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

[Anonymous]

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

The Netherland system has pretty much been debunked (as in homebirths are safer than hospital births). Infant mortality is one thing, perinatal mortality is another. When you see a site like that they immediately jump to infant mortality which is not comparable to perinatal mortality.

[Anonymous]

Anonymous wrote:

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

You are comparing apples and oranges. A licensed doctor practicing in a hospital setting is not comparable to a midwife, regardless of who says she is qualified, who chooses to go unlicensed and accept a fee for service. For example if someone asks their friend to help them deliver a baby at home and the baby dies prosecutors are not going to prosecute the friend. But this woman is in the business of delivering babies, without a license, and then accepting a fee for the service.

[Anonymous]

Karen attended my son's birth. I just want to clarify some things. She is hands off, but she is very intuitive. She does not hesitate to transfer to the hospital setting if she feels that is necessary. She helped me plan for a hospital transfer should things come to that, even suggesting the hospital she thought would be best. She is not dogmatic about home birth at all costs. In my situation, things went smoothly, but I was comforted by knowing she had me and the baby's best interest at heart, not just a unyielding commitment to home birth.

[Anonymous]

You what drives me crazy all the time when this comes up? There's a middle road that nobody seems willing or able to get to. Hospitals could create natural birth friendly environments within their walls -- midwives could practice freely there, women would be permitted to eat and move and walk and have whatever visitors they wanted, play music they wanted, turn lights down or off, get in the tub or shower, not be subjected to mandatory procedures like frequent routine cervical checks or nonstop fetal monitoring, etc etc etc. Midwives could be valued and trusted members of the hospital network, so that women could give birth in hospitals in truly hospitable environments (if that's what they choose), AND SO THAT IF ANYTHING SERIOUS *DOES* GO WRONG, THEY COULD TRANSFER CARE IMMEDIATELY.

I had two wonderful natural births at DC area birth centers, and all along, I thought how frustrating it was that so many people are so stubborn about being on one end of the other of the spectrum that this middle ground seems basically impossible.

[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

The Netherland system has pretty much been debunked (as in homebirths are safer than hospital births). Infant mortality is one thing, perinatal mortality is another. When you see a site like that they immediately jump to infant mortality which is not comparable to perinatal mortality.

Does infant mortality then refer only to full-term babies (37 weeks)? If so, I can't understand why home birth is a problem if the place where the Netherlands has a higher fetal death rate is between 28 and 37 weeks--why not simply change procedures for prenatal/labor care during that period, and leave practices for 37+ weeks the same?

[Anonymous]

Anonymous wrote:Does infant mortality then refer only to full-term babies (37 weeks)? If so, I can't understand why home birth is a problem if the place where the Netherlands has a higher fetal death rate is between 28 and 37 weeks--why not simply change procedures for prenatal/labor care during that period, and leave practices for 37+ weeks the same?

I'm worried that my question isn't clear--and also that it doesn't reflect the spirit in which I'm asking, which is genuine curiosity and not a desire to win an argument about birth practices in a place where I'll never be pregnant. Here's what I understand:

1. The Netherlands has a higher perinatal mortality rate than the United States. (Out of curiosity, by what #s/%s? Unlike some high school teachers, I accept answers from Wikipedia.) This refers to deaths of babies after 28 weeks gestation.
2. However, the Netherlands has a lower infant mortality rate.

When I look at these facts, it looks to my eyes as though the problem is what the Dutch system is doing between 28 weeks and some later point (which I guessed was 37 weeks gestation, but don't know--I'm sure someone will jump in to precisely define infant mortality). So are problems with the Dutch model relevant to the homebirth of full-term infants? If so, why?

[Anonymous]

Anonymous wrote:Does infant mortality then refer only to full-term babies (37 weeks)? If so, I can't understand why home birth is a problem if the place where the Netherlands has a higher fetal death rate is between 28 and 37 weeks--why not simply change procedures for prenatal/labor care during that period, and leave practices for 37+ weeks the same?

No, infant mortality refers only to babies that are not stillbirths, so babies that die during labor aren't counted among the live births. If a lot of babies die during delivery, infant mortality can still be low, but perinatal mortality will be higher to reflect those stillbirths.

[Anonymous]

Because the Dutch system is one of the few that is midwife led -- low risk women are presumed to see midwives, and only women who are determined to be high-risk by midwives get to see OBs.

What I think this issue shows is that a number of women who appear to be low risk on the surface are actually high risk and that the system for working out risk needs to be more effective. Or, perhaps, the training of Dutch midwives (which is light years beyond that of CPMs like Karen Carr) needs to be improved.

[Anonymous]

Anonymous wrote:Because the Dutch system is one of the few that is midwife led -- low risk women are presumed to see midwives, and only women who are determined to be high-risk by midwives get to see OBs.

What I think this issue shows is that a number of women who appear to be low risk on the surface are actually high risk and that the system for working out risk needs to be more effective. Or, perhaps, the training of Dutch midwives (which is light years beyond that of CPMs like Karen Carr) needs to be improved.

Thanks, this makes sense. Regarding midwifery in the DC area, I'm currently in my second pregnancy under the care of midwives. Both two practices I've been seen by (BirthCare and DC Family Health & Birth Center) have been very strict about risk factors and don't hesitate to drop clients they define as high-risk (as BirthCare apparently did with the mom who wound up working with Karen Carr, and as FH&BC is doing with me by requiring that for this pregnancy I deliver in hospital, albeit attended by a midwife from the practice).

[Anonymous]

Anonymous wrote:Because the Dutch system is one of the few that is midwife led -- low risk women are presumed to see midwives, and only women who are determined to be high-risk by midwives get to see OBs.

