The price of being the best.....is having to BE the best - Or: On how to make Homebirth even... - Page 6

[Turquesa]

Originally Posted by Kanna 

*chuckles* 

This is a bit unrelated and I'd do something similar in a heartbeat, but it did amuse me that you linked to an article which stated that "A review paper published in 2010, for example, found the risk of newborn death was two to three times higher for babies born during planned home births compared to planned hospital births." while arguing for homebirth.

Yea, yea.  I get it.    That was the first of thousands of hits that I got on the topic when I did a search.  All of those hits confirmed the accuracy of the the CDC's 0.67% statistic.  And I'm sure you know by now that these anti-homebirth medical groups are citing a meta-analysis that has been debunked ad nauseum.   

To your question on why you're wondering why I'm "focusing so intensely on those 0.67% of homebirthed babies when there is clearly a much greater problem in the U.S. with mainstream maternity care?":

From what I've gathered, there's a huge problem in the U.S. with mainstream maternity care...because of insurance. Which a lot of people don't have. So they, including moms-to-be have big holes in their health-care. Not because it isn't available. But because they're not able to pay for it.

Fair enough.  I, too, think that insurance status may play a significant role in the high neonatal and maternal mortality rates.  (In fact, we only have anecdotal evidence thus far, but numerous homebirth CPMs can tell you about all of the uninsured clients that they have because out-of-hospital midwifery offers uninsured women a MUCH more affordable option). 

So why aren't you focusing your concerns on THAT issue (among other factors contributing to the mortality rates) of women lacking health care coverage?   

Let me put it this way: Do you, from the bottom of your heart, wish to stop women and babies from dying in childbirth?  Because believe me, Kanna, a LOT more lives will be saved by shifting the discussion to U.S. health care injustices and underinsurance than they ever will be by nitpicking Midwife Erika's (and other midwives') credentialing process.  Unfortunately, while blinded by its zeal to stop American women from choosing homebirth, the American Medical Association completely has its priorities in the wrong place.

Perhaps by scapegoating midwives and women who choose homebirth and refusing to address problems of underinsurance and anti-evidence practices, they feel that they can blame-shift the problem of high maternal and neonatal mortality rates into somebody else's lap.   

[Turquesa]

Originally Posted by starrlamia 

Good post, but i dont think ive ever heard that the USA has the best healthcare lol just the opposite.

[Kim L Mosny CPM]

Originally Posted by Kanna 

Thanks for the input!

To give us a little bit more insight, is there a pdf of the 41 pages skills criteria somewhere? I browsed the NARM website and couldn't find it.

And what does the written exam look like? Especially concerning emergencies and safety? Could you maybe post a few example questions?

Thanks again!

Here are the 41 pages of skills verification... every skill listed must include a date of acquisition of proficiency and the preceptor's signature

Please keep in mind that this (verification of skills) is only PART of the entire NARM application

Test (Written Exam) Specifications begin on page 35 of the Candidate Information Bulletin

Here is a breakdown of the written exam by category.

CPM Written Examination Matrix

Content Area Total % of Exam / # of Items

I. Midwifery Counseling, Education and Communication .  .  .  . 5% / 17

II. General Healthcare Skills .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5% / 17

III. Maternal Health Assessment .  .  .  .  .  .  .  .  .  .  .  .  .  . . 10% / 35

IV. Prenatal .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  25% / 88

V. Labor, Birth and Immediate Postpartum .  .  .  .  .  .  .  .  .  35% / 123

VI. Postpartum .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .15% / 54

VII. Well-Baby Care .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5% / 16

[starrlamia]

The mom was already denied a homebirth with her original midwives due to the baby being breech, im sure they educated her or at least she would have had an inclination.

