Friday, February 8, 2013

Of Ethics and Home Birth




Or... Of Care Providers and Home Birth

Caveat: This was a hard blog post to write. Reading stories about the death of a baby is hard enough, but to read some of these stories from the mother's perspective is just heart-wrenching. As I have put this together, it seems very cut and dry... but I assure you it was not easy for me to do this as these are not easy stories  about which to read. I cannot imagine actually living through them and my heart goes out to each of these mothers, fathers, siblings, grandparents, etc and most especially, these sweet babies. I tried to use the names of the babies where I could but in some cases, the names were not given.

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Hospitals of course will see their fair share of infants that die b/c they obviously have much higher risk clientele. They have women who have zero prenatal care and walk in off the street. They have babies born at 23 weeks gestation. They have babies born to drug addicts. They have babies born with congenital birth defects. They will see and deal with every sort of high risk pregnant woman and the baby she carries.

When I was debating between home and hospital, I found one key question that really got to me:

Are there healthy, full-term babies routinely dying in hospitals that would have lived had they been born at home?

Are there?

Here are some stories of healthy, full term babies that have died or were injured at home births.... babies that  (most likely) would have lived had they been born in hospitals. And these are their care givers.

(You can click on the link for full the story or investigation. I am providing what I found to be the most shocking details in bullet-form lists under the names.)

Karen Carr, Certified Professional Midwife (CPM), Virginia
- baby was in breech position, which the midwife knew prior to labor; mother was 43 years old and was a first time mother
- baby's head entrapped during delivery for more than 20 minutes
- an additional 13 minutes passed while midwife attempted resuscitation before she called for emergency medical help
- baby died two days later
- money was raised by Karen Carr's supporters to pay for her legal fees... none raised for the family whose baby died
- Ina May Gaskin planned to testify on behalf of Karen Carr (Karen Carr accepted a plea agreement to avoid trial) 

Faith Beltz, Certified Professional Midwife (CPM), Texas
- midwife either ignored or did not recognize the signs of placental abruption (placenta detaches from the uterine wall)
- mother had a fever during labor, baby's heart tones were above 180, mother was passing blood clots and there was meconium in the amniotic fluid
- quote from the mother: "in the birth records, Faith repeatedly states that I was refusing to transfer. She NEVER said “transfer” to me. She never said “emergency”, or “abruption”. This is backed up by the other 3 people at my birth."
- quote from the mother "Please pay close attention to these words…the hospital was 3 MINUTES from my house. But that means NOTHING when bad things are happening and you are in hard labor. It took at least 30 minutes to get to the car. 30 MINUTES. Don’t fool yourself into thinking you are safer than you are."
- Baby Aquila was born still at home from an infection and complete placental abruption

Evelyn Muhlhan, Certified Nurse Midwife (CNM), Virginia and Maryland:
Complaint #2 of 5 of the investigation:
- administered Pitocin at a home birth, used vaginal chlorhexadrine (Hibiclens) to treat GBS infection, fundal pressure applied to help baby descend in second stage, misdiagnosed fetal station resulting in unnecessary episiotomy
- the mother called ambulance after 3 hours of pushing
- hospital transfer, baby born limp and blue, was OP with a nuchal cord, NICU stay for almost one month before transfer to a pediatric rehabilitation center, suffers from HIE and seizure disorder
- Johns HopkinsHospital ordered to pay out $55 million to the parents because the parents believe it was the hospital's fault the baby was not born in time to prevent the brain damage. The jury was not aware that it was an attempted home birth. The hospital is appealing the award.
Complaint #4 of 5 of the investigation:
- attempted HBAC (Home Birth After Cesarean)
- at 40.5 weeks, ultrasound indicated estimated weight of 9 lbs, 3 oz
- fetal heart tones indicated distress, 911 called, midwife delayed hospital transport and asked the EMS to "stand by" for over 20 minutes while the mother continued to push; EMS finally insisted on the transport
- cesarean performed immediately upon hospital arrival, baby was OP with tight nuchal cord and the uterus had ruptured
- baby was born still
- her license has been suspended by the Maryland Board of Nursing
- money was raised to help pay for the midwife's legal fees

