The American College of Nurse Midwives prepares to throw ethics to the wind


I’ve been wondering about the professional ethics of the American College of Nurse Midwives for years. Although they are well aware that American homebirth midwives, CPMs, LMs and DEMs are substandard practitioners, (even acknowledging it within their own publications), they have repeatedly allied with them. I’m not sure why they don’t see that it is harming their own reputation, but apparently they operate by the theory that “the enemy of my enemy is my friend.”

So their professional ethics have been suspect from the get go, appearing as it does that the ACNM values professional autonomy over the lives of babies and mothers. That impression of professionally unethical behavior was strengthened when the ACNM came out with a bald faced lie about the reliability of birth certificate data to support MANA in claiming that homebirth is safe when MANA showed quite clearly that it is not.

Now comes word that the ACNM is preparing to go even farther in unethical behavior. A new memo alerts CNMs that their organization “disagrees” with the American Academy of Pediatrics Committee of the Fetus and Newborn and the American College of Obstetricians and Gynecologists that waterbirth poses deadly risks to babies.

Are we really supposed to believe that a bunch of certified nurse midwives knows more about neonatal physiology than a group of neonatologists and perinatologists? Maybe ACNM believes it, but no one else will. Are we really supposed to believe that CNMs care more about whether babies live or die than the people who actually care for and save the lives of those babies? I doubt even the ACNM believes that. But what they apparently do believe is that waterbirth is their “turf” and just because a bunch of babies died from inhaling birth pool water contaminated with feces, or died of hemorrhage because their umbilical cords were torn off as they were lifted from the pool, is not reason enough for them to tell the truth about waterbirth.

The ACNM set out a memo to its members this morning:

ACNM believes this document does not accurately reflect the large and growing body of research that supports water birth as a reasonable choice for healthy women experiencing normal labor as well as birth.

What large and growing body of research? The ACNM doesn’t say.

Most water births occur under the care of a midwife and it has been a safe option for decades that provides comfort with good outcomes for the mom and her baby.

No one said otherwise. Most of the time giving birth in water, despite being non-physiologic and despite being dangerous, will end fine. But, of course, most of the time not buckling your infant into a car seat will end fine, too, yet we don’t say to mothers that if not buckling their infants into car seats improves the mother’s experience, she doesn’t need to use a car seat. Our babies are precious to us, and we want to mitigate risks of death, even when those risks are small.

However, this new ACOG/AAP opinion statement cautions about immersion in water during the second stage of labor. These cautions are similar to those in their prior publications, including warnings about a lack of data on the safety and benefits of water birth. The organizations refer to case studies of adverse outcomes, but case studies are not a reliable form of research, and should not be the foundation for their conclusion—that water births should only be considered as part of “experimental” clinical trials.

Case studies are generally the first warning sign that a medication or procedure is dangerous. For example, the companies that made a certain type of artificial hip presented a number of studies demonstrating the benefits of their new hip. The device was introduced into clinical practice based on those studies. It wasn’t until doctors began reporting unusually early failures of the device that both patients and physicians were alerted to the high failure rate of these devices.

The ACNM is either disingenuous or uneducated about the value of case studies in exposing unusual risks that occur unexpectedly when new medications, devices or practices are introduced.

Despite limitations, the best available research indicates that water birth is associated with perinatal outcomes similar to those expected in a low-risk population. In other words, healthy women and their babies generally stay healthy during and after normal labor and water birth. Therefore, water birth is a reasonable choice for healthy women to make in collaboration with their care provider, given the state of the science.

All you have to do is ignore the dead babies and you can keep recommending waterbirth!

The ACNM should be ashamed of themselves. They are placing their turf battles above the lives of babies who didn’t have to die. They are no different from Big Pharma who, when faced with case reports that a blockbuster drug has unexpectedly killed people it was supposed to benefit, insists that “their” safety data shows that the drug is safe and tthat no one needs to be warned about any risks.

Maybe things have changed since I practiced for years with dozens of CNMs. Those women cared just as much about babies as I did. They were highly educated, highly trained, and scientifically rigorous. Maybe I am naive, but I can’t imagine a single one caring more about her turf than about providing accurate information to mothers so they could make the choices that were right for them and their babies, not the choices that were advantageous for midwives.

The current leadership of the ACNM is apparently different:

Additional information will be forthcoming to members in the coming weeks to further support our collective efforts to maintain women’s access to water birth under appropriate conditions. These include:
• An official ACNM position statement on Hydrotherapy During Labor and Birth
• Articles to be published in an upcoming issue of JMWH
• ACNM’s official response to the ACOG/AAP committee

I can’t speak for others, but for me whatever the ACNM has to say is going to be ethically suspect. I don’t believe that they have even a tiny fraction of knowledge of neonatal physiology as neonatologists and perinatologists so their opinion is pretty worthless. And unlike neonatologists and perinatatologists who have no plausible reason to inflate the dangers of waterbirth, CNMs have an utterly self-serving reason to dismiss those risks; their desire to hold on to “turf.”

The ACNM commitment to “normal birth” and their cavalier willingness to dismiss babies who die at waterbirth reflects their preoccupation with processes that they can control and their demonizations of skills and procedures that are beyond their their education and training. But caring for women in childbirth is not supposed to be about process; it’s supposed to be about outcome, a healthy baby for a healthy mother.

The truth about waterbirth threatens CNMs. They’d rather suppress that truth and threaten babies lives.