When doctors refuse to supervise midwives, the answer is NOT to dispense with supervision

Time Out

Imagine that you’ve taken a job babysitting 7 year old twins. Each time you’ve babysat, they have been more difficult to supervise. They run riot through the house breaking things and then begging you to fix them before their parents get home. The final straw, though, was when you went to check on them playing quietly in their room and found that they set the bedding on fire with matches they retrieved from their night stand. After you put the fire out (the bedding is a total loss), the twins insist that they are allowed to play with matches.

You confront the parents when they get home; they acknowledge that yes, they did not have the heart to take the matches away from the twins because they really love fire. You announce that you are quitting the job and the parents confide that you are the 4th babysitter to quit in the last few months.

How would you feel if several days later you saw the parents alone at a movie theater and they cheerfully informed you that they left the twins home by themselves, because they begged to be left alone and promised to be good?

That’s exactly how many obstetricians feel when they learn of legislative attempts to dispense with physician supervision of midwives.

The latest effort is taking place in North Carolina:

North Carolina law has required for more than 30 years that certified nurse midwives — the only kind allowed to practice in the state — operate under the supervision of a licensed, practicing obstetrician.

The new law would require that midwives, “consult collaborate with or refer to other providers” if indicated by the health status of the patient. Certified nurse midwives would continue to be allowed to write prescriptions, now without the supervision of a doctor.

“This is huge for us,” said Jan Verhaeghe, a certified nurse-midwife with New Dawn Midwifery in Asheville. “To be considered independent providers, working as colleagues rather than one party having total liability. We may see many more nurse midwives moving to the area without these types of restrictions.

The impetus for the legislation is refusal of obstetricians to back up certified nurse midwives (CNMs) who attend homebirths. Although the newspaper article references a homebirth disaster attended by an uncredentialed “midwife,” the proximate cause is disasters at the hands of CNMs attending homebirths.

The problem erupted in May [2012] when Henry Dorn, MD, a High Point-based obstetrician, informed seven midwives he supervised that he could no longer serve as their licensed physician. Around the same time, another doctor supervising an eighth midwife told her that he could no longer afford the insurance costs.

Dorn’s action came in the wake of a homebirth death at the hands of one of the CNMs he was ostensibly supervising.

Since then CNMs who want to attend homebirths have found it exceedingly difficult to obtain obstetrician supervision. That’s entirely appropriate! No one wants to supervise anyone who is a danger to babies.

The situation is startlingly analogous to the twins who play with matches. The number of deaths at homebirth in North Carolina is astronomical, but the state is like the parents who won’t remove the matches. The only fail-safe has been the requirement for physician supervision, since midwives on their own refuse to recognize the danger.

The midwives insists that they will now bear responsibility for their own outcomes:

Advocates say the law eliminates undue restrictions on qualified practitioners, and “inappropriate liability” for physicians.

That’s as reassuring as the 7 year old twins who promise they will be careful with matches.

In case, the legislators in North Carolina have trouble imagining what happens when unsupervised midwives are responsible for a homebirth death, they can look to Michigan for reference.

Three years after their baby died following a botched breech delivery at an Okemos birthing center, a DeWitt couple has been awarded $5 million in a lawsuit against the midwife in charge of their son’s birth.

Ingham County Circuit Judge Clinton Canady has ordered former nurse midwife Clarice Winkler to pay Sara and Jarad Snyder damages for the death of their son, Magnus, in 2011.

However, it’s unlikely the Snyders will collect any money because Winkler did not carry malpractice insurance, said the couple’s attorney, Brian McKeen.

What happened to Magnus?

Sara went into labor on April 8, 2011. After nearly six hours of pushing, Magnus was born up to the chest, but his head was stuck.

For seven minutes, according to the lawsuit, Winkler attempted to pull Magnus from Sara’s body. He was eventually freed but was born blue and lifeless.

Greenhouse called paramedics four minutes later when their efforts to revive him failed.

Magnus spent 13 days in Sparrow Hospital’s neonatal intensive care unit before passing away from severe brain damage and organ failure.

The only time he opened his eyes, Sara said, was the moment before he died.

How did the midwives who presided over Magnus’ birth take responsibility for his death?

The Snyders originally sued Greenhouse Birth Center and three of the Greenhouse midwives who were present during Magnus’ birth — Winkler, nurse midwife Shelie Ross and a third midwife, Audra Post, who holds a non-nurse credential called certified professional midwife.

The midwives all filed for bankruptcy after the suit was filed.

In attempt to obtain some accountability, the Snyders filed a lawsuit against Winkler, the lead midwife. How did she respond?

She didn’t even bother to show up.

A baby died, and every single midwife involved washed her hands of the situation. Their concern extended only as far as protecting themselves and evading responsibility.

The conclusion is inescapable:

When midwives are so irresponsible and reckless with babies lives that obstetricians refuse to supervise them, only fools could imagine that the solution is to dispense with supervision. This is not a theoretical issue. The obstetricians’ refusal to supervise midwives is a direct consequence of babies who have died preventable deaths.

If this were healthcare, midwives would be drafting new and more stringent requirements both for supervision and to restrict homebirths.

But this is politics, so instead they are lobbying to free themselves of the last restriction on their irresponsible behavior.

The politicians are imagining the votes they might garner. The midwives are imagining the freedom from scrutiny they might obtain.

And no one but the obstetricians gives a damn about the babies who will die as a result.

  • het4

    Funny Amy, I can give you some very similar scenarios of adverse outcomes in the hands of “qualified board certified physicians” that (gasp) CONTINUOUSLY MONITORED and watched babies die on the monitor. If you want a risk free job, maybe you should have become a forecaster.

