What’s going on? I was reading Homebirth Debate, yes the scab I can’t help but pick and I clicked on the link to mamamidwifemadness and was met by a ‘blogger’ message telling me that the blog may only be accessed by invited readers. How annoying, now I can’t read the other side of the story Dr Amy has been writing about. Reading Amy’s interpretation it seems to me that there were examples of an American midwife’s management of an incident at a homebirth on this site, now I’ll never know what went on, and how the case was managed. I’ll never know if Dr Amy was right to be her usual scathing self.
I carried on my tour of interesting ( to me ) blogs and went to Cremede, a blog written by a Student Midwife who often makes really good comments about maternity care and cases that she as witnessed. Same message. I feel sad about that.
Why have they done this? Was it because they were receiving abusive comments? I have no idea but from experience, when commenting on Homebirth Debate, and especially NHS Blog Doctor, there can be some pretty foul and confrontational language used by other commentators. I used to respond to these antagonists as if they were worth my attention, even though were nearly always ‘anonymous’, perhaps ‘coward’ would be a more appropriate sobriquet. Now I just ignore those persons who are unable to express themselves without using profanity and verbal aggression, they are not worth the effort. I hope they have not stopped sharing their experiences because of other’s behaviour, can bullying and harassment happen on the internet and, if it can, how can it be controlled?
Image comes from How To Spot A Cyber Bully.
if you want to share your email with me doula *at* hamilton doula *dot* com, I can email the two items with you. I have them through my RSS feed. I imagine she ended up getting some nasty comments from Dr. Nutjob’s website.
mamaloo = Thank you for that. Will do. What I did read on Dr Amy it seemed as if mamamidwifemadness was upset by the way Dr Tuteur commented. The ‘good’ doctor can be super blunt, to the point of offensive.
This is terrible. I read mamamidwifemadness yesterday and it was fine. I tried the UK student midwife and was blocked. She wrote a post about one of my comments. I commented again. I thought maybe she’d blocked me. Not that I felt I said anything awful. If she reads your blog I’d like to be invited since the mail was about me.
Lisa – I really don’t know why they have both blocked their blogs. I hope that they read this and allow me access.
“If you can’t stand the heat, get out of the kitchen”. I don’t know about Cremede, but Morag’s blog was horrifying in its almost complete ignorance of good midwifery and massive radical ideology.
I don’t think Dr. Amy [Homebirth Debate] was excessively confrontational. Morag posted a story of real malpractice due to incompetency that fortunately did not result in a maternal death, although it could have done. Morag and her preceptor were simply lucky, but neither of them seemed to even know how close they were to a real tragedy. And Morag posted, on another entry, about how much she loves to see and feel blood, which is odd by any standard.
She seems not to understand that VBAC isn’t a “given”, as well, making sweeping statements about “80% of VBACs are successful” and implying that all women who have had previous C/S should have VBACs, without knowing that some reasons for initial C/S keep women from ever being VBAC candidates in the first place. In fact, the main impression I got from reading her last 10 posts was that Morag suffers from hubris, and we all know where that leads.
IMO, removing one’s blog from the public sphere, except in extreme cases of really vicious trolling [just not publish comments, if you don’t want feedback!] is the act of a coward.
Antigonos – Just off to work now so can’t comment, no time. Will respond later.
Hi all,
This reminds me of the saga of the teenagers that were bullied on myspace. This is a whole new era for us all, this very pubic domain where by some people hide behind a facade and make comments that may be harmful. After keeping up with most of the comments regarding this debate, I can understand how some people may feel offended. It is one thing to make comments, however we need to be mindful of peoples feelings and comments at times are negatively personal. How far do we go in the public forum in making personal attacks? when most often we do not have all the facts. What we have to go by is what is written and often that may be misconstrued by the indiduaval. How many times have you written something and you re read it, and it does not quite say what you wanted it to say? none of us are perfect, everyone has an opionion right or wrong. Ask yourself do you live in a glass house? I think it is time for this debate to die a natural death. I would like us all to remember that we are professionals and need to work together, collaboration with our peers, medical colleagues for the advancement of women, choice, safety and childbirth. Sure, make comments but remember, every one out there has feelings and even though debates may get heated, it is the women and facts that count not recriminations and innuendo.
REMEMBER THERE ARE FEELINGS ALL AROUND US! BE GENTLE WITH EACH OTHER
Antigonos – Who isn’t suitable for a VBAC in your opinion, just out of interest.
Dr Amy is nothing but confrontational. She should just report the midwife to the local midwifery board if there is a problem. The sort of bullying undertaken by some bloggers is overt and unnecessary. Posting opinion and disagreeing is one thing. insulting and demeaning when you have no actual knowledge of someone is just bullying. Dr Amy is an expert in this.
Dr Amy can’t distinguish between something that could be dangerous and completely normal midwifery practice. The other day she gave a UK student midwife an incredibly rude bullying dressing down in response to a description of the 3-6-9 rule for dealing with a fetal bradycardia. Amy’s fan club saw the sense of what Vicky was saying, but Amy’s enormous ego just can’t cope with being in the wrong ever.
