Homebirth standards? CNMs don’t need no stinkin’ homebirth standards!

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A little more than a week ago I pondered why the American College of Nurse Midwives has thrown ethics to the wind by supporting waterbirth although it has been shown to be deadly. It is one example of the way in which CNMs value their professional autonomy over scientific evidence.

Now comes another in, of all places, the Journal of Midwifery and Women’s Health. Three CNMs have written an extraordinary paper that demonstrates far more powerfully than I ever could that CNMs reject science based standards that might limit their autonomy, as if science based standards are somehow discretionary. The paper is Formulating Evidence-Based Guidelines for Certified Nurse-Midwives and Certified Midwives Attending Home Births by Cook, Avery and Frisvold.

The study was simple and straightforward:

Following a review of home birth guidelines from multiple countries, a set of home birth practices guidelines for US CNMs/CMs was drafted. Fifteen American Midwifery Certification Board, Inc. (AMCB)-certified home birth midwives who participate in the American College of Nurse-Midwives (ACNM) home birth electronic mailing list considered the use of such a document in their practices and reviewed and commented on the guidelines.

In other words, the authors compiled evidence based standards that guide the practice of homebirth midwifery in countries like the Netherlands, the UK, Australia and Canada.

The response of the CNM reviewers was horrifying:

The primary concern expressed was that an adoption of national guidelines could compromise provider autonomy.

Apparently the CNMs favored the implementation of evidence based standards for American homebirth until they saw what the evidence showed. When they learned they were not practicing in accord with international evidence based homebirth standards, they decided to ditch the standards instead of changing their practice.

That, in a word, is unethical.

What were these international standards that CNMs rejected and where did those standards come from?

Five countries with provincially or nationally promulgated home birth midwifery guidelines met these criteria: Australia, Canada, the Netherlands, New Zealand, and the United Kingdom. Published guidelines of these countries were then reviewed for common themes. The following criteria for planning a home birth emerged: determination of low-risk pregnancy, informed consent, hospital transfer if complications arise, singleton pregnancy, fetus in the cephalic presentation, no history of previous cesarean birth, and term pregnancy.

International midwifery guidelines small

Then:

After collection, review, and summary of these international guidelines, the primary author synthesized the information into draft home birth guidelines that could be used by US CNMs/CMs. The resulting 10-page document (see Supporting Information: Appendix S1) includes recommendations about licensure, physician collaboration, hospital transports, informed consent, documentation, client screening, equipment, medications, birth assistants, routine care of the mother and newborn, and emergency care of the mother and newborn

Five different countries; agreed upon basic standards for care… rejected by the CNM reviewers.

Even the authors were shocked:

… [T]he authors were surprised that the reviewers expressed greater interest in developing and implementing national home birth midwifery guidelines prior to reviewing the proposed guidelines versus after their review…

The primary concern raised by the reviewers was whether or not guidelines would impact their autonomy. Guidelines are intended to provide best practices from which providers can meet individual client needs but also discourage providers from diverging from safe practices. The reviewers specified that the proposed guidelines might not support them if they choose to attend the home birth of a woman with a breech presentation or a twin gestation or a woman who desires a trial of labor after a previous cesarean. While CNMs/CMs attending home births may have the skill to attend such births, the safety net available in an institutional setting is advantageous and may be preferable for such births…

Indeed, the authors feel compelled to re-state the obvious requirement for ethical practice:

Although ensuring client safety may at times conflict with provider and client preferences, safety is the first priority for improving the quality of health care.

Apparently not for CNMs.

The authors note:

Fundamental to international home birth guidelines that were examined in this project is a distinction between low risk and high-risk maternity criteria. Normal birth has been defined in a joint statement by the Society of Obstetricians and Gynaecologists of Canada; the Association of Women’s Health, Obstetric, and Neonatal Nurses of Canada; the Canadian Association of Midwives; the College of Family Physicians of Canada; and the Society of Rural Physicians of Canada as spontaneous labor with a singleton fetus in a
vertex presentation at 37 to 42 weeks’ gestation after an uncomplicated pregnancy. This definition is consistent with the World Health Organization definition and the UK Maternity Care Working Party definition supported by the RCOG and RCM. (emphasis in original)

We already know that American homebirth midwives (CPMs, LMs, DEMs) lack basic professional ethics. Now comes stunning confirmation that American CNMs attending homebirths are equally ethically bankrupt.

What should American women take away from this study?

It is yet more evidence that midwives who attend homebirths (CPMs and CNMs) value their professional autonomy over whether your baby lives or dies. It is more important for them to maintain control over you (and collect a fee from you) than to accurately advise you. Moreover, the homebirth safety data from countries like the Netherlands and the UK can’t possibly apply to homebirth in the US because even homebirth CNMs refuse to follow the guidelines that govern homebirth in those countries.

Homebirth is a fringe practice. We can argue about whether it might be safe under ideal conditions, but it CANNOT be safe in the US because the midwives who attend homebirths (CPMs and CNMs) explicitly reject safety standards. And as long as they continue to do so, babies (and sometimes mothers) will continue to die preventable deaths at their hands.

  • Deb O’Connell

    hmmm…. interesting. I haven’t read the article ..yet. I’m not a fan of attending ANY high risk pregnancies as a CNM – whether it be hospital or home attended and I just left my job due to the expectation that I WOULD manage them with “MD collaboration” which is such bullshit ;). I’ll read the article tomorrow and offer my two cents.

  • staceyjw

    This is proof of what philosophy does to a provider, even a well trained one.

    CNMs are excellent in the hospital system, but the ones that choose HB have more in common with LDEMS and CPMs than they do other CNMs. It’s no wonder they support LDEMs, they all are dedicated to the very same ideals, with cult like intensity. Those beliefs rule their practice, everything else- safety, evidence, informed consent- comes afterwards. FAR afterwards.

    The 24,000 question is- when will the CNMs that practice evidence based care do something about how their organization deals with this issue? I am sure the good CNMs are in the majority, because CNMs doing HB are not too numerous, but they seem to be awful quiet.

    I just do not know how anyone can look at the stats on breech or VBAC and think this is a good idea to do at home. Many say they do it because moms want it and are determined, but just because someone wants something does not mean you must provide it. If your patient wanted heroin, would you provide that as well, if they really wanted it, and threatened to go to a street dealer instead? Whats the difference?

    Also- the way they define “normal birth” makes me think- well of course everyone wants a “normal birth (save those that want an MCRS, of course). Who doesn’t want an uncomplicated pregnancy, and to go into labor without effort? This doesn’t mean its a goal to die for, and doesn’t mean you can make it happen.

  • CanDoc

    Chilling.

  • Guest

    I have been thinking about and discussing this article a lot today. On the one hand I am not surprised, and have seen many CPMs become CNMs then practice OOH. I always wonder who the CNMs are in instances such as this. On the other hand, I live in a state where the statute has *no* specific language regarding what CNMs can and cannot do in a homebirth setting. This is because it is assumed with their education and training, they will practice within their scope. Obviously this would be very unfortunately after the fact, but if something were to go wrong at home they would be taken before the board of nursing and expected to demonstrate that they were practicing within their scope. Since ACNM is a trade organization how would implementing these practice guidelines work?

  • Deena Chamlee

    Bofa of course I will not continue to pay other’s to exploit me, omg what was I thinking.

  • LMS1953

    OT. For about 25 years I thought I was a fellow of the American COLLEGE of Obstetrics and Gynecology. Then a couple of years ago, a group of CNMs I was hired to “back-up” advised me to read Ina Mae’s book. There, Ms Ina referred to ACOG as the American CONGRESS of Obstetrics and Gynecology. The midwives have a COLLEGE and not a CONGRESS. I am very concerned about word creep – witness the bullshit change to “client” in lieu of “patient”. The crunchy midwives and everyone at the hospital/birthing center did not refer to us as “Doctor” – we were expected to accept being addressed by our first names even in front of patients which I think was intended to be a verbal castration as opposed to a sign of friendship. Anyway, does anyone know what the CONGRESS BS is all about? It still says COLLEGE on the emblem on the Green Journal. When you google ACOG, you get it both ways – see the image.

    • attitude devant

      Obviously you don’t read your email from ACOG. We still are a College, but there is a separate legal entity which is the Congress. Why? Has to with tax law. The College is incorporated as a 501(c)(3) and is apparently unable to take certain advocacy positions. Ergo, the Congress does. Do I understand it? Not really. Is it new? Nope, the change happened in 2010.

  • LMS1953

    Midwives of all stripes clamor for more autonomy, patient access and reimbursement. Invariably, to “prove” the safety of homebirth, they cite European studies (in which women are vetted for risk and excluded for TOLAC, post dates, breech, twins, etc; and the “clients” don’t hold their breath until they turn blue and get their autonomous panties in a bunch so they can get their healing homebirth to wash away the sins of intervention at the altar of their sacrificial offspring). THEN, they HIDE statistics and later lie about them and obfuscate any rational interpretation that show how hideously UNSAFE homebirth is without such vetting and significantly unsafe ii is to any reasonable person even WITH the vetting. As a composite whole they leap at the prospect of developing standards when they had falsely assumed that such standards were to BROADEN and LEGITIMIZE their scope of practice. When confronted with the reality that such WORLDWIDE standards were to RESTRICT their scope of practice so as to better assure SAFETY, they shrieked away in horror and scurried back to the safe harbor of the Woo, chanting the usual incantations (trust birth … mumble mumble mumble….autonomy…mumble mumble mumble…dead baby card …mumble mumble mumble…variation of normal … mumble mumble mumble….Midwifery is not a profession to be trusted. At all levels, self-interest and cult behavior take precedence over safety and the best interest of the mother and fetus/newborn.

  • Deena Chamlee

    To the authors: Sometimes we can be so open minded our brains fallout. The entire College should be sampled not 15 who will inhetently be biased. Everyone should have a voice. Just because I do not attend homebirths up until this point in my career does not man my opinion is not valid.

    Dont let your brains fallout, sample everyone.

    • Amy Tuteur, MD

      There was not need to sample everyone. We want to know how CNMs who attend midwives actually practice and how they would responde to guidelines. It doesn’t make sense to sample the CNMs who don’t attend homebirths.

      • Deena Chamlee

        Many may if guidelines were implemented. We must make it safe because women will continue to have homebirths.

    • The Bofa on the Sofa

      I disagree.

      The claim of “not representative sample” is completely post-hoc.

      These reviewers were all for standards up front, but it was not until the guidelines were drafted that they objected.

  • manabanana

    Whoa, whoa, whoa waitaminute. Newsflash: 95% of CNM attended births occur in hospitals. From reading this article it’s clear to me that the authors do not espouse the beliefs or attitudes expressed by the minority of CNMs who participated in the study. Nor do I see anywhere that the ACNM as an organization espouses these reckless beliefs about ‘autonomy over safety.’

    The authors are reporting findings – not advocating for them.

    Not that these details will prevent you from trying to malign an entire profession – most of whom (95%) practice quite safely and effectively in hospitals with appropriate standards and collaborative relationships with physicians and other medical professionals.

