Midwife charged in DC? Karen Carr, CPM...

[Anonymous]

Anonymous wrote:

I too find this thread fascinating. I would add that "liability issues" is a prettier way to say that "there may be brain damage or death of the child or serious injury or death to mother, and the doctor or someone else who has insurance may be found at fault as a result of inaction, malpractice, or oversight."

Not exactly. There is an important distinction between liability risk and outcome risks. Limiting liability risk does not always limit outcome risks for the patient. The c-section rate increase from liability drivers come from the "time" argument. For example, a trial of labor for VBAC, breech, or any pregnancy can be fine but if there is a bad outcome, the plaintiff can always argue that the provider did not choose to move in a c-section in time. This becomes a finding of fact for a jury who may be more swayed by the emotional loss of a baby. The plaintiff can pull out expert witnesses who will say they would have done it sooner. If there is any logistical delay of even 10 or 15 minutes in getting into the OR, the hospital can also be open to liability. The doctor may have made an appropriate time call but if he did not realize that the OR team was not available at that moment he and the hospital still bear liability for the outcome.

The reverse does not hold true for bad outcomes from a c-section. Complication risks involved in surgery are more accepted within the defined standard of care. If the mother or baby has a bad outcome, even death, from a c-section it is much more difficult for the plantiff to win. The plaintiff can not win just because the death occurred, even if the death occurred because of the c-section or an infection resulting from the surgery. The plaintiff would need to show gross neglience on the part of the doctor which is hard to do or show that hospital staff recklessly violated procedures which again is difficult to do. You might think that a situation where the doctor did not make a large enough incision and the baby died or the doctor cut something else would trigger gross neglience. It often does not unless there is a consistent pattern of prior incidents which the hospital was aware of and improvement was not made. You almost would need to provde that the doctor was intoxicated or something else extreme to win the case. Since a c-section falls with defined standard care for many situations, you can not prevail by arguing that you should not have had a c-section even if the bad outcome would not have occurred with a vaginal birth.

From a liability standpoint, doctors would be better off giving everyone a c-section even though they would experience more bad patient outcomes not less. Hospitals would be much better off giving everyone a c-section. It is expensive and logistically difficult to have an OR and OR team standing reading to have the baby out in several minutes. They would avoid this expense and liability risk of a logistical problem. The hospital also makes significantly more money from operations than it does from a mother giving birth naturally. I'm actually very impressed with the ob/gyns who do fight this trend on behald of their dedication to bette patient outcomes. We focus often focus on the ones who are part of the problem rather than the ones trying to not give in.

Excellent post.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I am with you PP - this is exactly the heart of the issue.

and to this poster:

But outside those scenarios lets not kid ourselves - when you got an epidural you risked your baby's health for your own comfort.

Epidurals are safe for the mother and for the baby. Why shouldn't a mother be able to seek out comfort for her pain? I was definitely able to feel my contractions and the position of the baby when I had an epidural. The sensations were still there absent the pain.

Thanks for willfully misunderstanding what I wrote. Sure epidurals are generally safe, just like riding in cars, elective c-sections and vaginal breech births are generally safe. But epidurals are not zero risk to the baby or to the mother (duh). Its fine to make the choice that pain relief is worth some small risk to mom and baby, but do not pretend that you are not making that choice. The fact is, in a normally progressing labor, a hospital birth without an epidural is safer in absolute terms than a hospital birth with an epidural. That is becase there is zero risk to the baby or the mom from NOT having an epidural in a normal vaginal delivery. Again occasionally they are medically indicated, but that is in a tiny percentage of cases. So any mom who claims that she would not tolerate any risk to the baby, but then gets an epidural, is just a giant hypocrite.

Are you a pain specialist? Can you tell us about the current literature that links pain control quite strongly with faster recovery times? How about the literature that shows that inadequate acute pain control can lead to chronic pain as well as overall dissatisfaction with the experience? There is not "zero risk" to the mother who avoids adequate pain control out of fear of harming her baby.

What I'm getting here is that the mother is expected to take a greater risk with her future health with respect to pain control during labor, but expected to take a lesser risk with her future health by avoiding CS. Does that sum it up?