As for blogs shutting up shop occasionally…sometimes people get anxious about anonymity, sometimes they feel they may get in trouble for stuff they have written even if they have done nothing wrong – and given what a crazy world we live in, yes people can get in hot water about stuff they have written even if they have done nothing wrong. Do you think Dr Crippen would be able to continue to practice if everyone knew who he was?
I am curious how homebirth supporters believe that incompetent midwifery practice advertised on the web should be dealt with.
We can all agree (I don’t notice anyone disagreeing) that giving up without finding a source of a 1000 cc obstetric hemorrhage is completely indefensible. We can all agree (I don’t notice anyone disagreeing) that packing a vagina during a hemorrhage is unacceptable. We can all agree (I don’t notice anyone disagreeing) that Morag actually thought that what her preceptor did was acceptable, when it was gross malpractice.
I see a lot of people concerned about the feelings of the midwife, and no one concerned about the health of the patient.
Ultimately Morag password protected the blog because it occurred to her that she had publicly told a story of malpractice that the patient herself could read, not to mention the board of midwifery in her state. So we know what Morag did to protect her preceptor and herself. What I’d like to know is what Morag did to protect the patient. What did Morag do to investigate whether malpractice did occur, and how to be prepared for obstetric hemorrhage in the future.
Is homebirth midwifery about midwives and their feelings or is homebirth midwifery about patients and their safety?
Midwifemuse, your method for dealing with commentary you find abusive is by far the most sensible (ignore ’em), but I disagree with the implication that Amy Tuteur “bullied” Morag.
Publicly criticizing someone’s published opinions hardly constitutes bullying; it constitutes criticism–deserved or undeserved–which the subject is free to answer, as Morag attempted to do in her subsequent posts. Bullying implies the use of intimidation, cruelty or force against a weaker individual by a stronger individual. Amy Tuteur has no more power in this forum than does Morag, nor has she made any threats. If Morag feels intimidated (and I don’t know if this is the case), it is because she is either unable to articulate her positions persuasively, or unable to defend them.
Anyone who is intimidated by criticism–even that of Amy Tuteur’s blunt stripe–is well advised to refrain from expressing his or her opinions in the public arena.
Antigonos – (I had to look up IMO!) Unfortuntely I can only comment on 2 entries from Morag’s blog as I have never read her before, therefore I can’t really agree or disagree concerning her viewpoint on VBAC’s. The entries I have read are concerning the 1 litre PPH, there are some elements which intrigue me, the use of herbs being the most obvious. Dr Amy has commented and so I shall be discussing the rest of the entries that I have had sight of with her.
My comment regarding Morag perhaps being upset by Dr Tuteur stemmed from Dr Amy’s entry where she critiqued Morag’s blog post ” I have no fight with you “.
Is ‘getting out of the kitchen a good idea’? Morag is intense about her midwifery and I wonder if the response she received will only entrench her further in her ‘radical ideology’ with no possibility now of moderation from constructive commenting.
Infomidwife – ‘How many times have you written something and you re read it, and it does not quite say what you wanted it to say?’
Frequently. It often makes perfect sense to me and I have written it to be interpreted in one way and then, thanks to comments, I realise that others have read it enirely diferently.
There are times when I read something so contrary to what would generally be accepted as safe practice that I feel NOT to comment and question would be as negligent as the actions discussed. Equally, when an entry discussing a management of care is, in my view, excessively medicalised I will put forward an arguement for a more ‘relaxed’ approach. Is this critism or just a discussion regarding different approaches to care?
I agree about the professionals working together, this does involve discussions and exchanges of views.
Lisa – It’s the little side-swipes that get me, personal observations concerning intelligence etc
Yehudit – Yes, I read the thread where Vicky was ridiculed. I found it unsettling and it really did give the impression of bullying. (I hadn’t picked up on Vicky being a student midwife).
It turns out that Cremede has blocked her blog as she is no longer anonymous.
Amy Tuteur – “I am curious how homebirth supporters believe that incompetent midwifery practice advertised on the web should be dealt with”. The problem is, as I see it, that what could/should be a discussion someimes degenerates into what appears to be personal attacks, and this observation is not solely directed at you. Your blog describes itself as a ‘debate’ but my understanding of a debate is when participants each put forward their opinions ‘a process of inquiry and advocacy seeking reasoned judgment'(dictionary definition) but many commentators resort to something which resembles a slanging match, ‘a dispute in which people insult and accuse each other’ (dictionary definition). This does nothing to endear each faction to the others viewpoint and will often cause them to put up barriers and so further entrench them in their stance.
With regard to Morag’s post about the PPH, which I have now read. Yes, there were questionable aspects, not least the use of herbs but having read her account my perspective has altered slightly. When I read your ‘debate’ I had the impression that they had done nothing to find the origin of the bleed, having read her account though they did. The woman’s condition remained stable throughout and the bleeding stopped. The situation was not as severe as I had envisaged after reading your page. However, a PPH is a PPH and as such would require transfer to hospital if this was a birth attended by midwives, working within the NHS, in the UK. (You will read NHS Blog Doctor’s ‘Sharon’s story’ where the 1500mls PPH, and the Independent Midwives management, was discussed at length). I have no idea what the situation is in the US.