    Let’s remember that in the wack-a-loon realm of homebirth defining low-risk birth as a healthy pregnancy with *one* baby in vertex presentation between 37-42 weeks is a radically conservative assertion. Remember how Wendy Gordon, MANA, et al struggle to define ‘low-risk’ at all?

    “…spontaneous labor with a singleton fetus in a vertex presentation at 37 to 42 weeks’ gestation after an uncomplicated pregnancy.”

    I read the article and this is what I see the ACNM pushing for. Not the wild-west cowgirl attitudes of midwives who want to do whatever they want. And I believe this article is a step in the right direction in acknowledging that these reckless attitudes are out there. That’s how change will happen.

    • Squillo

      What the ACNM will do depends on what it perceives its membership wants. If the majority of CNMs don’t care about homebirth, the few that do will guide the org’s policy on homebirth, barring other considerations. At the moment, it’s probably in the ACNM’s interest do do nothing, at least until a significant proportion of its membership (or a group of motivated advocates) decides they want guidelines. I suspect the midwives who conducted the study are those motivated advocates, but they got shot down by another set of motivated advocates. I’d like to see a larger sampling of CNMs/CMs, both those who do homebirth and those who do not (and those who do not, but would like to.)

      • The Bofa on the Sofa

        Note that the authors were part of a “homebirth summit” held by the ACNM (and, iirc, included CPMs). One of the outcomes of the summit is that they agreed there needed to be standards for practice for HB.

        That was the consensus view, including the consensus view of the reviewers.

        So the authors did the right thing, and looked to the acknowledged successful midwifery systems, and said, what are the common attributes in terms of HB. And this is what they came up with.

        And that’s when the reviewers objected – when they found out that HB standards are not going to allow breech, twins, and HBACS.

        • Squillo

          So the question comes back to: are the reviewers representative of the ACNM membership’s views on guidelines or not? If the leadership was at the summit and agreed that developing guidelines was important, that’s a great step, but they have to sell it to the membership. If the reviewers are representative of the members with an interest in homebirth, it’s back to square one, because they clearly don’t really want guidelines. The members who don’t care about homebirth aren’t going to care much, except if they see it as a blow against autonomy. If the reviewer-mindset folks are loud enough, that’s what will happen. If I were leading the ACNM, I’d be very, very leery of making any move at this point.

          • The Bofa on the Sofa

            So the question comes back to: are the reviewers representative of the ACNM membership’s views on guidelines or not?

            Full ACNM? No. Then again, no one is claiming they are.

            Is it representative of the CNMs that do HBs? At that point, it is much closer to being representative. Moreover, these are the vocal members, so they are the ones who are going to be heard in setting policy.

            It may be that the silent majority is ok, but, because they are silent, their voices won’t ever be heard.

  • someone who has a clue

    Really, i would expect more from a “highly” educated harvard graduate. The articles that i have wasted my percious time that God has given me was a complete disapointment. The accusations in your articales are broad and unwarranted. I would assume that you dont have your own practice and if so it probably failed miserably and you probably sold out to a hospital and there money is going to your BS website! When is the last time you have gone to a CE that wasnt financially backed by some company that spends more money on lobbyist then the validity of the study itself! Bottom line MDS OF EVERY specialty misinform there clients and scare them into a more expensive options to make money, how is that for a generality! Whens the last time you looked down the assembly line! #Check whos paying your bills bitch.

    • birthbuddy

      Whoa, easy tiger. Your ignorance is showing.

    • OBPI Mama

      hahahaahaaa! I think you should go to your nearest Children’s Hospital and let the doctors know they are just in it for the money and thus misinforming all their patients and families. Thanks for giving me my first laugh of the morning!

    • http://momofmanyfeet.wordpress.com Bambi

      Wow! You’re pathetic. Try again.

    • Comrade X

      Learn to spell. Learn how to structure an argument. Learn some reading comprehension.

      Then come back.

    • Lombardi

      Troll
      or
      Conspiracy theory /persecution complex?

    • Luba Petrusha

      Most ironic nym ever………

    • GuestB

      Shoot – come back! I have your tinfoil hat!

    • http://www.antigonos.blogspot.com/ Antigonos CNM

      Good show! Unable to refute Dr. Amy’s assertions, go for the ad hominem attack! Very effective — it says more about you than about the validity of the arguments you criticize.

    • Medwife

      The grammar, the spelling, it burns

      • Mer

        I totally read the misspelling of precious as pernicious!

    • MaineJen

      LOL! Good one. Oh wait…you’re serious.

  • Guest

    Exactly why I revoked my membership. Just as many docs don’t follow the AMA, the same is true of many of us in midwifery (granted I’m still
    In my nursing portion). There are those of us equally appalled by the current leadership.

    • Deena Chamlee

      Then reup and fight for change with us!

      • The Bofa on the Sofa

        I disagree, Deena.

        You’ve complained about the leadership of the ACNM. You’ve complained that there is nothing you can do about it. However, if you want to hit them to make them wake up, the thing you need to do, as members, is get out. Let the ACNM know that you will NOT be a member until they put someone in charge with a clue.

        Why will they care if you keep giving them the money?

        • Trixie

          Obviously it would help if you write them a letter explaining why you aren’t renewing.

          • The Bofa on the Sofa

            Absolutely do that, too

            You get a massive campaign of CNMs not renewing membership, and making it clear as to why (“as ethical practitioners, we cannot accept the practices of the ACNM with the current leadership”), the association will change.

          • Squillo

            I think they need to convince membership that accepting guidelines is the best way to increase their ability to do homebirth and get paid for it. In California, for example, the “supervision” clause is a direct barrier to CNMs doing homebirth (and from my admittedly non-scientific anecdotal discussions with CA CNMs, most would like to see access to CNM-attended homebirth expand, even if they don’t want to do it themselves.) If the ACNM CA chapter went to the legislature and asked what it would take to remove that clause, I’d be willing to bet that guidelines would be one of the requirements.

          • The Bofa on the Sofa

            I think they need to convince membership that accepting guidelines is the best way to increase their ability to do homebirth and get paid for it.

            I absolutely agree. Having standards is GOOD for a profession, not bad.

          • Squillo

            Yes, but it has to be couched in terms of what the org is doing for the member: “This is how we are getting supervision requirements lowered and getting you access to third-party reimbursement and malpractice insurance that will cover both homebirth and hospital practice.”

          • The Bofa on the Sofa

            Yes, but it has to be couched in terms of what the org is doing for the member

            Of course, this is an organization that doesn’t fight unqualified posers in their profession, so that becomes a complex question.

          • Ainsley Nicholson

            Even better would be to create a new organization the holds its members to high quality standards, that the CNMs can join if they are disenchanted with the ACNM.

          • Deena Chamlee

            Trixie they don’t care. And if I get out I have no clue as tp the politics within the College and no access to members.

          • The Bofa on the Sofa

            Trixie they don’t care.

            Because there is no reason for them to care.

            Give them a reason to care.

            nd if I get out I have no clue as tp the politics within the College and no access to members.

            Why wouldn’t you have access to members? Don’t you know any CNMs? It’s not a secret society or anything.

          • Deena Chamlee

            Lol yes of course but I will never give up on The American College of Nurse Midwives to change. Getting out is giving up in my opinion.

          • The Bofa on the Sofa

            It doesn’t have to be. You don’t need to be a member to rally the other midwives. As I’ve said, it helps if you are not.

            “I was a member but quit because of ….” is a powerful statement.

            Unless you think that you are going to break into the leadership role, which I don’t think you are thinking.

          • Deena Chamlee

            I have endured craziness, but they are my colleagues no matter what. Antisocial not antisocial, they are my colleagues and together we must change. I will see how I am feeling come September when its time to reup.

          • The Bofa on the Sofa

            They will still be your colleagues if you aren’t a member of the ACNM.

        • Deena Chamlee

          Point well taken.

  • Durango

    You know, even though I chose homebirth lay midwives, I’ve since changed my mind and now don’t understand why you’d choose midwifery at all. If you’re going to be in a hospital anyway, why not go with the most thoroughly trained caregiver? We’ve certainly seen CNMs who are as woo-filled as CPMs, an ideology that can delay appropriate transfer of care.

    • toni

      I imagine CNMs would spend more time with you and be more IDK, more motherly(?) than doctors usually are. I saw my doctor I think twice during my labour and then he came in right before I delivered and buggered off again about 15 minutes afterwards. He was great when I saw him, upbeat and respectful, and I didn’t need to see him anymore than I did so I’m not complaining but some women might want a provider that can stay with them for longer periods, comfort them, have a friendlier relationship with the person delivering their child etc, Especially if, say, the father isn’t in the picture or something. As long as you have a CNM with their head screwed on right who has no hesitations about calling an obstetrician when needed I think it’s a good option for some

      • Haelmoon

        The midwife can play the role of deliverer and nurse. In some rural communities, it may actually be cost effect to have midwives to manage low risk pregnancies. They can provide prenatal care and come in to hospital for deliveries – then they don’t need nurses to have special OB training in smaller centres. However, in a large centre, it is just having your providers (nurses and physicians) rolled into one person. I am not entirely sure why it is so attractive, but there seem to be a trend to make the delivery all about the mother, and all of this extra emotional support for normal pregnancies. I don’t really understand it, but it is definitely a trend.

        • Elaine

          I think the nurse-midwives are usually touted as being lower intervention and also as following the “midwives model of care”. Having birthed with nurse-midwives twice, now I’m not really sure there would be such a big difference between a nurse-midwife and an OB after all in terms of the care they give. The midwives at the practice I used choose to “labor sit” and stay with you all through labor rather than just coming in at the end. I really appreciated that with my first delivery–knowing that the midwife, who I already knew and felt comfortable with, would be with me, rather than having mostly just a labor nurse I hadn’t met before. With my second baby I didn’t really care and would have been fine with just my husband and the nurse (who wasn’t there much until the birth was imminent, but maybe would have been there more if the midwife hadn’t been).

          But I know CNM practices that operate more like an OB practice with the CNM coming in just to deliver, so I dunno.

    • meglo91

      Well, it’s more efficient, cost-wise, to use CNMs for most of labor and doctors for when shit hits the fan. CNMs are trained professionals, but they don’t have to attend decades of training like doctors, which makes them cheaper. With both my kids CNMs did the fetal monitoring, administered meds, checked me, etc., but the OB caught the baby and supervised the pushing.

      • Deena Chamlee

        All due respect if that indeed was a CNM and not RN it is all shades of messed up.

        • meglo91

          So your comment has me thinking now that the folks who attended me during my daughters’ births were actually RNs and not CNMs. I gave birth in some pretty non-woo military hospitals, so if it’s not SOP to have CNMs there, I’d bet they were RNs. The more you know.