Colleenand Jerusha Goodwin, Certified Professional Midwives (CPMs), Idaho:
- June 2008: baby girl born without oxygen leading to permanent brain damage, $5millionsettlement awarded to the couple (not sure if they will get a dime though as the midwives are planning to file for bankruptcy)
- October 2010: umbilical cord not clamped before it was cut, significant blood loss to baby; on admittance to hospital, baby had respiratory failure and severe HIE. Baby died 14 days later.
- June 2011: diabetic mother; baby in distress during labor; midwife delayed paramedics from entering the patient's room for at least 4 minutes; baby died.
- August 2011: 48 hours of active labor, 10 hours of pushing; baby born limp and unresponsive with meconium staining around the mouth; midwife didn't call for paramedics for 11 minutes after birth. Baby died. Autopsy performed and stated "the cause of death was anoxic brain injury secondary to a prolonged vaginal birth complicated by meconium aspiration."
- a RALLY was staged in support of the midwives. What a slap in the face to the loss moms and dads who lost their babies at the hands of these midwives....

TheGreenhouse Birth Center, combination of CNMs and CPMs, Michigan:
- the parents were reassured that it was safe to have a vaginal breech delivery at their birth center
- quote from the mother, regarding breech vaginal delivery: "They made it seem like it was even safer than having a C-section at that point. There was no discussion, no use of the phrase ‘high risk.’ No discussion of how your baby may not survive or your baby may become entrapped."
- baby boy's head became entrapped in her pelvis after his body was born
- baby Magnus was born without a heartbeat, transferred to the hospital and died after 13 days in the NICU
- the mother is now an activist for safer out-of-hospital birth practices. Please visit SaferMidwifery for Michigan.
- Ina May Gaskin, along with a slew of other midwives, offered her support to the midwives but not to the couple who have been all but shunned by the community that once embraced them. The loss mother responded to this with an openletter to Ina May.
- pretty much par for the course that money was raised to help the midwives pay for their legal fees but not for the family, who is also paying legal fees and also had to pay for birth center fees, EMS fees, hospital fees, and funeral fees. 

Dr.Biter, OB/GYN, California:
- 7 cases of Gross Negligence investigated by the Medical Board of California, which led to license suspension
- after a new and completely separate incident, his license has been suspending indefinitely after a July 2012 home birth in which the baby died
- he still has followers that believe he lost his job b/c of his popularity and support of natural childbirth

CaraMuhlhan, Certified Nurse Midwife (CNM),New York:
- this is the midwife featured in the movie The Business of Being Born
- one mother labored for over 72 hours after her water broke, transferred to hospital, had 103 degree temp, baby born and rushed to NICU for a 5 day stay; midwife told the couple at the postpartum visit "I had a plan the whole time, and you just didn’t trust me."
- in 2003, a mother sued Muhlhan b/c her son suffers from Erb's Palsey as a result of trauma from shoulder dystocia during birth, which may be due to the way the midwife handled the dystocia; the mother also believes the midwife was negligent that she did not recognize the baby to be too large for vaginal birth
- in 2007, a mother lost her baby under Muhlhan's care. After a long labor, the baby's heartbeat began to decel during second stage; the baby was born still
- in 2009, another couple lost their baby under Muhlhan's care and is sueing her for negligence and for failing to transfer. The mother labored for 3 days before giving birth to a stillborn baby.

Tamra Roloff, Certified Professional Midwife (CPM), Washington:
August 2009 birth: warned by her midwife against ultrasounds, the mother did not know her baby was breech until she was in labor. The baby was partially born during the hospital transfer in their car but the head was entrapped for the remaining 15 minute drive. A doctor rushed out and delivered the baby with forceps in the back of the car. Mother needed surgery to repair her 4th degree tears. Baby needed resuscitation and was LifeFlighted to Portland. The baby boy died due to brain injuries.
March 2010 birth: after 34 hours of labor after the mother's water broke (labor that was plagued with maternal fever and high blood pressure), the mother suffered a seizure; hospital transfer; baby was born still after cesarean due to placental abruption that took place while she labored at home. The mother nearly lost her life as well and was LifeFlighted to Portland, due to eclampsia and acute respiratory distress.

