Fifty Ways to Have Your Baby (My Thoughts on the Midwifery Malpractice Issue)

I believe that the primary and first issue that makes birth unsafe for women and babies is that of malpractice in obstetrics.

Malpractice insurance (or lack of it) was one of the issues discussed as Senator Chuck Graham and Senator Wilson of MO filibustered the midwifery bill. I agree with a lot of what they said. I agree with the midwives. My "curse" and my "blessing" is to see multiple sides of an issue and I often find myself at worst, in the "middle of conflicts" and at best, just looking at amazement and rubbing my chin in wonder, at how people don't see the whole picture. People gotta get up and move to see the other sides. I can see that yes, in fact, the piano does have a row of black and white keys that make noise, if I am willing and able to go look at the other side. Medical malpractice is the piano. There are multiple sides -- all valid.

I believe that midwifery is just around the corner from a ride down the slippery slope to facing the same liability issues facing obstetrics -- and that, which contributes to and maintains their perspective on birth as dangerous. Sometimes I think I am weird and I wonder, "how come no one else is thinking like this?" Mama, do I feel that way now as around the country midwifery is being debated. And, I hate to gloat (ok, sometimes, I love it when my Hawk vision of the future comes to pass because it just makes me feel like I can trust my vision and intuition) -- but, I predicted this very issue of malpractice for midwives. In the past ten years it seems to me as the awareness and popularity of midwifery has increased, so have the stories of midwives being sued.

While I was a rabble rousing rebel (cuz, I am not now!) in state social services reform, my ex-husband was in family practice residency and the scuttle was always about malpractice stuff. And, the marriage ended (that needed to big time) during his obstetric residency primarily because of the even crazier changes in him about money and liability and "everyone out to get my money." My friend, a pediatrician told me that obstetric resident's "shop talk" was about malpractice, not birth. One of the blessings of being a spouse through five years of residency -- especially this week as my little friend, Jonathan, fired up my rancor at social services --- is that I have been "tuned in" to this malpractice issue AS I studied birth psychology and midwifery.

Back in the day, when I got my first "liability" insurance as a counselor, I asked my ex which limit amount I should get. He said, "Get the least because if you have $500,000 you'll get sued for that. If you have $2,000,000, you'll get sued for that." And, he added, if you are part of an agency, they will always be the "deep pockets." Well, not much has changed except the limits.

SOME SCUTTLE ABOUT MALPRACTICE:
A few years ago I read a research piece on malpractice that found that juries are swayed more by sympathy for the plaintiff than by the actual malpractice of the physician. When the injuries or pain and suffering were higher they tended to award more money even if they felt the doctor had not been negligent or wrong. On the other hand, if the plantiff had not suffered and the doctor was negligent or had malpracticed, juries did not award large sums. The point being, juries are not awarding according to the doctor's malpractice, misbehavior or wrong doing, but instead according to the plantiff's suffering and needs. This is across the board in medicine, but I suspect that in obstetrics, because it is a baby, there is a huge sympathy factor. This is probably what doctors refer to when they say birth is dangerous. ;-)

Many babies are being harmed in birth and as a result they have high medical and support needs. Parents of very injured children more often sue to get the resources to care for their children. Another reason patients is to get information that the doctor and hospital won't give out. (see http://www.sorryworks.org/). Reports are that there aren't actually that many cases filed in obstetrics. It's the huge 40 million dollars to one child that is the killer. I say smaller awards and more cases! If it was just about satisfaction or angry, disappointed acts of revenge, obstetrics would be shut down in short order. And, I have read that many of the malpractice insurance companies are doctor-owned. Oh, c'mon, right? It's gotta be the drug companies that own the malpractice companies. Or, Cheney.

