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

[Anonymous]

Anonymous wrote:

Anonymous wrote:I've read most of this thread, and I think it's interesting that no one has commented-- that OBs are, at times, absurdly conservative. And crying wolf means you don't listen when you need to. When doctors say things like VBACs are generally a bad idea (and many do say this, despite the evidence and guidance to the contrary) many people just stop listening b/c they know it's bunk. They loose trust in the medical community, which is so busy covering its liability that their credibility becomes shot. It's not the doctors faults, necessarily-- but the system is such that it's hard to tell whats true when a doctor says it and what's a doctor covering themselves.

Actually, this has been commented on multiple times...are we reading the same thread?

I've read this entire thread, and haven't seen this expressed so compactly or so well. (But then again, maybe all the pregnancy hormones have eaten my brain.)

[Anonymous]

Experience with midwife in context of a different system:
http://www.ahd.tudelft.nl/~jerry/jw2/Suzie/Birth_in_Holland.html

[Anonymous]

Anonymous wrote:Experience with midwife in context of a different system:
http://www.ahd.tudelft.nl/~jerry/jw2/Suzie/Birth_in_Holland.html

Yes, and the Netherlands has the highest perinatal mortality rate in western Europe. They are currently investigating their system to figure out what's wrong and why so many babies are dying.

[Anonymous]

Anonymous wrote:I've read most of this thread, and I think it's interesting that no one has commented-- that OBs are, at times, absurdly conservative. And crying wolf means you don't listen when you need to. When doctors say things like VBACs are generally a bad idea (and many do say this, despite the evidence and guidance to the contrary) many people just stop listening b/c they know it's bunk. They loose trust in the medical community, which is so busy covering its liability that their credibility becomes shot. It's not the doctors faults, necessarily-- but the system is such that it's hard to tell whats true when a doctor says it and what's a doctor covering themselves.

Yes, but why are OBs absurdly conservative? Because during the course of their 4 year residency and years of practice after that, they've seen thousands and thousands of births. While a few very busy homebirth midwives have seen several hundred births that have all been (supposedly) low risk, every OB has seen thousands of births ranging from natural and low risk to those in which every intervention available was needed to keep mom and baby safe. Yes, the majority of women and babies are fine, but for someone who trained for years to be able to deliver babies safely, losing even one baby or (very rarely) mother to a preventable cause is one too many.

Speaking more specifically about VBACs, a recent review found that a successful VBAC has a maternal morbidity rate (which includes uterine rupture plus other complications) of 3.1%, while an elective repeat CS has a maternal morbidity rate of 4%. Case closed? Well, look at the maternal morbidity rate for failed VBAC: 17%. If you add the successful and the failed VBACs, maternal morbidity is now 6.7%. About 75% of VBACs are successful, so there are many women out there who have had one or two and been fine. However, the OB has seen not just you, but hundreds of other women, many of whom have had bad or catastrophic outcomes. Of course most are going to be conservative, since they don't know if you're part of the 75% who will be successful or not, and all things being equal, they'd rather not preside over a disaster.

VBACs are making a comeback (under controlled conditions), and researchers are looking for ways to identify women who are more likely to have a successful VBAC so that the rates of failed VBACs will decrease. But blaming doctors for being conservative when they're the ones who have seen the most births and are held responsible for all outcomes (in a way that an unlicensed, uninsured midwife could never be) seems illogical. An unlicensed homebirth midwife can keep on practicing after losing several babies, and many have. But every single time there's a death or severe morbidity at a hospital, an OB's actions are reviewed by her peers, steps are taken to be sure it never happens again, and she has a good chance of being sued.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Experience with midwife in context of a different system:
http://www.ahd.tudelft.nl/~jerry/jw2/Suzie/Birth_in_Holland.html

Yes, and the Netherlands has the highest perinatal mortality rate in western Europe. They are currently investigating their system to figure out what's wrong and why so many babies are dying.

2009 CIA World Factbook, via Wikipedia (http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate):

Netherlands infant mortality rate (per 1,000 live births): 4.73
U.S. infant mortality rate (per 1,000 live births): 6.26

[Anonymous]

Anonymous wrote:2009 CIA World Factbook, via Wikipedia (http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate):

Netherlands infant mortality rate (per 1,000 live births): 4.73
U.S. infant mortality rate (per 1,000 live births): 6.26

Yes, but I said perinatal mortality, not infant mortality. Perinatal mortality includes all deaths from 28 weeks' gestation to 7 days after birth. Infant mortality includes all deaths from birth to 1 year of age, so it excludes stillbirths and includes deaths that happen months after birth. Perinatal mortality is an indicator of prenatal care and care during labor and delivery, while infant mortality is a measure of pediatric care.

According to the CDC, the perinatal mortality rate in the US has been hovering between 6.6-6.7/1000 live births for the past several years, while in the Netherlands, the perinatal mortality rate is ~10/1000 live births (the Peristat-II study from 2008 ).