    • MLE

      And they got off scot-free?

    • Amy Tuteur, MD

      So what? What does that prove?

  • Anon

    The CNM who attended my home birth in NC has malpractice insurance. She also has stict guidelines for practice (GDM testing, GBS, no VBAC etc). I was a RN at a free standing birth center in NC with very strict guidelines as well. The CNMS there also had malpractice insurance. I am now a hospital based CNM in NC, and I’m afraid that most of you don’t know what you are talking about. NC is one of only six states that still has this language for “supervision” written in the law. For me to even complete my application for a license it has to be signed by an MD. I’m sorry that everyone here is so against home birth, but the FEW CNMs practicing home birth in NC are not the problem here. When I say few, there really are four or five in the whole state. This law is about giving CNMs the independence to practice their trade. Even ACOG supports independent midwifery practice.

    • Guest

      ^This! CNMs are recognized as LIPs. I have been trying to comment on written practice agreements as much as I can on this issue. This was never about HB, this was about getting rid of outdated language in the statute that did nothing to improve outcomes. You can look at any other state where this language has been taken out and see that it has not had any adverse effects. Should OBs have to be supervised by MFMs? No, they consult and refer as needed, as do CNMs.

  • pinkyrn

    I disagree with the analogy. When I work in a hospital as an RN in L&D my supervisor is my nurse manager. Doctors, my coworkers, do not supervise my work. However, I am registered as a competent nurse in my state through a board of Nursing. I passed the NCLEX. I have a bachelors degree in Nursing. Not in Psychology or Art Therapy. Point is, I have the appropriate competencies and paperwork that usually indicates at the very least, I am a safe practitioner. Meaning I will practice within the standard of care. If I do not practice within the standard of care, I better have a really compelling argument for the discrepancy.
    If a doctor gives me an order that I find unacceptable, I do not just blindly do what they say. The doctor is not my supervisor, they are not in charge of my pay which is a good thing cause sometimes what a doctor or midwife would like me to do, I cannot provide. First I have a conversation with my co-worker, the doctor or midwife as to the safety of the order at hand. If we cannot come to an agreement, I start up the chain of command and more people get involved with the conversation.
    For example, if a woman comes into the hospital in labor, and reports that her provider has agreed to preform a breech birth, then a lot of people are going to get woken up with a phone call. If the doctor was my supervisor, I might be less outspoken when I see stupid shit. And all types of people do types of stupid shit, no one is immune.
    So I do not think Doctor should be responsible for the actions of other practitioners. I am responsible for my own actions as a professional. I believe CNM’s should be responsible and accountable for theirs.

    • Trixie

      Okay, but the point is, you’re supervised and your actions are accountable to a larger hospital system.

      • Guest

        See above and below. CNMs consult and refer just like docs. This is a bigger issue for APRNs (not just CNMs) than HB. CNMs have some of the best outcomes (in hospital at least) in the country. If CNMs in NC do indeed have bad outcomes OOH, than there is a bigger issue than written practice agreements. There are numerous states (NY for example) where this kind of language in the statute has been gone for years, and they do not have those kinds of outcomes.

      • pinkyrn

        Yes, in that respect, the physicians are supervised too.

  • DoulaGuest

    Interesting post with many points I agree with. If homebirth coverage was indeed the impetus for creating this bill, and NC does indeed have much higher HB mortality rates than other states I can completely get on board. I just have a few questions: I thought that this bill was, in effect, to get rid of the written practice agreement in NC. NC was one of just a handful of states that still has such language in the statute, and (in the hospital at least) CNMs who consult and refer without such language and continue to have good outcomes similar to comparable risk women seen by OBs. So, I wouldn’t expect getting rid of written practice agreements to have the sky falling over CNMs no longer requiring physician oversight, as we have seen throughout the country. I am also wondering was the CNM outcomes in other states that do not have CPMs practicing (like NY) for OOH birth would be? Just interested in comparing outcomes from states with and without written practice agreements for OOH births and AMCB midwives. In my state at least, there is no physician oversight required for CNMs practicing OOH, but if a midwife were to practice questionably, they are required to defend their practice to the board of nursing.

  • anonymity@@@

    What’s the issue? The fetus has no rights, so doesn’t matter and the mother’s autonomy is untouchable, so what is the problem?

    • Jacob Wrestled (Danielle G.)

      The issue is that people are offering a service based on claims that are fundamentally misleading, and then practicing their art in ways that contravene the assumptions most of us make about medical ethics. A women should be allowed to birth at home and to hire whomever she wants, but a provider of health care should have to meet certain minimal requirements to practice. The issue here are all the false claims made, and the bad judgements made in a vacuum, and the total lack of a system that holds anyone accountable.

      I am skeptical about the ability of home birth advocates to meet standards, because for them, rejecting the reality of medical risk factors and a blind optimism about the benevolence of nature are par for the course. Unfortunately, an home birth that takes science seriously and prioritizes the preservation of life over all secondary considerations would result in providers declining many clients, or (if you really follow the logic) would move providers of natural birthing services into hospitals. And that fact guarantees that providers will continue to resist a large body of evidence: it doesn’t cohere with their interests or their worldviews, which is of deep religious/personal/philosophical importance to them.

      But …let them prove me wrong. If they do, I will respect them for it.

      • anonymity@@

        Well formulated reply, thank you.

    • Amazed

      The issue is that incompetent providers trample on the mother’s autonomy by giving her false information, thus misleading her to use her autonomy for making decisions different from the ones she might have made, had she been presented with accurate information.

  • Sue

    “If this were healthcare, midwives would be drafting new and more stringent requirements both for supervision and to restrict homebirths.”

