The ever growing list of homebirth deaths has become so long that even Australian midwives have recognized that it is foolish to claim that homebirth is safe. The new tack? Proclaim that “mortality is in fact a very limited view of safety.”

That’s what Hannah Dahlen, national media spokesperson for the Australian College of Midwives, has to say in a piece in the Australian press that is a masterpiece of callousness and obfuscation, Home births: it’s time to broaden the focus of the debate.

First, Dahlen acknowledges what everyone but homebirth advocates have always recognized:

… studies have shown that when women with high-risk pregnancies give birth at home the perinatal mortality is increased. In fact, the evidence is now substantial enough that we can identify where the greatest risk lies; for example, women giving birth to twins (especially the second twin) and breech babies.

In other words, one of the prime motivations for homebirth, to ignore medical advice on twins, breech, postdates and VBAC on the theory that avoiding a C-section is “safer” than hospital birth, is completely contradicted by “substantial” scientific evidence.

But wait! Whether the baby lives or dies is a “kindergarten” view of birth!

When health professionals, and in particular obstetricians, talk about safety in relation to homebirth, they usually are referring to perinatal mortality. While the birth of a live baby is of course a priority, perinatal mortality is in fact a very limited view of safety.

Really? On what planet would that be?

Can you imagine an obstetrician saying to patient that we ought to take a broader view of obstetrics than whether her baby lives or die? Can you imagine hospitals declaring to expectant parents that there is more to consider in choosing a place to give birth than whether the baby lives or die?

There may be factors in addition to perinatal mortality that contribute to safety, but there is no possible view of safety that does not place mortality (perinatal and maternal) at the center of obstetric care. I’d be the first to agree that there is more to safety than merely ensuring the baby lives, but there is no possible justification for a definition of “safety” that includes letting the baby die.

Dahlen’s claim is not simply an exercise in extreme callousness, it is a particularly clumsy effort at “re-framing the conversation.” Just like MANA (Midwives Alliance of North America), Australian midwives are taking a page out of the tobacco company playbook (What do homebirth midwives and tobacco executives have in common?).

As the Tobacco Institute explained to its members:

Our judgement, confirmed by research, was that the battle could not be waged successfully over the health issue. It was imperative, in our judgement, to shift the battleground from health to a field more distant and less volatile…

Now Australian midwives have recognized that the homebirth debate cannot not be waged successfully over the issue of safety, since hospital birth is clearly safer. Therefore, it’s time to change the battle field.

Let’s compare:

Tobacco industry:

… [W]e try to change the focus on the issues. Cigarette tax become[s] an issue of fairness and effective tax policy. Cigarette marketing is an issue of freedom of commercial speech. Environmental tobacco smoke becomes an issue of accommodation. Cigarette-related fires become an issue of prudent fire safety programs. And so on.

Dahlen:

Freedom? Check.

Women’s right to control what happens to their bodies during pregnancy and birth may be enshrined in law but this right is frequently violated in practice. I find it ironic that the same professionals who fight for the right for a woman to terminate her pregnancy will fight against her right to give birth at home. The law in this country is on the side of women and self-determination.

Accommodation? Check.

It is time to stop talking about the statistics and start working together to make home birth and hospital birth as safe (physical, cultural, emotional, social, psychological and spiritual) as it can be.

Prudent safety programs? Check.

Home birth will not go away, it is here to stay, so let us all share the responsibility for making it safe and satisfying, as should be our goal with all maternity care options.

And, above all else, changing the focus? Check

The debate around home birth is about more than place of birth or associated perinatal mortality, it raises deeper and more complex issues: the right of women to have control over their bodies during childbirth, the rejection of the prevailing medical model and risk paradigm of pregnancy and childbirth, societies’ belief that they have an investment in the product of childbirth and therefore should determine what is considered safe, the culture of childbirth in a country and the position and status of women within a society.

Nice try, Ms. Dahlen, but the rest of us are not fooled.

Dahlen has essentially conceded the homebirth debate. She acknowledges that the scientific evidence shows that hospital birth is safer. Now she’s merely making callous and clumsy attempts to change the subject.

Dahlen should be ashamed of herself. The birth of a live baby is not a priority, it is the priority. Any midwife who believes otherwise demeans the profession.

No wonder Melissa Cheyney refuses to release the death rate of Oregon homebirths.