The packing of the vagina, can’t say that I am familiar with this, but it worked! If we have a woman with a 1st degree tear which is trickling blood initially we apply pressure to the tear and reassess after 5 minutes, often it will have stopped bleeding and it does not recommence. Admittedly though this is not a course of action I would take if the blood loss were excessive.
I am not expressing concen about the condition of the woman as Morag has stated that ‘she was never symptomatic……was happily hydrating orally and eating normally……..Her bleeding was minimal when we left and was not been anything other than normal at our 24 and 36hr visits’.
Homebirth midwifery is about the birth of an uncomprmised baby and a heailthy new Mum. Midwives, and Doctors, will often reflect upon their experiences and these musings will often encompass their own emotions, positive and negative. I frequently do this, I am not considering that my experience is more, or even equally as, important as the event I was involved in but it does assist in understanding why I did something or reacted to something and may help me to learn.
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Squillo – ‘your method for dealing with commentary you find abusive is by far the most sensible (ignore ‘em),’
Difficult to do though as they can interpret it as they have ‘won’ the arguement.
Did I say that Dr Amy had bullied Morag? It may be implied but I didn’t say it. I’ve looked up bullying, my on-line dictionary has been much used today (!), and it came up with ‘blustery: noisily domineering; tending to browbeat others’, I’ll leave you to decide if his could be applied to some of the commentators on Homebirth Debate.
‘Anyone who is intimidated by criticism–even that of Amy Tuteur’s blunt stripe–is well advised to refrain from expressing his or her opinions in the public arena’.
This is why have described Dr Amy’s blog as my ‘scab’. I know I shouldn’t comment because there will be unpleasant repercussions, but I just can’t help it.
We can all agree (I don’t notice anyone disagreeing) that giving up without finding a source of a 1000 cc obstetric hemorrhage is completely indefensible.
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Okay, head above the parapet…but I think it happens every day in tertiary units. Once the initial blood loss has returned to a more normal postpartum loss, if the woman is asymptomatic, if the uterus is well-contracted, if placenta and membranes appeared complete, if any tears have been sutured/are not bleeding…no, we wouldn’t go investigating her cervix, and especially not by pulling it down with a ring forceps, given that she is no longer bleeding and the immediate threat is over…
assuming asymptomatic, the woman gets transferred to the postnatal ward with the information about the extent of the pph of unknown origin, an FBC will be done, transfusion might be considered depending on result, she will have regular observations. But no, we might never be absolutely sure of the source (and you can get a total 1000 ml loss made up from a number of different sources simultaneously – which each on their own would be nothing to panic about) and assuming she remains asymptomatic and no further dramatic bleeding you wouldn’t then be anxiously looking for one. You would be watchful…you would read the FBC results and the clotting screen……you would make sure she passed urine and you would check her pads regularly… but you wouldn’t panic over the fact that you hadn’t found the source of the blood loss once it had stopped. It would only be if she became symptomatic and/or she continued to bleed that you’d be investigating further.
Yehudit – I’ve never, ever pulled a cervix down. I’ve visualised them but never ‘grabbed’ one, let alone pulled it out. I have seen an obstetrician ‘grab’ one. I’m a bit worried now because I haven’t got the appropriate instrument in my on-call bag, but there again neither has any other midwife in my area.
Within every trust I have worked for as a community midwife attending homebirths, and also when I worked at the stand alone birth centre, policy was to transfer to the obstetric unit if EBL was more than 500mls, and this was religiously adhered to regardless of the woman’s condition.
I agree that there is an arguement to assess each case individually but once you take the litigation threat into account it may be sensible to have a rule which deprives the midwife of making her own judgements but protects him/her from making a decision whch may prove to be disasterously wrong. Perhaps I would be more comfortable if the rule applied to different causes of PPH. Bleeding from an episiotomy or tear, which stopped following suturing, no evidence of haematoma, woman’s condition, vital signs within normal limits then observe. PPH from atonic uterus, large clots, low Hb, transfer, even if she stops bleeding in response to ergometrine she may well start to bleed again when the effects wear off.
I agree with all that. I was specifically referring to what happens in tertiary units. Dr Amy’s argument is that it is indefensible to not continue to investigate the source of bleeding… lalala, forgive my cynicism, but if every pph required certain identification of the source, then we’d be mighty backed up with women unable to be discharged long after they had stopped bleeding, because investigations left room for doubt.
The ring forceps thing is from the virtual combat between Morag and Dr Amy
“As we didn’t go after the cervix with the ring forceps, we will probably never know for sure…(say Morag)
To which Dr Amy melodramatically responds “They thought there might be a tear of the cervix but they never bothered to check? A tear of the cervix is a potentially life threatening complication. You MUST check for it if you suspect it, because if you ignore it, the patient will literally bleed to death.”
I think the guideline for transfer from home birth/FSBC if EBL is over 500 mls makes perfect sense, especially where pph is from atonic uterus (it doesn’t seem to have been in this case) and especially the issue over litigation and taking individual judgment out of the picture. But the ease of doing that – the guidelines, the expectations, the communication between professionals – flow from having an integrated home birth service. This is not the system Morag works within – and is also something which Dr Amy pathologically opposes.