    Yes, exactly this.

    In the highly regulated (public hospital) system where I work, every near-miss requires reporting and a careful consideration of preventability. HBMWery and other ”alt med” groups seem paradoxically to be sticking to a dark past where poor outcomes were just part of the deal.

  • Stacy48918

    The craziness of NCB people never ceases to amaze me:
    “Please help me have a home birth VBAC 30 miles out to sea”
    Ack!

    http://www.mothering.com/community/t/1402498/searching-for-a-midwife-to-attend-my-vbac-30-miles-out-to-sea

    • Trixie

      Wow.

    • Sue

      30 miles out to sea? Meh. A real Hero Momma would do it in the air, without a parachute, and wearing a clown suit.

    • Trixie

      Surely there are dolphins off the coast of Nantucket? Why not recruit some into midwifery?

      • Stacy48918

        Anyone know how that turned out? The couple Dr. Amy wrote about doing the “dolphin-assisted birth”? I was actually trying to find it online the other night, but no luck.

        • Sue

          I heard that the dolphins ended up chirping 911

  • Mom2Many

    So….I sat my 3 boys down after school today, (17, 14 and 12) and read them the part about the twins playing with matches etc. Their reaction was predictably shocked. I then explained in general terms what the comparison was when it came to midwives being accountability-free and was impressed with the level of understanding they exhibited. For the record, my kids are pretty average scholars, (haha TFB) but they understood the implications immediately. Great article Dr. Amy!
    And no, it is never too early to educate the parents of my future grandkids on the safest way to give birth! 🙂

  • CanDoc

    Yes, yes, yes and yes.

  • Renee

    I don’t know the cost for a CNM, but the cost of malpractice insurance for a CPM is very low. Another commenter here got a quote, just to see if the MWs claims of “unreasonable” premiums were lies.
    The cost? $4,500
    This is equal to the average cost of ONE BIRTH for most CPMs. It could equal the cost of 2 births, if the MW charges much less than average. Point being, $4,500 (the cost for a CPM with a year of experience, in CA) is NOT outlandish at all, for a MW that makes being a MW her career.

    Requiring malpractice coverage has the added, unintentional, benefit of keeping birth junkie hobbyists, and part timers, out of MWery altogether. Those types of MWs are extra dangerous. Even if they were actually trained and educated at some point, doing a few births a year is not enough to keep their skills at a level required for safety and competence. In Oregon, the majority of CPMs do between 1-5 births per year.

    • Young CC Prof

      My friend is an amateur pastor. He mail-ordered this license from some church no one’s heard of so he can occasionally perform weddings for people he knows, because he likes to perform weddings and he charges less than the professionals.

      Difference is, a mistake in performing a wedding ceremony will at the worst end in a cranky bride and resubmitted paperwork.

      • Beth S

        Yeah when I got married we got my stepdad ordained online so he could marry us because neither of us are big into the church. The difference is the worst thing he could do was forget a sentence here and there.
        I personally, would rather the midwife be able to practice in the hospital if I were going to use them. I just feel the standards are so much stricter that way, and as DH says at least if something were to go wrong we’d be in the best place to get it fixed.

    • lawyer jane

      Wow, do you have stats on that 1-5 births per year figure? shocking!

      • Are you nuts

        That really is terrifying. Would you fly in a plane with a pilot who only does 1-5 flights per year?

        • Trixie

          Just guessing here, but that’s probably another thing that’s still safer than homebirth.

    • Bombshellrisa

      http://www.themidwifeplan.com/ Southern Cross has a midwifery malpractice insurance plan, covers OOH births

      http://www.washingtonjua.com/rates.htm Here is the rates overview for a midwife in WA state to have malpractice insurance.

      • Bombshellrisa

        http://www.washingtonjua.com/rates.htm
        “New to Practice LM/CNM Base Rate: $5,150

        Covers the first 0-12 births for midwives whose policy starts within 12 months of first Washington State midwifery license date. This NTP rate applies to the first year of your policy and, if your first policy was pro-rated (ie. it started after July 1st and was for less than 12 births) also to your second full year.

        Established LM/CNM Base Rate: $6,867

        Covers the first 0-12 births for established midwives”

        These are NOT astronomically high rates. There are a lot of midwives in this state that will take other forms of payment (one in particular even posted she would take payment in the form of gas for her vehicles) and having to actually pay for malpractice insurance might cut down on the bartering for midwifery tab you see on almost all the CPM’s (in WA at least) webpage.

        • Trixie

          And god forbid they pay actual taxes like any respectable professional has to…gotta wonder how much of that barter income gets reported.

          • Bombshellrisa

            I was wondering that too. Here is a list of what one CPM is willing to barter for in exchange for midwifery packages (but she will not apply it to placenta encapsulation): “We are nearly always willing to trade for (equivalent monetary value of a full midwifery package):Firewood,Gas for our cars,Organic food/produce, Organic meat,Medical Supplies

            Currently willing to trade:
            Landscaping
            Excavating

            Home window replacement

            Hardwood floor refinishing
            Unfinished basement remodel
            Tree trimmings

            iPod capable stereo and speakers (3)
            ​A flat panel television (32″ or smaller)
            Mini fridge

            General help with clinic renovations”

            She is in the midst of remodeling a home to turn it into a birth center and that is what she means by clinic renovations. Keep in mind this is a midwife who has attended a total of 200 births, and has only two days a week that she will see patients.

          • Trixie

            I’m not sure what construction costs are in that area, but I got quotes to finish an unfinished basement, to code, and it was about 4 times what a CPM home birth costs.