In August, I wrote:

The minutes of the August 5, 2010 Board meeting reports that the state of Oregon asked for the ability to retrieve information on Oregon midwives from the database:

“Cheyney stated that the MANA board’s official policy is to give state-level accounts to professional organizations as a tool to evaluate areas where more training might be needed for the purpose of self regulation, and to not provide the data to regulatory entities.”

In other words, the database is only to be used by MANA itself, and not shared with anyone who could potentially identify unqualified midwives and discipline them.

It doesn’t take a rocket scientist to speculate that there have been an extraordinary number of deaths. Now comes information from a new source that confirms that suspicion.

A new website, Oregon Homebirth Midwife Info, has compiled a Midwife Directory that makes for stomach-churning reading. The directory lists midwives by name and includes reports of deaths as well as other major morbidity and actions taken against the midwives.

It is an incomplete list; not all Oregon midwives are included and there may have been additional deaths that are not recorded. Nonetheless, the statistics are no less than horrifying.

In the past decade, no less than 19 babies have died at the hands of Oregon homebirth midwives.

To put that in perspective, consider that there are approximately 1000 homebirths per year in Oregon and that the neonatal death rate for low risk women in a hospital setting is 4/10,000 (0.4/1000). That means that you would expect approximately 4 homebirth deaths per decade. Instead there were at least 19 deaths, for a rate more than 4X higher (375%) than expected.

No less than 16 midwives have presided over at least one death. Interestingly, only 2 were unlicensed midwives. The rest were licensed at the time of the death(s) and almost all had complaints filed against them with the Board of Direct Entry Midwifery. In other words, this information is available to Melissa Cheyney in her role as a member of the Board.

Homebirth kills babies. No one knows that better than Melissa Cheyney, who has, until now, successfully hidden the number of homebirth deaths at the hands of Oregon homebirth midwives, and who continues, in her role as Director of Research at MANA (Midwives Alliance of North America), to hide the number of babies who died at the hands of homebirth midwives across the country.

Two weeks ago I reported on 15 deaths at two hospitals in the United Kingdon (Promoting normal birth is killing babies and mothers). The 15 tragedies were united by the fact that midwives were so busy promoting “normal” birth that they failed to recognize complications or refused to refer patients to specialists in the face of complications.

The mounting death toll of midwife attended preventable neonatal deaths and preventable maternal deaths demonstrates that efforts to promote normal birth kill babies and mothers. That’s not surprising when you consider that promoting normal birth is fundamentally unethical.

An ethical medical professional recommends whatever is safest for the patient, not whatever is most beneficial for the provider.

Last week I posted the story of Joshua Titcombe, whose needless, senseless, entirely preventable death occurred at the hands of midwives who refused to acknowledge that he was ill and never alerted a pediatrician.

Today I came across the response of a midwifery professor published in The Guardian. According to midwife Sarah Davies, we need a new model for maternity care, not blame for individuals, a piece which could more aptly be titled “mistakes were made … but not by us.”

It’s a masterpiece of the genre employed by errant politicians and corporate malfeasors, the non-apology apology.

Ms. Davies acknowledges that mistakes were made, specifically mentioning:

… two maternal deaths at Queen’s hospital in Romford that should never have happened, and the abusive and neglectful behaviour by midwives …

… individual midwives treated women with disrespect – one midwife was heard to say: “Hurry up, or I’ll cut you.” …

Concluding:

But blaming individuals for failing to care is no solution when the whole system is wrong.

Actually, blaming individuals for their unacceptable, unprofessional behavior is an excellent solution. We even have a special word for that solution. The word is “accountability.” Health professionals who commit malpractice (for that is precisely what happened in these instances) should be held personally accountable for their failings.

According to Ms. Davies, though, the midwives are not responsible for those deaths, “the system” is responsible. In a remarkable bit of rhetorical jujitsu, Ms. Davies insists that the failure of the midwives to obtain help from other clinicians (obstetricians and neonatologists) is the result of a shortage of … midwives!

… the circumstances described reflect the continuing neglect of pregnant women’s core needs. The government has chosen not to recruit the 5,000 additional midwives the Royal College of Midwives has repeatedly stated are required.

Those two sentence sum up what is wrong with the UK maternity system, though not in the way that Ms. Davies had in mind.

First, Ms. Davies deliberately conflates the needs of pregnant women with the needs of the midwives who care for them. The core need of pregnant women is for safe, professional, compassionate maternity care. The core need of UK midwives is apparently full employment for UK midwives.