“Dr Amy’s argument is that it is indefensible to not continue to investigate the source of bleeding”
Not exactly. My argument is that it is indefensible to give up investigating for the source of bleeding because you don’t know how to investigate. It is indefensible to pack a vagina during a postpartum hemorrhage. The patient needs to be (and deserves to be) examined by someone who can find the source of the bleeding if it is possible to be found.
What particularly concerned me (in addition to the fact that the patient received inappropriate care) is that Morag came away from the incident without understanding that the care was inappropriate. In addition, when she realized that I had discussed the incident, she publicly proclaimed that she would not read what I had written since she knew it would be critical and, therefore, might make her feel bad. If you cannot bear to be criticized about the care of a patient, you shouldn’t be caring for anyone.
To me, password protecting the blog was symbolic of the entire episode. She did not understand that what her preceptor did was wrong and she would not bother to investigate. She could have removed the posts or could have modified them based on new knowledge. Instead she determined to keep on blissfully writing about mismanagement, but to hide it from anyone who might be in a position to know that it was wrong.
Midwifemuse:
Interestingly, both the dictionaries I use “in-house” (Webster’s and OED, in deference to my friends across the pond) list intimidation of a weaker soul as integral to the definition of bullying. In any event, if I inferred something you didn’t intend, my apologies.
I happen to think it’s a good thing you can’t leave the “scab” alone, repercussions notwithstanding. It makes debate more interesting and, occasionally, informative. Without the “scab-pickers” (love that image, BTW), public discourse would be dull indeed.
post 16 by midwifemuse seems to sum the whole thing up rather well.
I don’t think that homebirth is about the midwife but about the client and her baby but I do feel discussion and interaction surrounding this is important.
Yehudit – I have to say that when commenting on obstetric/midwifery issues which occur in the US it is often quite difficult as the system they operate appears so radically different from ours in the UK. I often rant about the maternity services I work within but the ease of referral from midwifery-led to consultant, and back again, seems to cause less rivalry, disagreement between the Doctors and Midwives and should be safer for the women and babies. I have been known to express my desire to be an Indie but cite the lack of insurance as the reason I shy away from that step. However, reading the recent entries concerning Indies and the DEM’s, the decision making and repercussons surrounding transfer within these systems means that I can now add the lack of easy switching between midwifery and obstetric care as a factor in my staying within the NHS.
“I often rant about the maternity services I work within but the ease of referral from midwifery-led to consultant, and back again, seems to cause less rivalry, disagreement between the Doctors and Midwives and should be safer for the women and babies.”
In the US the equivalent of UK midwives are CNMs (certified nurse midwives). They are completely integrated within the healthcare system. Doctors collaborate with CNMs all the time and many hire CNMs to work within their private practices because they are respected by patients and doctors alike.
American DEMs, on the other hand, are women who won’t or can’t complete the American requirements for midwifery. They created their own licensing board, which exists merely to give a “crendential” to women who are grossly undereducated and grossly undertrained.
American DEMs are not the equivalent of UK independent midwives. There is no UK equivalent. The closest thing would be if a group of women without formal midwifery education got together and made up their own “requirements” for a new “credential” and announced themselves to be qualified based only on their own assessment.
Yes, working entirely independently (as opposed to within a team) would put me off indie practice too – despite a (perhaps rose-tinted) desire to caseload.
I think US DEMs are a completely different (and varied!) kettle of fish from non-RN RMs in the UK. However, I think their existence is the logical outcome of the US obstetric-based maternity system, and so their vocal critics really only have themselves to blame. Here, Changing Childbirth didn’t change so very much (at least we are still (still!) trying to grapple with what it means to have a system of care in which women have choices and are in control of what is done to them by midwives and medics (no one is in control of nature, of course!). BUT…at least it expressed a shift in attitude which I think has been fairly fundamental. Maybe I am too optimistic?
Dr Amy – I agree that having the ability to identify the source of bleeding is, or ahould be, an integral part of a midwife’s practice. To be fair though to Morag and her mentor it seems that they did have the ability but were unable to put it into practice until they could move the woman to a suitable position and surface. I may be reading the account with rose-tinted glasses but I interpreted the use of the vaginal pack as an interim measure, I think that Morag mentioned 15 minutes. Quite a long time but understandable if you have a woman immediately post delivery who is not on a delivery bed which can be broken and transformed with lithotomy poles.
The password protecting, I feel, was a defence mechanism which, as I said before is counter-productive to her learning and assimilating. I symathise with her as she was obviously overwhelmed by the adverse comments and, being a student, has not yet the background to discuss the alternatives. As an experienced, long-qualified midwife I often find the ‘barrage’ when I leave a comment intimidating.
Squillo – ‘intimidation of a weaker soul’
Very true. In my reply to Dr Amy I alluded to the fact that Morag may be ‘a weaker’ soul due to her inexperience and, come to that I often feel that way too. Is it appropriate then that we, rather than patiently, non-judgementally explaining why a course of action is questionable, go in with ‘both guns blazing’?