Hurt by Homebirth stories, which highlights far too many negligently practicing midwives

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These are just some of the stories I have read that got to me. Sadly, there are more. A lot more. More negligence. More sweet babies lost. There have been (and continue to be) many more stories in the news and there are other stories that didn't make the news but the moms have shared their home birth loss stories on their blogs or in online forums, etc.

I don't think trusting what we see in dramatic television shows is the answer but we can't just cover our ears, yell "la la la la" and pretend that either birth always goes perfectly if a "woman is left alone to give birth as our bodies are designed to do" or that it only goes awry for those who don't fully "trust birth". Those are extreme beliefs that are not only dangerous but they are setting up any woman to feel like a failure if her birth does not go exactly according to plan. I can't tell you the number of times I have read a woman's birth story who feels that she has failed if any interventions come into play.

We also cannot support home birth midwifery to an extreme extent that we won't accept or acknowledge that not every birth will be normal, that low risk does not equal no risk, that not every home birth midwife is ethical, that not every home birth midwife is skilled enough to be able to handle certain emergency situations, even if they are certified.

Why is it such a hard pill to swallow for so many home birth advocates? Is it b/c it affects their livelihood? Is it pride? Is it ignorance? Is it fear?

As we are all very different, unique people, we will all process things in our own unique manner. Two people can witness or experience the exact same thing and walk away with a different perception and opinion of the event. These stories might not even make you bat an eyelash. They instead may make you roll your eyes and think "this crazy doula is just trying to scare me." But for me, reading stories like these didn't scare me. They shook me. They added a big dose of reality to a very romanticized notion that I once believed in... that birth is natural and normal, we just need to trust it and trust our bodies.


5 comments:

  1. As an OB/GYN, I never say never and I never say always. I have learned in the past 21 years that not everyone will follow text book rules. No HCP's crystal ball is perfect. But what I have learned and practice guidelines will agree is that a signicant amount of expected outcomes can be anticipated and predicted.
    If I have 100 women at 40 weeks closed, and 100 women at 40 weeks 3 cm open, majority of the women 3 cm will deliver first. But homebirth supporters say cervical dilatation doesn't tell you anything about when you will go into labor? Yes, some who are closed will have labor or SROM, but less likely too. Cervical exams CAN help a HCP counsel a women when to come to L&D. If its your first and your closed, stay home longer. If its your fourth and your 3 cm (worse if history of precipitous labors) have a lower threshold for deciding to come to L&D. Cervical exams CAN determine presentation and position. Surprise breech presentations at homebirth is malpractice. If a cervical pelvic exam cannot determine presentation, then quickly scan over the belly with a sono. Information is power to counsel your patient correctly. Again homebirth midwifes regect procedures that might cause clients to risk out and they lose money. Talk about the BOBB!
    Bigger babies and OP babies and FTM have slower labors and more likely to tear, but not always.
    Subsequent pregnancies are usually easier with shorter labors and less tearing, but not always.
    Ultrasounds can be off 1 (the woo believe 2) pound, but in either direction. Why is it the woo say ultrasounds are off 1-2 pounds for big babies so don't worry, and reassure IUGR mommies that ultrasounds are off 1-2 pounds, so don't worry. What if a big baby is 1-2 pounds bigger, or an IUGR baby is 1-2 pounds smaller? Doctors are siding on the side of safety.
    Oligohydramnois can only be improved with hydration by 1-2 cm, but only if you are already dehydrated. It doesn't help that much if your already hydrated and your AFI is only 4. All hydration you achieve won't help if the placenta is so mature and dysfunctional that fluids and nutrients won't pass through it.
    Breech babies may just deliver easily, but are less likely too.
    Twin babies may just deliver easily, but are less likely to.
    VBAC can deliver safely, but have more risk than a non VBAC.
    We understand this in every walk of life. I'd rather drive myself then let my teenager drive. I'd rather drive than take a bus. I'd rather cook with a stove than a small stick fire, I'd rather be in a yacht than a John boat. I'd rather know the weather report before I drive somewhere than not know it. I'd rather wake up knowing what day it is than just randomly figure it out. Or I can just trust life and live on a hippy cult Farm.

