can we have an honest discussion?

[liz-hippymom]

about how to #1 make sure the providers we choose are competent , and #2 how to improve flaws that are *currently* in the US homebirth system..

ok here goes-

as many of you know i lost my full term baby at a homebirth gone wrong... she was my fourth birth with a midwife, third at home. i was completely low risk up until the labor. my midwife missed very important signs- fever, fetal tachacardia, bleeding, meconium stained fluid.

since then i have been told by many that i am anti-homebirth- but this is not true.

i respect homebirth as a choice- i have seen how wonderful it can be..but i have also seen how bad it can be.

i have spent the last year struggling with what i can do, iykwim....

i want to have a discussion that keeps to the UA about how we all think things can be improved.

because the thing is, my midwife was very well reccommended, and had all the right "answers" to my questions...

maybe one thing is i was not asking the right questions?

what about other countries? i think a lot of the problem here is the way midwives are not part of the main medical community, meaning they don't often have OB backup, or malpractice insurance, or any training in major complications.  what if things were more like Canada for example?

what do you think?

[Marissamom]

I think one of the major problems with home-birth in the US is that it varies so much from state to state. there are states where Midwives are well integrated into the medical system, and there are states where a midwife can be arrested for attending a birth. and there are vastly different standards of training. I think the first thing that would make home-birth safer would be a national standard for licensing requirements. 

[kythe]

This is a really good topic. There are so many factors that influence homebirth safety. In recent years, I've been thinking a lot about the attitudes I've seen in the medical community.

My first impression of the relationship between midwives and hospitals was very positive. I had my babies in a free standing birth center with CNMs who also had hospital priviledges. Things went as smoothly and with as few interventions as many home births. But if I needed to be transferred to the hospital, I could have been there within 5 minutes and my midwife would continue to manage my care with little interruption.

In years since, I've come to see the other side of midwifery and hospitals through nursing school and from interviewing DEMs. My state licenses Direct Entry Midwives through the department of health. This licensure provides a legal scope of practice as well as guideline for training LMs in the state. But the level to which LMs are acknowledged by the medical community varies.

Some have little trouble with hospital transfers, taking a mother in and giving report to the staff about the patient's health history, monitoring during labor, and what led them to the hospital. But sometimes midwives find they are not even acknowledged or spoken to, and the mothers are taken in as unassisted births with no prenatal care. The staff starts at square one with their assessment, which significantly slows interventions and puts the mother and baby in further danger.

This seems based greatly on the individual views of the nursing staff and the rapport or reputation the midwife has with the facility. It should be based on the acknowledgment of the LM's legal status as the mother's provider up until that point.

The problem is how to change the attitude of the medical community in making home births more acceptable and less stigmatized. I don't know where to begin on this one, since I didn't have a good experience with this in nursing school.

[Plaid Leopard]

I'm so sorry for your loss, Liz.

I agree  that we need a national licensing standard and oversight process.

And I definitely agree that the medical community needs to be more accepting to midwives and homebirths. I am in the UK, and all midwives here, whether they are based in hospital or are independent home birth MWs, must attend university and be licensed by the National Health Service. Midwives are independent practitioners and attend most births, even those which in the US are considered higher risk. I suppose they could most be compared to American CNMs, but midwifery here is definitely separate from nursing. The important thing is that they work in collaboration with obstetricians and  other health care providers, so that women have access to the care that they need. Here is a page from the National Health Service on choosing where to have a baby.

http://www.nhs.uk/chq/Pages/916.aspx?CategoryID=54&SubCategoryID=135

The homebirth rate in the UK is around 2%. Women who choose to birth at home are guaranteed a NHS midwife to attend the birth (in theory anyway, it is true that sometimes women are discouraged from HB due to staffing shortages) or they can use an independent midwife.

I have to go but will be back a bit.

[liz-hippymom]

hi , thanks for the responses so far.

i do agree that all states should be uniform in laws, regulation, and i even think training. like the way a nurse trained and licensed in Texas would be just as well trained as one trained and licensed in Ohio. i also think the CPM title needs to go. midwives need more training. - maybe like Canada where they don't have to be nurses, but still have to have actual degrees? i don't know...

what do you guys think about malpractice insurance ? i think get getting all insurances and medicaid to cover midwives at home would be much more feesable if midwives carried malpractice insurance and had more education- like in Florida where midwives must carry malpractice insurance, but all insurances must cover homebirths. seems like a fair trade.

