so hostile to HB, they try not to transfer there if it can be avoided. (I was told this by the asst to the CNM.) It's just a fact of the matter that hostility upon transfer is a risk you take with HB - and I agree, it is a downside to HB in America today. But that's not the MW's fault!

Finally, I fail to see how regulation is a guarantee of safety of any sort. I'm seeing a CPM, and she happens to be totally illegal in Maryland (although legal and licensed in our neighboring state of Virgina - the whole thing is so stupid!) But consider thousands upon thousands of women annually are having wholly unnecessary major abdominal surgery, I'd say that being legal, licensed, and practicing in a hospital is no guarantee of safety in any regards! The fact of the matter is that women in American need to educate themselves to be smart consumers of maternity care. Blindly trusting your OB way too often leads to bad outcomes since they do things for their own personal convenience & liability-reduction - things that are not only NOT helpful, but HARMFUL to mother & baby.

But I would no more advocate 'blind' trust of a HB MW.

Actually, I think references for HB MWs are even easier to come by - since those of us who are NCB advocates tend to be a lot more educated about, and interested in birth then our mainstream counterparts who 'go with the flow' and bindly obey their OBs. If you can NOT find numerous positive recommendations about an HB MW from places like your MDC tribal community, LLL, Natural parenting groups, etc. then I would be worried! Sure, technically it's possible for an unlicensed MW to just mvoe to another state & keep practicing in a way that kills babies, but I think a bit of due dilligence would probably grant enough info for anyone to be suspicious of such a MW. Again, I don't see lack of regulation as having a detrimental effect on safety.

Flip that on it's head & how many women do you know who give glowing reviews of their OB because he "saved" her baby when the baby would have died otherwise - yet it's very likely that the fetal distress was iatrogenic in the first darn place?! Again, we know for a fact that very many of the CS performend in the US today are unnecessary - but I  would be willing to bet that most of those victims don't even realize that they were the victim of an unnecessary CS and think they had good care (i.e. the CS was necessary), and would therefore recommend the OB.

I just find your statements that HB MWs, if they are alegal or illegal, to be risky and not worth considering to be unreasonable, unfounded, and, well, just plain wrong.

& incidentally, many people don't consider an ultrasound to be some sort of "requirement" to make sure a mama is a safe candidate for HB. I may be wrong, but I think they are not even standard in other countries such as The Netherlands, where 30% of births are HB and their fetal mortality rate is among the best in the world (whereas ours is among the worst.)

Back to the original poster - sorry, but like MsBlack, I too don't quite understand what you're getting at. You didn't name anything specifically that she did that you find unsafe or troublesome. I don't think having an inexperienced asst is a bad thing - I view the asst as being there to learn, and then "help" MW by doing things like handing her whatever she needs, so I don't consider her lack of experience a problem.

Did she really truly not have any backup? Obviously since my MW's asst is just an apprentice, she couldn't be the only, or even primary attendant at my birth if my MW were not able to make it for some reason. But I asked who her back-up would be & it so happened to be another CPM in my area who I also met with & liked. (Again, considering she sees clients within a one-hour's drive+ radius, for clients in the Philadelphia area, she may call one backup MW, and for me in Baltimore, she'd call someone local to Baltimore. That makes a lot more sense to me than having ONE official "backup MW.")

If you don't feel she gave you adequate info for you to be making "informed consent" choices, then I guess that is a problem & I'm sorry to hear you were disappointed there. My MW gave me a whole binder full of info & we spend an entire hour chatting at each prenatal where I grill her on things - although, Ha - that's mostly just because I find birth fascinating & I WANT to discuss such things.

[ejg123]

Hi all. Thanks for your responses. It is my understanding that there is widespread agreement in the local mw community that our midwife was not practicing well. She is slowing down or closing her practice in part because of this. We were clearly misled and basic standards of care were not followed - I am sure of this, it is beyond hearsay. I am purposely vague because I do not wish to identify myself or her here. Certainly, ultimately, we should have challenged this. But she had practiced so long and was so kind to us that we did not. We were too trusting. I was tired. That said, I don't want to somehow remember our experience only through this lens. She had many gifts, but more as a support person and less as a professional with an emphasis on safety and informed consent. We should have trusted less and insisted more. It just reaffirmed to us that we must always be vigilant, and get second opinions. Probably we will always have shadow care. Hard issues. But I retain a sense of appreciation for a beautiful non-medical birth we had and the good intentions and care that our midwife gave to us.

[ejg123]

Just a quick follow up on this, just to be clear:

I don't know...I wasn't there at your prenatals, your birth, or the dead baby's birth...but it kind of sounds basically like you are saying that you had a great birth but now you're not sure your mw agrees with you about enough important things.  And you're not sure now, because of speculations that abound concerning another family's loss.

We had a great birth because there were no complications. Our concern was that if there had been complications, we do not feel confident that our mw would have handled this in the way we would have wanted - that her approach comes more from her own beliefs about how important interventions are as complications arise, rather than our beliefs. Further, we realized that many of her practices prior to the birth were guided by her own beliefs about the value of tests, precautions, and interventions, rather than helping us navigate these questions in the context of informed consent. This is not based on speculations about another family's loss, but our own experience of her practice and accounts of her practice by her peers and clients with whom we have spoken directly. We have not discussed it with her because we do not want to have some sort of confrontation. It is, for us, about dealing with this for our family and how not to repeat such mistakes on our part. It is not about making her feel bad or sharing the information with others. For us, it is the question about how much one can trust one's health care providers, midwives in particular - and how much we take up on our own in terms of how to handle emergencies, which interventions to choose, which tests to choose, what constitutes a problem that requires further investigation, etc.

[MsBlack]

I'm really glad to see your other posts, Texmati.  When these things come up (a homebirth death/disaster), too often there IS a bunch of speculation...I didn't mean to assume, but I thought it was possible you were influenced by that.  I'm glad you can appreciate the gifts that mw shared with you, and the fact of your lovely normal birth--and also glad that you have more info and insight both, for future reference.  Whatever can be said about the deficiencies in midwifery/homebirth care (due to lack of national standards/protocols/licensing for mws), it doesn't matter how well a system is put together and operated--in life it is always wise to remain alert, ready to take care of ourselves as best we can, take nothing for granted, etc.  No system is any substitute for remaining present and willing to respond each moment....such as really discovering pertinent info about a midwife, before committing to care and all through!

I think you hit the nail on the head when you spoke of how her ways were based more on her beliefs than on helping you guys navigate things according to your own beliefs.  This is an important thing to know, going in.  Most often, birth works so well that we don't especially need 'skilled care'--the personal support is enough.  It's when things don't go right that we really need a mw--and need to understand in advance how variations/complications might be handled...the choices we might make as parents, and the how to get support we need for our decisions.  It's ok for a mw to do things according to her own beliefs--her right to create her mw identity any way she likes.  But clients need to clearly know, in advance, what is up, how she works, all that.

[MsBlack]

oops, getting my threads and characters mixed up, sorry! 

My last post should have been addressed to ejg123, NOT texmati