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

[Anonymous]

Anonymous wrote:

Anonymous wrote:

I don't know enough about breech babies myself, but I can't help to think that there is probably a legitimate reason for why more OBs don't deliver breech babies vaginally. I'm no c-section advocate, and I hate how they are resorted to in situations where labor has simply stalled, etc., but I just can't believe that almost the entire medical establishment (which says breech baby = c-section) is somehow wrong...

It's absolutely driven by the insurance companies. Doctors routinely deliver breech babies in Europe.

Not in the U.K. they don't (where insurance companies aren't in business).

I delivered my second there and have first hand knowledge of the childbirth experience in the U.K. Not sure why everybody assumes insurance companies are always to blame, but really - not sure that is the case here.

[Anonymous]

here's an interesting article on home birth vs. hospital birth, evolution of the midwivery model of care to the OB model in the US, and the safety and cost differential between different birth options:

http://colorlines.com/archives/2011/04/childbirth_care_and_access_to_midwives.html

[Anonymous]

The New Yorker article was very interesting - thank you for posting. I'm very pro-natural birth and am concerned about the implications of all these c-sections and of the way birth is managed, but the author puts the debate in an interesting light in regard to c-section being reliable in many situations so that OBs don't need to be experts in a variety of methods.

The example they use in the article though - her baby was coming out sideways and her labor kept stalling because of it. She got an epidural part way through and then eventually had a c-section. I had a similar issue with my first (a homebirth). Long labor, baby was poorly positioned. Fortunately I had an expert doula and midwife with me who had all sorts of ideas. The one that worked was walking stairs. I walked all the way up my building's stairs and back down, was finally in transition as soon as I got back to our apartment and baby came out easily 20 minutes later. But it's that expertise and willingness to try other things (a lot of which you can't do if you are stuck on your back bc of an epidural or monitoring) that is lost as we demonize midwives and lose that knowledge.

[Anonymous]

Anonymous wrote:

I agree there should be more of the midwife model for those who want it. Not everyone wants it. Some women choose c-section for convenience reasons--that is their right. For example, there used to be a poster on these forums who elected to have c-sections so that her babies would have perfectly rounded heads. I don't agree with that, but again, her choice.

I wonder, then, if something went wrong with her elective cesarean birth and the baby died, would that mother sue and would the state would bring criminal charges against her doctor? Because all medical organizations warn against doing this, and go so far as to hint that that may be malpractice (First, do no harm, etc.) Because after all, the woman whose baby died with Karen Carr CHOSE a homebirth for her breech and the stats and organizations say that is dangerous too.

[Anonymous]

Very interesting thread with some extremely thoughtful posts.

I'm a nurse practitioner--to clear up the giving medication at home question, CNMs can, CPMs can't. Certified nurse midwives are a type of nurse practitioner; they are eligible to have DEA licenses and prescribing privileges. CPMs will never be allowed to carry medications--they don't have the education to make them eligible for prescriptive abilities. Also, oxygen is considered to be a "medication", so it falls under that umbrella.

With respect to breech births, it is very much a malpractice insurance issue where hospital based providers (OBs and CNMs) are concerned. The hospital typically pays malpractice insurance for its providers. For any procedure that is deemed too risky (either based on research data or based on in-house outcomes/lawsuits/payouts to families), the hospital can refuse to cover it because of the increased cost of the malpractice insurance. In turn, residency programs are not teaching the skills needed for breech birth (beyond the basics), as they most likely won't be put to regular use.

Also, I have to comment on the PPs discussion of "the woman's right to choose where to give birth." Totally, agree. But the OB midwife also has the right to choose his or her patients. If they do not feel safe and comfortable, they have the right to refer the patient elsewhere. There are some situations that just aren't safe for home birth in the eyes of the provider, no matter what the preference of the parents.

[Anonymous]

I can't help but wonder how much her not being licensed in VA is playing into these charges. Are they trying to make an example of her? CPMs lobbied the state very hard to get a licensing process in place to allow them to legally attend homebirths - prior to that they could be arrested for just attending a homebirth.

I am certain there have been other cases of homebirth related deaths in VA in recent years. It's hard to determine as they aren't separately reported as far as I can tell. But I haven't really heard anything (and can't find any stories) of other midwives in VA being charged for a baby's death. At least not since VA started licensing CPMs and allowing them to legally deliver in 2005.

[Anonymous]

The World Health Organization recommends a MAXIMUM c-sec rate of 15 percent for EVERYONE total- high risk, low risk, the whole world. (Althabe and Belizan 2006).

My understanding is that this is false -- the WHO has withdrawn the 15 percent rate recommendation as it was basically pulled out of their ass.

[Anonymous]

"Totally, agree. But the OB midwife also has the right to choose his or her patients. If they do not feel safe and comfortable, they have the right to refer the patient elsewhere. There are some situations that just aren't safe for home birth in the eyes of the provider, no matter what the preference of the parents."

But what are the factors that makes a provider decide that something is outside their scope of practice or comfort level?

Ideally, it should be a frank and ethical appraisal of their own limitations and abilities versus the risks of harm to the mother and baby.