Lisa – Yes,discussion and modulated interaction is the most productive way to exchange viewpoints.
CNMs are completely marginal to the US system (there are – what? – less than 8,000 of them) which relies largely on L&D nurses to provide labour care.
CNMs can’t do home births without obstetric back-up, and the veto of most obstetricians effectively means that the vast majority of CNMs will not do home birth there is no integrated home birth service anywhere in the US.
Contrast this to the UK system in which it is possible to have a home birth anywhere in the UK with a qualified midwife who works for the same NHS trust to which you will transfer if need be, and who works alongside obstetricians and other professionals, working to the same guidelines. (I’m talking about NHS community midwives here, not independents – who should work to the NMC rules and standards, but may not work to the same guidelines as that particular trust, since each hospitals guidelines will differ).
Dr Amy – That is a frightening picture that you paint regarding the DEM’s. I understood that they were becoming legal, standards were being laid down and regulation being achieved, is this not the case?
Yehudit – Thank you for the explanation about the DEM’s and CNM’s, and having read all this, ‘No, I don’t think that you are being too optimistic!’ I’m beginning to feel that my lot as a midwife in the NHS may not be quite as bad as I thought! Strike that, my lot in the NHS is not that bad, but would be a whole lot better if the government and the ‘powers that be’ stopped fiddling around with it and gave us more midwives, but that’s another arguement!
The closest thing would be if a group of women without formal midwifery education got together and made up their own “requirements” for a new “credential” and announced themselves to be qualified based only on their own assessment.
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Being qualified based on your own (i.e. your own profession’s) assessment is a pretty basic definition of what it means to be a professional: self-regulating, accredited by one’s peers. When the RCOG decides to change the requirements for the post-grad obs training, or when the GMC or NMC decide to change this or that requirement for registration as a doctor, nurse or midwife – that is in essence the same thing. Now I’m willing to believe that the competence required to achieve CPM status is significantly less than that required to achieve CM (the ACNMs accredited direct-entry programme) status. But I don’t think that is proven simply on the basis of being self-regulating. By that token, the ACNM wouldn’t be in a position to set requirements and credential CNMs or CMs…It is after all, what doctor’s have always done and what doctor’s fight hard to retain – the right to be self-regulating. No?
“CNMs are completely marginal to the US system (there are – what? – less than 8,000 of them) which relies largely on L&D nurses to provide labour care.”
No, CNMs are not marginal. They are the equivalent of UK midwives; the same level of training, the same level of experience, the same ability to manage patients on their own.
“CNMs can’t do home births without obstetric back-up”
That does not mean that an obstetrician needs to be present or even needs to be involved. It merely means that the midwife must ensure that she has a doctor willing to accept her patients in transfer, and someone she can collaborate with in the event of complications. If I understand correctly, UK midwives are no different. If you need to transfer the care of the patient you don’t dump her in the closest emergency room or start paging through the phone book. You know exactly whom to call for help.
US DEMs can’t get obstetricians to back them up because obstetricians find them to be unsafe providers. They don’t practice “indendently”. They are unqualified, no one will work with them, but they choose to practice anyway. This is not a benefit; rather it is a sign of being undereducated, undertrained and willing to take insupportable risks.
Midwifemuse: “I understood that they were becoming legal, standards were being laid down and regulation being achieved, is this not the case?”
Standards are laid down by the DEMs themselves, and those standards are far below any other midwives in the industrialized world. The “coursework” often consists in large part of homeopathy, reflexology, herbs, crystals and flower essences (I am not making this up). Their experience is limited to attending 20-40 deliveries. That’s it.
They are becoming legal, but that is in response to political pressure, and deliberate efforts on the part of DEMs to confuse legislators about the differences between DEMs and CNMs.
In my judgment, what is most concerning and most telling about American DEMs is that they refuse to release their safety statistics to the public. The Johnson and Daviss study (BMJ 2005) was undertaken with MANA in an effort to provide scientific evidence to present at legislative hearings. The collection of statistics did not stop in 2000, although Johnson and Daviss restricted their study to that year. MANA has continued to collect statistics up to the present day. They have publicly offered the safety statistics to organizations that can prove that they will use them for the “advancement of midwifery”. Even after you prove that you will use them for the “advancement of midwifery, you still have to sign a legal non-disclosure agreement which mandates penalties if you share the information with anyone else.
The fact that MANA is publicly offering the statistics to homebirth advocacy organizations means that the statistics have been fully analyzed. The fact that they will not release them to the public and have actually insisted on legal penalties for anyone who does release them to the public means that MANA’s statistics almost certainly show that homebirth is not nearly as safe as hospital birth.
The bottom line is this: Yehudit and Midwifemuse, I suspect that you would not agree to work with American DEMs because you would find them to be grossly undereducated and undertrained. You would not want your patients cared for by midwives that do not meet the standards that you have met. If you wouldn’t work with them, why would anyone else?
Yehudit:
“It is after all, what doctor’s have always done and what doctor’s fight hard to retain – the right to be self-regulating. No?”
