Homebirth midwifery and the problem of informed consent

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It’s hardly surprising that homebirth midwives have a serious problem with obtaining informed consent. That’s because selling homebirth midwifery services implicitly depends on being dishonest about the risks of homebirth: minimizing them, lying about them or omitting disclosure altogether.

Simply put, if homebirth midwives had to honestly disclose risks, they’d have very limited employment opportunities.

Therefore, homebirth midwives have devised a variety of strategies to avoid obtaining informed consent.

1. Delay

Melissa Cheyney and the Oregon homebirth midwives are masters of this strategy. They simply didn’t obtained informed consent for homebirth and when forced by the legislature to begin doing so, they stalled, and stalled and stalled again.

As I wrote two years ago, the legislature mandated informed consent by June, 2011:

… [I]t is remarkable that Oregon homebirth midwives have still not begun obtaining consent for these high risk situations, arguing repeatedly that they need “more time” to create consent forms. Homebirth midwives petitioned for and were granted an extension until October 15, and as the date drew near, they petitioned to postpone the requirement for informed consent until January 1, 2012. That request was formalized on 9/26/11. A little over a week later, having postponed compliance with the requirement for 6 months, Oregon homebirth midwives petitioned to postpone it a further 6 months.

The idea that they needed any extension at all is bizarre. The increased risks posed by VBAC, breech, twins and postdates pregnancy are well known and have been quantified for years. For example, obstetricians have been obtaining informed consent for VBAC for at least 20 years. The Board of Direct Entry Midwifery could easily assemble and print the information in one day.

But Oregon homebirth midwives depend on their friends in the legislature to protect them from even the most basic requirements for consent. I’m not sure that they have yet begun obtaining consent for high risk situations.

2. “More research is needed.”

Homebirth midwives will do just about anything to avoid acknowledging risks. Hence the inane claim by MANA executive Jeannette McCulloch, in a recent post on the blog of the Midwives Alliance of North America, that “no one knows” how to tell the difference between low risk and high risk.

More research is needed into what constitutes low-risk for home birth. It is critically important that mothers and their care providers have accurate, evidence-based information so that they can make true informed consent. Risk factors that need further examination include breech, multiples, post-dates, and a variety of different VBAC circumstances.

That’s funny. MANA’s official stance is that:

…[F]or low-risk women with a skilled midwife in attendance, home birth is a safe option for newborns with lower rates of interventions and complications for mothers.

Well, which is it MANA? Does “research show” that homebirth is safe for low risk women or do we need more research to figure out just what low risk really means?

Now you or I might think that statements like these represent confusion on the part of MANA about what constitutes low risk, but that’s not true. The EXPLICIT policy of MANA is that each homebirth midwife can “decide for herself” what constitutes low or high risk. That makes no sense at all until you remember that the entire point of MANA is to provide intellectual cover for homebirth midwives, who are nothing more than lay people, to do whatever they want to do.

Standards apparently are only for real medical professionals, not for homebirth midwives.

3. An “informed consent” form that doesn’t obtain informed consent

Some homebirth midwives, like Mountain View Midwives in Charlottesville, VA, have come up with an informed consent that doesn’t obtain informed consent:

Each
 woman 
must 
weigh 
for 
herself 
the 
risks 
of 
birthing 
outside 
an 
emergency
facility 
against 
the 
risks 
of 
in‐hospital
 birthing,
 where
 the
 risks
 of
 unnecessary
 interventions,
 emergency‐mentality,
 and
 hospital
 born
 infections
 present
 their
 own
 dangers.
 
 Babies
 (and
 very
 rarely,
 mothers)
 do
 sometimes
 die
 in
 spite
 of
 the
 best
 care
 and
 great
 love.
 
 It
 happens
 at
 home
 and
 in
 the
 hospital.

Evidently the folks at Mountain View Midwifery don’t know what informed consent actually is. They have written a release, not an informed consent. This is probably going to come as a huge surprise to them, but medical care is not the same as going to a water park or going skiing. In those situations, the park or the ski slope is not required to enumerate all possible risks of swimming or skiing. They simply need you to acknowledge that you are willing to proceed at your own risk.