What I think this issue shows is that a number of women who appear to be low risk on the surface are actually high risk and that the system for working out risk needs to be more effective. Or, perhaps, the training of Dutch midwives (which is light years beyond that of CPMs like Karen Carr) needs to be improved.

You sort-of hit the nail on the head here in that we (as a society) are becoming less and less healthy. We are more obese, with higher rates of heart disease, high blood pressure and diabetes than decades before...all of which effects the status of mom and baby during pregnancy. Many women have written to say that they have found their way into Karen's care after no one else wanted them or refused to allow them to birth their way, for safety reasons or otherwise. There are stories on this thread (and other places) talking about how Karen agreed to be their midwife at 38+ weeks pregnancy. She truly would not abandon any woman, which is a positive thing. However, most practicies will not accept patients after a certain week in pregnancy because it's just too close to delivery and they accept the entire liability of that woman's birth outcome without knowing much about her health status. That being said...some women are so desperate for a vaginal birth they may be willing to lie or fudge their medical history a bit, making themselves look healthier to get the outcome they want. This only hurts the woman since her provider cannot adequately assess the risk s/he has taken. In the case of a breech delivery of a primip well that's just risky period. It's one thing is mom has had a few vaginal deliveries under her belt, but when she's never been pregnant (or birthed a baby vaginally before) it's tough to say how easy her deliveries will be.

I do think 30 years in jail is ridiculously high though. Mom and dad assumed some risk when choosing to homebirth and had an obligaiton to think things through. Criminals often get much less time for rape and murder in our country, as an fyi.

[Anonymous]

Anonymous wrote:I'm worried that my question isn't clear--and also that it doesn't reflect the spirit in which I'm asking, which is genuine curiosity and not a desire to win an argument about birth practices in a place where I'll never be pregnant. Here's what I understand:

1. The Netherlands has a higher perinatal mortality rate than the United States. (Out of curiosity, by what #s/%s? Unlike some high school teachers, I accept answers from Wikipedia.) This refers to deaths of babies after 28 weeks gestation.
2. However, the Netherlands has a lower infant mortality rate.

When I look at these facts, it looks to my eyes as though the problem is what the Dutch system is doing between 28 weeks and some later point (which I guessed was 37 weeks gestation, but don't know--I'm sure someone will jump in to precisely define infant mortality). So are problems with the Dutch model relevant to the homebirth of full-term infants? If so, why?

According to the CDC, the perinatal mortality rate in the US has been ~6.6-6.7/1000 live births for the past several years, and the rate in the Netherlands is ~10/1000 live births (the Peristat-II study from 2008 ). This number reflects the number of babies that die between 28 weeks' gestation and 7 days after birth, so this number includes babies that never drew a breath (ie, they died before they were born), as well as those who die immediately after birth. Infant mortality only includes babies that are born alive and then die before one year of age, so stillbirths don't get counted there.

If a baby is born at 29 weeks' gestation and lives for 5 days before dying, this baby would be counted under both perinatal mortality and infant mortality. If this baby had died before being born (ie, was stillborn), she would have been counted among perinatal mortality but not infant mortality. If a mother goes into labor at 41 weeks but the baby has a nuchal cord and dies before being born, that baby would also be counted among perinatal mortality but not infant mortality. This last case is the type of case that the Dutch seem to be having too many of- cases in which the baby makes it to term but then for some reason isn't born alive. This is why a high perinatal mortality calls into question the way in which low-risk mothers are being identified for homebirth- in other countries (with different systems), more full-term babies are being born alive, but for some reason many are dying around the time of delivery in the Netherlands.

This is why perinatal mortality rates are a better measure for prenatal care and care during labor and delivery, while infant mortality is a better measure of pediatric care, and more generally, quality and access to medical care and socioeconomic conditions. A baby that makes it to 39 weeks' gestation before dying in utero is counted differently from a baby who dies of an infection at 9 months. The US is better at saving the baby at 39 weeks' gestation, but the Dutch are better at preventing the death by infection at 9 months.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

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%.

Are you saying that 4% of women that get a repeat csection die? Percent of what?

[Anonymous]

Anonymous wrote:

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%.

Are you saying that 4% of women that get a repeat csection die? Percent of what?

[Anonymous]

Anonymous wrote:

Anonymous wrote:

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%.

Are you saying that 4% of women that get a repeat csection die? Percent of what?

This study (Maternal morbidity following a trial of labor after cesarean section vs elective repeat cesarean delivery: a systematic review with metaanalysis, Rossi and D’Addario, American Journal of Obstetrics & Gynecology, Sept 2008 ) was a meta-analysis of many different studies, which means that the authors looked at many different studies and pooled the data to look at the differences in outcomes in VBACs and elective repeat CS. Those different studies were all done in different ways, but some of the typical things they counted as maternal morbidities were blood transfusion, postpartum fever, hysterectomy, uterine lesions, chorioamnionitis, endometritis, abdominal wound infection, operative injury, postpartum hemorrhage, and thromboembolic disease.

They found that women who had a successful VBAC had a 3.1% morbidity rate, which means that 3.1% of the women that were in these studies who successfully delivered vaginally after having had a CS ended up with at least one of the problems listed above. 4% of women who had an elective repeat CS ended up with at least one of the listed morbidities, and 17% of women who attempted a VBAC but were unsuccessful ended up with at least one of the listed morbidities.

When talking about people who die, the term used is "mortality." Morbidity means that there was a problem or complication, and some are generally more serious than others.

[Anonymous]

All who are poetic with such great information - thank you! I am much less educated on this than you all seem to be and I appreciate the serious (but easy to understand) conversation. Thanks!