    • Lori

      So, not CNM exactly but I’ll share. For me, a biggie was that ya get to be seen by a midwife earlier in your pregnancy here in Ontario. If you are low risk you may not be booked in until 24+ weeks or so, in which case prenatal care is done by your GP. This was the deciding factor for my choice in my first pregnancy because, while I very much liked my GP, she was a town over and getting appointments with her was really challenging.
      This pregnancy I happily returned to the same practice despite having switched to a GP 10 minutes away because I was so pleased with the follow up care. You have the option of daily home visits during week 1 postpartum and its one stop for you and the baby for the first 6 weeks. I can’t describe how nice it was that first week not “having” to leave the house, they even collected and dropped off follow up labwork I needed.

    • Durango

      The answers below are that it’s cheaper for the hospital to hire midwives, but nothing else, really.

      It’s hard to recreate my mindset at that time, but if an OB had been offering home birth I would have hired her over midwives, as I’ve always liked doctors (chose hb because “It’s modern times and childbirth safety is a given, why not give birth at home?”–makes me cringe, now).

      I think midwives are seen as being kind and friendly, but OBs are, as well. There are rude and brusque providers in both camps, though one does not usually discover that the midwife is awful until the birth itself. So are women hiring CNMs because they believe that CNMs are nicer?

      • Aki Hinata

        I can only seak for myself, but with my first baby I called my regular clinic for an appointment with the positive home test. The scheduler told me I had to go to that system’s women’s clinic and was given an appointment with a CNM without really knowing what that meant or whether I had other options. Their practice turned out to be OB’s and CNM’s in one office and I was happy with the care I recieved, but it wasn’t a concious choice on my part.

      • CanDoc

        Depends on the jurisdiction. In Canada, midwifery care is much more expensive than OB/GP care. One Registered Midwife makes about $80,000-$100,000 per year, attends up to 40 deliveries, and still ends up transferring a significant number of her patients to a physician for care, who then bills. An OB may bill (total gross, before paying staff/rent/taxes/etc) $350,000-$400,000 per year, but for that fee (in my town) attends 200 deliveries, provides prenatal/postpartum care, provides gynecologic consult services, and performs surgery and colposcopy. Which, by comparison, is a bargain. Province after province in Canada has grappled with this issue.

      • SuperGDZ

        I have no doubt that the experience with a CNM might seem nicer, almost certainly because a CNM will spend more time with the patient than an OB, who might be rushed and “brusque”. It still comes down to money though – the reason a CNM can spend more time with a patient is because her time costs less.

    • anne

      I chose a CNM integrated with an ob-gyn practice because I had some vague notion that she would be nicer and because I was in a new town without friends or family. She was awesome and sent me to the hospital at my 8 week checkup, lol, and kept sending me. At the practice I ended up seeing several CNM’s and a few OB’s. I had bad and good experiences with both.

      My CNM was very open to my needs and not against intervening at all. She agreed to induce me at 39 weeks if I hadn’t started labor because my pregnancy was so miserable, sent me to a pelvic floor therapist for prolapse, and at my one year appointment suggested that I plan my next pregnancy and come see her far before 8 weeks and start medication early in the hopes of avoiding the horrible HG I experienced in my first pregnancy.

      She also had no problem consulting with OB’s when she didn’t know something and telling me that’s why she brought another person into the room. The CNM I saw has extensive experience in developing nations and in setting up programs there to reduce maternal/fetal deaths, so maybe she’s just less into the woo because she’s seen so much suffering without medical care.

      I’m very curious what she thinks about the ACNM’s current maneuvers regarding homebirth.

  • Jessica S.

    OT: Harriet Hall writes on Water Birth at SBM – http://www.sciencebasedmedicine.org/water-birth-again/

  • Lisa from NY

    At least CNMs do have patients sign consent forms but don’t explain it to them.

    http://dyekorasumda.com/Docs/Informed%20DisclosureFpub.pdf

    • Lisa from NY

      See page 5. The words “it has been explained to me” are false. They do not explain it but expect patients to sign.

    • Ash

      The “A Final Word” section has so much emotional manipulation and BS. “This midwifery practice depends on you, our clients, to stand behind us in case of problems” I can’t even…

    • PrimaryCareDoc

      That is…horrifying. Wow.

      Remember illness begins with “I” wellness begins with “we”….This midwifery practice depends on you, our clients, to stand behind us in case of problems in the same way we place ourselves at personal and political risk so that you may have your choice of care and birthplace. In light of the controversial status of homebirth in the United States, as well as its prohibitive cost, this practice does not carry malpractice insurance at this time.

      That is shifting the blame at it’s finest. Everything is someone else’s fault. “Illness begins with ‘I’”. Fuck that. Seriously.

      I think Amy could do an entire post just on that “informed consent” form.

      • PrimaryCareDoc

        And she charges $7000. That’s just her professional fee. Not including supplies, labs, ultrasound, and the obligatory birth pool.

        And she balance bills and adds a fee for using a billing service.

        But yet she still can’t afford malpractice insurance. Right.

      • Trixie

        W.T.F. Pure evil.

  • attitude devant

    Come ON, CNM sisters! You CAN do better than this! You want autonomy? Fine, but with that comes the responsibility to act always in the best interest of the women seeking care from you. Not what YOU think is in their best interest, no! What studies tell you is in their best interest. To do anything less is a complete betrayal of their trust.

    I’ve been in OB/GYN for 25 years. When I first started there were whole realms of practice that I enjoyed very much: fertility, cancer surgery, pelvic floor reconstruction. Over the years those same fields have been taken over by newly trained specialists with much more extensive training than I. They get better outcomes for those patients. While I miss doing those types of therapies I would NEVER EVER forgive myself if a woman had a less-than-optimal outcome because I didn’t refer her appropriately to a ‘superspecialist.’

    Why don’t YOU feel the same way I do? You have plenty to offer women without resorting to inappropriately holding on to high risk mothers. Women like midwifery care—why can’t you be clear and say, “Hey, this is no longer a straightforward situation and you need more specialized care?” Because, guess what? I do that all the time. And it’s the RIGHT thing to do. And I still have plenty of work, and so will you.

    • Deena Chamlee

      It is so much deeper, attitude. So much deeper. If you have fellows, the FACNM, that are structured to give advice on the direction of the College, and these fellows are aligned with Ina and Missy change will not occur.
      They may manipulate your reality to think they are someone they are not, but once confronted their true personality come to light. It will get more bizarre before we implode.
      Notice, the water birth that proudly embraced the ACNM home website, is no longer there. They removed the water birth advertisement.
      Little at a time but its all out now, and implosion will occur is my prediction as more stand up.

    • toni

      Love this comment! Pride really is the worst. I discovered after getting married that I had this sex life destroying pelvic pain disorder, a regular gynaecologist (who later on delivered my son) diagnosed it and promptly referred me to a doctor in another nearby county. The first doctor was perfectly competent and most likely could have treated it but he said this other one was really passionate about this stuff and was the best in the state so off I went. He wanted the best for his patients isn’t that what it’s all about?

    • Stacy21629

      I’m a vet and I do that for dogs – if it’s out of my league, no WAY will I attempt the surgery/procedure/treatment/etc. I’ve flat out told owners – “No, I won’t attempt X just because you say you don’t care about my inexperience.” No. I know my limits and I’m not afraid to refer. Absurd that midwives won’t do the same for BABIES.

    • Medwife

      Well… Yeah. Of course. I want my patients to be healthy. I want their babies to live.

      Am I weird that I’d rather have “colleagues” than “sisters”?

      • Guest

        First sentence made hair on my neck stand up. Sisters? I don’t have sisters, I have colleagues. Do accountants have sisters or do they have colleagues?

        • attitude devant

          see above.

      • attitude devant

        Yes, agreed. I prefer colleagues too. But I was consciously echoing all the talk I hear from CNMs who feel they must support their CPM midwifery ‘sisters.’ It was a rhetorical device, not a reflection of my own word preference.

  • Jessica S.

    So I guess we can assume that, from at least those specific reviewers, we won’t ever hear “home birth is SO SAFE. Just look at the Netherlands, the UK, Canada, Australia…” as a defense for it here in the US? *snark*

    • Young CC Prof

      Whyever not? Data from countries with practice standards show that it is inherently safe, so therefore no practice standards are needed.

      • Jessica S.

        Standards by proxy, ok!

  • araikwao

    I’m confused, I thought it was the evil OBs that don’t do evidence-based practice! Now you’re telling me that MWs don’t? What will the NCBers say about that?!

  • Stacy21629

    Speaking of “no standards”
    Apparently there’s a CPM somewhere in Arizona willing to take on this trainwreck:
    1. grand multipara #8
    2. twins
    3. TTTS – laser ablation surgery
    4. twin A died
    5. amnio patch to correct amniotic fluid leak after laser ablation surgery

    And mom is STILL planning a homebirth in 3-4 weeks time. What a way to waste all that has gone in to saving this baby’s life…and there’s obviously a midwife out there willing to take her on. If the baby dies though, it’s all in cyberspace forever.
    stevenandersonfamily.blogspot.com
    https://www.facebook.com/pages/Are-They-All-Yours/343733185737078

    • toni

      What a beautiful family. I hope there’s a happy outcome.
      How do people get so silly? Believing known risks don’t exist or apply to them?

      • Stacy21629

        Both, I think. That the risks only exist in and because of the hospital/OB environment.
        After all she’s been through with this pregnancy, reading her plans to homebirth make me so mad I could spit. I’m sure it will all be OK too and then she’ll parade about how safe homebirth is.

        • Young CC Prof

          Grand multip with twins, one stillborn? I hope SHE survives. Her other children need a mother.

    • Jessica S.

      Out of curiosity, what is the standard procedure when a twin dies during the pregnancy? Does it depend on the gestational age? So tragic. I hope it works out ok, but I really hope they would increase those odds by taking care of it in a hospital. Shame on whatever midwife takes this on.

      • Stacy21629

        As I understand, it does depend on the gestational age and whether the living twin is in danger. Pre-viability (as this mom was, I think 18 weeks-ish when the baby died) carry to viability/term or whenever you need to get them out. Post-viability if there’s any risk to the living twin you’d just deliver.

        • toni

          You have to keep the dead baby inside you? Did I misunderstand? Wouldn’t it decay?

          • Stacy21629

            No – there’s no bacteria or oxygen there to cause decomposition. Extracting the dead baby would almost inevitably kill the other baby as well. The dead baby will be misshapen from lack of space and pressure from the live baby but otherwise intact and preserved though decomposition will happen quickly once it is delivered.
            Just exactly what you want your other 7 children 12 and under to see at your homebirth, right?

    • no longer drinking the koolaid

      And they are asking for money to help cover the expense of the ablation. Long way from having enough.

    • araikwao

      So, applying NCB standards here (and these views are *not* my own), that was a lot of intervention. Who, then are the babies that “weren’t meant to live”? Does that only apply to near-term stillbirths and intrapartum deaths?

      (Sorry if this sounds awfully callous, it’s not meant to be, I just find the platitudes are so inconsistently applied).

    • JMac

      Mother of God, what a frigging whackadoodle.