Informed consent is something else entirely.

The first and most important element of informed consent is:

… [D]isclosure by the [provider] to the patient of adequate clear information about the patient’s diagnosis; the alternatives available to treat the patient’s problem, including surgical and nonsurgical management; the benefits and risks of each alternative, including nonintervention … and a frank explanation of those factors about which the medical profession, and the individual [provider] in particular, are uncertain and cannot provide guarantees…

In other words, informed consent REQUIRES enumeration and disclosure of risks SPECIFIC to the individual patient’s diagnosis and proposed treatment.

Those are the three major ways in which homebirth midwives avoid obtaining informed consent for their services, but the real issue is not how, but why. The reason homebirth midwives are strenuously resisting informed consent requirements is that their financial success depends on HIDING the risks of homebirth. They are frightened to the core of informing patients of the risks of homebirth, because they know that the risks are real, substantial (particularly in the case of high risk situations), and frightening. Better to just hide them and wash their hands of all responsibility for the disasters that occur why they enjoy their birth junkie hobby.

The key to homebirth advocacy is NOT an informed patient. It’s a gullible patient who doesn’t know the real risks, but has been flattered into thinking that she is “informed.”

  • Melissa

    Is there an “informed consent” for women who enter a hospital to birth regarding Pitocin, AROM, epidurals, catheters, the 5:00PM C Section because your provider wants to go home? It should says something like Pitocin contractions will be stronger than your normal contractions, has a chance of not working, stressing your baby and puts you on a clock. Rupturing your membranes also puts you on a clock, has a greater chance of cord prolapse meaning emergency, increases your risk of infection and takes away your baby’s buffer to the strong contractions caused by Pitocin, your epidural can slow labor, making you unable to move and/or push effectively, doesn’t allow for proper fetal descent, you will most likely have a catheter placed to your bladder, increasing risk of bladder infections, and if all else fails, at 5PM, you will have a C/S at 5PM before your baby gets too tired or sick to continue laboring (because the doctor is tired of waiting). Where is that consent??? “Dr.” Amy, you need to present both sides of the story before bashing one side! Or maybe you should stay home and raise your kids (the way you have done for years without practicing a drop of medicine!)

    • Bombshellrisa

      Every NCB myth is represented here. Couldn’t pack more BINGO!!! into one post!! There is always somebody on call and there are hospitalists in L&D-that means doctors whose job it is to work shifts strictly in the L&D unit to make sure there is always someone there. Meaning nobody is getting a 5pm on Friday C-section because “doctor wants to go home/play golf/eat dinner”. And it may come as a shock but you are always ion the clock when your water breaks whether it happens in line at the grocery store or it’s AROM at the hospital.

      • fiftyfifty1

        “And it may come as a shock but you are always ion the clock when your water breaks whether it happens in line at the grocery store or it’s AROM at the hospital.”

        Although I would say that this On The Clock idea is mainly a myth. Women with preemies can go days or weeks with ruptured membranes if that’s what it takes to give the baby more time to mature. But being ruptured does increase the risk of infection. NCB will say this is only the case if you are getting vag checks, but that’s not true. It increases the risk with or without vag checks. But there is no absolute time limit. As long as a mom is showing no sign of infection, and is making progress in labor and is willing to accept antibiotics to protect her baby when called for, she can continue on. But if those things aren’t the case and the baby or mother are showing signs of compromise, then the OB is going to recommend c-section. It’s not due to The Clock but rather due to the situation.