[labortrials]

Personally, I think any/all poor birth outcomes (maternal and/or fetal) should be reported to state public health boards, and that info should be accessible to the public.  I'm not suggesting it should be advertised, but I think folks should have access to this information!  Poor outcomes happen in all birth settings, but it's really hard to get information.  You kind of "hear about it" from folks, and that's just not good enough.

I'm sorry your midwife didn't pick up on those key distress signals.  If she has NARM or MANA credentials, perhaps there is some way to report it?  Otherwise, all you can do it make sure anyone you know or hear of who is considering her knows what happened to you.  This includes to people who recommended her to you.

As a first time homebirther, it also just makes me want to know as much as I can about normal vs. abnormal labor.  IDK if that's really possible, and IDK if it's really in a woman's best interest to be worrying about the "what ifs" during labor, but it something to think about. 

Hmm . . .

[Plaid Leopard]

Until there is a more standardized system of licensing and oversight of midwives, I really think there also needs to be more education and information regarding homebirth and HB midwives, and what a MW can and can not do, and should or should not do. Obviously, individual MWs should be very honest  about their training, their statistics, and their strengths and weaknesses. Midwifery schools and accreditation boards should be honest about what midwifery is and is not, and should certainly have very strict training and discipline protocols in place.

But the education and information also needs to come from the mainstream medical community. It is not helpful for "consumers" when ACOG or OBs or other medical professionals dismiss all midwives as incompetent and ignorant, and paint all homebirthers as crazy, ignorant trend-followers. Just by looking here on MDC we see that there are many different types of women, from all educational, cultural and religious backgrounds who choose to birth at home for many different reasons. It would be nice to see ACOG et al. say that they recognize that some women will choose to HB, and outline the steps they should take to ensure that they have a competent carer and a safe pregnancy and birth. Then of course, the OB community would have to take steps to collaborate and cooperate with MWs.

I think this approach would be more effective and safe than alienating women who do not want to have a hosital birth or follow standard medical protocol. It is hypocritical for the general medical community (obviously not all doctors or OBs have the same attitudes) to rail about the dangers of midwives and homebirth, but then contribute to the risk by limiting women's choices and denying them access to care when they do need it. Not everyone agrees that HB is safe, but knowing that some women will choose to HB no matter what should lead OBs to want to improve the situation and not make it worse.

Lastly, there needs to be better record keeping and more actual studies (not just meta-analyses of studies) to look at the safety and perinatal and maternal outcomes of homebirth in the US.

[Plaid Leopard]

I agree Liz. I think uniform training and regulation is key.

And uniformity doesn't have to mean that all midwives practice in the same way. Here in the UK, the midwifery schools have to meet certain standards of  training, but each school has a slightly different approach to applying those standards. Likewise, individual midwives practice in different ways. Some are more hands-off, use alternative and complementary therapies etc, while others are more quick to intervene, and follow a more medical model and wouldn't be caught dead with a homeopathic remedy in their hands.

I do think that MWs should have to have mal-practice insurance, but obviously that insurance has to be affordable. Most MWs dont make a lot of money to begin with...

[kythe]

Originally Posted by liz-hippymom 

what do you guys think about malpractice insurance ? i think get getting all insurances and medicaid to cover midwives at home would be much more feesable if midwives carried malpractice insurance and had more education- like in Florida where midwives must carry malpractice insurance, but all insurances must cover homebirths. seems like a fair trade.

Malpractice insurance does not make birth safer. It increases the rate of interventions since practitioners try harder to protect themselves from liability. This sounds good on the surface since it seems to increase the practitioner's responsibility, but it greatly inhibits freedom of practice. When practitioners are motivated by threat of lawsuits, they tend to perform procedures they wouldn't otherwise find necessary because they are afraid they may miss something and be sued for negligence.

The purpose of malpractice insurance is to protect a practitioner from being financially destroyed in a lawsuit. Ironically, midwives are often put out of business by the malpractice insurance itself because the premiums are more than they can afford. Midwives don't make nearly as much as doctors.