 

Originally Posted by Kanna 

[RealMidwife]

Hi Kanna,
You do seem like you're genuinely looking for answers, and I appreciate that you haven't resorted to the playground antics you mention. 
I did still feel a bit odd about your post and after thinking about it, realized it was because saying you want to make homebirth safer carries with it the implication that there are flaws that need to be improved. Now, if I'm wrong, and your standpoint is more about how to continue to improve what I think is a good system, then I misunderstood and apologize. If there was a specific hole in the system, I would definitely want to fix it immediately. To me, the data hasn't shown that there is a safety issue with out-of-hospital birth. 
I am curious to see the MANA data released, but as I've worked extensively with the researchers in how to ensure we are fully compliant and that our clients are 100% represented in their data set, I don't have any conspiracy theories about why it isn't out yet. Up until 6/2011, entering births in that database has been voluntary for midwives. In 6/2011, it became mandatory for all clients of licensed Oregon midwives to be entered into the database at the start of care. So, I think it will be a while before we get a full picture of what's going on. 

Now, about the data already being discussed: I've heard criticism regarding using the CDC wonder data for out of hospital births, for reasons already mentioned on this thread and the one before it. Even if the numbers were 100% accurate, I don't think it gives a complete picture of midwifery care, and from the outside it's hard to understand. How can we know what the story of those infant losses were? Did the clients know ahead of time, and still choose to welcome their baby at home? Most hospitals, when confirming a fetal demise during pregnancy, will encourage the parents to go home and tale their time, and come back when they're ready to birth the baby. They may choose to continue with a homebirth plan in that case. Or, a baby with anomalies incompatible with life, known in advance by ultrasound. Or, a baby with unknown anomalies when the parents declined ultrasound in pregnancy. I just can't help but think that those are in the numbers too. 
As for evidence of negligent/incompetent midwives, I don't think the anecdotal evidence of these birth stories being posted is enough. I'm not AT ALL blaming or pointing fingers at the grieving parents. I feel devastated by their losses, and the possibility of losing a baby affects EVERY DECISION I make as a midwife. But. We don't have both sides of the story. We don't have these women's charts (not that we should, I just bring that up as a way to see the other side of the story). With only the grieving, understandably heartbroken, parents' side of the story, it's difficult for me to judge whether there was negligence involved. Not to say I'm not judgmental! But I try, when thinking of my fellow care-providers, to believe they thought they were acting in the best interest of the family, or supporting the family's wishes. (Not just midwives. I also believe that about OBs, pediatricians, etc). So, I don't believe there is enough evidence to support the idea that midwives are poorly-trained and acting negligently, and that we need to do something about it. 
As a licensed midwife in my state of Oregon, we are required to peer review any birth that meets our non-absolute or absolute risk criteria. Also, absolutely anyone (even from within our board) can file an anonymous complaint about a midwife, where our board then reviews the chart involved, contacts the parents, etc. We are creating a much more extensive review process as well, where we can request a peer review of a challenging case, with detailed chart review etc. Some of us even get to attend the hospital review when a loss happens (and is transported to the hospital). So, from my perspective, there is a system of checks and balances going on. 
In terms of licensed or unlicenced: I do think, especially in this climate that it makes sense to require licensure. In my opinion, many midwives who are unlicensed cannot afford the fees involved. To compare, the CNM yearly license fee is under $200 (maybe even under $100? Feel free to correct me on this) and the midwifery licensure fee is now $1800 a year. For most midwives, that is prohibitively expensive. Why? A busy midwife working in a birth center (not a great example, bc part of working in a birth center is that these fees are covered for you) makes around $4000 a month before taxes. That yearly license fee represents almost a month of take-home pay. There isn't any other license that can be compared cost-wise. So, if we did come to a place of thinking safety would be better maintained if midwives were licensed, we'd need to get somewhere on that fee.
Speaking of CNMs, you had mentioned "upgrading" the CPM to a CNM. Unfortunately, the CNM degree has it's flaws, which is why I chose not to get it. I wasn't interested in a bachelor's in nursing, and didn't find it relevant for my midwifery studies. I was much more drawn to the program I attended, a Bachelor's in midwifery, with (at least) three years of school dedicated to midwifery alone. I don't agree that you have to be a nurse first to be a midwife, and wanted to spend as much time as possible on midwifery studies. 
The other thing being brought up a lot is malpractice insurance. Again, prohibitively expensive. I definitely hear what people are saying about having babies with life-long care needs. But again, I don't see this as a safety issue: our clients know completely from the first visit when they sign the hiring agreement exactly what our education is, level of experience, and that we don't carry malpractice insurance. Because I know people don't always read what they sign, I go over it verbally too. So, if the client is made aware that we don't carry it, and still makes a choice to hire that midwife, what's the problem there? Again, not seeing anything that needs changing because these are things we already do. From what I've read by the people vocally hurt and angry about their midwifery care, a lot of it seems related to lawsuits: upset that they felt they had no recourse against their midwife. Again, because we don't know both sides of the story, we don't know whether the clients knew any of that going in. I do know both sides for one of the stories circulating here, and like all stories, the two sides are very different.  Knowing that information makes me have a (healthy, I think) dose of skepticism about the other stories. I know it's an unpopular position to question grieving families, so let me be absolutely clear: I'm devastated for your loss. I can't even begin to know what you've been through. I just can't judge the midwife from your stories without knowing both sides, seeing the chart, etc, things that aren't going to happen.
What I said about malpractice also brings up something else I've seen lately: a lack of belief/understanding about informed choice. There seems to be a belief that if women were given true information, they wouldn't choose what they've been choosing. That seems so insulting to those women! Not everyone is going to make the same choices, and women have a right to choose their care provider. We go to great lengths to make sure a woman has all the information at hand, and I can safely say we give a lot more time to this than hospital-based providers do. On every test/screen that comes up, we give clients a pamphlet about it with pros and cons, risks and benefits, possible outcomes. We also discuss the test and make sure they know what the hospital protocol and standard of care is. We have time for this in our hour-long appointments. If something has an especially increased risk (but is still legal!) we have the client write out themselves what we've discussed, and what the risks are. That way, we know they really get it and they're not just signing their names to a piece of paper.
Sorry for the lengthy post! In summation, I think we have to agree there's a lack of safety before trying to make it more safe. Mainly because if we don't know what is unsafe, how can we correct it?

