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Posted February 17, 2009 | comments 6 Comments

Legislation would impose new rules on midwives

By Sally Voth -- Daily Staff Writer

Obstetricians and certified professional midwives have differing philosophies when it comes to ushering babies into the outside world.

However, a bill before the General Assembly might bring them into a closer working relationship. At least, that's the hope of certified professional midwife, Brynne Potter.

Del. Matt Lohr, R-Harrisonburg, has introduced a bill that would amend the regulation of midwifery.

It would require that midwives inform patients of potential risks associated with delivering at home, "including but not limited to special risks associated with vaginal births after a prior C-section, breech births, births by women experiencing high-risk pregnancies, and births of twins or multiples."

Lohr said the bill is motivated by a desire to protect mothers and children, and was brought to him by Dr. Catherine Slusher, an obstetrician and gynecologist in Harrisonburg.

"Right now, midwives, when they begin working with patients, they have to go over forms about their practices and what they do, and what we're trying to add. ... is a notification sheet that basically educates patients on high-risk categories," he said. "It just comes down to safety.

"I certainly support midwives and support what they do. We just need to make sure we are giving these women all the information that they need."

A second Lohr-sponsored bill, which would deny reimbursement to midwives who attend high-risk home births, didn't make it out of committee.

While researching several cases involving midwives that went before the Virginia Board of Medicine, Lohr said he found that each involved a high-risk patient.

According to the Board of Medicine's Web site, a Virginia Beach midwife's license was suspended for at least two years following two stillbirths to morbidly obese women who delivered breech babies.

In one case, the mother carried strep B, and failed a one-hour glucose-tolerance test, according to a Board of Medicine order. The midwife moved up the woman's estimated due date, and waited more than 24 hours after her water broke before performing a vaginal exam, the order says.

Despite the fact that the baby was premature and she'd never delivered a breech baby, the midwife didn't send the patient to the hospital, and in fact didn't call paramedics until the lifeless baby was born, the order says. The midwife had the mother sign a consent form to continue the delivery despite the breech position of the baby.

"However, the informed consent to a home vaginal breech delivery signed by Patient A and her husband did not specify stillbirth or death of the baby as a risk of such a delivery," the order says.

The baby had a ruptured liver and a strep B infection, it says, and an autopsy indicated a C-section could have saved the baby, who was born in January 2008.

The same midwife was involved in another stillbirth last June. That mother was Rh negative and was 42, among other risk factors.

In that case, the midwife spoke to paramedics about the partially delivered breech baby, telling them to wait a half hour for her to get to the patient's home.

Lohr said the bill was originally met with some opposition, but now the midwifery lobby has come on board, Lohr said.

That's true, said Rebecca Bowers-Lanier, lobbyist for the Commonwealth Midwives Alliance.

"We decided that we not only support it, but [wanted to] strengthen it so that all midwives can work with the Board of Medicine in creating standard practices around informed consent and disclosure," Bowers-Lanier said.

While midwives provide informed consent throughout every stage of pregnancy, she said, "it hasn't been standardized, and they realize that."

Potter, who is the policy liaison for the Commonwealth Midwives Alliance, said she thinks the proposed legislation will be "precedent-setting."

"The thing I'm most excited about is medicine and midwives are going to be on the same page," she said. "I feel like this is the first step in a peace process between physicians and midwives practicing in Virginia."

Good communication between ob-gyns and certified professional midwives will benefit mothers and babies, said Potter, who practices in Charlottesville. The bill should help reassure physicians that midwives are providing their clients with adequate, informed choices, she said.

The midwives alliance is submitting a substitute to the bill that would require information given to expectant mothers be "evidence-based," Potter said.

"We will let the evidence, the research, the studies dictate what we tell our clients in terms of risks of home births," she said. "That is the midwife model of care."

Most women interested in having their babies at home are healthy, according to Potter, who says she attends about 40 births a year.

About two dozen certified professional midwives practice in Virginia, Bowers-Lanier said. These differ from nurse-midwives who mainly work in hospitals in collaboration and consultation with doctors.

Marshall University and Shenandoah University have recently teamed up to offer a master's degree in nurse-midwifery. Shenandoah has had the degree program for several years now.

"Certified professional midwives only attend births outside of hospitals," Bowers-Lanier said.

She said the C-section rate for women who use midwives is between 5 percent and 9 percent, compared to 31 percent for women who give birth in hospitals in Virginia. Bowers-Lanier said about 10 percent of women who intend to have home births wind up in the hospital.

"Most people go in for pain relief," she said. "They just can't make that final push and they need pain relief."