    • Lynnie

      This is merely anecdotal, but I have heard several women say that they weren’t dilating properly and getting prepped for a c-section, including getting an epidural, and the epidural allowed them to relax and dilate and then be able to give birth naturally. Or the stories of women who were exhausted and an epidural allowed them to rest enough to be strong enough for the pushing stage. The BS that epidurals slow down labor is simply not the case from what other mothers have told me.
      Another anecdotal story… I was induced because of my high blood pressure. There was no cascade of interventions. The only intervention I needed was the induction. No epidural, no c-section, very minimal tearing. My son did have some issues after the birth, but that was because of my blood pressure, not the induction.
      The problem with the NCB movement is that they use fear mongering to beat people into submission to their ideals. Pretty much every sane person will fear a place that they are told will take away their autonomy and treat them like cattle and basically do harm to them. My main issue with the NCB movement is that they aren’t afraid of telling lies to get their point across. They take a person who is already wary of hospitals or doctors and tell her that hospitals are torture chambers and doctors are knife wielding monsters. That is NOT true. Yes, doctors make mistakes. Nurses make mistakes. Midwives make mistakes. Every person who works in the medical field has made mistakes. Hospitals are different that just having a random midwife come to your house is that there is a greater level of accountability for mistakes and disciplinary actions done against bad doctors or nurses. Many NCB midwives, when they are held accountable for their mistakes, cry persecution and do all they can to avoid accountability. I don’t mean to say that all doctors are good and all homebirth midwives are bad. I am not saying that there aren’t idiot doctors out there delivering babies. I have a friend whose teenage son still has health issues because the idiot doctor didn’t suction his lungs properly of meconium.
      Well, enough rambling for me today. I am procrastinating doing my housework today. I need to get at it.

      • Melissa

        I have worked L&D for 16 years and have seen ALL of the problems I listed. In those 16 years, I have seen babies die at the hospital and NOT ONE come in from a homebirth dead! You call can keep your antihomebirth views and I will keep mine….That women have the right to choose where to deliver if they are low risk! I guarantee that the women who are induced are NOT told of any risks. They are offered induction at 39 weeks and who wouldn’t want to be done a week early! They jump at the chance without knowing that a first time mother has a 50% chance of failed induction. Evidence shows that out of hospital birth is as safe as hospital birth for LOW RISK women. Read your facts and not just people in the right wing!

        • Amy Tuteur, MD

          Considering that you are from Montana, where there are only 300 homebirths per year across the entire state, it isn’t surprising that you haven’t seen any homebirth disasters. That, of course, tells us nothing about homebirth, but it does tell us that you aren’t particularly good at logical thinking.

        • Young CC Prof

          I personally know 5 people who died in car crashes and at least a dozen who were hurt. I don’t know anyone who died in a motorcycle crash. Therefore, by your logic (personal observation), cars are more dangerous than motorcycles.

    • Young CC Prof

      Nope. Informed consent includes the real risks, but not the made-up ones.

    • Trixie

      I’ve had pretty much all of those interventions except AROM, and yes, I was given the necessary information to make an informed decision each time. My c-section was at 4 pm, though, so my doctor must have wanted to knock off early…oh wait, actually, it was a Saturday, and she missed her kids’ sporting event to be there, and had more deliveries after me. Well, there goes that theory.

    • Captain Obvious

      Wow, Miss Gloom and Doom here. Show me a study that proves pitocin contractions are stronger than spontaneous labor contractions at the same frequency. Pitocin is titratable, you can even stop it and within 2 minutes the effects will diminish. Can’t do that with spontaneous contractions if they are every 2 minutes. Of course you can give terbutaline to slow things up if needed. To me that’s like saying I get wetter in the rain than I do in the shower. The strength of the contraction is just that, no matter how you create them, spontaneous, nipple stim, pitocin.
      Plenty of research now demonstrates that epidurals do not slow down labor even if you get on before 3 cm. Some epidurals actually help by relaxing you and your pelvic muscles to help the baby descend and help you relax and cope to tolerate the longer labor comfortably.
      AROM has its purposes. I like to know if there is meconium present. It can accelerate labor. I once debate on a thread whether gravity helps shorten labor. A crunchy mom provided low quality studies that stated it may shorten labor by as much as 80 minutes. If first time labors last on the average 15-20 hours, that isn’t much. I agree with walking for comfort though. But studies have shown AROM can shorten labor more than gravity/ambulating.
      ROM doesn’t put you on a clock. My fifth child had PPROM at 33 weeks and delivered vaginally 3 days later. You watch maternal temp, maternal HR, FHR, maternal WBC and CRP, and other parameters to determine when to perform a cesarean.
      Please show me studies of this 5 pm phenomenon you speak of. Labor is basically followed by whether the baby is tolerating labor and if adequate progress is being made.