          • Ash

            Found the website of Foothills Midwifery that has the bartering system….the PDF “resources” at the bottom of the website make me sick. In the Rhogam PDF it says you can decrease antibody formation by “decreasing interventions”, including avoiding ultrasounds.

          • Bombshellrisa

            Yeah, and if you look at the cities she does homebirth in, they are FAR from a hospital that could handle a transfer train wreck. The hospital across from the future birth center she wants to build is TINY. And sorry, but if the bridge over the river is closed further down the highway, even an ambulance isn’t getting through and the detour takes a really long time. (This list is from that website and I can believe anyone would trust someone so inexperienced, in an area so rural to attend them).

          • AmyP

            One of our acquaintances did a birth center birth about an hour away. When I nosily looked up the birth center info, I eventually realized that she was driving an hour out of our town of around 200,000 people (with two big hospitals, one of which has a level III NICU) to go to a birth center in a town of 20,000-30,000 with a hospital to match.

            That feature alone of her story just boggles the mind.

          • MLE

            I definitely want to spend my pregnancy excavating something for my midwife.

          • Sue

            Hmmm- what does the tax office think?

          • misled (former) midwife

            as a former apprentice, i can tell you, none of it gets reported. and none of the cash payments either

          • Karen in SC

            Income tax fraud can be anonymously reported to the IRS. I encourage anyone with knowledge of this to do so. irs.gov, use “fraud” is the search box.

          • Bombshellrisa

            To be fair, it’s a little hard to report “Husqvarna riding lawn mower” on a tax form. Also some midwives take payment in bales of hay, silver and gold.

          • Trixie

            Sure you can. You are supposed to report all barter income. There’s a form for it. http://www.irs.gov/taxtopics/tc420.html

          • Trixie

            Remember, the IRS has a hotline where you can report tax evasion…..

    • S

      I don’t understand why the premiums for a CPM would be so low. Given their atrocious safety record, wouldn’t the insurance companies have to figure on a pretty high probability of paying out? How could they provide decent coverage and still make money?

  • Anna T

    The story described in the article is heart-breaking and infuriating. Why was a breech delivery even attempted in a birthing center? It should have been done in the hospital and closely monitored. I know some will speak against vaginal breech births altogether, but it can be done safely if the OR is ready and waiting (as it was for my SIL. Vaginal breech worked for her with her first, but not her second. She agreed to a C-section when it was necessary.)

    Second, SIX hours of pushing?! Are they mad? Are they insane?? Why did they wait so long?? All the “health care givers” involved should be thrown in jail.

    • yentavegan

      Mothers rely on the perceived professional knowledge of their midwives. A mother fully trusting the “professional” midwife working at the birthing center, would never know that her labor is not progressing normally. The laboring mother is like being held captive by the midwife/birth center. We can look back in hind sight and wail about six hours of pushing as being terribly abnormal but the mother in the throws of labor is blameless. IMO.

      • Anna T

        I wasn’t blaming the mother, certainly when you’re in the midst of active labor/pushing, and exhausted with pain and fear, you aren’t able to think straight. I’m blaming the midwives or whoever supervised the birth. Surely they realized something is wrong? Or did they think it’s normal?! She should have been rushed to emergency care HOURS sooner. It might have made the difference between life and death.

        • yentavegan

          I know that you were not blaming the mother. Sorry if my post made that unclear!

        • Beth S

          I agree, I keep thinking with my wimpy pain tolerance issues, if I were even to try unmedicated homebirth I would probably end up in the hospital if there were things like hours of pushing. It would just hurt too darn much.

        • MaineJen

          I may be mistaken, but I think baby Magnus was the case in which the birth center had NEVER done an out of hospital breech birth before…they just read up on how “safe” it was and were excited to try it…along come Magnus’ parents who fit the bill perfectly…and the midwives completely neglect to mention they’ve never done a breech birth out of hospital before. Am I thinking of the right case? Lord knows there are so many to choose from…

    • Amazed

      But babies die in hospitals too! Have a heart. Oh wait, you are a Tuteurite, so you don’t have one.

      • Mom2Many

        Please tell me this is sarcasm…

        • KarenJJ

          Pretty sure this one is sarcasm.

        • Jessica S.

          Definitely sarcasm! Amazed is quite skilled at it. 😉

          • Amazed

            Ah, so you’ve read my little theory about the equally stubborn fiance choking the evil nurses with the IV? Well, reading the post I was replying to, can you really say that was so far-fetched?

        • Amazed

          It’s sarcasm. Bad thing is, regular posters only know it’s sarcasm because they know what I think. Let’s face it, if my screen name wasn’t attached to it, it could be any homebirth advocate thinking those things for real. We have seen them here.

  • Lena

    So does that mean that these newly autonomous midwives are now legally required to carry malpractice insurance? Or will they just follow their CPM sisters lead and drop off their disasters at the nearest hospital so an OB can get sued?

    • Sue

      They can’t have it both ways, surely. If you carry the clinical responsibility, you carry the financial one too.

    • S

      CNMs still have to protect their nursing licenses, though, right?

  • Renee

    Let’s take this even further shall we?
    Down thread, Anon wisely said (edited):

    “Now, the parents come home from the movie, find their home burned to the ground, one child permanently disfigured, and the other still playing with matches. The news crew shows up and they blame you, the former babysitter, for the parents’ problem; the parents wanted to have a good evening experience. Because you wouldn’t provide it, they had no choice but to leave the children alone with the matches”

    I will add-
    Then, the parents sue the EMS and fire department**.

    First, they blame the firefighters, saying that they did not arrive fast enough to save the kids, and the home, from the fire. The EMS/firefighters actual response time, from 911 call, to arrival, was very quick, even though the home was not near a fire department. But, because 911 wasn’t called until a neighbor saw flames coming from the roof, the house had already been subsumed by flames at the time of the call.