The real clincher is that midwives rarely get sued at all. But some hospitals require CNMs to carry insurance as an overt way of pushing them out of business. Sure, they can practice there, if they are held to the same standards as doctors. Since they can't do this, they have no business at all and no accomodations are made for them.

[Plaid Leopard]

I wanted to ask why you believe that the title CPM should go? What do you think these midwives should be called? And do you believe that all CPMs are under-trained and under-educated?

While I do believe that there should be uniform training standards in midwifery, I don't think that midwives need to have a university degree to be good, competent midwives.

[carriebft]

I am so torn on this because, one on hand, I think limiting homebirth to low risk women, having high standards for midwives before they are allowed to practice, requiring malpractice insurance, etc would all go a long way to decreasing homebirth deaths and injuries- esp from things like hypoxic death. I believe the mechanism for this would be that midwives would take on less higher risk women, they would be doing more "hands on" things during labor (ie, more monitoring), they would be more likely to transfer when potential problems arise, and they would have that back up OB and hospital. They would also have access to more tools at home because they are trained and certified to use them.

On the other hand, choice would be decreased. In Canada, many women would not be able to have a homebirth who could have a homebirth here. How important is that choice? that's the sticking point for me.

And sometimes I feel elitist when I talk about these things because all my pregnancies have been so easy, low risk, etc. All my births have been those bread and butter births...plus I have access to an awesome homebirth CNM team who have all these things I am talking about (access and training in medications, IVs, pit, etc, back up doctor, malpractice insurance)

[IdentityCrisisMama]

It is my understanding that one of the obstacles to further improving the safety of homebirth in the United States is the relationship between homebirth midwifery and transfer care.  I would think making headway in our communities to be sure that transfer care is not hostile to homebirth would be a great step forward.  

[liz-hippymom]

i tend to not agree. especially after having met two woman in my state with babies with extensive Brain damage from their (home) births. they have no money to pay for the care their children need. i think it is irresponsible of any care provider to not carry it- in my state almost any small business owner carry some kind of liability insurance including terminators- tell me why a bug terminator is legally required to carry malpractice insurance, but not someone who delivers babies?

what we are talking about here (in regards to insurance) is what happens when a midwife is at fault?? the families should just cry, go bankrupt and get over it? Even for my daughters death i paid almost 10k out of pocket, not including her midwife's birth fee (4k) which my insurance paid. we simply did not have the money for counseling for me or my husband or my children, who really could have used it.

Originally Posted by kythe 

Originally Posted by liz-hippymom 

what do you guys think about malpractice insurance ? i think get getting all insurances and medicaid to cover midwives at home would be much more feesable if midwives carried malpractice insurance and had more education- like in Florida where midwives must carry malpractice insurance, but all insurances must cover homebirths. seems like a fair trade.

Malpractice insurance does not make birth safer. It increases the rate of interventions since practitioners try harder to protect themselves from liability. This sounds good on the surface since it seems to increase the practitioner's responsibility, but it greatly inhibits freedom of practice. When practitioners are motivated by threat of lawsuits, they tend to perform procedures they wouldn't otherwise find necessary because they are afraid they may miss something and be sued for negligence.

The purpose of malpractice insurance is to protect a practitioner from being financially destroyed in a lawsuit. Ironically, midwives are often put out of business by the malpractice insurance itself because the premiums are more than they can afford. Midwives don't make nearly as much as doctors.

The real clincher is that midwives rarely get sued at all. But some hospitals require CNMs to carry insurance as an overt way of pushing them out of business. Sure, they can practice there, if they are held to the same standards as doctors. Since they can't do this, they have no business at all and no accommodations are made for them.

[Hannah32]

Liz, I've been following your blog and your story for awhile now and I just want to say that I think you are very brave (and thick-skinned) to keeping put your POV out there. 

Is it true that all the homebirth midwives in Europe are also licensed nurses? I've read that somewhere, but I wasn't sure. It seems to me that they should be. That would be one way to definitely improve things. 

[labortrials]

Originally Posted by IdentityCrisisMama 

It is my understanding that one of the obstacles to further improving the safety of homebirth in the United States is the relationship between homebirth midwifery and transfer care.  I would think making headway in our communities to be sure that transfer care is not hostile to homebirth would be a great step forward.  