[Anonymous]

Anonymous wrote:motions hearing today just ended
results
- plead child endangerment, plead performing invasive procedure.

sentence time served, community service (50 hours), don't provide midwifery service in VA, don't apply for license in VA, fines less then $10,000.

case closed

done!!!!!!!!!!!!

so does this mean there won't be a civil suit from the parents? or is that still a possibility? i would REALLY love to hear the mom's statement on what went down and why she made the choice to pursue a home birth in this situation. i'm assuming since this won't go to trial, we will never know.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I am with you PP - this is exactly the heart of the issue.

and to this poster:

But outside those scenarios lets not kid ourselves - when you got an epidural you risked your baby's health for your own comfort.

Epidurals are safe for the mother and for the baby. Why shouldn't a mother be able to seek out comfort for her pain? I was definitely able to feel my contractions and the position of the baby when I had an epidural. The sensations were still there absent the pain.

Thanks for willfully misunderstanding what I wrote. Sure epidurals are generally safe, just like riding in cars, elective c-sections and vaginal breech births are generally safe. But epidurals are not zero risk to the baby or to the mother (duh). Its fine to make the choice that pain relief is worth some small risk to mom and baby, but do not pretend that you are not making that choice. The fact is, in a normally progressing labor, a hospital birth without an epidural is safer in absolute terms than a hospital birth with an epidural. That is becase there is zero risk to the baby or the mom from NOT having an epidural in a normal vaginal delivery. Again occasionally they are medically indicated, but that is in a tiny percentage of cases. So any mom who claims that she would not tolerate any risk to the baby, but then gets an epidural, is just a giant hypocrite.

Are you a pain specialist? Can you tell us about the current literature that links pain control quite strongly with faster recovery times? How about the literature that shows that inadequate acute pain control can lead to chronic pain as well as overall dissatisfaction with the experience? There is not "zero risk" to the mother who avoids adequate pain control out of fear of harming her baby.

What I'm getting here is that the mother is expected to take a greater risk with her future health with respect to pain control during labor, but expected to take a lesser risk with her future health by avoiding CS. Does that sum it up?

Interesting points. But I have never heard anyone I know who had an epidural-free birth complain of chronic pain and I have heard several stories about people having recurring headaches and/or back pain from epidurals. Yes, I know, anecdotes are NOT data, but just sayin...

[Anonymous]

The fact is, in a normally progressing labor, a hospital birth without an epidural is safer in absolute terms than a hospital birth with an epidural. That is becase there is zero risk to the baby or the mom from NOT having an epidural in a normal vaginal delivery.

is this science, or your opinion?

[Anonymous]

It's safe to say that MDs kill and seriously injure a lot more people than midwives do.

I think it's safe to say that you have no clue whatsoever.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I am with you PP - this is exactly the heart of the issue.

and to this poster:

But outside those scenarios lets not kid ourselves - when you got an epidural you risked your baby's health for your own comfort.

Epidurals are safe for the mother and for the baby. Why shouldn't a mother be able to seek out comfort for her pain? I was definitely able to feel my contractions and the position of the baby when I had an epidural. The sensations were still there absent the pain.

Thanks for willfully misunderstanding what I wrote. Sure epidurals are generally safe, just like riding in cars, elective c-sections and vaginal breech births are generally safe. But epidurals are not zero risk to the baby or to the mother (duh). Its fine to make the choice that pain relief is worth some small risk to mom and baby, but do not pretend that you are not making that choice. The fact is, in a normally progressing labor, a hospital birth without an epidural is safer in absolute terms than a hospital birth with an epidural. That is becase there is zero risk to the baby or the mom from NOT having an epidural in a normal vaginal delivery. Again occasionally they are medically indicated, but that is in a tiny percentage of cases. So any mom who claims that she would not tolerate any risk to the baby, but then gets an epidural, is just a giant hypocrite.

Are you a pain specialist? Can you tell us about the current literature that links pain control quite strongly with faster recovery times? How about the literature that shows that inadequate acute pain control can lead to chronic pain as well as overall dissatisfaction with the experience? There is not "zero risk" to the mother who avoids adequate pain control out of fear of harming her baby.

What I'm getting here is that the mother is expected to take a greater risk with her future health with respect to pain control during labor, but expected to take a lesser risk with her future health by avoiding CS. Does that sum it up?

Interesting points. But I have never heard anyone I know who had an epidural-free birth complain of chronic pain and I have heard several stories about people having recurring headaches and/or back pain from epidurals. Yes, I know, anecdotes are NOT data, but just sayin...

I'm not the pp you are responding to, but I think you are confusing epidurals with spinals....