      • Karen in SC

        But CO, there are no studies. She has “other ways of knowing.”

    • Sullivan ThePoop

      So you think hospitals should lie to women just like homebirth midwives? I don’t see the point.

  • NCBer No More

    I was never informed by my birth center about the increased risk of death to my baby. I was never a “true believer” and would have switched to a hospital birth right away if I’d been given this information. I’m so angry about it today (half of the anger is at myself for not seeking out this info). I feel mislead and I’m wondering if I and others I know could sue the birth center for not giving us informed consent.

    • Karen in SC

      Was there an adverse result? I’m not a lawyer, so don’t know about suing but at a minimum you could make a complaint to the governing body in FL. In my state, SC, it would be the Dept of Health & Environ. Control. DHEC just shut down a birthing center here to investigate at least one, maybe two, deaths.

      • NCBer No More

        No adverse result. I had a minor complication during labor, so my midwife transferred me to the hospital during labor, where I got much better support from L&D nurses IMO. I have since learned that this birth center is being sued for malpractice in association with a baby’s death in 2009. I never knew about this while I was pregnant. I also got lots of crappy advice, like I should take cohosh and skipping antibiotics for my GBS is “ok if that’s what I want to do.” So I don’t think they did anything against state law, but I feel I got really lousy care! I’m just so enraged by this buyer-beware mentality that it was my responsibility to check all these things. I trusted my midwives and I paid them to be my experts and guide my care, and it turns out they really don’t know what they are talking about. I did find the website for FL where I can file a complaint. If I can find anything to complain about, I will absolutely do it! I really think they should be required by law to disclose the increased prenatal mortality risk to their clients. I mentioned the idea of suing because I want to explore all avenues for retribution and hoped someone here might know.

    • NCBer No More

      All the CPMs in FL use the same informed consent form. I found it on this midwife’s website. I’m positive I signed one of these: http://www.blissfulbeginningsbirth.com/uploads/1/2/1/4/12149594/consent_for_lm_care.pdf

      I find it to be really vague. No where near the quality of disclosure of the hospital forms I signed.

      • Karen in SC

        that’s what had been said on this blog for years. Sorry you were put in that position.

  • Eddie Sparks

    Medical student first year ethics lecture: informed consent must include an explanation of the risks of the proposed intervention, all alternative treatment options and the risks of doing nothing, that is SPECIFIC FOR THE INDIVIDUAL patient. (my caps).

    The example given is that of cataract surgery for a patient who is already blind in the other eye. The risks of the cataract surgery must be explained including the risk of total blindness for this patient, including the impact of that disability, which would not necessarily have to be emphasised for other patients.

    My interpretation is that although a standardised form might be a useful tool for providing some elements of informed consent, it cannot meet all the requirements because it wouldn’t meet the need to provide risk/benefit information individually tailored to each woman’s situation. With home birth that would even have to include factors such as distance from emergency facility, transport means available, etc. as well as detailed information about the woman, her pregnancy and co-existing medical conditions.

    When health care providers individually decide for themselves what the risks are, and then “inform” the patient, that is NOT informed consent. That is medical paternalism and disrespectful of women’s autonomy and competence to make decisions for themselves.

    Putting the burden of discovering and evaluating the risks on to the patient (along the lines of the “release form”) isn’t even pretending to inform patients about anything.

  • Zornorph

    Question – who are their allies in the Oregon State legislature? And what members there (and elsewhere) can be lobbied to regulate this sort of thing? As a libertarian, I’m very wary of regulation, but in this case, it’s not just the mother putting herself at risk for doing something stupid (which she has every right to do) but the baby, who is not being asked. Are there any congressmen or Senators at the national level with any interest in this issue? What about in the Dept of Health and Human Services?