WHO IS RESPONSIBLE FOR A BABY'S BIRTH?
Well, at first glance, that doesn't really seem like such a tough question. Obviously, a woman is responsible for her birth, right? She's responsible for conception, chosing to continue a pregancy, her life during gestation, and then when she goes home and forever more. WHY NOT during labor and birth? (Sounds of screeeeching to a halt). Not in America. I am really rubbin' my chin these days with this far away, deep-in-thought, furrowed-brow look I get. (See my daughter's favorite picture of me here -- favorite because she says my frequent thinking pose is funny. I don't like the picture. It was my 49th birthday after being up all night and third day of travel. I have that post-two day birth look. We are in Washington DC and I was thinking "Why doesn't the federal government here do something about the bull shit in obstetrics and malpractice and create a national evidenced-based Standard of Care birth that gives responsibility back to women?")

The REAL problem is that WOMEN are zero allowed to be RESPONSIBLE for their body and baby during birth, and frankly, in our litigious society, very few people are. It USED to be that the people who chose midwives and homebirth -- especially when CNM weren't around -- chose so because they wanted a certain experience and they were WILLING to be responsible for their CHOICES and their baby. Believe me, the ex and I had lots of discussions about this -- who is liable, at fault, to blame -- all of the non-responsible for self words. Residents learn to hate lawyers. What stories -- ever hear of an "around the world" enema? Seems lawyers need it more than most people do. I would argue that the problem is not either or just doctors versus lawyers (but gosh, is the "them or us" mentality so prevalent in both?) The relationship (problem) is a three-prong relationship --- doctors, lawyers, and oh, yeah, the patient. I have advocated for PATIENT RESPONSIBILITY for a long time. I have believed staying away from both medical and legal matters whenever possible.

I take my health and my body very seriously and I am responsible for my health. Interestingly, when one does this, one naturally (s'cuse the pun) moves away from the medical model for preventive and maintenance health care. One gets into the body-mind perspective and gets accused of being "in to that new agey" stuff, and not only believes what the medical field told us, but starts to do it! Eat better, exercise, manage stress and even do some massage, Tai Chi, and Yoga -- now that it is clear to most Westerner that this is not evil and Jesus would do it, too. So, the point is, that it is really not in medicine's best interest for us to do what they promote. Crazy. Just like in birth -- the advice extolled upon women to do prenatally does not apply during birth and then is requisite again postnatally. Eat, drink water, exercise, don't lie on your back, low stress, and oh, yeah, DON'T DO DRUGS. It passes to your baby. (http://www.babykeeper.blogspot.com/).

The bottom line MALPRACTICE ISSUE in obstetrics is because someone -- other than the woman -- is always held responsible for the outcome of the birth. Everyone knows this so why doesn't anyone look at the issue of the obstetricians "wrongly" or at least disproportionately being held accountable for birth outcomes? Liability in general in medicine in the last twenty years has increased beyond belief. Some folks we know will deny it but my insider's scoop tells me, yeah, obstetricians know what they are doing to avoid malpractice that is also leading to increased surgical births and that is know to be more dangerous for both mother and baby. The consumer gets driven along, herded like sheep. It just so happened -- for the doctors -- to be the same thing that gave them more freedom over their schedules too. So, for years, I have been quite concerned about the future of MIDWIFERY "in the system" and predicted that the practice of midwifery will also be usurped by LITIGATION. Either way women and BABIES will be the ones to pay the price -- in many ways. This year I actually have not been a supporter of legalizing DEM or CPM because I believe the malpractice liability problem continues to drive the problems in obstetrics. Without fixing the obstetric liability problem, I see nothing but serious consequences for midwives.

The huge problem that Senator Wilson kept talking about (she WAS filibustering, remember) is that someone is going to be responsible for the outcome. If a CPM "stays at home too long" (a common problem from the obstetric point of view) isn't the doctor going to be responsible then? It's a damn good question -- I've been wondering myself for a long time. I have observed that homebirthers and midwives sometimes do wait longer than they should (and, it happens in hospitals too with OB's and CNM) and I have observed that one of the reasons (not always conscious) is the concern for how they are going to be treated by medical staff. It's a very legitimate concern. My ex said what I heard another senator saying over and over. "It's not illegal to have a homebirth -- any woman can choose to have a homebirth, but just don't expect us to clean up the mess when it goes wrong." WHAT BS -- this is exactly what obstetricians are supposed to be prepared to do --- and they do it ALL THE TIME. Nurses manage the labor "under the doctor's orders -- yeah, yeah." The doctors shows up to do the delivery -- it either goes well or not.