[Kanna]

*waves hi*

Currently lots to do at home....it'll take me a while to respond. But I guess MDC and this thread will be around for a while yet  ^_~

[jenrose]

There aren't good studies on the safety of home vs. hospital because in many ways the data just doesn't exist at a meaningful level. To truly compare CPM care to OB care, you can't just look at "Where the birth happened", but where the parents planned for the birth to happen, who they were seeing  in pregnancy, etc. We saw from one look at the data that comparisons of birth at term showed better results for OBs...but given current OB practice, how much less likely is an OB patient to make it to term in the first place? How many are likely to be "risked out" for specious reasons, and therefore managed by a high risk practitioner? 

I'm not going to go to the studies right now, but to personal experience. 

I had an embolism when I was 19, due to a then-undiagnosed heritable thrombophilia and birth control pills (prescribed by a CNM working for a student health clinic, ironically, after I told her, "You know my mother had a clot while pregnant, are birth control pills safe for me to take?") It was misdiagnosed by several practitioners until I finally took my sorry ass to the ER where they figured out I'd lost 3/4 of my lung capacity to a massive embolism over the course of three weeks. Clot busting drugs gave me my lungs back, but from then on out, I was labeled "High risk".

I got pregnant about 18 months later (see: birth control pills nearly killed me), assumed because of the high risk label that I'd have to seen an OB, went to an OB and was told, "No you're too high risk for us, you have to go see the perinatologist."

So don't get me started on the whole "OBs see higher risk patients anyway". Confronted with anything remotely out of the "usual" set of problems, they seem to pass the buck way faster than a midwife will. 

The perinatology clinic said, "You're fat and you had a clot, you're high risk, here, take heparin."

My mother nearly died during her last pregnancy taking heparin. First she clotted, then went on heparin, they never got her stable, the placenta abrupted, clotted, and then she nearly bled to death while losing the baby.

I said no.

They sort of blinked and shrugged their shoulders and I had zero problems with clotting, due the the serendipity that WIC's only palatable frozen juice was 100% welch's pure grape juice. Which is an anticoagulant, but no one knew that at the time. I saw a naturopath, who had me take garlic and ginger to reduce my clotting risk, as well.

My blood sugars were on the low end of normal. My blood pressure was ridiculously normal. Despite being fat, I had nice ankles even up to term.