DING DING DING!!!

Carrie - it does sound like you have an ideal set-up in your community.  That's awesome!

I also see the requirement for malpractice insurance as a limitation.  You can see how the FEAR of malpractice suits has had an impact on obstetrics.  The main reason I'm not going to even TRY and have this baby at the hospital is because of defensive obstetrics.  To a certain extent, licensure poses the same problems for the practice of midwifery.

Low risk . . . yeah, if you limit homebirth midwifery to TRULY low risk pregnancies, then many more women and babies are left to over-medical management.  Plus a low-risk pregnancy does not necessarily mean a low-risk birth or that a poor outcome won't happen.  I gestated two babies simultaneously last time with no incident.  Heck, I was still mowing the yard at 36w pregnant.  There was NOTHING high risk about my pregnancy.  However, I had no option other than the hospital.  And 75% of twins in my state are born by cesarean.  Totally unethical.  (I will say that in my case, a cesarean was appropriate, and I knew that ahead of time, and had a u/s at the hospital to confirm double footling breech before I consented to the surgery.)

So, ICM, your point has been on my mind for quite some time - months if not years.  I know that my future includes some sort of local mobilization to let our OBs know that they can't continue to treat our homebirth CNM like an outcast, verbally abuse our homebirth transfer families, and at best ignore our homebirth midwives.  Do you have any ideas?

[kythe]

Originally Posted by liz-hippymom 

i tend to not agree. especially after having met two woman in my state with babies with extensive Brain damage from their (home) births. they have no money to pay for the care their children need. i think it is irresponsible of any care provider to not carry it- in my state almost any small business owner carry some kind of liability insurance including terminators- tell me why a bug terminator is legally required to carry malpractice insurance, but not someone who delivers babies?

what we are talking about here (in regards to insurance) is what happens when a midwife is at fault?? the families should just cry, go bankrupt and get over it? Even for my daughters death i paid almost 10k out of pocket, not including her midwife's birth fee (4k) which my insurance paid. we simply did not have the money for counseling for me or my husband or my children, who really could have used it.

Malpractice insurance will not influence this at all. It will not pay for damages in poor outcomes, this is not the role malpractice insurance has for doctors. The only purpose of malpractice insurance is to protect the provider (doctor or midwife) financially in a lawsuit. That's it. A mother can sue her midwife for damages because her baby was born brain damaged whether or not the midwife has malpractice insurance. The existence of th insurance will not affect the outcome of the case in a court of law. If the midwife loses, she may be put out of business with the debt she created for herself from your lawsuit. But that's what you wanted anyway isn't it? If she were forced (by whom?) to carry the same malpractice insurance doctors carry, it would probably equal her annual salary and she would be out of business just from that alone.

Doctors are not legally required to carry malpractice insurance, it does not affect their license. Hospitals are the ones who require it for practitiners there because they don't want to be held financially responsible in case of a lawsuit. Obstetrics is a field with a relatively high number of lawsuits in comparison with other fields, hospitals are trying to cover themselves.

Locally, we used to have several hospitals with CNMs working there. Over the years, they have gradually begun requiring CNMs to carry the same malpractice insurance as OBs. The result is that CNMs no longer carry hospital priviledges. Historically, malpractice has been used as a way to get rid of midwives, doctor's competitors.

[nilatti]

In my community, there are several practicing CPMs, who deliver babies at home, as well as a group of CNMs at the hospital. A couple of years ago, the midwives--both hospital and homebirth--started getting together for quarterly breakfasts. They share knowledge, discuss difficult cases, celebrate their victories. Several of the HB CPMs practice as doulas for hospital births. They've managed to get involved at the hospital to the point that the OBs know them, and, with only a few exceptions, respect them as fellow members of our local medical community.

What this means is that my CPM was able to honestly tell me that she had mostly had very positive transfer experiences, wherein she and her patients were welcomed at the hospital. There are a couple of OBs there who still frown on homebirth (including one who has a 40% C-section rate and a 75% episiotomy rate...), but for the most part, there's a real environment of collegiality. I also mentioned her name to my family doctor, and all he said was, "Oh, I hear good things about her."