However, in the hospital malpractice concerns as well as licensure risks also act as a counterpressure for conservative management. What reins in the illegally practicing midwife? Most lawyers won't sue her on a typical judgment sharing basis because she won't have deep enough pockets to make it worthwhile, she is practicing illegally anyway (so no licensure pressure can be brought to bear) and we have seen in this case as in others the "homebirth community" will side with midwives over injured parents and babies.

So really -- the only place where protection from illegally/unethically practicing midwives can be sought is in the criminal law system.

[Anonymous]

Anonymous wrote:The World Health Organization recommends a MAXIMUM c-sec rate of 15 percent for EVERYONE total- high risk, low risk, the whole world. (Althabe and Belizan 2006).

My understanding is that this is false -- the WHO has withdrawn the 15 percent rate recommendation as it was basically pulled out of their ass.

I had to LOL here.

[Anonymous]

I have been following this thread and at first didn't want to post a response or comment but felt that there is another issue that is being over looked by the people citing "other countries". You have to compare the quality of life of those women in said countries. One argument could be that they tend to do more physical work with their bodies than most of us on the East Coast do. They walk, clean their own homes and at times work with their husbands. My grandparents had a farm and grandma was working with him the day she gave birth to #5 (I think she had a total of 8 children) in the middle of the field (other women helped her). However, the very next day, she was back on the farm but took breaks to breastfeed. I know that there are some women here who might be capable of doing that but let's not assume that every woman can.

There is also the issue of a woman's anatomy. While some prefer the "boyish hips" you have to realize that there is a reason your body produces hormones to relax the joints and a lot of times its the woman with the wide hips/pelvic bones who may have an easier vaginal birth than the one with narrow hips/pelvic bones.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

I agree there should be more of the midwife model for those who want it. Not everyone wants it. Some women choose c-section for convenience reasons--that is their right. For example, there used to be a poster on these forums who elected to have c-sections so that her babies would have perfectly rounded heads. I don't agree with that, but again, her choice.

I wonder, then, if something went wrong with her elective cesarean birth and the baby died, would that mother sue and would the state would bring criminal charges against her doctor? Because all medical organizations warn against doing this, and go so far as to hint that that may be malpractice (First, do no harm, etc.) Because after all, the woman whose baby died with Karen Carr CHOSE a homebirth for her breech and the stats and organizations say that is dangerous too.

I agree, but I think there will always be some subjectivity to these decisions. For example, there could be a concern about cephalopelvic disproportion. If the mom wanted a c-section anyway for personal reasons, her doctor might go along with this because of the possible risks of vaginal delivery with CPD. A c-section might be planned based on this concern without even trying labor first to see if any progress could be made. The diagnosis would state "c-section for cephalopelvic disproportion". Therefore medically acceptable.

[Anonymous]

Anonymous wrote:Which she/he said should be NO MORE than 15 percent. Thus 15 percent or more of those c-sections at these university and large hospitals are unnecessary.

No, because some (many?) women have elective/convenience c-sections. However you feel about that decision, it's inappropriate to include them in those statistics. Of course, I have no idea how many occur.

[Anonymous]

I think I this earlier, but just because it was mentioned by the CNM above. I had a homebirth with a CPM and she had oxygen, pitocin and an IV. So maybe they're not allowed to have them, but they frequently do.

[Anonymous]

10:48 here, answering 10:59:

But what are the factors that makes a provider decide that something is outside their scope of practice or comfort level?

Ideally, it should be a frank and ethical appraisal of their own limitations and abilities versus the risks of harm to the mother and baby.

I have no idea, but this is where the real problem lies. Was there unusual pressure from the family? Inappropriate assessment of the mom/baby/labor? Inflated sense of ability on behalf of the midwife? Some combination?

Something happened here that resulted in poor judgement, which in turn resulted in a poor outcome. Terribly sad for all involved.

[Anonymous]

Anonymous wrote:10:48 here, answering 10:59:

But what are the factors that makes a provider decide that something is outside their scope of practice or comfort level?

Ideally, it should be a frank and ethical appraisal of their own limitations and abilities versus the risks of harm to the mother and baby.

I have no idea, but this is where the real problem lies. Was there unusual pressure from the family? Inappropriate assessment of the mom/baby/labor? Inflated sense of ability on behalf of the midwife? Some combination?

Something happened here that resulted in poor judgement, which in turn resulted in a poor outcome. Terribly sad for all involved.

At first, I was inclined to agree with the bolded statement above. BUT, we don't know what really happened. And we definitely don't know that they baby wouldn't have died in the hospital. Breech births have higher risks in any situation, and I'm not familiar enough with the facts in this case to say that anyone did anything to CAUSE the baby to die. Sometimes, babies die. It's a horrible reality, and if I were these parents I'd want someone to blame too. The question is whether it really was someone else's fault or not. Then again, this is why I personally wouldn't attempt an at home breech delivery...I don't know enough about the risks involved to make the call and I'd second guess my decision every second for the rest of my life if my baby died. Plus, I'm not sure there's support for the conlcusion that home births for breech babies have BETTER outcomes (for baby) than hospital breech births (vag or c). If anything, it seems inconclusive either way.