    Secondly, They claim that they were never personally warned, by a firefighter, about the *true* dangers of leaving kids alone with matches. They said the firefighters were negligent because they knew the kids were firebugs (from past fires), but didn’t stop them.

    Thirdly, they blame the kids’ pain and suffering on the firefighters actions. They say that when the kids were picked up and carried out of the fire, by strangers wearing scary masks and tanks, that this is what traumatized the children. The parents think the firefighters acted rushed, and impersonal, while pulling their kids from the fire; even though they were exceedingly considerate, and caring, as soon as they were out of the burning building.

    Maybe these parents really did not know that leaving the kids alone with matches like this was dangerous.
    Maybe they never knew anyone that had kids that died in fires, and fires were rare, and always in other neighborhoods. Maybe they had other friends that left their kids alone all the time, that said matches were no big deal, and burning things was just “kids being kids”. but they sue the deepest pockets anyway, because otherwise they have zero hope of ever getting enough money to care for the permanently damaged child. After all kids don’t have insurance, and cities have deep pockets.

    ** This is an important point: in this scenario, the parents sued the people that helped them (firefighters/OBs), instead of those that hurt them (kids/CNMs). They blamed the babysitter for not offering to supervise kids that were clearly dangerous, but they also blamed the rescue team.

    Sara did NOT do this! She blamed those that were negligent, and the laws that allowed such people to practice. This is NOT about her situation!

  • They don’t want physician supervision? Fine – then they can do the things that need to be done to be considered autonomous providers. They can carry malpractice insurance. They can have a well defined scope of practice and they can face significant penalties for practicing outside of that scope of practice. They can get the educational credentials and they can be regulated by government like every other autonomous profession.

    • Renee

      EXACTLY. They want all of the benefits of being independent, with zero of the responsibilities, This is their standard operating procedure, for all things related to being a MW.

      For the life of me, I have no idea why we even entertain their demands. It really is simple- no standards, no over site, no insurance, NO WORK, and NO Medicaid/ insurance funds.

      In business, if you don’t have the required insurance to protect others from your error/negligence, you just do not get to operate. Period. There is no “well, OK, I see you cannot afford insurance, so its fine to skip it!”. Only MWs get this option. And the day your baby is born the the oct deadly event for everyone.

      We would never allow this, even from people that do work with less danger to the public. Yet we let MWs kill and we do nothing?

      • Sue

        And guess what? When you start being held both clinically and financially (even criminally) responsible for the outcomes of your decisions, you start being more cautious, risk-averse and maybe even behave more like an OB. “Surprise!”

    • Jacob Wrestled (Danielle G.)

      Yes. THIS.

    • Guest

      The majority of CNMs already everything you’ve stated above.
      Hospital based CNMs are held to the policies and scope of practice within a hospital system. The issue lies with HB CNMs who practice outside a scope of practice and with CPMs who want the ‘rights’ to do it all, but don’t invest in the actual education, practice guidelines and malpractice to know any better.

      • DoulaGuest

        The OOH CNMs I know have the same education as hospital based CNMs (they are are ACME educated and AMCB certified). They also carry malpractice, and have a practice handbook based on ACNM recommendations. I do see CNMs who were once CPMs or practice with CPMs, and those are where the problems arise a la the story mentioned in the article.

    • Medwife

      Well… Yeah. That’s how that goes.

  • lawyer jane

    Off topic: I know of a mom on medicaid who had to move states at 34 weeks pregnant and can’t find a new provider that takes medicare. Any ideas how this mom can find prenatal care and not just have to show up in a random ER in labor? This is the the DC/MD/Va area.

    • Guesteleh
    • attitude devant

      She should go to the delivery room of her choice with a pregnancy-related complaint. “The baby is not moving” is a good one. Then she should ask the nurses to help her find one. Typically the person who sees her for the “baby not moving” complaint will take her on.

      • Ob in OZ

        great answer. sometimes you just have to work the system a little bit.

    • An Actual Attorney

      If she is a DC resident, try Unity Health Care, http://www.unityhealthcare.org.

      Also she could try Washington Hospital Center’s OB/Gyn clinic, http://goo.gl/OD8RHK. A lot of the dr’s on Guesteleh’s list work there (Any address on Irving St is likely in that complex).

      Georgetown has a big OB/Gyn department, http://goo.gl/On9o3w, and is in the same med star network. I think that is where the best NICU is, but that is based on an old memory.

      But, the DMV (as we in the know people call it) is a big area, so she might want to think about what hospital she can actually get to in rush hour. Last thing she’ll want is a plan that puts her delivering on a bridge over the Potomac.

  • moto_librarian

    You know, I always assumed that requiring physician backup was simply a way to ensure that midwives had a channel for collaborating with physicians in the care of their patients. Instead of viewing this relationship as a benefit for their patients, they see it as an obstacle since in theory, it should force them to adhere to their scope of practice. Unless there is a legal requirement for midwives attending OOH birth to carry malpractice insurance, why should we expect them to collaborate with other professionals when they obviously have been reluctant to do so even when it was a firm requirement? This is ridiculous.

  • Amy M

    Do these CNMs carry malpractice insurance? I would imagine the hospital based ones do, but what about the ones who also take on home births on the side? Are they able to get the insurance? If so, that would be the one factor that would make a difference, because then when the shit hits the fan, they will be held accountable, instead of the supervising OB. If they are excluded from holding insurance because they do home births, then yeah, they may as well be CPMs. I mean, sure their training probably counts for something and they are more likely to recognize a problem than most CPMs, but if they are doing home births, it wouldn’t be shocking if their ideology trumps that, and wo/insurance to protect the families, then yes, it’s only a matter of time before we see another Magnus Snyder situation.