    • Lombardi

      Just from glancing at this webpage I would say this mother is part of the Biblical Patriarchy or Quiverful movements. Which is a whole other level of crazy demand on woman on top of the living naturally.
      http://aboverubies.org/index.php/2013-11-12-17-55-51/english-language/birth-stories
      I wish Dr Amy would do a write up on these movements because they are a distinct and do not fit the typical HB mom stereotype. These are not new age hippies giving lip service to female empowerment. Feminism is a bad word in their world. They believe that the only way a woman can serve God is via the roles of home keeper, mother, and help met (totally obedient wife). Each child is a blessing and the use of family planning is against God. Each child is a weapon in the culture war to help bring God’s kingdom so the mothers of many are prized in the movement as the ultimate females. This movement puts a lot of pressure on families to keep women and children out of the world unless they are Evangelizing (which is why they can have websites, blogs, and in the case of the Duggars TV shows). Home birth is a way mothers in this movement prove their rejection of the secular world.

      • toni

        If memory serves Dr Amy already wrote a post on the duggars. I don’t recall her saying anything critical. Mrs duggar does not appear to have had all those children under duress and they all seem happy and well adjusted to me.

    • rh1985

      All I can think is how foolish she is after doing so much to save that baby…

  • Theresa Murphy Schmidt

    Please don’t lump all CNMs into one category. We don’t all feel that way, nor do we all practice in such a manner. There are many homebirth CNMs (I don’t do homebirth) who would gladly adopt a national set of standards. The majority do NOT attend twins, breech, or TOLACs at home. Yes, there are outliers, but they don’t represent nor speak for all of us.
    I practice in a freestanding birth center and have full hospital privileges. We have clients who risk out of birthing in the birth center, but could still have a hospital birth with us. Often times, they instead choose to have a homebirth with a lay midwife. This is because the CNMs will not provide them with the birth they desire… because we don’t feel it is safe. This is how most CNMs practice.

    • moto_librarian

      Do you not understand that even the authors of this article were dismayed by the attitude expressed by their peers? “We’re not all that way” is doing nothing to alleviate this problem.

      I say this as someone who was extremely happy with the CNMs who delivered both of my children in a hospital. I am extremely dismayed to see that most home birth providers care more about their own egos than the well being of their patients. You say that you aren’t a home birth midwife, so you are not being labeled as a problem. Please get over your hurt feelings and demand that the ACNM get off their collective ass and quit supporting crappy midwives.

      • Theresa Murphy Schmidt

        I do understand. And my feelings are far from hurt. I don’t think sampling 15 HB CNM’s is representative of all. As I said, I don’t do home birth. Nor do I want to. But I know many who do in other parts of the country, and I’m fairly certain that safety is their #1 priority.
        I know some who probably step out of their comfort zone because they know women will choose unassisted home birth, which is even less safe. I’m not defending their actions, just offerng another side to consider.

        • The Bofa on the Sofa

          What other side? The other side of straw?

          Then again, I’ve said it a ton of times. If your defense of your profession has to resort to “not everyone is awful” then your profession has a problem.

          Come on, Theresa, instead of crying about how it’s not you, why don’t you start kicking the shit out of the idiots who are doing this crap?

          Get on the offense and get them out of the business, so that you don’t have to spend your time defending yourself?

          What have you done today to get the bad CNMs out of business?

          You want to defend the profession? Get rid of the bad practitioners.

          • Deena Chamlee

            Bofa give her a break. I think she is brave to come in this forum and share.

          • The Bofa on the Sofa

            No, I won’t.

            I’m going to chide her as I have done with you in the past.

            I get so tired of the “oh we aren’t all terrible” defense. If you know there are bad practitioners and you don’t try to do something about them, then you are part of the problem.

            You’ve done it yourself, Deena. You’ve rocked the boat. It got you in trouble, but you’ve done it.

            And that is what it takes. More people doing that.

          • Deena Chamlee

            Well I certainly got abused vertically and laterally. But I don’t regret any of it. And FYI, I am glad you chided me. You all taught me and woke me up.
            They are standing up in Oregon, and this article is others standing up.

          • attitude devant

            Deena, hang in there. We appreciate your grappling with this

          • Jessica S.

            You take the chiding in stride. That says a lot about a person! :)

          • The Bofa on the Sofa

            and FYI, I am glad you chided me. You all taught me and woke me up.

            I know.

            That’s why I disagree with your request to back off. You are a great example of someone whose light-bulb went on, and, as a result, you are doing great things.

            It is people like you and Theresa that have the ability to make things happen. No one in the ACNM is going to listen to me. Or even Dr Amy, apparently. It has to start with the membership.

          • Trixie

            Thanks for being here, Deena.

          • Jessica S.

            *cheers*

    • Guest

      I’m curious. What are the risk out parameters at a birth center?

      • Guest

        I’m not being snarky. I really am interested in what risks out of a birth center. As a medwife I do not interact to much of a degree with birth center homebirth midwives, nor lay midwives. If I don’t interact with them in practice, I truly am isolated as to what degree the woo exists within our profession. I really am curious.

        On side note, in all fairness I believe SOB has been very respectful in its attempt to maintain a degree of separation between the CNM’s and homebirth CNM/CPM/DEM.

        • http://www.antigonos.blogspot.com/ Antigonos CNM

          This is part of the problem: “birth center”, just like “midwifery”, can refer to the whole gamut, ranging from the accredited institution in close cooperation with a medical center, staffed by CNMs, or a completely unequipped set of rooms staffed by birth junkies who claim to be midwives. Depending on the state, there can be absolutely no oversight or supervision.

        • meglo91

          Well, I can tell you that here in Alaska, the birthing center my friend’s baby died at does not risk out AMA primips with borderline GD who are post-dates (42+3). In fact, when my friend repeatedly asked questions like, “Is this safe? Should I be here?” she was told yes, of course. So it appears to vary considerably by location.

      • Trixie

        “Birth center” can mean lots of things. The birth center she works at is accredited and the midwives have hospital privileges and collaboration and transportation agreements with a local hospital. They refer out to OBs and MFMs and risk people out appropriately. Totally different than a couple of hack CPMs in a room.

        • Guest

          Thank you. That’s exactly what I was wondering.

      • Theresa Murphy Schmidt

        To birth in an accredited birth center, you must be healthy and have an uncomplicated pregnancy. No hypertension. No diabetes (except GDM well-controlled with diet & exercise). No breech. No twins. No VBAC. No previa or low-lying. No oligo or poly. No preterm. No one past 42 weeks. No one with abnormal FHT’s in labor. I could go on… The list is quite extensive.

        • Trixie

          And from what I hear, you are very quick to refer out to doctors, for any concern. And it’s the doctors who make the final determination as to whether the patient needs to be risked out to the hospital.

          I’m not sure if you’re a new reader to SOB; in many other posts she’s said repeatedly that she valued her working relationships with CNMs, respects most of them (at least the ones with hospital privileges) greatly, and that this seems to be a problem with ACNM leadership rather than most hospital-based rank and file CNMs. But you have to agree that ACNM is ridiculous.

          • Theresa Murphy Schmidt

            I am new to this site… stumbled across it when FB suggested it as a page I might be interested in. So no, I don’t know the entire backstory. I just felt like that post was universally anti-CNM all because of a few who don’t necessarily represent all of us. The same holds true for any profession — including OBs. Most are great, some aren’t. It’s the bad eggs that give the entire profession a bad name… and drive women to seek extremes such as unassisted homebirth or homebirth with an unqualified attendant.

          • http://www.antigonos.blogspot.com/ Antigonos CNM

            I’ve been around here — and Dr. Amy’s previous blog, Homebirth Debate, for years now. She isn’t against midwifery per se, just against the phenomenon of pseudo-midwifery that is US direct entry midwifery, and against US homebirth in particular because of the way it is practiced [no backup, etc.] which makes it even more dangerous than homebirth in general [countries such as European ones with all the standards, etc. in place still show homebirth to be more dangerous than hospital birth, but at least the dangers are minimized. In the US, “everything goes”.

          • Trixie

            I really hope you stick around! There are other CNM commenters here and I’m sure your perspective would be welcome. Dr. Amy tolerates dissent and does not delete or ban anyone except spammers. We all have things we have disagreed with her about, but the commenters here are really, really smart people.

            And yes, Dr. Amy has gone after bad OBs in the past as well.

          • Guest

            Please take the time to read through Dr. Amy’s post, you may find you’re glad you’re here. As a fellow CNM, I stumbled across this site years ago when pulling GBS lit years ago and came upon Wren’s story. I was hooked. This site has become a source of sanity when I feel like I am endlessly hitting my head against a brick wall in practice. At times a few commenters seem antiCNM, but the general tone distinguishes CNM’s practicing within the guidelines. It’s the risk takers and rogue practitioners that are being called out as a plague to mothers and babies. My identity is in the way I practice, not so much the title I hold which is why I became ok with the label I fought for so long: medwife. Some discussions on SOB may challenge your beliefs, but critical evaluation is part of our growth.

        • AlexisRT

          Supposedly (I have been told this multiple times, but I am not eligible for other reasons) both birth centers nearish to me will attend VBACs IF you have had a successful VBAC. I’m in your state. Both are accredited, and the midwives have hospital privileges. One also does home births (Lancaster County, however).

          • MaryAnne

            You are correct. Some birth centers do VBACs for women who met specific criteria.

          • Theresa Murphy Schmidt

            I’m not sure where my phone came up with “MaryAnne”, but this was posted by me (Theresa).

          • Deena Chamlee

            Lol probably April’s Fools

          • Trixie

            The Lancaster one will do second VBACs in the birth center but not at home. Which I’m not sure makes sense, since the birth center is pretty far from the hospital.

        • Trixie

          Do you allow water birth there? Not labor, but actual birth? I’d be curious for you to go back and read what she wrote about water birth last week.

    • The Bofa on the Sofa

      Please don’t lump all CNMs into one category

      Who did that?

      • Theresa Murphy Schmidt

        Indeed, the authors feel compelled to re-state the obvious requirement for ethical practice:

        Although ensuring client safety may at times conflict with provider and client preferences, safety is the first priority for improving the quality of health care.

        Apparently not for CNMs.

        This passage is what I’m referring to.

        • Trixie

          Okay, but the authors of the study are also CNMs, and she’s siding with them. She has written about the research of Judith Rooks, CNM, in Oregon being valuable data about the dangers of home birth there. She is not against midwives. She’s against the woo-infested leadership of ACNM, who for some reason defend CPMs and value autonomy over safety. She qualifies it by saying “American CNMs attending homebirths.”

        • Sue

          In most professional situations, the overall outcomes of the profession are a reflection of the degree of regulation and standardisation of practice. Otherwise, consumers have no way of knowing what to expect of their provider, and outliers with poor outcomes don’t bear the consequences or mend their ways.

          It is time for the professional organisations and regulators of the midwifery profession to hold all providers to account for their practice and outcomes. That should be no threat to people like you, but can reign in the rogues.