The effect this has is that it makes homebirth safer, because the CPMs aren't scared to go to the hospital.

Liz, when I've read where you talk about your story, I'm always kind of shocked. When  my MW and I discussed the birth plan, she gave me a list of conditions--pretty much all of the things you listed at the top of this thread--and said, "If one of those things happens, we stay home but monitor the baby much more closely. If two of them happen, I give you the option of going to the hospital. If three of them happen, we ARE going to the hospital, possibly in an ambulance." That made me feel really safe. She had a plan, I knew what the plan was, and she felt that going to the hospital was definitely part of the plan, in certain circumstances. Luckily, I didn't need to transfer, but I know of other situations where she transfered with people because of warning signs. 

[liz-hippymom]

you are very wrong. i know from my own experience and from many others i have since talked to that it is VERY difficult to get a lawyer to take a case against a midwife without insurance. even if you get  a lawyer to take the case  and win- she will not have the money to cover your medical expenses she will claim bankruptcy. medical malpractice insurance is what can pay if something terrible happens and the parents are left with huge bills. what do you mean by 'it will not pay damages"? where do you assume damages get paid from?

Originally Posted by kythe 

Originally Posted by liz-hippymom 

i tend to not agree. especially after having met two woman in my state with babies with extensive Brain damage from their (home) births. they have no money to pay for the care their children need. i think it is irresponsible of any care provider to not carry it- in my state almost any small business owner carry some kind of liability insurance including terminators- tell me why a bug terminator is legally required to carry malpractice insurance, but not someone who delivers babies?

what we are talking about here (in regards to insurance) is what happens when a midwife is at fault?? the families should just cry, go bankrupt and get over it? Even for my daughters death i paid almost 10k out of pocket, not including her midwife's birth fee (4k) which my insurance paid. we simply did not have the money for counseling for me or my husband or my children, who really could have used it.

Malpractice insurance will not influence this at all. It will not pay for damages in poor outcomes, this is not the role malpractice insurance has for doctors. The only purpose of malpractice insurance is to protect the provider (doctor or midwife) financially in a lawsuit. That's it. A mother can sue her midwife for damages because her baby was born brain damaged whether or not the midwife has malpractice insurance. The existence of the insurance will not affect the outcome of the case in a court of law. If the midwife loses, she may be put out of business with the debt she created for herself from your lawsuit. But that's what you wanted anyway isn't it? If she were forced (by whom?) to carry the same malpractice insurance doctors carry, it would probably equal her annual salary and she would be out of business just from that alone.

Doctors are not legally required to carry malpractice insurance, it does not affect their license. Hospitals are the ones who require it for practitioners there because they don't want to be held financially responsible in case of a lawsuit. Obstetrics is a field with a relatively high number of lawsuits in comparison with other fields, hospitals are trying to cover themselves.

Locally, we used to have several hospitals with CNMs working there. Over the years, they have gradually begun requiring CNMs to carry the same malpractice insurance as OBs. The result is that CNMs no longer carry hospital privileges. Historically, malpractice has been used as a way to get rid of midwives, doctor's competitors.

[kythe]

Originally Posted by liz-hippymom 

you are very wrong. i know from my own experience and from many others i have since talked to that it is VERY difficult to get a lawyer to take a case against a midwife without insurance. even if you get  a lawyer to take the case  and win- she will not have the money to cover your medical expenses she will claim bankruptcy. medical malpractice insurance is what can pay if something terrible happens and the parents are left with huge bills. what do you mean by 'it will not pay damages"? where do you assume damages get paid from?

If money, rather than prevention of health problems, is all you want out of an adverse event, you will find yourself seeing an obstretrician for your birth. Malpractice insurance generally costs more than a midwife's annual salary. Midwives can't afford it. Where there is malpractice insurance requirements, there are no midwives. Locally, we have no CNMs in hospitals because of this, and CPMs don't carry insurance.

[kythe]

I'm just adding: I'm sorry about the above post. I posted quickly and just realized that sounded really rude. I don't think I can edit it now though

I'm speaking from things I've seen too, but its quite possible that experience varies greatly according to what state you are in. This too, is a problem since there are no national standards for regulating midwifery practice.