    • Susan

      I don’t think malpractice carriers would likely cover out of hospital birth. Do they ever? Anyone know?

      • Amy M

        So the insurers can maybe cover specific situations? Like only if the midwife if practicing in the hospital at the time of the incident, or something like that? I guess that would make sense, seeing as how home owner’s insurance works that way.

        ‘Cause I was a little surprised to see home birth midwives (CNM or not) willingly taking on responsibility. But if their insurance coverage doesn’t extend past the hospital doors, then they would still be in the clear when they mess up.

        • Busbus

          As I understand it, even insurance providers who might be open to cover homebirth would charge exorbitant premiums – as they should, given the heightened risk. Homebirth midwives couldn’t afford those premiums without significantly increasing their prices. Another possible outcome (this is entirely hypothetical) might be that insurances might demand certain safety standards, such as no breech or vbac and stringent transfer guidelines. That, of course, would be great and result in fewer deaths, at least. But midwives don’t want their practice curtailed. Because they are not responsible providers, and instead driven by ideology.

          • The Bofa, Being of the Sofa

            Insurers set premiums to offset the cost of payouts.

            If the premiums are exorbitant, then that is because their payouts are exorbitant.

            You’d think that there would be a lesson in there…

          • Susan

            What would really happen I suspect is that the midwives would say that the cost of malpractice insurance is exorbitant not because it really is risky but that home birth is maligned and misunderstood and REALLY is as safe or safer but that the evil OBs are out to get them and on and on … and that therefore they don’t carry malpractice and just sign right here where it says you are willing to take the risk and it’s not my fault if anything goes wrong ( wink wink)

          • Karen in SC

            But is it really exorbitant? I remember someone posting awhile ago that the premiums were around $5000. A midwife that does 25 births a year only has to raise the fee $200.

          • Amy M

            So what do you think they would do, should the insurers pull that one? I mean, the ones who are actual, usually hospital based CNMs…would they stop doing home births? Adhere to the safer rules laid down by the insurance? This is all hypothetical…I suppose the ones who were hell bent on homebirth would do it anyway, uninsured and the rest would give it up, but it would be interesting to know their thoughts on the matter.

          • The Bofa, Being of the Sofa

            My question, even if malpractice insurance is “required,” what’s to stop anyone from running afoul of the insurance rules for practice? So insurance doesn’t cover the resulting lawsuit…the patients pay the price, and nothing happens to the midwife except that SHE goes underground. Because she has no ethics.

          • Amy M

            True, but then she loses her hospital job too. That probably means something to some of them.

          • The Bofa, Being of the Sofa

            Unfortunately, it doesn’t mean much to those who most seriously need to have hospital oversight.

          • Young CC Prof

            I’ve said before that if you want to institute responsible home birth practice with just one law, requiring malpractice insurance would do it, since the insurance providers themselves would set appropriate conditions.

          • Susan

            I can’t help but think of the situation in Florida ( where I grew up and where my two older kids were born)

            http://www.nbcnews.com/id/5234637/ns/health-health_care/t/doctors-going-without-malpractice-insurance/#.U4S9MCgR-W4

          • Melissa Becker

            Actually, Florida does require that licensed midwives have insurance. Midwives practicing without insurance are not licensed and can be brought up on charges.

            http://www.floridahealth.gov/%5C/licensing-and-regulation/midwifery/licensing/index.html

            Doctors choosing to go without insurance can do so because they do not have licensing requirements to do so. But a midwife practicing without insurance can have her license removed for failing to maintain the requirements of the licensing.

          • Bombshellrisa

            Washington state requires it too, but this is what Lori Carr, CPM says on her website “The midwife does not currently carry malpractice insurance due to the

            prohibitive costs which would have to be passed on to the clients” http://www.highlandmidwife.com/docs/Homebirth_MWcare.pdf

          • Trixie

            She wrote some real BSC stuff on Elder Midwives a while back, didn’t she?

          • Bombshellrisa

            That would be a yes!

          • Trixie
          • Susan

            Odd laws. Thanks for the info. The amount midwives must carry is pretty low though. Still, seems like doctors should have a similar requirement.

          • Busbus

            I completely agree.

      • Young CC Prof

        Many birthing centers at least have insurance. However, in my state over the last decade or two, most have had to close their doors as the price of said insurance became unsustainable.

        And yes, insurance companies can and do place conditions on their policies.

    • R T

      https://www.cisinsurance.com/Midwives/free-quote.cfm this company says they cover home birth!

      • Amy M

        Must be insane premiums though….I wonder if the women who want home births would be willing to pay the higher out of pocket costs for the experience?

        • Thankfulmom

          In a private message board I am in, I see a lot of women willing to pay for a midwife attended birth even though they qualify for medicaid. Truly the experience is more important to them than taking care of other needs.

  • Karen in SC

    I had my teeth cleaned this week. After the hygienist was finished, the dentist came in to check after her and examine my mouth and teeth. Note that hygienists take at least a two year regimen of college or tech school classes, and have to pass a licensing test.

    • Elaine

      And if you had to wait a little while for the dentist to come check your teeth, nobody was going to die.

    • Therese

      Well, yeah, but that’s clearly so the dentist could charge you for her time, not just the hygienist’s time!

    • Mariana Baca

      The hygenist and the doctor perform different functions. The dentist isn’t there to “verify” that the hygenist can clean teeth, they are there to inspect and diagnose your now-clean teeth. You can go to cleanings without seeing a dentist (say, if you go get cleaned more often than you need to see a dentist), but it doesn’t replace the dentist visit. (if paying oop, you might even get charged differently).