But yes, I will agree that infant mortality in the US is way too high. I think it's related to disparate income levels and lack of access to good care for infants and children, but that's a completely different topic.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Experience with midwife in context of a different system:
http://www.ahd.tudelft.nl/~jerry/jw2/Suzie/Birth_in_Holland.html

Yes, and the Netherlands has the highest perinatal mortality rate in western Europe. They are currently investigating their system to figure out what's wrong and why so many babies are dying.

2009 CIA World Factbook, via Wikipedia (http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate):

Netherlands infant mortality rate (per 1,000 live births): 4.73
U.S. infant mortality rate (per 1,000 live births): 6.26

My high school student is not even allowed to use Wikipedia as a resource!

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I've read most of this thread, and I think it's interesting that no one has commented-- that OBs are, at times, absurdly conservative. And crying wolf means you don't listen when you need to. When doctors say things like VBACs are generally a bad idea (and many do say this, despite the evidence and guidance to the contrary) many people just stop listening b/c they know it's bunk. They loose trust in the medical community, which is so busy covering its liability that their credibility becomes shot. It's not the doctors faults, necessarily-- but the system is such that it's hard to tell whats true when a doctor says it and what's a doctor covering themselves.

Actually, this has been commented on multiple times...are we reading the same thread?

I've read this entire thread, and haven't seen this expressed so compactly or so well. (But then again, maybe all the pregnancy hormones have eaten my brain.)

The inference was made multiple times.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Experience with midwife in context of a different system:
http://www.ahd.tudelft.nl/~jerry/jw2/Suzie/Birth_in_Holland.html

Yes, and the Netherlands has the highest perinatal mortality rate in western Europe. They are currently investigating their system to figure out what's wrong and why so many babies are dying.

2009 CIA World Factbook, via Wikipedia (http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate):

Netherlands infant mortality rate (per 1,000 live births): 4.73
U.S. infant mortality rate (per 1,000 live births): 6.26

My high school student is not even allowed to use Wikipedia as a resource!

Special link for your high school student:
https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html?countryName=Netherlands&countryCode=nl®ionCode=eu&rank=191#nl

I assume CIA factbook is allowed?

[Anonymous]

Anonymous wrote:I assume CIA factbook is allowed?

Yup, but perinatal mortality still =/= infant mortality.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I've read most of this thread, and I think it's interesting that no one has commented-- that OBs are, at times, absurdly conservative. And crying wolf means you don't listen when you need to. When doctors say things like VBACs are generally a bad idea (and many do say this, despite the evidence and guidance to the contrary) many people just stop listening b/c they know it's bunk. They loose trust in the medical community, which is so busy covering its liability that their credibility becomes shot. It's not the doctors faults, necessarily-- but the system is such that it's hard to tell whats true when a doctor says it and what's a doctor covering themselves.

Yes, but why are OBs absurdly conservative? Because during the course of their 4 year residency and years of practice after that, they've seen thousands and thousands of births. While a few very busy homebirth midwives have seen several hundred births that have all been (supposedly) low risk, every OB has seen thousands of births ranging from natural and low risk to those in which every intervention available was needed to keep mom and baby safe. Yes, the majority of women and babies are fine, but for someone who trained for years to be able to deliver babies safely, losing even one baby or (very rarely) mother to a preventable cause is one too many.

Speaking more specifically about VBACs, a recent review found that a successful VBAC has a maternal morbidity rate (which includes uterine rupture plus other complications) of 3.1%, while an elective repeat CS has a maternal morbidity rate of 4%. Case closed? Well, look at the maternal morbidity rate for failed VBAC: 17%. If you add the successful and the failed VBACs, maternal morbidity is now 6.7%. About 75% of VBACs are successful, so there are many women out there who have had one or two and been fine. However, the OB has seen not just you, but hundreds of other women, many of whom have had bad or catastrophic outcomes. Of course most are going to be conservative, since they don't know if you're part of the 75% who will be successful or not, and all things being equal, they'd rather not preside over a disaster.

VBACs are making a comeback (under controlled conditions), and researchers are looking for ways to identify women who are more likely to have a successful VBAC so that the rates of failed VBACs will decrease. But blaming doctors for being conservative when they're the ones who have seen the most births and are held responsible for all outcomes (in a way that an unlicensed, uninsured midwife could never be) seems illogical. An unlicensed homebirth midwife can keep on practicing after losing several babies, and many have. But every single time there's a death or severe morbidity at a hospital, an OB's actions are reviewed by her peers, steps are taken to be sure it never happens again, and she has a good chance of being sued.

This was very well put and clearly written by someone who has experience working with doctors. Unlike the large majority of the homebirth community who only views modern obstetrics as the enemy and is okay to tailor the available research to fit their idealogies rather than what the real situation often is.