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    1. Ummm.... I love this post. Anonymous OB, I think I know who you are.... Can you write to me privately? I'd love to share your thoughts in a blog post. Obviously, I can share anonymously. danielle at douladani dot com

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  2. Interested in giving some advice Danni?

    http://community.babycenter.com/post/a39429250/home_birth_horror_stories

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  3. Intriguing that nobody here is mentioning all the horrific side effects of hospital births. I see nowhere in this post where the majority of women who birth in hospitals are manipulated or downright forced into interventions they either don't want or don't understand. I see nothing that relates the actual studies done that show home birth to be as safe as hospital birth. Ever heard of the studies done on ultrasounds? I hadn't either with my first two babies, I find out now with my third that these studies point to possible damage to the baby. Do these darling doctors point out to women that epidurals can interfere with their ability to bond with their babies and breastfeeding? The answer to that is a great big NO! You list a few births over the entire country, one of which I know for a fact that the parents themselves refused to blame the midwife even upon threat of neglect from the state. Babies and mothers are dying in hospitals every day from horrendous 'care' and yet that is simple a 'tragedy' and everyone assumes that nothing could have been done. Birth plans are ignored, women are treated like cattle, and fathers are told that they have no right to speak. Our country has a c-section rate that is well over double the safety level and you ask why? Well one obvious reason is because doctors are forcing c-sections on women who do not need them. Is it probably safer to birth breech in a hospital? Well yes except that doctors don't even know how to assist a vaginal breech baby, they only know how to perform major surgery that does not guarantee a better result. Twins are the same and many hospitals really don't allow a vbac or if they do their rules are so strict that you might as well not try. Those are the higher risk women, if you want to read an even sadder story start researching the number of perfectly healthy women that get manipulated into c-sections for no reason other than lack of good quality care. Inductions MIGHT have a place after 42 weeks, women are induced BEFORE 40 weeks on a regular basis which is proven to have worse results than waiting. Your ultrasound size? Yeah, woops we were off by a pound and a half and now your baby is tiny and since we induced you which led to a cesarean and then promptly took your baby away from you they won't latch and you not only missed their first moments of life outside the womb but now cannot breastfeed either. These happen every day in hospitals! Every day women are subject to multiple people shoving their fingers into her vagina for no valid reason, curiosity is not valid. How about women being forced to lie down on their back to labor and birth? Evidence based care states NO and yet this is common practice. So far home birth is sounding pretty good to me. In fact, after two hospital births home birth is sounding so good that with my third I was completely willing to do it totally alone if need be. Luckily I have found midwives willing to come out and be a safety net if there is an emergency but I was 34 weeks before I found them. If cpm's were allowed to practice everywhere women like myself, who have suffered physical and psychological assault from hospital birthing practices would not be forced to such measures. In fact, women might not have to suffer such assault (very real assault) in the first place.

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    1. The point of my blog is to show the other side of home birth. These are stories that I did not hear when we were planning a home birth for our first child.

      I'm sorry you had a traumatic experience with your hospital birth. No where in my blog do I claim that all doctors are perfect nor do I claim that every hospital birth is perfect. But in asking myself where I believed my baby would be SAFEST, the answer for me over and over again has shown to ME that my babies are safest delivered in a hospital. The information I have read on both sides of this argument and the experiences I have had have led me to this place.

      I also find it very hard to believe (b/c there is NO EVIDENCE to support such claim) that a baby will not bond as well with his or her mother if she has an epidural or any other interventions. This is a "theory" (at best). There is no evidence to support it and it's a horrible way to guilt mothers who have had necessary interventions into thinking they did something wrong and now their child won't love them as much. Horrible and sad.

      Our c-section rate is double what it should be? How do you know this? What evidence do you have to show that our c-section rate is double what it should be?

      And what studies do you have to show the proof of safety of home birth vs hospital birth in the United States? There are none. May I suggest you read my Business of Being Misled blog post.
      http://whatifsandfears.blogspot.com/2012/12/the-business-of-being-misled.html

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