Women are at risk when obstetricians, family doctors, CNM, CPM midwives, and consumers don't work together. This is clearly the case in the US and we know from other industrialized friends with better mortality rates that when doctors, nurses, and midwives are socially respected for the role they each play, it is the birthing WOMAN and the NEWBORN who benefit. WHEN is the MOTHER AND BABY going to become the object of VALUE in our eyes and in our FIFTY STATES -- rather than who is to blame, who is at fault, and who pays? Furthermore, speaking of the MOTHER, why isn't a women both allowed and expected to be responsible for her body and her baby from conception and beyond? I have come to believe that it is critical that we as a society begin to see that MALPRACTICE TORT REFORM is a much bigger issue than CAPPING AWARDS. It's about a woman and man being responsible for bringing another life into theirs -- they are responsible for every moment from conception forward. Our society and our systems are for support -- not control and to take the blame for our choices that don't work out as we planned. There ought to be integrity to our system that truly protects us and holds those accountible who do act maliciously, neglectfully, or stupidly. I don't see ANYONE in OB or LAW or LEGISLATURE even talking about the bigger problem -- WOMEN need to be held responsible for her choices and her birth and our social and political will should be to to put children's needs first and to care for families.

PEOPLE are ZERO RESPONSIBLE for their own CHOICES, decisions, and health. That's a huge problem that CREATES the misuse of the legal system to wrongly sue doctors. We Americans are all for the freedom and choice and our rights -- but not so big on the responsibility part. In the late 80's I went to mass on the 4th of July and this was the subject of Father John Prenger's message. "Freedom isn't free. It takes responsibility and that is often at a cost." The lack of personal responsibility for one's health --- promoted by the system -- is a huge problem. The cost of responsibility is that THE PERSON WHO CHOSE gets to live with the consequences. And, so doctor's get to choose in obstetrics -- and now women believe it's their "right" and "choice" to choose drugs and surgeries.

SOMEONE needs to address this LITIGATION issue that is out of control in obstetrics. NOT even as obstetricians leave their profession and via media we are threatened with the impending lack of them (the canaries out in the rural parts of every state fell a long time ago), is there a COLLECTIVE WILL to FIX MALPRACTICE. Nope, that would involve giving REAL POWER back to the people. RESPONSIBILITY. AND, people don't want to be responsible for their body and their choices -- lifestyle choices of diet, exercise, spiritual practices. Our culture is lead by the need for more drugs.

SO, birth is a REFLECTION of a big-ass problem in our society. WHO gets hurt as the obstetric medical machine grows exponentially and drug companies CONSUME US as they pay to push through whatever agenda they want? BABIES, sweet, little souls coming into this life are being hurt. The more we grind down this path, the LESS REGARD there is for the BABY.

Birth as THE BABY'S BIRTH ... it is not the mother's birth. It is her experience of giving birth, bringing her baby into this world, but it is the baby's birth. The baby will live his life with what happens in labor and birth (and conception, gestation, and infancy and beyond.) Birth is not the doctor's -- s/he should not be expected or allowed to misuse lifesaving technology as routine or to give him or her a sense of control over potential lawsuits or to manage his time. We all know this is the case.

So, regarding MIDWIFERY AND OBSTETRIC MALPRACTICE, I have two big concerns:

One is that in the United States we NEED a national EVIDENCED-BASED Standard of Care in obstetric medicine. HOW can obstetrics be so scientific if there are FIFTY WAYS to do it? Each state does it's own "thing" and -- to my knowledge -- not even obstetrics has a State Standard of Care. Please correct me if I am wrong -- I would love to know of a state that has an EVIDENCED-BASED standard of care. Evidenced based, by the way, would include PROTOCOLS and POLICIES that EVERY hospital, doctor, and nurse had to follow. For example, a woman may not induce her baby or surgically have her baby removed from her (like a tumor) for non-medical reasons. She may not use narcotics during birth (as she is not socially allowed during pre and post natal period). Cytotec may not be used. A woman has a right to choose a VBAC and to birth at home. Money is allocated to care for gestating mothers -- promoting aware conception, nutrition, time-off, preparing for natural birth (massage/touch, therapy, education), and extensive post-natal care. I met a woman from Malaysia last week and learned about the care of the woman after birth -- amazing.