Second, is there a shortage of midwives in the UK? Perhaps, but this is not an example of it. These were not overworked midwives who did not have the time to attend to their responsibilities. These were midwives who had more than enough time to “care” for patients who should have been cared for by specialists.

These tragedies occurred because midwives deliberately took on work that properly belonged to others in an apparent effort to protect their turf. The preventable deaths at both hospitals include cases in which obstetricians were told that their help was not needed and parents were told that the expertise of pediatricians was unnecessary.

Thirteen babies and mothers are dead at the hands of midwives, but Ms. Davies apparently thinks that this is the perfect opportunity to praise midwives:

All the research indicates that continuity of midwifery care gives the best physical and psychological outcomes for women and babies …

Apparently not, since thirteen babies and mothers are dead specifically because their midwives did not provide the best care.

Student midwives … are dedicated, caring individuals who make many sacrifices as they learn how to help women have a safe, satisfying birth experience …

How nice, but what does that have to do with the disasters that occurred? Nothing.

Because of the lack of recruitment, many newly qualified midwives struggle to find posts.

How sad, but what does that have to do with the disasters that occurred? Nothing.

For the long-term health of mothers, we desperately need a different model for maternity care – one that is community based; gives midwifery continuity; and where birth takes place at, or close to home for most healthy women.

Really? Would community based care, homebirth and midwifery continuity have prevented any of the thirteen deaths? Of course not, but it would lead to greater employment opportunities for midwives and that’s more important.

What led to the deaths of these babies and mothers? Midwives putting their needs ahead of the needs of patients. Ms. Davies is doing the exact same thing in this piece: putting the needs of midwives ahead of the needs of mothers.

The CDC has just released its annual report on birth statistics, Births: Final Data for 2009. Once again, the C-section rate has risen:

In 2009, the total cesarean delivery rate reached a record high of 32.9 percent of all births, a 2 percent increase from 32.3 percent in 2008. This is the 13th consecutive year in which the cesarean delivery rate has risen …

There are a number of reasons for the continuing rise, but one of the most important is obstetrician liability concerns. I wrote about a spectacular example yesterday, the recent $144 million verdict against a Michigan hospital for neonatal injuries sustained by a large baby due to shoulder dystocia. The cause of action was failure to offer a C-section. Shoulder dystocia cannot be predicted in advance and the scientific evidence is that prophylactic C-section for macrosomia does not improve outcomes. But that didn’t stop the lawyer from arguing or the jury from believing that a prophylactic C-section should have been recommended.

There is simply no way we are going to get a handle on C-section rates if we continue to ignore obstetricians’ concerns about liability. As I first wrote in March 2010, obstetricians have been desperately trying to explain how liability concerns are driving the rising C-section rate, yet they are consistently ignored.

It’s rather surprising since obstetricians perform the C-sections and have much greater insight into their motivations than anyone else. But everyone from insurance company executives to health policy experts to natural childbirth advocates disparage and ignore doctors’ explanations. How do they justify ignoring the very people whose behavior they wish to change?

Law professor Sandra Johnson offers insights into doctors’ concerns and how they are ignored in, of all places, a law review article entitled, Regulating Physician Behavior: Taking Doctors’ “Bad Law” Claims Seriously.

Doctors frequently claim that the very law intended to improve the lot of their patients is instead making the doctors provide poor care. These “bad law” claims are levied against malpractice litigation that makes doctors practice “defensive medicine”; … against antitrust laws that prevent doctors from organizing themselves in ways that would produce more cost-effective and accessible care; and against regulations that impede important medical research. These “bad law” claims assert that the law’s effort to promote patient health and well-being has actually caused significant harm.

And why have these concerns been ignored?

Medicine’s complaints … [have come] to be characterized as the work of a self serving guild, rather than a profession motivated by altruism and armed with expertise, or at least as the work of the recalcitrant “bad apples” who continued to resist improvements that the more enlightened among them embraced. These narratives marginalized physicians’ … claims and diminished them as a source of legitimate information about the effectiveness of reform efforts.

Rather than addressing the substance of doctors’ arguments, experts and lay people have denied that there the complaints are legitimate, ascribing them to greed and self interest. Yet in the case of medical liability, as in other areas of medical “reform,” doctors are often right.