        • http://www.antigonos.blogspot.com/ Antigonos CNM

          To be honest, I’ve known obstetricians I wouldn’t trust to deliver a pizza, let alone a baby. But the system has ways of controlling them [eventually]. Why do these rogue CNMs think they can get away with anything? And they are “rogue”. Most of the US CNMs I know are responsible women.

    • Trixie

      The Midwife Center in Pittsburgh is a great organization; I’d be totally comfortable with a relative of mine being under your care, and I have several friends who’ve delivered there (some in hospital, some at the birth center).

      • Deena Chamlee

        More of us are excellent than are not. But we still have to change leadership in order to address homebirth and birth center birth. CPMs practice in both locations.

    • Busbus

      I’m glad you’re posting here, and I’m glad to hear about your practice! Please stay and read/comment more (even if you get some flak). One of the great things about this blog is that there is real debate in the comments. That debate needs to happen more places if we want things to change.

    • http://www.antigonos.blogspot.com/ Antigonos CNM

      I’ve never understood the American obsession with personal freedom and/or autonomy at ALL costs. I am very glad there are parameters I must not/should not cross in my practice. What these rogue CNMs don’t seem to understand is that there are limitations on what doctors can do, as well –they aren’t entirely free agents — possibly not spelled out by a “higher authority”[although loss of hospital privileges is usually a sufficient deterrent for a doctor who repeatedly transgresses hospital protocols] but in the form of censure by either committee or department head or, in extreme cases, by loss of license [vide Dr. Biter]

      I don’t think that a woman has a “right” to a home birth in any and all circumstances. I’ve never had a burning need to deliver a breech or twin pregnancy at home, I don’t have to “show the world” that I laugh in the face of established practice, and I have a tough time understanding why those who have the education to know better persist in thinking they are capable of bucking the odds.

    • The Computer Ate My Nym

      How far are you from the hospital? My concern with a free standing birth center is the lack of immediate access to OR and ICU facilities, a blood bank, etc, for emergencies.

  • Medwife

    That is extraordinarily disappointing.

  • http://safermidwiferyutah.wordpress.com/ Safer Midwifery Utah

    If someone chooses a midwife its usually because they TRUST the midwife more than a doctor, but they aren’t willing to make standards that would honor the trust women put in their care providers. Its disgusting.

    • Young CC Prof

      We should make a meme for that: Trust in your homebirth midwife is a one-way street.

  • Deena Chamlee

    Note the authors whose ethics are intact are not FELLOWS. They are PhD who are not inthe club because they have ethics. Yes I imagine this is just the beginning of US with ethics Standing Up.

  • Squillo

    Apparently the reviewers were under the impression that the purpose of guidelines is to support the practitioner in whatever she want to do.

    Great. Now I can disregard all those pesky editorial guidelines. Like Anne Rice, I don’t need no steenkin’ editor!

    • MaineJen

      Ooooooh I think she needs an editor… ;)

  • Happy Sheep

    I am a little confused – In Ontario, CNMs are allowed to attend HBACS, even on women without a proven pelvis. A good friend of mine was strongly encouraged to HBAC with her second through hospital based, government paid CNMS!

    • DaisyGrrl

      There is no requirement for Ontario midwives to be CNMs. They are required to complete a 4-year degree in midwifery, followed by a practicum (I think it’s at least 1 year). While I hope there’s overlap between the nursing curriculum and the midwifery curriculum, Ontario midwives do not have the same level of education as a CNM.

      • Haelmoon

        The Ontario guideline is that they have to support a women if they choose a HBAC. There is considerable disagreement between different groups of midwives in the province. Generally, those at the college seemed much more woo-filled than those I actually worked with in practice. I know at least one group that actively refused HBAC, even though they knew this might “get them in trouble” with their college.
        Here in BC, HBAC is officially endorsed, but not as widely supported. But it is not supported by the Obstetricians in generally – we actually have a memorandum that the midwives show their patients that we do not support the practice of HBAC and recommend that they all deliver in hospital. It is useful when the can show that their colleagues do not support a practice when discussing the risks with their patients.

        • Guestll

          The fairly large clinic of Ontario midwives who cared for my daughter and me will not do HBAC. Apparently the senior RM witnessed a terrible outcome years ago, and that was that.

        • DaisyGrrl

          I’m glad to hear that most Ontario RMs are sane. The leadership does come across as extremely woo-filled. Several local midwifery collectives also strike me as wooish (links to MANA on their website, etc).

          I was looking through some regulator websites a few weeks back and found letters relating to a push by Ontario midwives wanting to attend instrumental deliveries (this was from a few years back). The physicians’ group was clearly not enamoured of the idea and the midwives hit back with “but we’re experts in normal birth! We should be allowed to use the vacuum extractor.” It was alarming.

    • Becky05

      There is more disagreement about the rule against prior cesarean than some of the other rules, which can be seen in the chart above. I think this is fool hearty considering the evidence we have from VBAC at birth centers which isn’t reassuring.

  • http://kumquatwriter.wordpress.com/ Kumquatwriter

    Repulsive.

  • Deena Chamlee

    I told you all about the fellows. This fight will get alot more shocking before a complete collapse occurs. Very much like Rome.

  • Gretta

    Whoa whoa whoa… Hold the phone! I thought CNMs were the educated ones… The ones you could trust? The ones who worked with doctors? I’m so confused.

    • Young CC Prof

      I think the ones who work in hospitals are. The ones who do home births are just as bad as the other midwives, presumably because “medwives” know it’s impossible to do safe homebirth, especially in the USA where it isn’t integrated properly (no-pre-registration at the hospital, for example.)

      • Guest

        Exactly. Medwives can glance at the addendum provided in this study regarding proceeding with homebirth after consultation with a physician and laugh…seriously, how can you follow ACOG guidelines for management or induction of labor of chronic or gestational HTN in a homebirth setting? Many homebirth CNM’s ‘counsel’ on GDM screening and patients walk away with one fasting or PP glucose as a ‘negative’ screen so consults won’t happen. And oligohydramnios is kind of like breech, if you don’t look for it it doesn’t exist so you don’t have to consult or refer out if it exists. The list is endless in how lack of conformity to standards of care will not change a thing even if guidelines like this were adopted.

    • Anj Fabian

      I suspect the average CNM is still all that.

      The people who have the power are apparently extremists.

    • Squillo

      The reviewers in question were “[f]ifteen American Midwifery Certification Board, Inc. (AMCB)-certified home birth midwives who participate in the American College of Nurse-Midwives (ACNM) home birth electronic mailing list,” so it is possible that they aren’t representative of CNMs as a group, or even of CNMs who do homebirth.

      • The Bofa on the Sofa

        But they are “Board Cerfified”

        Granted, Jay Gordon is a Fellow of the AAP and is a total whack, but it just happens that this sample of board certified HB midwives just happen to oppose guidelines?

        OBTW, if you look at the paper, the authors emphasize the fact that they were all supportive of guidelines beforehand, but changed their tunes when they found out what they were.

        • Trixie
        • http://www.antigonos.blogspot.com/ Antigonos CNM

          “Board certified” depends a lot on which Board is doing the certification.

          • The Bofa on the Sofa

            Yeah, but if the problem is a board with bad standards certifying loons, then you can’t argue that these 15 are unrepresentative of CNMs doing homebirth. In fact, you seem to be saying that these 15 are basically what you expect given the board certification standards.

          • http://www.antigonos.blogspot.com/ Antigonos CNM

            To be honest, here is where I’m out of the loop, because I’m not in the States. Precisely how “Board Certification” for nurse-midwives works is unclear to me, but I presume each state has its own board, and its own criteria, and a CNM must, like an RN, get a license for the specific state in which she intends to practice. If so, what is sufficient for one state might not be elsewhere.

            Here is where the lack of national standards, and national certification/licensing can be problematic. During my years in the US [left in 1974], registered nurses licensed only in the states of California and NY had reciprocity for licensure in all other states because the licensing criteria in those two states were the strictest. An RN coming from, say, Washington, DC, to NY had to repeat her licensing exam and possibly even do additional courses before being accredited.

          • The Bofa on the Sofa

            I presume each state has its own board, and its own criteria

            No, they are certified by the “American Midwifery Certification Board, Inc. (AMCB)”

          • Squillo

            It is confusing, though, because a state may have a state midwifery board, but that doesn’t have anything to do with certification or credentialing. Just like the state medical boards have nothing to do with whether or not someone is an MD or is board-certified in their specialty–they just determine whether or not a doc meets the state’s criteria for practice.

          • Squillo

            Yes, it’s the difference between licensing and certification. Each state has its own licensing requirements, but the certifying body for CNMs/CMs is national. You cannot be a CNM or CM in the U.S. unless you are certified by the AMCB. You can, however, be a “licensed midwife” without being AMCB-certified. (You can also be a CPM, which is a national credential, without being licensed by the state.)

          • Medwife

            Every certified nurse midwife or certified midwife had passed the AMCB exam. To get a license you apply to your state board (usually nursing board, I think in some states the medical board is the licensing body). Most states require you to maintain your RN license as well. To maintain your AMCB certification you have to pay every year and complete a certain amount of continuing ed hours as well as AMCB specific modes. The state licensure maintenance has its own payment and CEU requirements.

          • http://www.antigonos.blogspot.com/ Antigonos CNM

            Thanks for the information.

          • Medwife

            There is reciprocity among many more states now.

      • http://www.antigonos.blogspot.com/ Antigonos CNM

        The quote you have above does NOT actually state that the participants are CNMs. It is possible to join ACNM without providing evidence [beyond your say-so] that you ARE an actual CNM.

      • manabanana

        15 AMCB trained midwives.

        Out of 13,000 in the US.

        Clearly this is a representative group.

        • Squillo

          I agree–I don’t think it’s necessarily a representative group. If they were recruited from a homebirth discussion board, they are probably the most vocal and interested in homebirth, and possibly the most “radical.”

          • The Bofa on the Sofa

            BUT

            they are also Board certified, which means that they have been designated as HB practitioners.

            How many HB certified midwives are there? Certainly not 13000.

  • Amy Tuteur, MD

    My husband actually called me from work to ask if I’m sure that the paper is not an April Fool’s Day joke being played on me. He couldn’t believe that any professionals would actually admit to such blatantly unethical behavior.

    Even the authors are shocked.

    • The Bofa on the Sofa

      Btw, do you know the authors? They refer to the outcome of the HB summit, so it sounds as if they were participants, so that would mean that they are not unfamiliar with the community. Or so they thought.

      • manabanana

        One author, Elizabeth Cook, is a former CPM. Shortly after completing her CPM, she went on to become a nurse, a CNM and a WHNP, she’s also completed a DNP. Have to wonder what caused that change – because no woo-infected lunatic goes through that much schooling to endorse homebirth.

        http://works.bepress.com/elizabeth_cook1/cv.pdf

        Melissa Avery and Melissa Frisvold are about as far from rabid home birth advocates as you can get.

        http://www.nursing.umn.edu/faculty-staff/melissa-frisvold/index.htm

        http://www.nursing.umn.edu/faculty-staff/melissa-avery/

        This article is an attempt to address the problems with OOH birth and the lack of safe practices standards in OOH birth.