Slusher, of Harrisonburg Ob-Gyn Associates, said she and other obstetrician-gynecologists have seen cases of midwives attempting to deliver babies for women who have previously had C-sections. The American College of Obstetricians and Gynecologists recommends that labor only be tried if an obstetrician, anesthesiologist and operating room are immediately available, she said.

"These patients are at risk for uterine rupture," Slusher said.

That almost always results in a dead baby and is dangerous for the mother, she said.

"Our concern is for women to think it's an OK thing to do at home," Slusher said.

There have been failed attempts at home deliveries after C-sections, she said, which led doctors to realize this practice was occurring.

"I'm not opposed to people having choices and being able to do what they need to do, but I do think the people responsible for home deliveries ... need to also assume the responsibility to conduct them in a safe fashion," Slusher said. "I have no idea how many are going on in the region. What I'm concerned about is if one is going on and [the uterus] ruptures at home, [and] the mother and baby die, that's one too many. Especially, if that person wasn't appropriately counseled that it was an inappropriate delivery to try at home.

"Anything that we can do to make the home midwifery practices safer and more practical would be welcomed by the obstetric community because when they have disasters, they fall in our laps unexpectedly for cleanup. They fall into whoever's on call lap. You have inherited a disaster and get the privilege of dealing with it and owning it. When you have never been consulted throughout the entire pregnancy and when it's inappropriate, it becomes an even greater problem."

Contact Sally Voth at svoth@nvdaily.com

6 Comments | Leave a comment

    Dr. Slushe's comments about VBAC being unsuitable for homebirth because of the risk of rupture are uninformed. The risk of a uterine rupture is extremely low, and the risk of that rupture being catastrophic is even lowen. If Dr. Slusher were in the habit of giving her patients evidence-based informed consent, she would know that. As a woman who has had 3 VBAC's, 2 of them at home under the watchful eyes of Certified Professional Midwives, I feel much safer attempting VBAC's at home where I am not pressured to accept unnecessary interventions just because they are someone's policy, even though there is no evidence to support their usefulness. I would much rather labor with a midwife who is with me constantly, rather than sit in a hospital with a nurse who pops in from time to time and a doctor who pops in even less frequently. I think the proposed legislation is good. but I'd like to see it go one step further and apply to all OB's in Virginia as well. All practitioners who provide any sort of care to pregnant women shold be required to give their patients informed consent of the benefits AND RISKS of all procedures they recommend, and that informed consent should be based on the scientific evidence that is available (complete with numbers and statistics and studies to back them up). I can assure you that this is not being done by OB's in Virginia.

    I take issue with this sentence: "The baby had a ruptured liver and a strep B infection, it says, and an autopsy indicated a C-section could have saved the baby, who was born in January 2008."

    I don't see any way an autopsy can prove this preterm baby would have been "saved" had the baby had been born by C-section in a hospital. If this baby had a strep B infection, it may have been dead already, or very very sick in utero prior to the midwife's arrival and may have died regardless of the method of delivery.

    I don't know the story but I do not know any licensed midwives who plan to deliver preterm, breech babies at home. This sounds more like an accidental home birth where someone went into labor too quickly to get to a hospital before she could be transferred. I bet there are 2 sides to this story.

    I'm a consumer of homebirth midwifery care, and I'm glad that midwives and doctors can come together and agree that evidence-based informed consent should be obtained in the course of all maternity care. In the case of CPMs, this is redundant, because informed consent is always obtained, but more information is always better than less.

    However, burdening a woman's ability to use a midwife for VBAC (or other so-called "high risk" births) will not have the intended effect of protecting mothers and their babies. Rather, it will have the effect of removing the safety net these women seek, of having a trained midwife with them, who is able to recognize complications early and facilitate transfer to a hospital if necessary.

    I realize that many physicians would like to force all women to give birth in hospitals, especially women seeking a VBAC. Unfortunately, most of these physicians are unwilling to attend VBACs themselves, or else refuse to recognize a woman's basic right of informed refusal (which is necessary to have in order for there to be, properly speaking, any meaningful right of informed consent to treatment whatsoever.) As long as hospitals refuse to serve VBAC patients, women will seek out midwives (and not the other way around - midwives do not seek out high risk clients), and physicians cannot change this fact by removing women's access to trained and licensed midwives. The course of action physicians such as Dr. Slusher urge upon legislators will do nothing more than remove the public oversight of these births that is part and parcel of the CPM licensing statute, and end up with women going out of state, hiring unlicensed midwives not subject to state oversight, or just going it alone.