    • areawomanpdx

      Yes, the Oregon midwives pay a lobbyist (a couple thousand dollars a month!!) and have several oregon legislators in their back pocket. Julie Parrish is their greatest champion, but there are others as well. They have built a coalition of small government republicans and pro-choice democrats, none of whom understand what is really at stake.

  • Amy Tuteur, MD

    I’m curious. Can any homebirth midwife or homebirth advocate find any midwifery consent that fufills the requirements for informed consent?

  • Elizabeth

    The Colorado Midwives Association (for CPMs) is having a whole portion of their annual conference devoted to informed consent. I’d *love* to see what they come up with….

    http://www.coloradomidwives.org/component/content/article/52

  • There’s a term for providing medical services (I know they’d love to argue birth is not “medical”) without informed consent – medical battery. They prattle on about “empowered” birth, but if you neglect informed consent, you haven’t empowered anyone but the health care provider to take advantage of a patient. The sad thing is, that without women actually demanding accountability for these violations, they will continue to happen.

    • I’ve demanded action because of the battery that happened to me (in the hospital and at a birth center). No one wants to do anything. I’ve tried incredibly hard to get something done. The medical board doesn’t care even though the law says they can fine physicians for ethics violations. The board told me they only invetigate if treatment was appropriate for my diagnosis. I am really traumatized by it all, I haven’t been able to go to a doctor since all this happened (meaning I couldn’t get follow up for a c-section, for one thing…).
      If someone knows of a resource to help me with this (in utah) please let me know. Attorneys either tell me they won’t help or just don’t answer.

      • Shameon – this is a tremendous problem – and is incredibly frustrating for those who find themselves on the receiving end of care that they feel has violated their rights. Unless there is catastrophic injury AND the pockets to pay for it (ie. medical malpractice insurance) the costs and risks of litigating are often too great for an individual woman to bear. As a result, the case law in this area remains thin. Because the case law is thin, the risk of negligent providers being held to account remains slim. Because the risk of being held accountable is slim, there’s no incentive to change practice (including no incentive to actually carry malpractice insurance) – and women and their children continue to suffer. The access to justice issue must be addressed first…in Canada – Birth Trauma Canada has recently launched a Maternity Legal Action Fund to fill this need. It remains to be seen whether or not it will raise adequate resources to support cases through the Canadian Legal System.

  • Are you nuts

    Dr. Amy – I would love to see you propose a draft of informed consent! Then send it to Oregon to let them know that no more delays are necessary.

    • theadequatemother

      ditto! And lets include the consequences of severe unrelieved pain during childbirth.

      • Are you nuts

        Unfortunately I don’t think it would make a difference. An informed consent loses its sting if the person handing it to you says, “Now this is some riduculous government form that you have to sign because as you know, evil doctors and big pharma are in bed with congress….but as we all know home birth is safe.”

  • Amy M

    Also, you were saying informed consent requires enumeration and since the midwives have no idea what they are talking about, they can’t possibly enumerate. Even beyond hiding anything, they certainly can’t explain the risks and benefits to the procedures they don’t know how to perform to solve problems they can’t figure out exist.

  • mydoppleganger

    Side note: my local vbac support group *think of the major one* cough cough* is actually stressing me out. Their posts are chatting about not showing up for a c-section, denying a c-section no matter what, etc. I feel like no one will post a more common sense approach. The natural birth crowd is easy to label midwives and doulas “rockstars” but at the end of the day, the OB is most often the bad guy. Nothing has hurt my interest in natural birth movement like the current dogma that is around now. Aah, just needed to vent.:)

  • FormerPhysicist

    Actually, it ticks me off that often informed consent doesn’t include the real risks of doing nothing. When I went through the standard informed consent form for my tubal ligation with my OB/GYN, it did not include the risk of no sterilization and possible pregnancy. Since my pregnancy complications left me unable to use hormonal bc, an IUD or a diaphragm …

    We had a good, if somewhat cynical, laugh over the omission.