No. All doctors are regulated by the states in which they practice. They are not regulated by themselves.
That does not mean that an obstetrician needs to be present or even needs to be involved. It merely means that the midwife must ensure that she has a doctor willing to accept her patients in transfer, and someone she can collaborate with in the event of complications. If I understand correctly, UK midwives are no different.
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The difference is that an obstetrician (or more precisely, an NHS obstetric unit) can’t refuse to be the ‘back up’ of a registered midwife – they MUST provide back up to the home birth service and cannot veto the provision of a home birth service by registered midwives.
“US DEMs can’t get obstetricians to back them up because obstetricians find them to be unsafe providers.”
But CNMs also can’t get obstetricians to back them up in out of hospital settings (both home and birth centres), despite your lauding of them as safe providers. In effect, US obstetricians have a power of veto over the provision of a home birth service by CNMs no matter how safe they are as practitioners, how close to the hospital, how good the transfer arrangements, or how low-risk the client.
This is completely different from the UK, where the woman has the right to be attended by an NHS midwife at home, with ambulance service back-up for transfer and NHS maternity unit to receive her if needed, regardless of the view of any particular obstetrician about the wisdom of her choice.
All doctors are regulated by the states in which they practice. They are not regulated by themselves.
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Therefore…in those US states that have Licensed Midwives of some variety, based on CPM or other criteria it follows that those DE midwives who are also LMs (or whatever the local licensing system lays down) are not regulated by themselves, but by the states in which they practice.
Honestly, I don’t have a problem with you saying that the licensing in this or that or all states is insufficiently stringent, or that the training requirements for CPM status is inadequate . But you can’t make that case simply on the basis that they are ‘self-regulating’. All professions are self-regulating (definition of what it means to be a profession) with some degree of statutory oversight – which appears to exist in many States of the US (i.e. wherever DE midwives must be licensed by the state to practice).
Yehudit,
The key point that you keep ignoring is that there already were standards. DEMs didn’t like (or could not meet) the existing standards for midwives so they got together and made up the “standards” that they preferred.
The analogue in your system is not independent midwives. The analogue would be if a group of lay people decided to call themselves midwives and make up their own “standards” and their own “credential”. Perhaps they might announce that they were CLMs (certified lay midwives). Would you agree that their much less stringent standards qualified them to be a midwife? Would you support their right to opt out of standard midwifery training and make up their own “training”? Would you believe that making up their own “training” and calling themselves CLMs made them qualified to be caring for patients?
If the RCOG were in a position to effectively prevent RMs attending out of hospital (home and birth centre) births then I would be unsurprised if a lay midwifery movement grew up to do a job that RMs were unable or unwilling to do for fear of losing their registration. I wouldn’t like it at all, but it would the logical outcome of the obstetric veto on domicilary service by RMs and I would know where to lay the blame.
What do you think of the CM qualification accredited by the ACNM? This is the rough equivalent of our direct-entry programme here, and the extension of it across the US (it is currently only recognized in a few New England States) might very well attract DEMs who do not want to become CNMs.
p.s. I generally don’t care for patients.
Yehudit,
You have dodged the question yet again. Regardless of their reasoning, would you support a group of lay people getting together, making up their own “standards” and calling themselves CLMs? Would that make them midwives qualified to care for patients?
As to CMs, it sounds great to me.
I have said I wouldn’t like it. Not sure how that is dodging the question. However, if RMs were not willing or able to provide care to women wanting home birth, then “lay midwives” might be the *only* people willing to provide care, which I guess would make them the most qualified people (unless you think unassisted birth is preferable?) to do so – given the paucity of other options.
Why don’t you campaign for the recognition of CM qualification more widely, which would make it more attractive to those DEMs outside of those three New England states in which it is currently recognized? NGM would likely have done CM training years ago if it had been recognized in her neck of the woods. And why don’t you support the creation of home birth services with proper back-up where they can be provided with greater safety than the current non-arrangements of dump and run?
Yehudit:
“And why don’t you support the creation of home birth services with proper back-up where they can be provided with greater safety than the current non-arrangements of dump and run?”
Because homebirth is inherently unsafe and no amount of arrangements can make it safe. As a general rule I do not promote any practice that will put the lives of substantial numbers of babies at risk.
Well, I don’t think the evidence bears that out, but as I’ve become fond of repeating we shall await the NPEU study with interest. However, in the meantime, and taking into account your beliefs about home birth – what would be wrong with a policy of harm reduction?
Yehudit:
“what would be wrong with a policy of harm reduction?”
My policy IS a policy of harm reduction. US DEMs are not fit to practice and therefore, should not be practicing.
But hang on…now we’re back to DEMs, rather than home birth per se. It’s always round in circles with you – what about the CNMs and CMs who offer home birth? Do you think they are not fit to practice and therefore should not be practicing?
Yehudit:
“what about the CNMs and CMs who offer home birth? Do you think they are not fit to practice and therefore should not be practicing?”
No, I think that no one should be offering homebirth.
Dr Amy – “No, I think that no one should be offering homebirth”.