[Anonymous]

Anonymous wrote:

Anonymous wrote:
I do actually agree with this one statement and I am not the PP who called you crazy by the way. I think you are frustrating but not crazy. I am the PP you are responding to here. I do not think all doctors suck or that all medical training is subpar. But sometimes that is the case. I hope we all know that. My point was (and I think you might be deliberately misreading all of my comments) that women are capable of researching their practitioners and making their own choices. That's it. I have never specifically defended the CPM credential. I have even said that I would not hire one myself and at my age and with my specific risks, if I were to give birth again, I would do it in a hospital with an OB/GYN.

I'm sorry I'm being frustrating- it really isn't my intention. I guess the point I'm trying to get at is that it's not really fair to say that it's a woman's responsibility to research her practitioner and make a choice based off of that when you're talking about CPMs.
If you have several OBs and/or CNMs that have been recommended to you by friends and family, you know that they've all received similar training and hopefully are all competent to do what they're supposed to do. Your decision is mostly about personal compatibility, not the skills that that CNM/OB does or doesn't have. For example, you're probably more worried about the CNM's rate of using certain interventions (epidurals, CS, induction) and their personal attitudes about VBAC or NCB. Unless you've heard a horror story somewhere, your assessment really isn't about the CNM/OB's credentials; it's about how a typical birth by one of their typical patients lines up with how you envision your birth going.

If CPMs are selling themselves as better/safer than hospital birth, and your CPM provides you with the names of a few happy clients, what does that really tell you? According to her credential alone, she's attended many, many fewer births than a CNM or OB. Is it then your fault when your CPM doesn't do appropriate neonatal resuscitation when your baby doesn't start breathing immediately, since yours is the first hypoxic baby she's encountered? Or what if she's attended over 1000 births, but when you ask about how many babies have died she says that there have been a few, but all were due to birth defects. Is that true? How do you know? What research can a woman really do to ascertain that her particular CPM is appropriately trained and prepared, since the CPM credential all by itself really isn't that reassuring?

Agree totally with second quote !!! To the first person quoted: It IS easy to misread your comments the way you write them! Medical training is so highly regimented, structured, examined, and so long - it's not subpar, rest assured, not in this country. If that's not how you truly feel I'm relieved to hear that!

[Anonymous]

Anonymous wrote:

It's safe to say that MDs kill and seriously injure a lot more people than midwives do.

I think it's safe to say that you have no clue whatsoever.

Oh please. There are more doctors, in the world, than midwives. That was the point this poster was making.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:
I do actually agree with this one statement and I am not the PP who called you crazy by the way. I think you are frustrating but not crazy. I am the PP you are responding to here. I do not think all doctors suck or that all medical training is subpar. But sometimes that is the case. I hope we all know that. My point was (and I think you might be deliberately misreading all of my comments) that women are capable of researching their practitioners and making their own choices. That's it. I have never specifically defended the CPM credential. I have even said that I would not hire one myself and at my age and with my specific risks, if I were to give birth again, I would do it in a hospital with an OB/GYN.

I'm sorry I'm being frustrating- it really isn't my intention. I guess the point I'm trying to get at is that it's not really fair to say that it's a woman's responsibility to research her practitioner and make a choice based off of that when you're talking about CPMs.
If you have several OBs and/or CNMs that have been recommended to you by friends and family, you know that they've all received similar training and hopefully are all competent to do what they're supposed to do. Your decision is mostly about personal compatibility, not the skills that that CNM/OB does or doesn't have. For example, you're probably more worried about the CNM's rate of using certain interventions (epidurals, CS, induction) and their personal attitudes about VBAC or NCB. Unless you've heard a horror story somewhere, your assessment really isn't about the CNM/OB's credentials; it's about how a typical birth by one of their typical patients lines up with how you envision your birth going.

If CPMs are selling themselves as better/safer than hospital birth, and your CPM provides you with the names of a few happy clients, what does that really tell you? According to her credential alone, she's attended many, many fewer births than a CNM or OB. Is it then your fault when your CPM doesn't do appropriate neonatal resuscitation when your baby doesn't start breathing immediately, since yours is the first hypoxic baby she's encountered? Or what if she's attended over 1000 births, but when you ask about how many babies have died she says that there have been a few, but all were due to birth defects. Is that true? How do you know? What research can a woman really do to ascertain that her particular CPM is appropriately trained and prepared, since the CPM credential all by itself really isn't that reassuring?