  • Babydoc mom

    Admittedly, I wok in a system where there are licensed midwives who do some home births. But there are a few differences:

    – midwives carry malpractice insurance
    – they have clearly defined criteria for involving OBs and also for transferring from a home setting (although I have seen some people play games with this)
    – for the most part, all of our different professionals (OBs, GPs, pediatricians, RNs and RMs work collaboratively (most of the time)

    Even then, at the end of the day the disasters are generally winding up dumped on the OBs to fix/save. At least our model results in all parties being accountable, and I have seen consequences and remediation to all types of practitioners. And the liability is shared (though the MDs still have the deepest pockets….).

    How does this proposal Ben make sense

  • Mel

    “Maureen Darcy, a member of the joint midwifery board and the head of the Chapel Hill Birth Center said she has had patients drive from the Outer Banks to give birth at her facility in Chapel Hill. (…) Darcy said she knew of five or six bad outcomes from home births in the last two years, with babies hospitalized in a NICU or dying. But Darcy said she didn’t know of any litigation that arose form these cases. She also said nobody knows of how many good home births are happening in the state, and she fears that instead people will “go underground.”

    “Russ Fawcett, a representative from NC Friends of the Midwives (representing certified professional midwives, but not certified nurse midwives), said there are plenty of reasons midwives don’t face the same threat of malpractice as obstetricians.

    “Malpractice cases against midwives as a whole are exceedingly rare,” said Fawcett, “because of the shared decision making model between families and midwives.”

    To recap:
    *5-6 babies have died or ended up in NICU due to home births in SC under current regulation.

    *Rather than tightening regulation up in light of those bad outcomes, we should loosen regulation so people don’t go rogue…. .which makes no sense in light of serious problems under regulation. (It also implies that, ya know, 5-6 deaths/ serious injuries are not a real problem. Not compared to the tsunami of UC injuries that would occur if you keep the current system in place.)

    *OB’s don’t need to worry about being sued about supervised CNM mistakes! We’ve emotionally enmeshed the families deeply enough they’ll be your best defenders after you’ve maimed or killed their babies.

    And yet, the current system is still safer than my home state of Michigan.

    New state motto: If you seek a pleasant peninsula to maim or kill babies with no fear of oversight, look around you!

    • moto_librarian

      I abhor Russ Fawcett! Let me provide some translations for Russ. For instance, he says it’s “because of the shared decision making maodel between families and midwives.” Translation: the midwife and her supporters will emotionally manipulate the parents to the point where they are convinced that what happened was either unavoidable or a result of something that the parents did wrong. He also fails to note that midwives typically have no assets, thus making it difficult or impossible to find a lawyer to pursue a malpractice claim. But yeah, let’s pretend it’s because midwives are teh awesome.

      • Susan

        I was just searching for information on this topic and found this disturbing link.

        http://www.midwiferytoday.com/articles/protecting_sisterhood.asp

        • Amy Tuteur, MD
          • Susan

            Yes, a very disturbing image indeed. I also found a discussion at 10 cm on this issue.

            http://10centimeters.com/why-there-is-no-excuse-for-midwives-to-work-without-insurance/

          • The Bofa, Being of the Sofa

            That post is old, but I want to resurrect some discussion to point out something I didn’t see anyone else mention.

            Midwives complain about the high cost of premiums. The post did a wonderful job of researching it to find out the insurance costs. They are told they could get insurance for something like $22K. Let’s make it $21K for simplicity.

            But think about this. It is mentioned that Faith Belz might have 4-6 patients a month. Let’s call it 60 a year. That means that the insurance cost is $350 PER DELIVERY! Holy smokes, that’s huge.

            And that’s for someone really busy. Let’s cut it in half. Someone who does 30 deliveries a year would be paying $700 per delivery just in insurance.

            Now, given my comment above how insurance companies set premiums to cover their costs, this is telling us that they are figuring the malpractice costs will average out to something like $500 per delivery.

            Now, I know OBs pay a lot in premiums, and maybe one of our locals can weigh in. Insurance premium per delivery. What’s the cost?

            (that ignores the cost of gyno malpractice insurance, even, which midwives aren’t going to be paying)

          • Susan
          • Guest

            CNMs in a collaborative practice carry identical malpractice coverage as the collaborative physicians. Many health systems (assuming hospital based CNM NOT attending HB) required identical coverage. Additionally, it takes a gyne practice to maintain a full scope obstetric practice, so cannot discount the presence or cost of gyne coverage in malpractice insurance considerations for CNMs.

  • Ennis Demeter

    I saw the news about the Greenhouse Birthing Center judgement this morning. All of my respect to

    • Susan

      The Snyder’s deserve a lot of credit for trying to make sure this doesn’t happen to others. I also think that perhaps their attorney deserves some kudos too for taking on a case with no deep pockets.
      I have reread the story of Magnus more than once and it’s compelling for many reasons, but what hits home is that they had no idea of the risks of a breech birth at all, never mind out of the hospital, because they understandably trusted their health care provider, a CNM. It could happen to anyone. They weren’t really even steeped in the woo.

      • Young CC Prof

        So much for the “people will just go underground” argument.

        Do you know why the sale of ivory is so strongly discouraged, even antiques or pieces made from elephants who died of natural causes? Because supply creates demand. If it’s out there, people get the idea that it’s something to want. If home births are just not done, very few people will do them.

        From 2007 to 2012, home births with a midwife (of some description) rose from 0.36% of all births to 0.6%. Unassisted home births also rose slightly, from 0.2% to 0.25%. The presence of midwives who will attend out of hospital births increases out of hospital birth.