        • Medwife

          I know a couple people who became CPMs and in the process realized they wanted a better quality of education. Neither of them attend home births now.

    • Anj Fabian

      I am appalled, but not shocked and not surprised.

      Someone who was burned by her homebirth midwife was shocked and gratified that I and others believed her. I told her that I had read and heard so many home birth stories that sounded very much like hers. The pattern is familiar.

      Midwives rejecting responsible, ethical practice because they reject almost every constraint on their practice? Many times we have seen the American midwives do that and say that.

      This time it’s louder, clearer and with more feeling. That’s the only difference.

      • Squillo

        I’m not surprised either. Autonomy is a (or maybe “the”) big issue for advanced-practice nurses as a group right now. Guidelines are not regulations, but I suspect the ACNM leadership isn’t going to be anxious to take up the cause of anything that is even perceived as conflicting with that.

        • Amy Tuteur, MD

          Sometimes I wonder if the emphasis on autonomy comes from jealousy of female physicians. Until the last few decades, women could not be autonomous medical professionals because the barriers to entry to medical school were too high. Now medicine, and obstetrics especially, is filled with autonomous women physicians and some midwives and nurses resent those women and simultaneously crave the autonomy and respect that women physicians command.

          • Deena Chamlee

            Amy come back …….it’s not that. There will never be autonomy, only shared autonomy with docs regardless of gender. Until we can manage ourselves ethically and accept responsibly for such midwifery is doomed for failure.
            Respect is earned and not given freely without trust and ethics.

          • Trulyunbelievable2020

            What women physicians are autonomous from standards of care?

          • Amy Tuteur, MD

            Female physicians have professional autonomy (to determine who needs an induction, for example), NOT autonomy from practice standards.

          • attitude devant

            Yes, but I’m an autonomous woman physician, and I follow practice standards…..

          • http://www.antigonos.blogspot.com/ Antigonos CNM

            This is an excellent point, Dr. Amy. And, it needs to be remembered, that it was only in the 60s that the principle was legally established that a nurse is responsible for her own actions, and could not use as a defense “I was given an order to do such and such by an MD” [or the MD demanding that a nurse follow an order she felt was wrong, with "I am in charge of you; you do what I say, the responsibility is mine"'] The concept that a nurse and doctor COLLABORATE in care, rather than the former being subordinate to the latter, is a fairly new thing.

    • Trixie

      It would be pretty great if someone were to leak the names and choice comments of some of these CNMs from this listserv.

      • Medwife

        Oh, they got the reviewers as volunteers from the listserv? Ha! That would explain it. Bunch of whack jobs (at least the most vocal contributors are).

        • Trixie

          That’s how I read it; I don’t know anything other than what was written above.

    • Amazed

      My first thought was that this post was an April Fool’s Day joke being played on US!

  • no longer drinking the koolaid

    I am thinking that this is because the CNMs who do home births were already of the mindset when they went to midwifery school, that this is how they would practice. Just had a friend CNM write me that she is leaving a hospital based midwifery practice to join a hospital based freestanding birth center. She is thankful that she can now practice as a midwife, rather than a medwife. She was asking for good reference books so she can learn all about herbs and other non-allopathic healing methods. I have a couple of those books, but I put little stock in them. She just assumed I would know. This is the assumption the public has about CNMs, and that CNMs have about each other.
    I am very disappointed in my own kind. All the horn blowing that we do about EBM and this is what it comes to.

    • Guest

      Imagine the difference it would make for CNM’s to have a decade or two of L&D nursing experience under their belts before going out to make rogue decisions and ignore EBM. It’s one thing to attend a few dozen births and remain ignorant, the volume of experience isn’t there and the ‘warnings’ and ‘risks’ can be brushed off. Put those future CNM’s in a community hospital on night shifts for a few decades and they may come away a bit more jaded and less able to fall for the woo. When bad things happen and your resources are limited, you become grateful for the ready access afforded in an institutional setting. Instead we have new nursing grads who can’t wait to ‘catch babies’ and become CNM’s who readily continue the on the path of woo, blatanly ignorant of just how bad ‘bad’ can really be at home.

      • Amy Tuteur, MD

        Imagine the difference it would make if homebirth midwives were ethical. They are apparently under the impression that their autonomy is more important than whether babies live or die.

        • Guest

          Until otherwise shown, there is no construct within my limited comprehension in which ‘homebirth midwives’ and ‘ethical’ can intersect. It just doesn’t. Wouldn’t it be refreshing to hear from a few homebirth CNM’s to understand what efforts they take to ensure their practice is evidence-based and their population of women are truly low-risk. Better than that, I would like to hear them speak out against how unethical their rogue homebirthing counterparts are. Do THEY see a distinction. Medwives have spoken out to distinguish themselves, let’s hear it from HB CNM’s?

  • Just Saying

    Part of their consent form:

    “I have voluntarily chosen for the upcoming labor and birth of my child to occur in a home setting until such time arises that it is necessary or desirable to be transferred to a an acute care facility. I am aware that in an emergency situation transfer to a hospital may result in a delay of care. I hereby assume full responsibility for the consequences of my decision to attempt a home birth.It’s always the patient’s fault when something goes wrong”

    The midwife is never wrong. She does not make the decisions. Ever. Probably the best proof how unprofessional they are.

    A plummer, a car mechanic, takes more responsibilities for his work.

    • Mishimoo

      Lots of the guys in my family are mechanics, they can (and will) be held legally responsible if their work causes or contributes to injury or fatality. If someone screws up in a workshop, the customer’s family and friends tend to raise a huge fuss and spread awareness that “Hey, don’t go there! That workshop sucks, there was an incident and we’re very unhappy about it”. Sadly, this doesn’t seem to be the case for homebirth midwives.

      • DaisyGrrl

        But I’m guessing workshops carry professional liability insurance for exactly such an eventuality. You know, so if someone is injured as a result of their work there is actually money to compensate the victim. Why homebirth midwives think they’re exempt from liability is beyond me.

  • Josephine

    OT: My twins were born by c-section yesterday at 36w, 3d! No NICU time needed. Baby boy is 6 lbs, 14 oz. and baby girl is 5 lbs, 13 oz. Both have great blood sugars (despite my pretty intense gestational diabetes), are learning to eat pretty quickly, and they are holding their heads up and looking around. I had a great team of doctors and nurses despite there being a few slightly scary moments during surgery, and I am very happy. My mild preeclampsia appears to have gone as well, thank goodness! Special thanks to Amy M for all the advice these last several months. Hope you all have a wonderful Monday.

    • Young CC Prof

      Awesome! So glad they are here and safe and thriving!!!!!!

    • Anj Fabian

      Happy babies day to you!
      Have a smooth and comfortable recovery.

    • moto_librarian

      Congratulations! So very glad that things went well!

    • Mel

      Congratulations!

    • Carolina

      Happy birthday to your babies! Good job getting them here. What a nice outcome

    • Dr Kitty

      Congratulations!
      Enjoy them, and hope your recovery is quick and easy.

    • Burgundy

      Congratulations! Twins rocks (a twin myself)!
      Hope you have a speedy recovery and have lots fun time with them.

    • Amy M

      Congratulations!! Good luck and feel free to ask more questions! There’s an FB page called “STuff 4 multiples” that u might find helpful.

    • Mishimoo

      Oooh congratulations on the safe arrival! So glad that you’re all doing well despite the scariness.

    • Amazed

      Congratulations and welcome to the newest additions to your family!

    • araikwao

      Congratulations, that’s wonderful to hear! All the best with recovery and settling in with your newbies!

    • Jessica S.

      Hooray! Those are good sized twins! Congrats and enjoy, momma!

    • Busbus

      Congratulations! That’s wonderful! Wishing you all the best for your recovery and the first few weeks!

    • http://www.antigonos.blogspot.com/ Antigonos CNM

      Mazal tov!

    • Maria

      Congratulations!

    • anion

      Awesome news, congrats!!

  • The Bofa on the Sofa

    Oh, so rich in content. Let’s see….

    The reviewers specified that the proposed guidelines might not support them if they choose to attend the home birth of a woman with a breech presentation or a twin gestation or a woman who desires a trial of labor after a previous cesarean.

    “Might not support them”? Ya think?

    The following criteria for planning a home birth emerged: determination of low-risk pregnancy, informed consent, hospital transfer if complications arise, singleton pregnancy, fetus in the cephalic presentation, no history of previous cesarean birth, and term pregnancy.

    Um, no maybes about it. This explicitly says no twins, no breech, no HBACS.

    Five different countries; agreed upon basic standards for care… rejected by the CNM reviewers.

    And remember, these 5 countries are routinely trotted out as the models of HB midwifery. So it’s “Why can’t we be like the Netherlands?” OK, here’s what you need to do. “Oh no, we can’t be like them.”

    Normal birth has been defined …as spontaneous labor with a singleton fetus in a vertex presentation at 37 to 42 weeks’ gestation after an uncomplicated pregnancy. This definition is consistent with the World Health Organization definition.

    Wait – the WHO doesn’t consider twins or breech to be a variation of normal? But they do recommend breastfeeding until the age of 2. I thought they were wise?

    Now comes stunning confirmation that American CNMs attending homebirths are equally ethically bankrupt.

    I think this is the key issue.

    CNMs can be great working within the system. However, those that are running off doing HBs are not representative of CNMs on the whole. They are the extreme of the lunatic fringe (although I fear that the lunatic fringe itself does extend even into the hospital).

    Articles like this are really insightful, however, in that they really expose the seedy underbelly of what’s happening. Maybe this will catch the attention of more CNMs and make them realize just how far out there their sisters are.

    Seriously, who, among the legitimate CNMs, could not read this and say, wait, what? You can’t accept the basic, core guidelines for midwifery from the places where midwives are most common? What is wrong with you people? What do you think you are doing?

    • theadequatemother

      equally likely they will see the sample of 15 and decide it’s not “representative”

      • The Bofa on the Sofa

        Possibly. Did any of the HB midwives actually say, “That looks great! Let’s do it!”

        • no longer drinking the koolaid

          Or, better yet, “No problem. I already practice this way.”

          • Young CC Prof

            There probably are some. Pity there’s no way for their clients to find which ones they are.

      • Young CC Prof

        Probably. Five out of five countries have detailed and specific guidelines? Just a coincidence! I mean, that’s p=0.03, doesn’t mean anything!

    • DaisyGrrl

      Having seen the numbers on breech birth in the MANA study, I can’t understand any midwife in her right mind wanting to take on that kind of risk. I’m also not seeing how they can call homebirth safe while simultaneously not following any safety protocols.