But then we are back to the fact that there are women who choose to have a homebirth, even if this is not an option offered by health providers and even when they have been advised against it. I feel that since this is the case it is better to have available a trained resource to assist them at the birth, and to therefore reduce the risk to them and their baby.
midwifemuse:
“But then we are back to the fact that there are women who choose to have a homebirth, even if this is not an option offered by health providers and even when they have been advised against it. I feel that since this is the case it is better to have available a trained resource to assist them at the birth, and to therefore reduce the risk to them and their baby.”
That is certainly a legitimate point of view, but there are other legitimate points of view as well. There are other similar situations in public health. Some people believe that since drug addicts are going to shoot up anyway, it is better to provide them with sterile needles to prevent HIV transmission. Others think that providing sterile needles facilitates drug abuse without having any impact on HIV transmission since they pass the needles around after they use them.
As a general matter, I am usually unpersuaded by arguments that have an element of blackmail in them. I find the backmail tactics of homebirth advocates particularly disturbing. It makes no sense to respond to an argument that amounts to: I am willing to risk my baby’s life for my “experience. It is up to you attend me to minimize the risk; otherwise I will expose my baby to even more risk without you.
And what about the blackmail on the other side? I am disturbed that women who want hospital births can effectively be forced into CS because no hospital provider in the vicinity offers VBAC.
Yehudit:
“And what about the blackmail on the other side?”
I don’t understand the analogy or why you think it is blackmail.
Dr Amy – Gosh, comparing providing care to women who opt for a homebirth with drug addicts and the provision of sterile needles, that is really provocative stuff. There is such a reality chasm between those two situations that I don’t feel I have to offer a counter-arguement.
Is a woman deciding she wants a homebirth blackmail, or just her demonstrating her right to choose. Using another far-stretched analogy; a patient is diagnosed with leukaemia which could possibly be successfully treated, without treatment they will die. They refuse treatment. Would any care provider then refuse to provide the personal and medical care required until they die?
It’s not just another continent, is it? It’s another planet!
midwifemuse:
“Gosh, comparing providing care to women who opt for a homebirth with drug addicts and the provision of sterile needles, that is really provocative stuff. There is such a reality chasm between those two situations that I don’t feel I have to offer a counter-arguement.”
The issue is the same. Should we facilitate a situation that is dangerous because the patient threatens to do make it even more dangerous if we don’t help.
As I’m sure you know, there are no right or wrong answers in philosophy and we reason by finding comparable situations and compare and contrast them.
To me, the argument that women who have a homebirth will do it anyway has an element of blackmail. Should we be responding to that type of blackmail? What principles of medical ethics can guide us in determining the best response?
Wondering if you have had a chance to read the bullying articles I wrote for Midwifery Today? I think the online debates are similar in nature to the bullying that happens “real time”. I think that Amy’s homebirth debate blog is important because it is real : as homebirth midwives we forget that for the majority of women (not just doctors) this is their viewpoint. My personal opinions on Amy’s blog aren’t favorable, but that is because we see the world (and women’t bodies) in a very different light. I hope the debate keeps raging!
Wow – lots of debate… & Amy’s here. Ye gads, I would think a positive site like this would give her palpitations! I’m so sad that Morag has gone ‘undergound’ & I’ll ask if you can have access for sure Midwifemuse. I have put my blog back up as I am no longer anon & it is too late to mourn it now! I am just going to have to make sure my cohort know that i’ll never write about them, as that was the initial problem apparently.
I will not stop writing & I will not stop having an opinion!
Oh, & Amy, my first catch was a homebirth, it was faaaaaaaaaabulous! Everyone survived, including me 🙂
marinah – No, I havn’t read your article, is it available on-line?
Agatha – Pleased that you are back up and running, and delighted that your first ‘hands on’ was at home, the root of midwifery care.
Mmm hmmm, me too! I’ve been exceptionally lucky in my experiences in that i’ve had 7 homebirths in my placement blocks. I go on to Delivery Suite on Monday & I have to say, that whilst I like the ‘control’ of the environment, it’s not got that magic of leaving a new family tucked up in clean sheets in their bed as dawn is breaking.
Agatha – ‘the ‘control’ of the environment’
Well expressed if what you mean is knowing that there is an easy, fluid transfer if a situation becomes high risk. The ‘control’ that I object to is a)centralised monitoring and b)people, especially the Drs, feeling that they can wander in at any time when you are are caring for a ‘low-risk’ woman.
Midwife muse,
I made the decision to step off the more public blogosphere in large part due to the incredibly aggressive and meanspirited comments which came flooding in after Amy’s posts. I’m a student, I’m learning and I’m weary (the fact that I was up all night at a beautiful, effortless dawn homebirth might have something to do with all of this :)). While I realize I’ve been called a coward, in the absence of any other protective mechanism I’m ok with taking my blog private for a bit. I feel ok walking away from bullies. If you’d like to read along please by all means send me an e-mail. I’m open to discussion and differing opinions, I’m even grateful for them, especially from midwives who know homebirth. I have much to learn and I’m open to where and from whom that happens. I confess I object to name calling off the bat, with no knowledge of the case which I made a short comment about. I’m not sure I know many folks who engage in friendly discussion with folks who kick things off with words like ‘negligence’ and ‘malpractice’.
