Sunday, February 15, 2009

When a baby dies during homebirth attempt

I believe in homebirth. I believe most of the time with no medical intervention women can give birth naturally to healthy babies. I believe there are intrinsic and complex biological factors that happen during natural labor & birth that create important biophysical changes that help us become more loving and sane humans. I believe the medical system interferes too much, gives too many epidurals, and does way too many c-sections. But the reality is medical intervention saves mothers and babies. Nature's system is designed to help the strongest survive. We no longer have 12 children and expect half to live to adulthood. We are evolving as a species. Medical intervention when needed is lifesaving, and life affirming. When parents chose to birth at home, they do so after weighing the risks versus benefits, they make a choice wanting to make the healthiest choice for their child. They choose midwifery care because they want a professional to let them know when things are not normal, to make the call for appropriate medical intervention, when it is needed for them as an individual, not because it is a routine practice designed to prevent lawsuits rather than complications.

I believe in direct entry midwifery. I do not think you need to be a nurse, or even have a college degree to learn how to deliver a baby safely. But I have spent my entire life training midwives because I have seen far too many midwives practice with far too little training, and unfortunately I have seen too many babies die that could have been prevented with better care.

Part of the problem is the inconsistent nature of training for direct entry midwives. MEAC (Midwifery Education and Accreditation Council), NARM (North American Registry of Midwives) are working to address this. And the quality of training has improved over the years. However we are still a ways behind. I know because over the last 25 years I have been teaching and operating midwifery schools, I have hired graduates from accredited midwifery programs, and apprentice trained midwives, many with years of experience, and more than most fall appalling short in the education to teach much less practice. There are so many gaps in some midwives training, it is not surprising medical people still call us Lay (as in untrained) Midwives. I started teaching midwives to breach those gaps, and I am incredibly proud of Aviva Institute. Even though, we are a tough academic program, 50% of our students wash out in the prerequisite or first year. I am committed to keep going. Because of what happened to my dear friend Jenifer and her baby Emmett. Her loss, her pain, her grief, is what is going to keep me going. Keep me working long hours for no money, keep me on my computer when I would rather play with my grandkids or read books. Baby Emmett will help drive me.

I talked to Jenifer yesterday for some time, she gave me details about the birth, I have to admit to being so angry, I could throw something. I have only heard the mother's side, not seen medical records, and I am not objective, I love Jenifer, I hurt for her loss. I am angry due to the midwife's actions, or lack of them, not giving the kind of care I think is reasonable and prudent. Going far too long with ruptured membranes without checking vitals, letting her push too long, and some awful things the midwife said. But that is only part of my anger, because unfortunately I have seen it before, the midwife with the mindset that homebirth is the desired outcome not a healthy baby. Midwives in my community have lost babies in very similar circumstances, or with breeches, twins, or have taken risks that really make me wonder what the agenda is. I believe homebirth is a philosophy not a place; it is about having the healthiest baby possible.

Having a full term otherwise healthy baby die during the last hours of labor is considered preventable. Sometimes everything is done that can be done at the time and it is with 20/20 hindsight, that you can say, we should have done this instead. But the worse cases for the parents (and for the midwife), is knowing that if transport to the hospital would have happened sooner, the baby would still be alive. The greatest pain is the loss of a child, but to lose a child when it may have been prevented, that is truly the worse that can happen. Homebirth families face an even greater stigma, where everyone thinks, of course this happened, "you were crazy to try a homebirth".

Part of the problem that happened here was not even the fault of the midwife, although she holds responsibility too, but the fault of the system. The system provides inadequate training for direct entry midwives, and those midwives with extensive medical training CNMs, are not generally allowed to do home births. Europe trains excellent non nurse midwives who have great outcomes. But even those with good training, midwives in the US often have poor if any OB back up. The obstetrician that Jenifer saw during her pregnancy refused to see her if she had a homebirth and a complication. In Ricky Lake's film "The Business of Being Born", her producer meets with a wonderful OB/GYN, who says you will likely have a nice birth at home, but if you have a problem I will be there. Her baby was preterm and breech, the midwife assesses the situation and says, we need to go to the hospital now, she goes, and a healthy baby is born. That is the system we need everywhere. Midwives need to not be afraid to transport mothers to the hospital. When midwives work in collaboration with OB/GYNs, maternal-child health is improved.

There were multiple failures here that lead to the preventable death of this beautiful baby boy. None of them the fault of the parents, who made a reasonable decision to birth at home after carefully looking at all the risk factors, selecting a midwife with extensive experience. They assumed as a health care professional she would do her job and protect life of their child. When it became clear to them there was a problem, they insisting on going to the hospital, despite the advice of the midwife. Part of the failure here is by the midwife, and likely not intentional negligence, but perhaps lack of training or experience. But most likely a mindset, a belief in homebirth, a reliance on anecdotes instead of evidence, fears of legal problems with transport, and just plain hubris. I have seen it before midwives making bad calls based on their own egos. This use to be the realm of doctors, hubris killing people, it is terrible to see it in midwives.

Part of the failure here is the system, we have inadequate OB backups. If OB/GYN practice was ruled by common sense not malpractice insurance companies, Jenifer would have had a doctor she trusted, at a hospital she preferred, and may have consulted and went in to the hospital before it was too late. Massachusetts is an alegal state; midwifery is allowed but not regulated. Licensing would have given the midwife parameters that may have saved this baby. We need better training for midwives, the CPM credentialing process needs to be strengthened and we need better support for direct entry midwifery schools.

None of this is going to change the horrible reality that for this family their beautiful baby boy is gone. That their grief is not only for the loss of their child but for the choices they made. Now the hospitals and doctors can say, this is why, homebirth is unsafe, CPMs are lay people without training. The loss here makes me so sad, and angry. I can channel that into work at Aviva Institute. We have the BEST, Birth Emergency Skills Training course, a weekend CEU course, to train out of hospital midwives. We are adding another one next week. Intrapartum Fetal Assessment for out-of-hospital midwives. Practicing midwives who take our course continue to say, I can't believe how much I learned. Midwife by midwife I know our work makes a difference, it just was not enough for this mother or this baby.

Crying and working is helping me deal with this, but mostly I pray for understanding. I know that the Creator is the giver of life and death, and that faith helps me even though I don't understand. I pray for the midwife, I know she must be hurting, but mostly I pray for Jenifer and Jay, for their healing.


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