      I suspect that the absence of guidelines is intentional. A poster a while back was saying that in malpractice suits, the plaintif must demonstrate that the care provider fell below the standard of care. Organizational care guidelines help establish what a reasonable practitioner would and would not do. By not outright banning breech homebirths, the ACNM is covering its collective ass. If there’s no prohibition on the practice and other practitioners are engaging in the practice, it becomes harder to say that the conduct was malpractice. I don’t know how lack of informed consent would work in a possible suit, but the lack of a professional scope of practice/standard of care would certainly be a major hurdle to overcome.

      • Young CC Prof

        Actually, I think some of the breech homebirths were inadvertent. Careful reading revealed 118 transfers for “malposition” and a great many breech babies delivered by c-section. I think there were quite a few surprise breeches in the MANA study, although they didn’t say anything about it one way or the other.

        • DaisyGrrl

          That makes it even worse in my mind. The numbers sucked. Either the midwives weren’t properly screening their clients or they didn’t know how to properly identify position (hence “surprise” breeches). Regardless, the numbers were bad enough that attending a planned breech homebirth should be prohibited.

          • Young CC Prof

            As in many other instances, poor screening is not an excuse for poor outcomes, since screening is part of proper practice.

            Or, you could be like a six-year-old trying to win a game. “No, that one didn’t count! I wasn’t ready!”

          • http://www.antigonos.blogspot.com/ Antigonos CNM

            It can be assumed, I think, that a significant proportion of women who want to deliver at home do NOT do much, if any, prenatal testing [as being "unnecessary"]. That means a homebirth midwife is essentially walking blindly into who-knows-what kind of situation, which ought to be, in itself, enough to risk out a patient.

      • Squillo

        I can’t understand any midwife in her right mind wanting to take on that kind of risk.

        Because there is no risk to her. She’s not going to be sued, she’s not going to be arrested unless she’s unlicensed in a state that requires one, and she’s not going to be disciplined by any midwifery body. The odds are still in her favor that no one will die as a result of her stupidity, and she gets to brag that she’s delivered breech babies. Remember, homebirth midwifery is all about the midwife, not the client or baby.

        And yes, I agree that the current lack of guidelines is intentional, but I also suspect it has less to do with malpractice concerns (in this case) than it does with the fight to get homebirth reimbursed by insurance.

        • DaisyGrrl

          Good points. I think the fight to get insurance reimbursements is going to blow up in their face though. NICUs are expensive and if midwives don’t practice in such a way as to minimize their risks, the insurers won’t reimburse their services.

          • Busbus

            You’d hope.

        • The Bofa on the Sofa

          Can you connect the dots for me?

          1) midwives can do whatever they want
          2) …
          3) Insurance covers it
          ?

          There’s an Underpants Gnome problem here that I don’t understand.

    • Amy Tuteur, MD

      I suspect that it won’t change the minds of the ACNM leadership, which is what really counts. They have repeatedly demonstrated they value their professional autonomy over scientific evidence. I imagine that they support MANA for the same reason. They don’t agree with what CPMs do, but they suppport their right to do it.

  • Lori

    This is so disappointing because a measure like this is, in my opinion, exactly what is needed to bridge the gap for people who are going to seek out a homebirth regardless (the types who end up with CPMs or DEMs) to still ensure safe practice standards. I think the majority of women interested in homebirth would not pursue it if there were a clear safety guideline of which they fell outside of the criteria.

    I can’t speak for everyone in Ontario obviously, but it does seem here that, while homebirth is viewed as a reasonable option that is desired a significant minority of the population, when someone is “risked out” they don’t shrug their shoulders and go looking for some unlicensed quack provider or attempt to have an unassisted homebirth. Could be I live in a less “crunchy” area or something, but it does seem like people trust their providers when they are told it isn’t safe to try for a homebirth because of x, y, or z reasons.

    • Lori

      Or maybe I am too cynical and they are just punking us. It is afterall April Fools Day…
      C’mon CNM’s you didn’t really mean it, did you?

    • Busbus

      I agree with this. There might be a fringe of UC-inclined nuts out there, but I also think that most homebirth clients who stop being low risk would absolutely transfer care to a doc IF APPROPRIATELY COUNSELED. (Saying, “the ultrasound technician will play the dead baby card” does not count.)
      It means having the professional ability to “disappoint” your clients and not sugarcoat anything. It means having standards that you, the homebirth midwife, will not break – not even for your clients’ “ideal birth” wishes – because it is THAT important.

      I actually think that a lot of homebirth clients would be *more* inclined to follow their homebirth midwife’s recommendation than their OB’s recommendation (“if even my midwife thinks it’s dangerous…”).

      In any case, I think that the argument that women will go to have a UC if the midwife doesn’t attend her is faulty for two reasons – 1st, if you cannot convince a mother with risk factors to go to the hospital, you are doing it wrong and should work on your delivery (no pun intended). And 2nd, if a client would really rather UC than go to a hospital, and against your recommendation at that, then I think that you shouldn’t have taken her on as a client to begin with. Midwives who do take on these kinds of clients have chosen to do so – they operate in the fringe and make money off it. They are not blameless “victims” of their nutty clients.

      • Comrade X

        In the UK, midwives and doctors don’t get to “fire” patients for doing stupid shit, but women who homebirth against medical advice are as rare as hen’s teeth. We have proper risk-out criteria and proper pre-natal monitoring, all free at the point of use, and we don’t have any kind of epidemic of crayzeh bitchez UC-ing from Land’s End to John O’Groats. The “safety standards will just lead to more people taking insane risks” thing is pure bullshit.

  • The Computer Ate My Nym

    The primary concern expressed was that an adoption of national guidelines could compromise provider autonomy.

    You say that like it’s a bad thing. Yes, there are and should be limits on provider autonomy. I can’t prescribe imatinib for cancers other than CML and GIST tumors, no matter how much stock I have in Novartis (none, as it happens, but someone could…) I can’t give patients treatment that they don’t consent to no matter how much I think it will help them. I can’t run an experimental protocol without IRB oversight and informed consent. And I can’t step out of the bounds of accepted standard of care without very good reason, documentation, and agreement by the patient. These are limits on my autonomy which are there for the good and sufficient reason that individuals aren’t all knowing or inevitably ethical and no organization can truly be trusted to police itself. Welcome to the real world.

    • The Bofa on the Sofa

      I just don’t understand the idea that having professional standards infringes on “autonomy.”

      If that is the case, then NO ONE has autonomy in any profession. Good gravy, they seem to think that they should be able to do anything they want. No one can do that. We all have to adhere to standards.

      • Young CC Prof

        I have to show up for class at the scheduled time, provide grades and other paperwork, and stick to my syllabus, which was based on a course outline written by departmental consensus. Oh the humanity! It’s infringing on my autonomy!

        • The Bofa on the Sofa

          OT, but yes and no. Actually, no, you don’t HAVE to stick with the syllabus. It’s your course, you can teach what you want. Academic freedom, and all that (besides, you’re tenured – what are they going to do? Fire you?)

          Moreover, even when you do it, you don’t have to do it well. You can phone it in.

          OTOH, it does not work well to be a person who does not work or play well with others, and there will be consequences in terms of having to do things that you’d rather not be doing (and monetary issues – the dept can absolutely cut your salary)

          • Young CC Prof

            Actually, I can’t have my salary cut except as across-the-board reductions due to financial exigency. I CAN be fired for failing to fulfill the basic requirements of my job. Tenured teachers being actually fired is pretty rare, but tenured teachers quietly resigning when they know the employer has a good case… it happens more often than many people realize.

            And of course, the department can totally schedule me for that 8 am class and 7 pm class, four or five days a week.

          • The Bofa on the Sofa

            And of course, the department can totally schedule me for that 8 am class and 7 pm class, four or five days a week.

            This is a more likely outcome.

          • DaisyGrrl

            They might also stick you with all the intro classes. Then “lose” the funding for a TA to help with grading.

            I’ve attended a couple of faculty meetings where schedules were discussed (small department, many many required courses for the degree). It was invariably the most fractious meeting of the year.

          • Young CC Prof

            I’m a CC prof (Community college). I already teach mostly intro classes, and we have no TAs. (luckily, we also have small classes, mostly <30.)

            Fortunately, schedules are written by the chair, not by committee. You tell him what you would prefer, he accommodates you as far as the needs of the department permit, as long as you haven't made yourself too obnoxious lately.

      • sleuther

        Heaven forbid my contractor and the electrician he hired to wire up my kitchen don’t believe in any of this “professional standards” or “housing code” garbage GAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACCCCKKK (sorry just got electrocuted)

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    It’s almost like homebirth CNMs are striving to meet the lowest common denominator – BC and Manitoba allow HBAC’s so they must be okay and Manitoba apparently thinks that both breeches and twins are also suitable for homebirth, so that too must be okay!

    • http://www.antigonos.blogspot.com/ Antigonos CNM

      I am curious: to what extent do midwives in Canada have permission for what most of us would consider dubious levels of risk for home birth because there are significantly large patient populations living in remote regions where hospital birth is difficult to arrange?

      [Probably seen too much "North of 60" and read too many Dana Stabenow/Kate Shugak novels]

      • DaisyGrrl

        I wonder about this as well. The discussion downthread about Manitoba is enlightening. I would have thought that the homebirth criteria would have allowed for some distance from the hospital because of the pockets of remote populations.

        I know that there are special considerations for aboriginal/northern populations but I don’t know the details (especially in these remote communities). Even 10 years ago, it was common for women to fly south to give birth in the city (they’d fly out a few weeks before due and stay in special housing). I suspect this is still common (I have a friend who lived up north when she was pregnant two years ago and flew south for the birth). So for these populations, it makes sense to have a bit more latitude to attend out-of-hospital birth. This is, of course, assuming that women have true informed consent and the ability to freely choose between home and hospital.

        If you’re interested, I found an overview of aboriginal midwifery practices in Canada: http://www.aboriginalmidwives.ca/aboriginal-midwifery/practices-in-Canada

        many of them are in remote regions.

  • DaisyGrrl

    Wow. That is shocking. Nurses should be concerned with providing the safest possible care to their patients. While not every patient will accept every recommendation for intervention, it is absolutely unacceptable that CNMs refuse to adopt safety standards that are in the best interests of their patients.

    I have said before that the philosophy of midwifery is fundamentally flawed and anti-woman. I would really like to see a group of midwives anywhere prove me wrong. While I know that there are individual midwives who practice prudently and think this type of behaviour is unacceptable, I have yet to see anything coming out of a major group of midwives that demonstrates an overriding concern for patient safety.

    • The Bofa on the Sofa

      Is this what you really think or is it your herpes infection talking?

      (sorry, I have been laughing at that all morning; I just had to bring it up)

      • DaisyGrrl

        :) I’m glad it made someone smile. I can’t wait to get home to check out the youtube video.

        • The Bofa on the Sofa

          When you do, you will realize why I am going to call you Ramone from now on.

  • Mel

    I do not understand this obsession with autonomy.

    You can theoretically be completely autonomous in your day-to-day life, but the second you start a job, business or career, you trade absolute autonomy for income – a decision that 99% of adults make without angst or regret.

    Relationships curtail autonomy, but most people have multiple relationships.