REMEMBER: in my dream world the WOMAN and MAN are responsible for their baby from conception beyond, no time excluded, so that physicians are not responsible. Of course, in this world obstetrics is not self-overseeing and regulatory. There are mechanisms to stop physicians who do harm. And, importantly, there is a plan to care for the newborns who are injured, whether it was the "fault" (if you must) of the mother, the doctor, or the baby. I have heard of what I think is a great plan. New York looked into it based on something Indiana was trying in the mid ninties. For every birth, the doctor, the hospital, and the insurance company put in $300 in to a "pot" over which the state is the fiscal agent. Any parent with a baby with needs can apply to access the fund for services. This alone would take care of many malpractice suits -- if baby's needs are cared for, people are less likely to sue, AND, the state is overseeing birth care providers.

In my world, there is an alternative to the reasons for litigation. One reason is that doctors do harm -- sometimes it is just because they are human too. Sometimes they are negligent, also because they are human. Sometimes, they are grossly negligent because they are "bad people" or "poorly trained" or whatever. A good system has way to SUPPORT the workers in the system. The American system of obstetrics, supported by laws and consumers, quite frankly, in my opinion, is as traumatizing to doctors and nurses as it is women and babies. Our system of care does not respect doctors. They are the worker bees, I always say. Look around at the hospital next time you go and see all of the brick, mortar, and glitz (that we Americans expect in order for it to be acceptable) and look at all of the employees it takes to run a hospital. WHERE does that money come from? WHO GENERATES IT? Doctors. Every test, procedure, and appointment is possible because of the worker bees, the doctors. OF COURSE, they make a lot of money for it -- why not? They save our lives. But, they get no where near what they generate..... AND, they don't make anywhere near that if they try to go out on their own. Health insurance, drug companies, and malpractice insurance --- they are for the doctor what the induction, epidural, and staff controlled environment are for the mother and baby. Things that disempower. Doctors can't practice real medicine anymore.

Legalizing midwifery ain't gonna change any of this. Women and babies aren't going to be safer. That's my sad, long-avoided, but inevitable conclusion. Sorry.

So, yeah.... fifty ways to have your baby. Every state has it's own social and political will that dictates medical care and access. Fifty different ways -- all based on science -- (snort and an eye roll) creates a POOR QUALITY of maternal health care --- for women and NEWBORNS. From state-to-state, hospital-to-hospital, doctor-to-doctor, and nurse-to-nurse there is no standard - and yet, they all claim to be scientifically grounded. Lord o' mercy, it's just not possible. The United States is an awesome place, but fifty ways to do birth scientifically? C'mon. Obstetrics is a mess.

My second concern in MIDWIFERY and OBSTETRIC MALPRACTICE is that in both there is no indication of women being responsible for their bodies and their baby from conception and beyond, including their baby's birth. "WHO will be responsible for the outcomes?" is the question Senator Wilson kept asking and it's a good question. What is wrong with this culture, I ask my self, that no one else is asking, "HOW can women and men become responsible for their baby's birth AND receive quality, responsive care from a trained caregiver who is a member of a qualified team (Doctor, midwives, nurses)? WHAT IS BEST FOR THE BABY? As Senator Wilson pointed out, often the physician is with the woman only when it is time for the birth. Women are managed by nurses -- I most often see doctors come for the birth after hours, more than twenty-four, of management by the nurses. This is only one of the reasons many women want midwifery care -- they want to have a relationship with the person who enters into this intimate, sacred, and sometimes dangerous experience of birthing their children (the end result of their sexual, intimate union).

