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.