    Physicians are already protected by the CPM statute in Virginia from liability arising from any transfer for CPM care. They should be focused on ways to encourage women to come to the hospital for VBACs positively, such as guaranteeing VBAC attendance for all women who want it in every hospital in the state. They could also enhance the safety of homebirthing mothers by having a good and respectful attitude about accepting transfers. They should encourage transfers, and not grumble about the "mess" they have to "clean up" as Dr. Slusher calls it. Seamless transfer would enhance safety, and transfering patients who need medical care is a responsible, not an irresponsible course of action for a midwife to take under appropriate circumstances.

    Women of Virginia want to use state-licensed Certified Professional Midwives and they are a safe option. OBs should support SAFE birth in Virginia and facilitate midwifery care, and safe and seamless TRANSFER of care to OBs, for every woman who chooses it.

    I am the Mother of three children all born at home. I believe that the medical community must do more to lower the rate of cesareans preformed. This is a real problem and The March of Dimes has stated that the over use of induction, cesareans and other interventions are leading to increases in premature birth and LBW babies. I am concerned about these outcomes that contribute to the infant mortality numbers we are seeing in the State.

    Ms. Voth,

    Before you write such an article, you should research the topic about which you are writing, rather than serving as a mindless mouthpiece. You are grossly ignorant about midwifery care, and, sadly, terribly ignorant about VBACs, risks thereof, and worst of all, about the risks of having a VBAC in a Virginia hospital.

    The actual risk of uterine rupture for a VBAC is 1 in 7000. For comparison, the risk of miscarriage from amniocentesis, a procedure recommended for all women over 35, is 2 in 100 (2%). Yet, OBs recommend this for ALL women over 35. Clearly, risk isn't what is motivating Dr. Slusher. I highly doubt she has ever told a patient the comparative risks.

    C-sections are a phenomenally lucrative procedure for OBs and hospitals. OBs charge more than $1000 more for a c-section than a natural birth. Hospitals rake in the money for the anesthesia, two extra days in the hospital, the frequent need for NICU care for the infant, and operating room costs. A natural birth costs a hospital under $10,000. A c-section costs more than $30,000, not including NICU fees. C-sections are profitable business and the only people who suffer are women and babies.

    Now, for a VBAC mother who births at home, birth is straight forward - the 1 in 7000 risk of a rupture and the other risks that apply to ALL women giving birth for the first time. A homebirth is drug and intervention free.

    I wanted to have my VBAC in the hospital with an OB but was told, first by my OB, then other OBs that attending a VBAC was NOT CONVENIENT FOR THEM. Not unsafe, just inconvenient. The only way my OB would agree to a VBAC was if I consented to have labor induced with Cytotec. Cytotec causes uterine ruptures in women who have NEVER had a prior c-section. It is a VERY DANGEROUS drug (the FDA bans its use for such purpose), but it is routinely used in obstetric inductions. My OB never mentioned that cytotec inductions have a 1 in 4 (25%) chance of causing a uterine rupture for women who have had a prior c-section. When I confronted her with the facts and the risks, she told me that she DID NOT care. She also wanted to augment my labor, another practice that is PROVEN UNSAFE for women with prior c-sections.

    After calling numerous OB offices in Northern Virginia, I found that such practices are the appalling standard of "care" for women who have had prior c-sections.

    Consequently, I decided to use a lay midwife because she was far MORE EDUCATED about safe VBACs and about VBACs in general that any OB to whom I spoke. I have had two wonderful VBACs at home since.

    I find your ignorance of obstetric practice shameful. Nest time you choose to write about midwives, and VBACs, then please educate yourself about VBACs and the unsafe practices inflicted upon women who attempt to have them under the "care" of OBs. Midwives are a MUCH safer option for almost every woman considering a VBAC, and consequently are the choice of EDUCATED, INTELLIGENT women who have done their research about birth.

    I think what concerns me is that many OBs talk about the risk of uterine rupture as if it is a common occurence during a VBAC. I delivered my second child recently by VBAC. I researched birthing the baby at home with a home birth midwife. She gave me more evidence-based information on VBAC and risks than my OB did. I ended up having a hospital VBAC with a midwife, however, I feel that the home birth midwife had more information on VBAC than the OB. To respond to Dr. Slusher saying, "Our concern is for women to think it's an OK thing to do at home" --- VBAC is OK to do at home. Let the patient decide.

    I think it's quite negative of Dr. Slusher to say, "because when they [home birth midwives] have disasters, they fall in our laps unexpectedly for cleanup." How often has Dr. Slusher actually, personally dealt with one of these "disasters"? What does she define as a disaster? Also, it makes it sound as if there are never any disasters in OB practice. With a c-section rate of about 30% for women who birth in a hospital with an OB, I would like to suggest that OB practice doesn't seem "disaster free" itself. I am not trying to be negative; just trying to show both sides.

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