Agree totally with second quote !!! To the first person quoted: It IS easy to misread your comments the way you write them! Medical training is so highly regimented, structured, examined, and so long - it's not subpar, rest assured, not in this country. If that's not how you truly feel I'm relieved to hear that!

I understand the point that you're trying to make, but seriously? There is quite a lot of variety in the quality of training at different medical schools within this country. If they are all the same, why are some schools more sought after than others? Why are there rankings at all? And just like any other profession, there are good, dedicated doctors and there are doctors who are less good.

I understand that people have concerns about the training level of CPMs. I have concerns about it myself. But let's not sit here and pretend that all med schools, residencies and doctors are created equal. They are not and you need go no further than this forum to find people looking for "a good OB" in the area to see that.

[Anonymous]

Anonymous wrote:I understand the point that you're trying to make, but seriously? There is quite a lot of variety in the quality of training at different medical schools within this country. If they are all the same, why are some schools more sought after than others? Why are there rankings at all? And just like any other profession, there are good, dedicated doctors and there are doctors who are less good.

I understand that people have concerns about the training level of CPMs. I have concerns about it myself. But let's not sit here and pretend that all med schools, residencies and doctors are created equal. They are not and you need go no further than this forum to find people looking for "a good OB" in the area to see that.

No, all med schools are not created equal, but they're much more equal than any other graduate training you could find. All MDs have to pass national knowledge and skills tests before graduating, and no medical school in the US is "known" for having students not pass. There are several reasons why some medical schools are more famous than others, but student education really isn't that high on the list.

The differences you are attributing to medical schools are probably due to different residency programs (with different patient populations), as well as personality differences. For example, in rural New Hampshire my husband couldn't get his giardia infection diagnosed in a timely manner, most likely because those doctors never see giardia. In Texas, however, it's a quick and easy diagnosis. That doesn't mean that doctors in NH are incompetent or poorly trained- it means that in their residency training, they never see anyone with giardia.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I understand the point that you're trying to make, but seriously? There is quite a lot of variety in the quality of training at different medical schools within this country. If they are all the same, why are some schools more sought after than others? Why are there rankings at all? And just like any other profession, there are good, dedicated doctors and there are doctors who are less good.

I understand that people have concerns about the training level of CPMs. I have concerns about it myself. But let's not sit here and pretend that all med schools, residencies and doctors are created equal. They are not and you need go no further than this forum to find people looking for "a good OB" in the area to see that.

No, all med schools are not created equal, but they're much more equal than any other graduate training you could find. All MDs have to pass national knowledge and skills tests before graduating, and no medical school in the US is "known" for having students not pass. There are several reasons why some medical schools are more famous than others, but student education really isn't that high on the list.

The differences you are attributing to medical schools are probably due to different residency programs (with different patient populations), as well as personality differences. For example, in rural New Hampshire my husband couldn't get his giardia infection diagnosed in a timely manner, most likely because those doctors never see giardia. In Texas, however, it's a quick and easy diagnosis. That doesn't mean that doctors in NH are incompetent or poorly trained- it means that in their residency training, they never see anyone with giardia.

Fair enough. But your point that there are some people who are more trained on one particular kind of medical issue than other issues is actually relevant to this discussion as well. If I wanted or needed a c section, I wouldn't want anyone other than an experienced obstetrician performing it. But if what I wanted was a non-surgical delivery, I would personally prefer to have a provider who is NOT a surgeon and who is more trained in unmedicated nonsurgical birth to assist with that birth.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I understand the point that you're trying to make, but seriously? There is quite a lot of variety in the quality of training at different medical schools within this country. If they are all the same, why are some schools more sought after than others? Why are there rankings at all? And just like any other profession, there are good, dedicated doctors and there are doctors who are less good.

I understand that people have concerns about the training level of CPMs. I have concerns about it myself. But let's not sit here and pretend that all med schools, residencies and doctors are created equal. They are not and you need go no further than this forum to find people looking for "a good OB" in the area to see that.

No, all med schools are not created equal, but they're much more equal than any other graduate training you could find. All MDs have to pass national knowledge and skills tests before graduating, and no medical school in the US is "known" for having students not pass. There are several reasons why some medical schools are more famous than others, but student education really isn't that high on the list.

The differences you are attributing to medical schools are probably due to different residency programs (with different patient populations), as well as personality differences. For example, in rural New Hampshire my husband couldn't get his giardia infection diagnosed in a timely manner, most likely because those doctors never see giardia. In Texas, however, it's a quick and easy diagnosis. That doesn't mean that doctors in NH are incompetent or poorly trained- it means that in their residency training, they never see anyone with giardia.