Professor Johnson explains that doctors’ liability concerns are not simply ignored; even when they are directly addressed, they are often dismissed as irrelevant by those who don’t or won’t understand their impact on individual practitioners. She identifies a number of these dismissive behaviors.

All’s not well that ends well

Policy experts and lay people alike often point to the fact that physicians win most malpractice suits as evidence that doctors shouldn’t worry about being sued. But as Prof. Johnson notes:

The enforcement process itself [in this case, the lawsuit] also imposes significant penalties in the course of identifying violators. These penalties are distinct from formal penalties levied after a conclusive finding that a violation has occurred. These “penalties of the process” exert their own deterrent effect. When substantial, they will produce avoidance behaviors on the part of those who might fall within the investigative net even though the likelihood that they will be subject to formal sanctions is nil or close to it.

In other words, the risk of being sued has a deterrent effect, regardless of whether the doctor wins or loses. And who would know better than the doctors themselves?

The deterrence effect of these informal penalties may produce results that actually undermine the goals of the formal legal requirements. Yet, they are all but invisible—they make no appearance in the formal description of the standards and procedures incorporated in the law. The best information available concerning the operation of this shadow system of enforcement comes from the people who experience it, those doctors who claim that there is “bad law” causing them to avoid doing the right thing.

The interminacy of law

Lay people in particular like to claim that if the doctor “does the right thing,” he or she has nothing to worry about. That is startlingly naive view.

… It is hardly ever the case that lawyers can tell doctors: “I assure you that you have nothing to be concerned about … You are safe.” … So, instead, what doctors often hear lawyers say is: “Well, anyone with a filing fee can sue you, but they are not going to win.” This consolation … has to ring hollow to anyone who has been the defendant in any suit, even one that is eventually dismissed. Instead of reassurance, one could understand that this phrase would be heard as confirmation of the unpredictability of the legal hammer.

Asymmetrical legal risk

At times, legal risk is lined up entirely on one side as the doctor looks at the risks of particular decisions… [W]hen we began our work on pain management in 1995, only the doctor who prescribed opioids for his patients in pain faced investigation, sanctions, and liability claims. The doctor who used the less effective medications and neglected their patient’s pain faced no legal risk at all.

The same asymmetrical risk applies to C-sections. An obstetrician who fails to perform a C-section can be accused of negligence if there is anything wrong with the baby. An obstetrician who performs a C-section, even one that is not medical necessary, faces no legal risk at all.

Professor Johnson’s most important message is that it is time to start taking physician liability concerns seriously instead of dismissing such complaints are motivated by greed and self interest:

[We] must accept that well-intentioned regulatory standards and enforcement systems can have negative outcomes as physicians react, and patients suffer as a result. Taking physicians’ “bad law” complaints seriously brings physician behavior to the table as a credible and legitimate factor in evaluating the performance of the law… Taking “bad law” claims seriously appreciates that the behavior-inducing effects of the enforcement effort may thwart the goals of the regulation itself.

The bottom line? If we continue to ignore obstetricians liability concerns, the C-section rate will continue to rise.

Geoffrey Fieger, famous for representing Dr. Jack Kervorkian, is now notable for a new reason. He just won one of the largest medical malpractice verdicts in history in an obstetric case. The claim? Failure to perform a C-section, of course.

A Detroit-area newspaper reported:

In what appears to be the largest medical malpractice lawsuit verdict ever awarded in Michigan, a Macomb Township family has been granted $144 million in a case against William Beaumont Hospital of Royal Oak…

Markell was born with cerebral palsy and hypoxic-ischemic encephalopathy, and attorneys argued the condition was a result of a traumatic labor and delivery at Beaumont Hospital in Royal Oak…

Markell was 10 pounds, 12 ounces when she was born Dec. 1, 1995 …

The birthing process also caused a brain hemorrhage and bruises to Markell’s body…

She suffered a fractured left clavicle during the delivery and “had no respiratory effort,” as well as seizures, according to court documents.

In other words, Markell was a macrosomic baby who suffered a severe shoulder dystocia.

Shoulder dystocia cannot be predicted in advance although the risk rises in babies over 10 pounds. The scientific evidence, often touted by homebirth and NCB advocates, is that prophylactic C-section for macrosomia does not improve outcomes.