    • Therese

      Well, that would be because that the risks of doing nothing vary so much by person, right? I’m guessing my risks to getting pregnant would not be the same as yours. But surely any doctor that was worth anything at all would verbally go over the risks of doing nothing with each patient.

      • FormerPhysicist

        Yes, but it’s my impression that the baseline risk of pregnancy/childbirth is high enough that it’s almost always riskier than anything one does to prevent pregnancy.

        They at least need to have a checkbox/signature line on the standard form that the risks of doing nothing have been discussed. Maybe some forms do – mine didn’t.

        Edited for clarity.

        • Therese

          That is probably true, but do you think every single woman should be offered sterilization and told that it is a safer option than getting pregnant?

          • Young CC Prof

            Well, if a woman ASKS a doctor about permanent sterilization, I think it might make sense for the doctor to compare the risks of the procedure to the risks of a pregnancy, just to put it in perspective.

          • auntbea

            The only problem I see with this is that there are less invasive (and permanent) ways to prevent pregnancy. But yes, all women should be offered contraception.

  • EmbraceYourInnerCrone

    I do love this (not) “lower rates of interventions and complications for mothers.”

    They say that like interventions are a bad thing, yeah sure, you won’t have interventions, and if you need them to help your baby or yourself due to an unforeseen complication…too bad.

    Shoulder dystocia that can’t be quickly resolved(my aunt), too bad. Baby stuck because it’s head is too big for the mothers pelvis and your midwife doesn’t believe in getting ultrasounds(my niece with both kids) too bad. Placenta previa and transverse lie with preterm labor and hemorrhage (my mom with my brother) too bad. Nuchal/too long cord wrapped around the baby’s neck, twice (my sister with her 3rd kid) too bad.

    All these babies and their mothers are alive because they delivered in a hospital and had those horrible interventions. My aunt had a normal 6lb first baby. Her second was 11lbs and big shoulders. They broke his collar bone to deliver him(1959). My niece had big headed babies and C/S for both. They let her do a TOL with the second but it did not go well so, second C/S.

  • mollyb

    I remember when I agreed to my c-section, the surgeon went through a laundry list of possible complications (infection, blood clots, damage to the bladder, etc etc) and I had to sign off on each one. There was no attempt to hide anything or be dismissive of the risks involved. THAT’S informed consent.

  • Mel

    MANA – This one’s free for you:

    I, the undersigned, recognize the following risks of giving birth at home.
    – I am choosing to undergo birth without immediate access to emergency medical services. This means the following situations could occur.

    My baby will be at higher risk for dying during labor. This could be due to lack of monitoring of the child during labor, inability of the attendant to detect problems while monitoring, lack of skills to intervene when trouble occurs, refusal to call an ambulance when appropriate and/or delay of advanced medical techniques due to delayed transfer.

    My baby will be at a higher risk of dying after birth. This could due to attendant incompetence in newborn health assessment, attendant’s inability to perform basic resuscitation techniques, attendant’s inability to perform advanced resuscitation techniques, refusal to call an ambulance when appropriate or as a result of delayed advanced medical techniques due to transfer time.

    I am at a higher risk of dying during or after birth. This could be due to attendant failure to monitor correctly, inability of of the attendant to detect problems while monitoring, lack of skills at the basic or advanced level to intervene in emergency situations, refusal to call an ambulance when appropriate and or delay of advanced medical treatments due to delayed transfer.

    I have discussed all of these outcomes with my birth attendant and fully understand risks inherent in my choice.

    • auntbea

      Bravo!

    • GuestB

      Now THAT was fantastic!

    • Karen in SC

      Having discussed and initialed all the potential risks, I still trust birth. Signed: ________________

    • Ainsley Nicholson

      Don’t forget a paragraph about the danger of brain damage to the baby (and life-long expensive medical care) or other neurological injury (erb’s palsy, etc).

      • KarenJJ

        Also something along the lines I “I don’t have malpractice insurance, therefore any future medical costs due to transfer or childbirth injury or brain damage will be born by yourself even in the event that I am shown to be an incompetent medical provider”.

  • manabanana

    Thank you for this.