Fair enough. But your point that there are some people who are more trained on one particular kind of medical issue than other issues is actually relevant to this discussion as well. If I wanted or needed a c section, I wouldn't want anyone other than an experienced obstetrician performing it. But if what I wanted was a non-surgical delivery, I would personally prefer to have a provider who is NOT a surgeon and who is more trained in unmedicated nonsurgical birth to assist with that birth.

I see this a lot, and it really confuses me. Do you know any OB/GYNs personally? Why do you think that they have less experience with unmedicated nonsurgical birth than a CNM? Have you looked at OB/GYN residency requirements? OBs have attended tons and tons of births, and since CS accounts for ~1/3 of all births (and a much lower percentage of first-time deliveries), of course they have extensive experience with unmedicated nonsurgical birth. All things being equal, OBs prefer uncomplicated vaginal deliveries. They're easier, the mothers tend to go home quicker, and the OB gets a comparable amount of money for less work. Of course, if the OB specializes in high risk pregnancies then she probably doesn't see as many "uncomplicated" deliveries, but I don't think you're referring to that population.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:
I do actually agree with this one statement and I am not the PP who called you crazy by the way.

If you have several OBs and/or CNMs that have been recommended to you by friends and family, you know that they've all received similar training and hopefully are all competent to do what they're supposed to do. Your decision is mostly about personal compatibility, not the skills that that CNM/OB does or doesn't have. For example, you're probably more worried about the CNM's rate of using certain interventions (epidurals, CS, induction) and their personal attitudes about VBAC or NCB. Unless you've heard a horror story somewhere, your assessment really isn't about the CNM/OB's credentials; it's about how a typical birth by one of their typical patients lines up with how you envision your birth going.
If CPMs are selling themselves as better/safer than hospital birth, and your CPM provides you with the names of a few happy clients, what does that really tell you? According to her credential alone, she's attended many, many fewer births than a CNM or OB. Is it then your fault when your CPM doesn't do appropriate neonatal resuscitation when your baby doesn't start breathing immediately, since yours is the first hypoxic baby she's encountered? Or what if she's attended over 1000 births, but when you ask about how many babies have died she says that there have been a few, but all were due to birth defects. Is that true? How do you know? What research can a woman really do to ascertain that her particular CPM is appropriately trained and prepared, since the CPM credential all by itself really isn't that reassuring?

Agree totally with second quote !!! To the first person quoted: It IS easy to misread your comments the way you write them! Medical training is so highly regimented, structured, examined, and so long - it's not subpar, rest assured, not in this country. If that's not how you truly feel I'm relieved to hear that!

I understand the point that you're trying to make, but seriously? There is quite a lot of variety in the quality of training at different medical schools within this country. If they are all the same, why are some schools more sought after than others? Why are there rankings at all? And just like any other profession, there are good, dedicated doctors and there are doctors who are less good. I understand that people have concerns about the training level of CPMs. I have concerns about it myself. But let's not sit here and pretend that all med schools, residencies and doctors are created equal. They are not and you need go no further than this forum to find people looking for "a good OB" in the area to see that.

Actually there is truly not that much difference (within the US). The main and most important part of your training will also be residency - which again is highly regulated to provide a similiar experience across the country. Rankings take many things into account: A famous doctor practicing there, excellent research publications (a big one for rankings), ...
I do agree with your points regarding dedication, personality, and so on - that is where people differ of course. Oftentimes your best practioners are the ones that know their limits and know when to ask for another opinion, no matter how advanced and experienced themselves, the best are the ones who do care about their patients, and it shows.
Honestly, when we are looking 'for a good pediatrician' etc on the board, we are looking for likable personalities, good 'bedside manner', empathy, thoroughness... that will make the difference between two people having gone through the same kind of training.

[Anonymous]

Anonymous wrote:Fair enough. But your point that there are some people who are more trained on one particular kind of medical issue than other issues is actually relevant to this discussion as well. If I wanted or needed a c section, I wouldn't want anyone other than an experienced obstetrician performing it. But if what I wanted was a non-surgical delivery, I would personally prefer to have a provider who is NOT a surgeon and who is more trained in unmedicated nonsurgical birth to assist with that birth.

I guess this goes back to the point of picking a provider based on her "birth philosophy" and doing your research about your provider. Fair enough, but I have to admit that I go with the provider that can do more every time.