  • Anonymous

    I agree with you on this Dr Tuteur, but I think that it could actually be worse than your analogy. I would also add:

    Now, the parents come home from the movie, find their home burned to the ground, one child permanently disfigured, and the other still playing with matches. The news crew shows up and they blame you, the former babysitter for their problem because they wanted to have a good evening experience and because you wouldn’t provide it, they had no choice but to leave the children alone with the matches

    With the children, the house gets burned down, and they don’t go to another house and burn it down. However, with the midwives, they go from house, to house, to house.

  • Mariana Baca

    “The finally straw” should be “The final straw”

    • Amy Tuteur, MD

      Thanks. Fixed it.

  • The Bofa, Being of the Sofa

    So OBs have decided that it’s too risky to have a CNM doing homebirth to serve as a backup, so the solution is to … put it in the hands of the less qualified providers without backup?

    How does that even make sense?

  • bomb

    The babysitting analogy is really spot on. If midwives don’t want supervision, then they shouldn’t behave like children in need of babysitting.

    • Therese

      Does the same apply to a CNM in a hospital? If she doesn’t act like a child she should be free of OB oversight?? The thing about the babysitting analogy is it doesn’t matter how exemplary the 7 year old twins behave. They are 7. They need a babysitter even if their behavior was always perfect. It is the same with midwives, there should be OB oversight no matter how exemplary of medical caregivers they are.

      • NoLongerCrunching

        Hospital CNMs accept supervision because they recognize the value of doctors trained to deal with complications.

        • They also accept supervision because they’d lose their hospital jobs if they didn’t. It is a very effective means of control — just as doctors cannot behave any way they wish in a hospital setting either without consequences.

      • Young CC Prof

        Keep in mind, the vast majority of CNMs are delivering babies in hospitals, doing prenatal care as part of a group practice and/or providing basic gynecological/well woman care in the community. The ones who take on home births are the exception, and in the USA, their willingness to take on home births already puts them outside the realm of normal prudent health care.

        • Young CC Prof

          *Runs to favorite CDC data. Runs back.*

          Specifically, of the more than 300,000 babies delivered by CNMs in 2012, 95% were delivered in a hospital, 2.5% in a birthing center, and 2.5% at home, with a handful born in medical offices or elsewhere, probably inadvertently. Of the 3.6 million births in hospitals with doctors, I suspect many mothers received midwife care for part of their pregnancies or even part of their deliveries. Most CNMs are part of the solution.

          • Therese

            Not sure what that has to do with my point. My point was that all midwives should have OB oversight, it has nothing to do with whether they act childish or not, as bomb seems to say it should depend on. The ones that act childish shouldn’t be practicing at all, actually.

          • Guest

            CNMs are Advanced Practice Nurses, just as Nurse Practitioners are, who by definition are independent providers. NP’s and CNM’s both vary by state whether a collaborative physician is required for full scope of practice.

            Perhaps I am untrue to my profession when I admit I am quite content with the system as it is where APNs maintain a collaborative relationship with MDs. As it stands, I wouldn’t want anything less for my patients or my role as a provider.

            The definition of APNs as independent providers should allow CNMs to practice without a collaborative agreement. However, until ACNM denounces its professional relationship and support of NARM and MANA, it will continue to promulgate a culture of substandard providers and practice based upon ideals rather than evidence.

          • pinkyrn

            In my state, all CNM’s must have a professional relationship with an OB Doc. Over site sort of puts the OB in a bad position. An analogy would be when Family Practice Docs. (Doc went through med school, no O.R. skills) do L&D, they are required to consult with an OB if their patient is in need or a C-section.

        • You cannot really compare the hospital situation with the US homebirth one, even for CNMs. Hospitals have efficient means of enforcing practitioner compliance [removal of admitting privileges, for example] if Dr. Pompous Ass or Ms. Pompous Ass do not adhere to the hospital’s policies. Homebirth midwives, no matter what the qualification or lack thereof, have no such restrictions. Insurance is only a secondary issue, really. It is all about regulating the profession, and midwifery simply isn’t adequately regulated in the US.

          Nothing short of a national register of midwives, who have met rigorous educational and practice standards, and the criminalization of midwifery NOT compliant with those standards is going to match the kind of supervision a hospital can enforce. A doctor who wants to do his own thing is first disciplined by the hospital he is using, then, if there is additional malfeasance, can be brought up before the state licensing authorities and lose his license to practice [vide Robert Biter]. Should a doctor continue to be a loose cannon, he can face criminal charges and imprisonment, because practicing medicine without a license is a crime.

          Some states do have regulatory legislation re midwifery on the books, but it is mostly not enforced because the midwives in question are “under the radar”. Making the practice of midwifery, whether in or out of hospital a criminal offense unless the midwife is within a framework of oversight, is just about the only way I can see to get the “cowboys” out of business. [And educating the public that ONLY a licensed midwife is permitted to practice midwifery, too. The average layperson has no frame of reference as to whether someone purporting to be a “midwife” really is held to a basic level of competence or not]

      • Montserrat Blanco

        Not exactly. CNM are well trained in childbirth. They are even trained in how to resolve some complications. And if they work at a hospital they do have all the resources available. I am a doctor working at a hospital (not an OB) and I do trust my nurses to call me if something happens to my patients out of hours. They are well trained to spot alarm signs.

        • Ob in OZ

          I agree, but the oversight is still present, just a bit more distant.

          • doctorex

            This seems like part of the point. When oversight is a normal expectation and an available support, the people being overseen don’t make nearly as many insane decisions and mistakes.