But that didn’t stop Fieger from arguing or the jury from believing that in this case a prophylactic C-section should have been recommended:

In the lawsuit, attorneys for the VanSlembrouck family accused the hospital and its physicians of being negligent in many ways, including failure to recommend or offer a cesarean section procedure …

And though we know, as NCB and homebirth advocates are fond of declaiming, that, due to limitations in the existing technology, estimates of fetal weight vary as much as 2 pounds in either direction in the 3rd trimester, that didn’t stop Fieger from arguing or the jury from believing that the hospital could have obtained an accurate fetal weight prior to the onset of labor:

The VanSlembroucks also accused the hospital of providing negligent prenatal care, including a failure to establish a reliable estimation of fetal weight.

This case is an excellent illustration of the pressures on obstetricians.

Yet no less an authority than our friend Jill Arnold, counseling women on how to avoid an “unnecesarean,” decries prophylactic C-sections for macrosomia, going to far as to disparage the “dead baby card.”

… Is this “recommendation” of a c-section based on evidence or is it merely the practice of defensive medicine? The burden of proof is on the doctor wanting to schedule a primary c-section for a non-diabetic woman.

At this juncture, doctors are known to share a personal anecdote about shoulder dystocia in which the baby died or suffered nerve damage during birth to support their recommendation and scare the pregnant woman into compliance. This is also referred to as “playing the dead baby card.” Such events are tragic for all parties involved, including the labor and delivery staff. They are also EXTREMELY rare and unpredictable.

The American College of Obstetrics and Gynecology does not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g, stating that ” …it is safe to allow a trial of labor for estimated fetal weight of more than 4,000 g.”

Jill appropriately cites 7 specific studies that recommend against prophylactic C-section for macrosomia.

But it did not matter to this jury that the scientific evidence does not support prophylactic C-section for macrosomia. It did not matter that, due to limitations in existing ultrasound technology, it was literally impossible for doctors to establish a fetal weight any closer than 2 pounds in either direction. All that mattered was what was clear in hindsight: a C-section would have prevented the tragedy that befell this specific child.

Jill Arnold is correct that a C-section for macrosomia is defensive medicine, but as I have argued before, and as this case demonstrates, defensive medicine works. It prevents heartache for patients and it prevents massive judgements for failure to perform a C-section.

They say that the best defense is a good offense, and perhaps that’s what Kim Mosny, CPM had in mind when she publicly posted the story of a perinatal loss on her Facebook page. Mosny has appeared across the internet proclaiming the safety of homebirth. Perhaps she fears that her association with a tragedy might raise doubts about her claims.

On October 8, 2011…, [the baby] died inutero (while inside the uterus) as a result of a hidden, complete placental abruption (where the placenta shears off the uterine wall). [The baby] was stillborn at 12:19am on October 9, 2011, taken by cesarean section to protect [the] mother’s health…

Clinically, there is no explanation for this rare event other than to acknowledge the biological risk of all pregnant women because they have a placenta attached to their uterus…

Kim wants you to believe that there was no way this could have been prevented.

… Midwives care only for low-risk women, who have healthy life-styles; who do not smoke, drink alcohol, or abuse drugs, and who’s medical status is determined to be healthy, without medical conditions or diseases that would risk them out of care. Thus, there were no other risks that could be determined as causal for this client’s placental abruption. As a result of the abruption, the baby was very quickly deprived of oxygen and he died. He felt no pain. Thankfully, the mother remained stable and did not suffer medical complications herself.

And she wants to be sure that we know that the parents are not blaming her:

Our clients wish to convey their satisfaction with and confidence in their care providers, both the midwives of the Home Birth Midwifery Service … stating the course of their care was thorough and comprehensive. They received excellent care throughout.

Technically speaking, everything that Mosny wrote may be true. However, she left out some critical details that cast a very different light on the tragedy.

1. The patient was 42 weeks and 1 day when this stillbirth happened. While the actual precipitating event that led to the baby’s death may not have been preventable, the death itself may have been preventable. The stillbirth rate rises steadily at the end of pregnancy, and 42 weeks is considered the outermost cut-off for induction and delivery of the baby. Had this patient been induced in the hospital before 42 weeks, the outcome would likely have been a healthy baby.

2. Mosny is silent on whether the patient was in labor at the time of the abruption. She does not claim that the patient experienced decreased movement or sudden onset of pain. Whether the patient was in labor at the time that the abruption occurred is highly relevant.