MALPRACTICE AND LEGALIZING MIDWIFERY -- IT'S ABOUT RELATIONSHIPS
Having a relationship with the caregiver is a critical factor in birth. In my field -- interestingly, excluded from the birth team -- we acknowledge that a woman brings all of whom she is to the birth experience. She is more vulnerable and more powerful than at any other time in her life. A woman is statistically more likely to be abused by her partner during pregnancy. She is building another human being -- her body and mind and soul are functioning as when she is not pregnant. She has often been abused, had drug problems, working, in school, has finanical concerns, eating disorder, health issues, relationship problesm -- all of this is heightened during pregnancy. Her stuff comes up in birth because she is vulnerable and she must let her body work to do what the thinking brain can not comprehend. To leave the neocortex, head place, means the other stuff comes racing up -- fears of her body not working, fears of being a mother, etc., etc., etc.

THE baby experiences and responds to all of this and doctors and midwives are, sorry, clueless about this -- because the sentience of the baby is denied. A woman does not have a relationship with medical caregivers that lends to her being able to share the issues or process the fears that will contribute to the complications -- during the pregnancy or in labor and birth, or even afterwards. Why are birth counselor/therapists not on the team? The obstetrician must support a woman through all of this in her labor and birth. They can't and don't want to. If she can't deal with her own emotional pain and life issues before and during pregancy, she won't be likely to handle pain in labor either. I believe this is where the mutual reliance by doctor and woman on induction and drugs comes in. She is allowed in our society to not have to deal with her stuff and to prepare for giving birth. She can just let the doctor take over and be responsible for her body and baby. It's just unreasonable to expect a doctor or midwive who have no control over the woman's life to be the only ones held liable for what happens in the labor and birth.

I believe it socially, morally, and scientifically wrong for women and doctors to rely on drugs for her, without regard for the baby. It's creating this mess. It's not reasonable to expect a woman to give up control and responsibility to the doctor and hospital. We need to think about the BABY and what the baby needs -- physiologically, emotionally, and spiritually -- and how all of these drugs, interventions, and ensuing stress affects the baby -- for life.

REFORMING obstetrics is the answer to the problem of the loss of doctors to malpractice premiums and to the increasing demand by women for choices and quality PERSONAL care. It is really amazing to me that this is not seen as part of the solution. Reforming obstetric care is different from tort reform. Creating effective, quality maternity care is not about capping awards. It is about making birth safe for everyone, including baby, mother, and caregiver. Truly, I believe, the industrialized nations with better mortality rates are those who engender and mandate professional and respectful roles and relationships between doctors and midwives. They work in partnership. Obstetric medicine does not respect a woman or physiology, the foundation of their practice. MISSOURI legislators are going to again skip on de-criminalizing midwifery because the lines are drawn. So sad, Missouri, or some state, could lead the nation in creating a model that focuses on what is SAFEST for the BABY and that addresses the malpractice issue/tort reform specifically for obstetrics, and gives women choices for QUALITY maternity care.

ONE MORE RANT ABOUT DRUGS
What underlies all of these is something that is totally lost in our society -and that is that a women needs to be responsible for her baby's birth. I am outraged at the focus on a "woman's right" to 'CHOOSE" to induce her baby's labor, and to have narcotics in birth when the research is clear that these are detrimental. I have written about this on http://babykeeper.blogspot.com/2006/05/safety-in-birth-doctors-vs-midwives.html. It is a travesty bordering on criminal that birthing "under the influence" of narcotics (with fentanyl, a synthetic opiod in epidural) is socially allowed and promoted by physicians and accepted by women, and then the doctor is held liable for the outcomes. What are doctors thinking?

The BABY gets to live with what happens. EVERY BABY gets to live with the consequences and effects of their conception, gestation, labor and birth. What is best for the baby should be our focus. I am pretty hard line about this -- and that society begin to expect women to be responsibility for her CHOICES and her BABY from conception beyond. Labor and birth can not be excluded and handed over to others to be liable for, nor can it be overtaken, manipulated, and controlled without becoming what we now see in our society. AND, it can only come to pass that a women, not a doctor or a midwife, is responsible for her choices and her baby's birth when there is a real discussion of the very serious problems in obstetrics.

Safe, healthy, and responsible maternity care can only be achieved with science-based care and respectful, cooperative relationships between women, midwives, and doctors are the social expectation and will. Fifty ways to have a baby in the US -- and what is the real, scientific foundation for birth?