They say that the best defense is a good offense, and perhaps that’s what Kim Mosny, CPM had in mind when she publicly posted the story of a perinatal loss on her Facebook page. Mosny has appeared across the internet proclaiming the safety of homebirth. Perhaps she fears that her association with a tragedy might raise doubts about her claims.
On October 8, 2011…, [the baby] died inutero (while inside the uterus) as a result of a hidden, complete placental abruption (where the placenta shears off the uterine wall). [The baby] was stillborn at 12:19am on October 9, 2011, taken by cesarean section to protect [the] mother’s health…
Clinically, there is no explanation for this rare event other than to acknowledge the biological risk of all pregnant women because they have a placenta attached to their uterus…
Kim wants you to believe that there was no way this could have been prevented.
… Midwives care only for low-risk women, who have healthy life-styles; who do not smoke, drink alcohol, or abuse drugs, and who’s medical status is determined to be healthy, without medical conditions or diseases that would risk them out of care. Thus, there were no other risks that could be determined as causal for this client’s placental abruption. As a result of the abruption, the baby was very quickly deprived of oxygen and he died. He felt no pain. Thankfully, the mother remained stable and did not suffer medical complications herself.
And she wants to be sure that we know that the parents are not blaming her:
Our clients wish to convey their satisfaction with and confidence in their care providers, both the midwives of the Home Birth Midwifery Service … stating the course of their care was thorough and comprehensive. They received excellent care throughout.
Technically speaking, everything that Mosny wrote may be true. However, she left out some critical details that cast a very different light on the tragedy.
1. The patient was 42 weeks and 1 day when this stillbirth happened. While the actual precipitating event that led to the baby’s death may not have been preventable, the death itself may have been preventable. The stillbirth rate rises steadily at the end of pregnancy, and 42 weeks is considered the outermost cut-off for induction and delivery of the baby. Had this patient been induced in the hospital before 42 weeks, the outcome would likely have been a healthy baby.
2. Mosny is silent on whether the patient was in labor at the time of the abruption. She does not claim that the patient experienced decreased movement or sudden onset of pain. Whether the patient was in labor at the time that the abruption occurred is highly relevant.
3. Mosny is silent on when and how the patient was diagnosed and transferred to the hospital. If the transfer was during labor, it took place too late to save this baby’s life. Homebirth advocates are fond of claiming that even when an emergency occurs at homebirth, there is plenty of time to transfer to a hospital. But there are a number of obstetric emergencies, none of which are rare, that must be treated within minutes or the baby will die. One of these is a major placental abruption.
4. The treatment for an abruption that results in a perinatal fatality is vaginal delivery. There are two exceptions: if the patient had a previous C-section and requests a repeat, or in the case of massive bleeding. In this case, the baby was a first child, and, according to Mosny, the bleeding was confined to the area behind the placenta (hidden abruption). Therefore, a C-section in this case was probably the result of obstetric indications unrelated to the baby’s demise, such as cephalo-pelvic disproportion.
As soon as I read Mosny’s Facebook post about the tragedy, I suspected that there was more to this story than she was revealing. In the first place, it is unusual for any provider to publicly announce a stillbirth. Second, it seemed that the purpose of the announcement was to publicly absolve herself of blame. But that begs the question: why would she feel it was important to publicly renounce blame for a stillbirth in the absence of risk factors?
It turned out, however, that there was at least one major risk factor for stillbirth, and that her description of what happened, while technically true, omitted key facts that shed a very different light on the situation.
I contacted Mosny to offer her an opportunity to comment on the specific circumstances surrounding a perinatal death that would justify a public announcement that it was unpreventable. She did not offer any clarification.
Unfortunately, there is a real possibility that this was a classic homebirth tragedy. A patient who should have been risked out from homebirth, who should have been induced earlier, experienced a catastrophic complication, and by the time the patient was transferred to the hospital, the baby was dead.