This is a reply to Amy’s fantastic post about patient safety and the marginalization of midwives. While physicians have flocked to defend and rationalize an induction and cesarean on a non-pregnant woman with pseudocyesis, she points out that the same community often villainizes midwives for less.
The consensus on Facebook and around the web was that if midwives had been involved in an incident of this magnitude, they would have had their licenses revoked post-haste. Why? Because all kinds of disciplinary actions are made against midwives, whether they are practicing safely or not. Very often, the complaint is issued by a physician rather than a patient.
Dr. Amy swooped in to criticize direct entry midwives (pretty much proving the point) and a midwife named Margie wrote a gorgeous comment defending direct entry midwives that is as worth reading as the original post. For example:
And, if you think that CMN’s are the answer then you need to open your eyes and look around you. You would see communities such as mine where there is a population of nearly 2 million people without a single hospital that allows CNM’s to handle childbirth; a community that doesn’t have a single freestanding or hospital connected birthing center; a community with a cesarean section rate nearly 40%. In our state as in the majority of states, a CNM is regulated by the state nursing board and hey[sic] are pretty much treated like any other nurse in that state, unable to do anything without a doctor taking full responsibility. If, as you stated, these CNM’s are so educated and capable, then why are they still treated as underlings of the birthing community? Why are they not allowed to practice midwifery as they see fit? Why are they not allowed to make serious pregnancy and delivery decisions and only call in physicians when they feel it’s appropriate? Why are they not allowed to do procedures that they feel skilled in, such as vaginal breech deliveries, even though the doctors they work with are not skilled with or comfortable doing? Why are they NURSES first and then midwives?
Once you go and read Amy Romano’s full post and Margie’s full comment, you can come back and read my reply:
Margie, that was wonderful! *clap clap clap*
Amy, thanks for this post. I wish I had made a comment last night when I read it for the first time, but I needed some time to process it. I still don’t know if I can articulate a good thought, but I’ll try.
This is why I left midwifery and went to medical school. I was training with a direct entry midwife. She was being investigated for delivering an IUFD. It was a known IUFD. The father of the pregnant patient was a practicing ob/gyn in another state. He sat in on an ultrasound, and talked with his daughter about inducing at a hospital or waiting to go into labor and going ahead with a delivery at the birth center. She wanted to deliver naturally at the birth center, and did with his support, blessing, and presence.
The problem came when the midwife needed someone to sign the death certificate. She called around to physicians and the medical examiner, and one of them called in a complaint to the health department.
Apparently, state law requires that a midwife in Florida only participate in the delivery of what should be a healthy, uncomplicated labor and delivery of a healthy, normal baby. Although there was no question as to whether the prenatal care was adequate or if the IUFD could have been avoided, she is still being investigated four years later.
Yes, their constant probing has uncovered disgruntled former employees with dirt to dish, irregularities of paperwork, and the like. But, as my medical jurisprudence professor taught us, anyone can be busted for paperwork or charting errors. Anyone. They will find a technical error. It doesn’t matter what the complaint is about, they will pull years worth of charts (like they did with her – 5 years worth) and pore over them to find any charting error.
She has had to continue to try to run a birth center with all of her charts missing, various inspections and raids, and scrutiny of her past patients and anyone who has ever worked with her. All for delivering a known IUFD with compassion the way the patient wanted it to be, with no complications.
There are a lot of reasons why I decided to go to medical school. I had planned on it before midwifery school, actually. But, this was the event that led me to leave midwifery, especially direct entry midwifery, and go to medical school. I did not want the scrutiny, the bizarre overregulation, (at least in Florida – mandatory transfer of any postpartum patient with total blood loss of more than 500cc, for example), the lack of respect, or the hostility from the mainstream obstetrical community. I didn’t want to sit there with an impending investigation for what I would consider good care, going over five years of charts, terrified that I made a mistake, tempted to go back and “fix” items here and there on charts of uncomplicated, healthy, successful deliveries, to make sure that there were no holes or oversights that would cause me to lose my license.
I figured I could go into medicine and get away with a helluva lot more. I am not going to jump on a physician bashing bandwagon or anything – I respect many, many obstetricians and other physicians, and think that it is a wonderful field, or I wouldn’t be joining it. That being said, after being to a lot of hospital births, either as transfers from our center or as a doula or friend of the patient, I saw just how unsupervised and unscrutinized a private obstetrician with hospital attending rights can be. As long as you are not violating a major policy, like allowing trial of labor for VBAC *eye roll*, or letting patients and fetuses die, or majorly abusing the staff, there is an awful lot of pure, unadulterated autonomy. For all of the malpractice complaints, obstetricians should be happy that their practice patterns and standards of care just have to meet a bare minimum (baby comes out) to not get investigated by the licensing board. If every doctor I know who didn’t give informed consent before an episiotomy, (much less did one as a routine practice!) or had more than 500cc of blood loss without calling in a specialist had to worry about losing their license, it would be a very different atmosphere. Not that I think that is the answer. I just didn’t want to live with that spectre looming over me. I took the malpractice boogeyman instead. (which midwives still have to deal with, too.)
I completely agree with Amy. Punitive measures aren’t the answer. I am not asking to have these obstetricians run out of town, tarred and feathered. I think the whole system needs to be examined, focusing on the needs of the pregnant women, first.
That means recognizing and treating mental illness without doing an unnecessary induction and surgery, and then blaming and ridiculing her afterward. No sane woman goes through a two day induction and cesarean without being pregnant. Sane women who are pregnant want to avoid that! That means not investigating their practitioner for delivering their IUFD in an environment that was safe and good enough for a live fetus. That means allowing near miss reviews and apologies from physicians without placing them in legal jeopardy. That means not pitting obstetricians and midwives on opposing sides of a battle, where it seems women and babies are the ones caught in the crossfire.