3. Mosny is silent on when and how the patient was diagnosed and transferred to the hospital. If the transfer was during labor, it took place too late to save this baby’s life. Homebirth advocates are fond of claiming that even when an emergency occurs at homebirth, there is plenty of time to transfer to a hospital. But there are a number of obstetric emergencies, none of which are rare, that must be treated within minutes or the baby will die. One of these is a major placental abruption.

4. The treatment for an abruption that results in a perinatal fatality is vaginal delivery. There are two exceptions: if the patient had a previous C-section and requests a repeat, or in the case of massive bleeding. In this case, the baby was a first child, and, according to Mosny, the bleeding was confined to the area behind the placenta (hidden abruption). Therefore, a C-section in this case was probably the result of obstetric indications unrelated to the baby’s demise, such as cephalo-pelvic disproportion.

As soon as I read Mosny’s Facebook post about the tragedy, I suspected that there was more to this story than she was revealing. In the first place, it is unusual for any provider to publicly announce a stillbirth. Second, it seemed that the purpose of the announcement was to publicly absolve herself of blame. But that begs the question: why would she feel it was important to publicly renounce blame for a stillbirth in the absence of risk factors?

It turned out, however, that there was at least one major risk factor for stillbirth, and that her description of what happened, while technically true, omitted key facts that shed a very different light on the situation.

I contacted Mosny to offer her an opportunity to comment on the specific circumstances surrounding a perinatal death that would justify a public announcement that it was unpreventable. She did not offer any clarification.

Unfortunately, there is a real possibility that this was a classic homebirth tragedy. A patient who should have been risked out from homebirth, who should have been induced earlier, experienced a catastrophic complication, and by the time the patient was transferred to the hospital, the baby was dead.

Isn’t every patient entitled to give informed consent for medical care, with the provider explaining risks and benefits of each available option? Oregon homebirth midwives don’t think so.

New state regulations enacted earlier this year mandated informed consent:

Beginning on June 1, 2011, each LDM [licensed direct entry midwife] must provide risk information as published on the agency’s website www.Oregon.gov/OHLA, and obtain informed consent for the following circumstances:

(a) Out-of-hospital birth;
(b) Vaginal birth after cesarean (VBAC);
(c) Breech;
(d) Multiple gestations; and
(e) Pregnancy exceeding 42 weeks gestation.

It’s now November, yet Oregon homebirth midwives are NOT obtaining informed consent in these high risk situations. That’s a remarkable turn of events for two reasons.

First, it is notable because a specific regulation was required to address the fact that Oregon homebirth midwives were not fulfilling their ethical obligation. Every healthcare provider is ethically and legally required to provide accurate information about the risks of any medical care. Oregon homebirth midwives SHOULD HAVE been providing information about the increased rate of perinatal death at homebirth, and the further increase in risk posed by VBAC, breech, twins, and postdates pregnancy. Oregon homebirth midwives flagrantly disregarded this obligation and Oregon officials felt compelled to make informed consent mandatory for license maintenance.

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

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

Moreover, the requirement for informed consent does not depend on provider convenience. Can you imagine a doctor arguing that he didn’t obtain informed consent for gall bladder surgery because he hadn’t had time to prepare a consent form? Can you imagine an oncologist arguing that he didn’t obtain informed consent for a patient to refuse chemotherapy in favor of herbs because he didn’t have time to prepare an consent form? Of course not.

Can you imagine a doctor insisting that he needn’t obtain informed consent for gall bladder surgery for any patient in the next year because that’s now long he would need to prepare a consent form? Can you imagine an oncologist arguing that he needn’t obtain informed consent for any patient in the next year to refuse chemotherapy in favor of herbs because he didn’t have time to prepare an consent form? Of course not.

Yet that’s precisely what Oregon homebirth midwives are arguing:

Amend OAR 338-025-0120 to extend the implementation date for risk information packets by requiring that each LDM provide risk information as published on the agency’s website regarding out-of-hospital birth, malpresentation birth (breech), multiple gestations (twins), vaginal birth after cesarean (VBAC), and births exceeding 42 weeks gestation (post-dates) beginning June 1, 2012.

There is no plausible reason to take a year to amend a consent form, especially since the information has been known for decades and can be accessed in moments on Google. So why are Oregon homebirth midwives arguing for repeated extensions to the informed consent requirement?

It’s simple. They don’t want to obtain informed consent.

If Oregon homebirth midwives are are required to provide patients with accurate information about the real risks of homebirth, and particularly about the increased risk of high risk homebirth, they will have many fewer clients.