Sometime in the third trimester, I started fantasizing about locking myself in the bathroom at the hospital and not coming out until the baby was born. Good instinct. I hired a midwife to act as my labor support. 

Had I not, the contractions I started having at 35 and 36 weeks would have sent me in to the hospital, where they would have seen me dilate from 1 to 2 and then things peter out, and they would have jumped on the high risk bandwagon and scared me into "augmenting" what was really just annoying prodromal labor. My midwife instead came out to my house and checked me, listened to baby, had her oxygen with her in case things actually did take off faster than we could get to the hospital, and when things petered out, she said, "Good. Have a half glass of wine and a bath and call me if they pick up again."

She came out and sat with me through contractions at least 3 times before I hit term. She wasn't a CPM yet, she was an apprentice-trained midwife without a high school diploma, with more common sense in her little pinky than the entire hospital had, combined. Because she was there with me, checked baby, paid attention, and had as her priority to help me keep things normal, I didn't end up going into the hospital until I was in labor for real, at 40 weeks 3 days.

I told the hospital "No" at every turn. No, they couldn't use the belts to keep the monitors on, if they wanted to monitor, they could stand there and hold the damn things in place. Nurses bore easily. This resulted in textbook intermittent monitoring. No, with a clotting disorder, I do not consent to have heplocks or IVs placed unless I actively need IV meds. EVER. No, I didn't want to talk to the anesthesiologist. No, I don't want to sit down, I want to walk.

That hospital had a 90% epidural rate. They had no freakin' CLUE how to manage a labor like mine. Not one thing they did made the process safer, and the rapid cord clamping made my daughter anemic. Forcing me into a semi-sit to push created a nasty tear. A clueless doctor who thought that my desire for "natural" meant she should take fewer stitches in my bottom meant that my bottom will never, ever be the same without surgery. Nurses came to "check my incision" and "Ask how the drugs were helping" even though I had not had a cesarean and didn't even know the drugs had been prescribed (and was not taking them). Because of faint, faint staining of the waters, they stuffed a suction tube down my daughter's throat to her vocal cords, despite the fact that she was screaming her fool head off and clearly fine.

I spent the next 11 years reading about birth. I was so done with the whole medical establishment that I knew that with my risk factors (by then I'd added asthma and apnea and another 30 pounds) I might not find a midwife, but there was no way in hell I was going back to OB care. I planned for a UC, but miscarried. Ironically, a day after talking to a perinatologist about being able to consult with him on some of the risk factors, and having him tell me, "90% safety isn't good enough". I'd written back to him saying, "You can't guarantee 100% safety. You can't guarantee I won't miscarry next week."

After losing the baby, I got pregnant again, and interviewed midwives, because I wanted some access to the system if I needed it. Of the four I interviewed, only one truly demonstrated commitment to informed consent and my right to refuse treatments I did not feel necessary. I ended up hiring her, and because she trusted me and I trusted her and she LISTENED, I did have her at my birth, and she helped keep me from panicking when things weren't "textbook" but were still safe enough for home. In the hospital, I would have been sectioned. In the hospital, my baby would have been in the NICU. Neither option would have improved our outcomes over what we did at home. In fact, most of the kids with her syndrome born in the hospital end up having MORE problems than my little girl does. 

This pregnancy, I have a different midwife for a variety of reasons, and it's really the ideal. No one can come up with research to demonstrate the safety of this approach, but I'm being seen by a midwife who consults regularly with a perinatologist. I will birth at home, 7 minutes from a high-risk facility. Our door-to incision time may be as short as 15 minutes if it comes to that. My midwife is okay with me getting ultrasounds as needed, and taking prescribed medications. We have a plan for coping with my risk factors. They are all, currently, decently controlled.

And while I may be 300+ pounds with a host of chronic medical issues, I also have a history of very normal births, fast, no gestational diabetes, no high blood pressure, adn even now, at 7 1/2 months pregnant, my bp is running 102/58, my glucose has never managed to get higher than 112 (1 hour after eating) and  no one has given me any convincing data that hospital birth would likely improve out outcome, and there's plenty of evidence it could hurt us if we did it unnecessarily. 

All that said, I NEVER hand my care over to anyone. Ever. That way lies malpractice and I've regretted it every time I've tried.