    In short – If autonomy is the absolute, cardinal virtue by which you base all decisions, move to the middle of nowhere and be a hermit. For the love of God, DO NOT BE A MIDWIFE.

    • The Bofa on the Sofa

      The problem with “autonomy” in work is that it comes with responsibility. You don’t get to be autonomous in your job because your boss is responsible for your outcomes. Therefore, you answer to her.

      So the question is, do the CNMs who insist on autonomy also handle the responsibility? What recourse is there for patients if they screw up? Doctors have that, in spades. Doctors pay for their mistakes (literally). You want autonomy? Got malpractice insurance?

      And then you get into the problem. If you DO have malpractice insurance, you can’t be doing crap like hb twins, because the insurance won’t cover it. Then again, so what? If you do mess up, what’s the patient going to do?

      Autonomy comes with responsibility.

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    OT – the woman in Ontario (the one that had a transverse baby, who has moved into position since and could not get an epidural) has come to an agreement with her OB and the plan is currently a planned cesarean under a general. She is very relieved. I am hoping everything goes well.

    • DaisyGrrl

      What a relief! I’m glad she and the OB were able to come to an agreement and I hope all goes well for her.

    • alannah

      I’m glad to hear it. From everything I’ve heard before I really hope that this won’t end up as another example of ‘Canadian cesarean bait and switch’. You haven’t had a cesarean until you’ve had a cesarean.

      • http://Www.awaitingjuno.blogspot.com/ Mrs. W

        I wish there was an actual measure for that – I’d love to know exactly how often it happens.

    • Dr Kitty

      I hope it all goes to plan, but would advise her to document everything carefully.

  • wharves of sorrow

    I would feel safer with an OB who will do interventions right away than a CNM who might wait longer to get me interventions than an OB would.

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    It’s amazing that midwives would rather provide rather convincing evidence that the practice should be banned rather than aggressively adopt safety standards and regulations in order to effectively defend the option as being reasonable. I guess they’d rather ALL be unemployed, rather than just having those who are unqualified find alternate employment.

    • The Bofa on the Sofa

      This is something I hinted above. Following these types of guidelines has not prevented midwifery from succeeding in all the other countries. In fact, if you think about it, if midwives practice more safely, they can actually expand their opportunities. It is the fact that they are careless gits that cause the problems.

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    I note British Columbia, Manitoba and New Zealand allow for home birth after cesarean…1 in 200 risk of uterine rupture, that absent urgent cesarean and medical management has devastating consequences. Further, absent CEFM, has a high risk of going undetected until it is far too late. So do these jurisdictions value vaginal delivery over healthy outcomes? Are they cost conscious to the point of callousness?

    • wharves of sorrow

      Either way they are putting female life at risk and I find that very sexist.

    • theadequatemother

      Why do you think that Manitoba allows attempted twin and breech home delivery if a physician signs off on it? Is it because of a large population of mennonites that won’t accept provincial insurance and pay for all their care out of pocket? Anyone know?

      • Zoey

        As a Manitoban with some (non-professional) interest in this, my understanding is Manitoba’s legislative framework (The Midwifery Act and Regulation) establish the College of Midwives as a self-regulating body that develops and enforces it’s own standards of practice. Most midwives in Manitoba are CNMs (although a few are the equivalent of CPMs because they were grandfathered in if they were practicing before regulation in 1999). Therefore, it is reasonable to assume that the midwives in Manitoba feel like they can handle these complications in an out of hospital setting based on whatever evidence they use to develop their standards of care. However, their standard of care for women past 40 weeks is to administer herbal and homeopathic remedies to attempt to induce labour, so I have my doubts about the quality of evidence on which all of the recommendations are made.

        And most Mennonites, at least those living in a colony far from Winnipeg probably won’t be eligible for a home birth in Manitoba. A lot of rural women here are incensed that midwifery standards don’t allow them to give birth at home when home is a significant distance from the nearest hospital. I remember seeing lots of Mennoite / Hutterite women at my prenatal appointments with my OBs as well, so some get conventional medical care for sure.

        • theadequatemother

          I’ve cared for them as well…they pay privately but generally accept modern conventional medical care.

          Thanks for your considered answer.

          • Zoey

            No problem. Not sure how helpful it is though.
            I have a lot of personal reservations with the way midwifery is practiced here to be honest. But, I find that most women are more concerned with increasing access to out of hospital birth and licensing more midwives than changing the standards of care to be safer for mothers and babies.
            I do know that our “birth centre” (an out of hospital birth centre about 15 minutes drive from the nearest hospital with no ability to handle emergencies or on site physician back up) will not take VBACs I know for “political reasons” – basically because this centre cost millions of dollars in public money and it would look really bad if a baby died what would be a preventable death there. Apparently they are lobbying government right now to change this though.

          • theadequatemother

            I thought the birth center in winnipeg did have a death or a near death/ HIE outcome or near miss (can’t remember) and was shut for a while and has now reopened.

            I have personal reservations with the way midwifery is practiced also. I get involved with those patients when they transfer from home (usually for epidural due to pain/ exhaustion). Have seen two neonatal deaths under midwives (both hospital births!!!) and one after homebirth transfer (wasn’t involved, heard from colleague when I relieved in AM)…and that’s in just a few years of working part time / mat leave etc. Lots of 6 hr + pushing, some followed by PPH.

            But I’ve also seen our midwives expertly handle a cord prolapse on the way to the OR and shoulder dystocia and facilitate needed interventions. So I think its really uneven.

          • Zoey

            Not sure about that, but it would not surprise me at all if there had been an incident. I feel like it’s only a matter of time until there will be one.

            If there was a close call or incident, then it didn’t make it into the media. Most media stories about the birth centre have been around how it sits empty most of the time because high risk women can’t use it and women that want a home birth give birth at home. I have always felt that it was a big waste of money and that they could have better used the money used to build it to improve the two maternity hospitals here. Having to share a room with 4 other women post-partum was pretty crappy, so there’s a lot improvements that could be made to the hospitals for sure.

          • Jessica S.

            Good god! You shared a postpartum room with 4 other women? I think I would’ve had a nervous breakdown.

    • Michelle

      No, they don’t allow for home birth after caesar in NZ that I know of, and in fact require consultation with an obstetrician, and birth in hospital with appropriate monitoring. I think it’s covered under “low risk” and other guidelines put out e.g. “Care of women with breech presentation or previous caesarean birth.” rather than criteria for home birth itself which is why it doesn’t appear. It’s an given that these guidelines and other practice criteria (such as hospital protocols) for managing such situations as VBAC is followed.

      The guidelines for VBAC say (in part): “All women who have had a previous caesarean must be referred for consultation with an obstetrician during the antenatal period, preferably prior to 36 weeks.” and “There should be immediate access to obstetricians/paediatricians and caesarean facilities.”

      Similarly the guidelines for breech say (in part) despite it not being stated baby must be cephalic: “Women with uncomplicated (extended or flexed leg) breech presentation at term should be offered a caesarean after full discussion of the risks and
      benefits.”

  • moto_librarian

    I am simply stunned. I truly believed that CNMs as a whole were committed to evidence-based practice. I have become increasingly concerned over the years by the infiltration of woo into the CNM model of care, but I didn’t realize that it had actually become the norm for those presiding over home births.

    I have never suggested that home birth be made illegal, but the fact that even CNMs are more interested in preserving their autonomy over the well-being of their patients should give pause to any woman considering a home birth in the United States. I think that midwives are obligated to share this information with their patients, but I doubt that they will. Keep doing what you’re doing, Dr. Amy; you may be the only avenue for presenting the truth to women and their families.

    • wharves of sorrow

      I think it should be illegal to give birth at home intentionally. I also think it should be illegal for a healthy person to not be vaccinated because it only puts the vulnerable at risk.

      • moto_librarian

        I disagree wholeheartedly with you regarding home birth. I still believe that a woman has autonomy over her body. If she is mentally competent, she cannot be compelled to give birth in a hospital. Ethically, I have huge problems with a woman who values her experience over safety for her baby, but the thought of forcing her into a medical procedure leaves a very bad taste in my mouth. I firmly believe that if we would stop licensing quack midwives, there would be far fewer high risk shenanigans going on at home.

        I think that healthy people should be required to be vaccinated. I think that the “personal belief” exemptions are bullshit. In a homebirth situation, the mother and baby are the only ones at risk; shunning vaccination puts infants, the elderly, and anyone who is immunocompromised at risk. IMO, they are not equivalent.

        • Young CC Prof

          Of course, it SHOULD be illegal for people with little training and no professional standards to call themselves midwives, encourage women to birth at home regardless of risk profile, and advertise and charge money for this service.

          Bodily autonomy, absolute unless it interferes with the bodily autonomy of another already born person. Healthfraud, blantantly immoral.

          • moto_librarian

            This a thousand times, Young CC Prof!

          • Jessica S.

            Yup, this is the way to go.

        • wharves of sorrow

          But giving birth IS an medical event, women need proper care and if they are choosing give birth in their unsanitary home that seems mentally incompetent to me. Homebirth will always be more risky and if something goes wrong they’re off to the hospital anyway, might as well be in that safe environment to begin with.

      • Lori

        Just curious but do you also think abortion should be illegal?

      • R T

        That’s crazy talk! A woman has the right to give birth all alone in a kiddie pool if she wants! No adult should ever be forced to do anything medically they don’t want to do. You can’t force some one to get chemotherapy for cancer, you can’t force someone with major heart disease to start exercising and stop eating high cholesterol foods, you can’t force medical decisions on sound minded adults against their will! Why in the world would you say that? An adult human being has the right to put their own life at risk whether you approve of it or not! As long as they are not endangering the life of another already born human being. If you criminalize homebirth, you’ll have to criminalize abortion as well. Then you’ll have to completely outlaw medical informed consent of any kind! You mention sexism in one of your other comments, but there can’t possibly be anything more sexist than saying home birth should be illegal! Now all of that aside, how to you know for sure if someone gave birth at home intentionally or not? It’s just like the laws trying to criminalize intentional miscarriages!

        • wharves of sorrow

          Its not just her its also her baby that will be effected. That is baloney, criminalizing home birth should have no effect on abortion, abortion is reproductive care same as hospital birth. No its not, obviously the law would make exceptions for accidental home birth but intentional home birth is child abuse and women shouldn’t be allowed to hurt their own bodies so much when damage can be avoided by having an OB. It’s not sexist, if home birth was illegal women’s health could be protected and their babies. I fear places allowing homebirth are trying to cut costs and it could come at the cost of mothers who don’t know any better. In the long run investing in hospital births for every woman would be cheaper bc disability of mother and baby could be better prevented. I don’t want it to come to poor women being stuck with homebirth and brainwashed into thinking its better.

    • theadequatemother

      makes sense to me…if you want to catch babies and don’t like oversight you would move to a predominantly home based practice. I wonder what a similar survey of hospital based CNMs would show. Probably much different results.

      • moto_librarian

        I certainly hope so.