The state of Oregon should refuse to grant any further extensions. Informed consent is a requirement for all healthcare providers and there should be no exception for Oregon homebirth midwives.

Tomorrow, Ricki Lake is releasing More Business of Being Born, a direct to DVD sequel to her first movie.

My piece on Time.com details What Ricki Lake Doesn’t Tell You About Homebirth.

Organizers of the Home Birth Consensus Summit are trumpeting the nine statements of common ground that emerged from the meeting. According to the press release:

Although many of the participants represented stakeholders who have long been on opposite sides of the fence when it comes to the practice of delivering at home or in a freestanding birth center, the group was able to reach agreement on core sets of principles and to forge a shared commitment to quality maternity care for women and their babies in all birth settings.

Frankly, it is much ado about nothing.

Here are the statements statements:

1. We uphold the autonomy of all childbearing women…
2. We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes…
3. We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes…
4. .. [A]ll health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice…
5. We believe that increased participation by consumers … is essential to improving maternity care…
6. Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings…
7. We are committed to improving the current medical liability system …
8. We envision a compulsory process for the collection of patient … data on key … outcome measures in all birth settings….
9. We … affirm the value of physiologic birth … and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies…

The are so banal as to be nearly meaningless, and everyone agreed with them prior to the Summit. It put me in mind of a summit between two bitterly warring countries that is declared a great success because everyone agrees that … peace is good. There’s nothing substantive here and the most critical issues are not addressed.

I was interviewed by a reporter for Medscape about by impressions of the Summit results:

“On any substantive issues there was no agreement: The idea that women should have autonomy…that there should be some sort of standard,…everyone agreed on that beforehand as no-brainers.”

Dr. Tuteur takes exception to the summit’s wishes “not to examine, debate, or form a consensus statement regarding the evidence published regarding safety or maternal–newborn outcomes of planned home birth.”

“One of the things that I found most disturbing about the summit was that one issue was off the table from the get-go: there would be no discussion of whether home birth is safe, and that’s really the key issue,” …

I commented on the fact that the existing scientific evidence and state and national statistics show that American homebirth has triple the death rate of hospital birth for comparable risk women. The problem is so serious that MANA refuses to release the death rates for homebirth midwives.

“It does not take a rocket scientist to surmise that [the Midwives Alliance of North America’s] own data show that homebirth with an American homebirth midwife is not safe,” Dr. Tuteur noted. “Withholding that information from patients is both unethical and immoral.”

And, of course, I mentioned the inadequacy of the CPM credential:

“One thing that most Americans don’t realize is that American homebirth midwives have a pretend credential they give themselves, called ‘Certified Professional Midwife,’ and any similarity to Certified Nurse Midwife is confusing and deliberate, … There is no possible way that a high school graduate with a mail-order certificate is qualified to take care of anyone,” …

I am no diplomat (that’s no surprise to anyone who reads this blog regularly), so perhaps in the world of diplomacy it is a great achievement to hold a conference and announce you agree on a bunch of things that everyone already knew you agreed upon, while simultaneously refusing to address critical substantive issues. But it seems to me that this Summit was nothing more than a public relations ploy to elevate the status of homebirth midwives, giving the impression that they were “invited to the table” by the expedient of creating the table and issuing all the invitations.

The two principle issues in American homebirth did not produce consensus, and one was off the table from the start. The two critical issues, threshold issues on which everything else is based, are these: American homebirth increases the risk of perinatal death, and the CPM credential does not meet the standards of any other first world country. If homebirth advocates refuse to acknowledge or even discuss these issues, the results of any consensus summit are meaningless.

Last week I wrote that the relentless effort by UK midwives in promoting normal birth is killing babies and mothers. At Furness General Hospital in Cumbria 6 babies and 2 mothers have died preventable deaths, including Joshua Titcombe:

Hoa Titcombe, 34, gave birth to Joshua at the end of a normal delivery. But nine days later the baby bled to death after suffering a lung infection which could easily have been treated with antibiotics.

Joshua’s father James contacted me to share more details about Joshua’s birth and needless death. He gave me permission to share with you the presentation he created to ensure that Joshua will be remembered and that his death will serve a purpose, focusing attention on the substandard midwifery care that is the result of midwives protecting their “turf” and refusing to refer complicated cases to obstetricians and pediatricians.

My deepest condolences to James and Hoa. No parent should have to endure what they have suffered.