[Anonymous]

I'm sorry to be slow, but I stil can't figure out how to access the link for the lawsuit - the link referenced in this thread does not work. Is the suit in Alexandria district or circuit court?

[Anonymous]

Anonymous wrote:I'm sorry to be slow, but I stil can't figure out how to access the link for the lawsuit - the link referenced in this thread does not work. Is the suit in Alexandria district or circuit court?

It's not a lawsuit - it's a criminal case. The link only works in Internet Explorer.

[Anonymous]

Anonymous wrote:

Anonymous wrote:
IF it were true negligience on her part, then she should be found guilty and face jail time, though 30 years seems a bit harsh. But, the definition of negligience should be accurate, not just attending a high risk homebirth. If she gets jail time, should we not make doctors similarly criminal, if they have an elective c-section go wrong? Is not the doctot negligient in the same degree? He attended a birth, performed an unnecessary surgery because the patient wanted it. Will we assume the patient was not fully aware of the risks and trusted the doctor's willingness, interpreting that to mean the procedure was safe?

TammiK

The difference is with a licensed doctor that you have recourse -- lawsuit, medical board review, revoke license, prosecution, etc. There is already a system in place to deal with a doctor who is unlicensed or negligent. When you are dealing with an unlicensed care provider who has been hired by a person to provide an illegal service then the recourse isn't so clear. Considering the charges it looks like sort of threw everything at her thinking some of them would be dismissed or reduced to lesser charges. I do think that 30 years seems a bit harsh but that is probably what the charge carries rather than what she will actually get.

What I was saying was that the doctor would not be held criminally negligient unless he actually did something negligient. If I chose an elective c-section and died from surgical complications, my husband could not file a lawsuit unless the doctor was truly negligient. The fact that the doctor chose to do the surgery-one that carried risks and was unnecessary-would not be sufficient. He could not argue that I did not understand fully the risks. He could not charge the doctor with criminal negligience for doing an elective--unnecessary--surgery. He could not argue that his wife would still be alive if the doctor refused to do an elective surgery. If both midwife and doctor do something that carries higher risks than the alternative because the patient desires it, then if it's criminally negligient for one, it should be criminally negligient for the other. That's all I'm saying. It's a double standard. The midwife can be charged for simply practicing in a high risk situation, but the doctor can choose to do a higher risk surgery for no reason and not be charged.

TammiK

[Anonymous]

Anonymous wrote:What I was saying was that the doctor would not be held criminally negligient unless he actually did something negligient. If I chose an elective c-section and died from surgical complications, my husband could not file a lawsuit unless the doctor was truly negligient. The fact that the doctor chose to do the surgery-one that carried risks and was unnecessary-would not be sufficient. He could not argue that I did not understand fully the risks. He could not charge the doctor with criminal negligience for doing an elective--unnecessary--surgery. He could not argue that his wife would still be alive if the doctor refused to do an elective surgery. If both midwife and doctor do something that carries higher risks than the alternative because the patient desires it, then if it's criminally negligient for one, it should be criminally negligient for the other. That's all I'm saying. It's a double standard. The midwife can be charged for simply practicing in a high risk situation, but the doctor can choose to do a higher risk surgery for no reason and not be charged.

TammiK

At the moment it looks as if elective c-sections done before the woman is in labor result in slightly higher morbidities for mothers and slightly lower serious morbidities for babies. Spontaneous vaginal delivery has low maternal and neonatal morbidity, but assisted vaginal delivery and c-section after the mother has been in labor for hours are both associated with higher rates of morbidity for mom and baby. That means that for women who sail through their vaginal deliveries, they made a good choice. But for women who run into problems after laboring for many hours, they and their babies are now subject to much higher levels of risk than if they had had the c-section before labor started. But how do you tell these two groups of women apart? There are some ways to categorize women and pregnancies into high- and low-risk groups, but low-risk women can carry high-risk babies. That's one of the reasons that elective c-sections aren't prohibited: there's no way of knowing before labor starts who will be better off with the elective c-section and who will be better off attempting the vaginal delivery. In other words, the risk of elective c-section isn't measured against zero; it's measured against the (unknown) risk of a vaginal delivery that hasn't happened yet plus the ongoing risk of stillbirth (which increases quite a bit starting at ~36 weeks' gestation).

This is all pretty much beside the point, though. If I set up an operating room in my home to perform cardiac catheterizations on people, it really doesn't matter if my success rate is good or bad. I'm not allowed to perform medicine on people without a license, and it's in the state's best interest to keep people from perfoming medicine without a license, which is why it's against the law. Even if this midwife has maternal and neonatal morbidity and mortality rates that are better than those of the local OBs (which I very much doubt), she still can't perform medicine without a license, and the fact that she was has opened her up to a whole new world of liability.