I think the thing I object to so much is that no CPM/LM (also known as DEM) can make herself heard on ‘Homebirth Debate’. There is no respectful discussion. She (and some of her readers) simply attacks – and let’s be real that is what she does – anyone who attends homebirths, and by extension the women who chose this for *their* families. I object to that, and like many before me I’ve decided not to engage.
I am fortunate to be studying in a state where midwives are licensed and work beautifully within the system. We train alongside nurse midwives, attending births inside hospitals both here in the states and abroad, and we train with LM’s, specializing in the care of low-risk women outside of hospitals. I attend an accredited school, for which I receive federal financial aid, and there I am instructed by medical professionals of all stripes (including some of the University of Washington’s physician faculty and ACOG’s current state president for crying out loud). Graduates from my school are practicing in Australia, New Zealand, Canada and the UK. Forgive me when I get a little irked at Amy’s insinuation that all DEM’s are ignorant, poorly educated hacks. Again, it doesn’t engender much desire for a friendly chat. I, the midwives I work with and the women we serve are supported in Washington State by a system which has licensed homebirth midwives for almost 30 years, and in which our professional services are integrated well into the medical system. Homebirth is a legally recognized, (and insurance reimbursed!) choice for childbearing families in Washington State. LM’s here don’t have to claim legitimacy from the medical establishment, we’re an accepted, well-regulated, piece of the picture, regardless of how Amy feels about it.
I can accept that Amy (and others) object to the way that particular bleed was handled, I’m ok with that. Just in choosing to specialize in normal, vaginal, home births we differ. I objected to the tone of her posts, and to some of the vicious comments which flooded my inbox. We will never agree, she will always think homebirth is beyond acceptable. The decisions I make when I am a licensed midwife *may* differ from the calls my current preceptor makes. How exactly we managed that bleed seems beyond the point.
This blogging thing is complicated, and recently for me it’s been painful.
Believe it or not I only just found your blog, it’s lovely.
Thanks for listening.
Cheers, Morag
Hi there!
You can find all four articles online 🙂 The first is at:
http://www.midwiferytoday.com/articles/bullying_1.asp
I hope it is useful to your debate 🙂
thanks so much,
marinah
Being a doctor complete outside of the obstetric field here are my observations:
1) Historically birth with minimum availability of medical assistance had significant rates of perinatal and maternal morbidity and mortality (and still witnessed in Third World Countries)
2) There are multiple factors that contribute to mortality. However we know that countries with C-section rates falling below 20% demonstrate higher birth risks than those above.
3) There is significance variation in C-section rates within Western countries with no clear difference in outcomes across much of this range.
4) The evidence base of the whole practice of obstetric medicine (and home birth) is generally poor.
5) Risk assessment is imperfect in determining exactly which mums are likely to experience birth complications. There is no perfect system to reduce complications to zero. More research is needed.
6) If mothers are reasonably well selected then the risk of natural home birth can be substantially reduced. However, the risk still probably exceeds that of hospital delivery. The real question is whether the relative risks is acceptable to all those concerned (including the unborn child)
Finally, the important issues is that whoever is involved in delivery of the child:
1) They have appropriate training under a regulatory body
2) They can demonstrate compliance with clearly stated standards
3) There is a process of accountability for deviations from acceptable practice
4) Appropriate auditing and review is undertaken to identify when complication rates are being exceeded. Any adverse outcome should undergo detailed investigation and peer review.
5) Accurate information is provided to the mother about the absolute and relative risks of the the choices they make. Not just ‘bad things’ can always happen or ‘I have seen many successful natural breech deliveries’ or ‘Caesarian’s are the safest solution’
Indemnity is a separate issue. Most governing authorities consider this to be a statutory requirement rather than a personal consideration between heath-deliver and mother. I think this is a sensible thing to protect the rights of the public.
Sitting on the fence – An extensive and comprehensive summation. Not sure if ‘sitting on the fence’ is an appropriate nom de plume as my impression is of someone unhappy with the concept of homebirth. I’m assuming that you are from Australia? Do you have anything like CNST? In the UK your ‘important issues’ are all covered by this.
I personally am apprehensive about the idea but I also know of well educated and respected people who have weighed the risks and elected to choose this path. However, I support the freedom for people to make the choice as long as they are well informed and they appreciate the consequences – good and bad (which in childbirth I believes involves at least two people ).
A doctor or any allied health professional’s first job is to provide options and risk:benefit ratios to the client/patient but not force them into a decision. Someone cannot feel obliged to accept a Caesarian as much as someone shouldn’t feel pressured to give birth in a swimming pool. The second job is to ensure that good care is delivered even if it disagrees with their personal opinion. The duty of care is not immediately broken just because my patient doesn’t do what I advise.
I find representatives from the extreme edges of both camps quite parochial and frightening with their stance. The unfortunate result is that the mother feels they are being torn in two about their final decision. I would be afraid to meet some of these people if I had ‘chosen wrongly’.
At the end of the day, both mums should feel proud about what they have done rather than guilty that they have chosen one or other path.