MBC: Standard of Care under SB 1950 ~ my 2002 letter to MBC Consultant Dr. Chase – detailed explanation of issues

DEC 29, 2002 – WORD COUNT 6,447

Patricia E. Chase, M.D.
Medical Consultant
Medical Board of California
1426 Howe Ave, Suite 100
Sacramento, CA 95825

Dear Dr. Chase,

I enjoyed meeting you at the Midwifery Task Force meeting on November 7th, 2002.

On behalf of the members of the California College of Midwives, I look forward to consulting with you during the development of regulations defining an appropriate standard of care and level of supervision for community-based midwifery practice.

Legal Conventions that apply to Professional Standards of Care

We asked our attorney for advice on the legal conventions that generally apply to professional standards of care. According to him, a professional standard refers to a code of ethics, a standard of practice statement, and various guidelines developed and adopted by an organization or society whose membership is comprised of professionals of the discipline in question. These statements are subsequently identified in the licensing statute or regulations and require the practitioner to practice in accord with his or her professional society’s standards.

This criteria is subsequently utilized by the regulatory agency as the template to judge the competency of the practitioner and as the foundation for any formal accusation of unprofessional conduct should substandard or negligent practice occur. These professional standards are also used by the courts in defining malpractice.

California licensed midwives are resolute in believing that any appropriate standard of care for licensed midwifery in the state of California would be developed primarily by the professional organizations of California licensed midwives, as is the case for both nurse-midwifery and obstetrics.

Luckily, the California Association of Midwives, which is the oldest organization representing midwives and has the largest membership and the California College of Midwives (representing a smaller number of LMs) both have similar documents that fulfill that criteria for a professional “standard of care”.

These documents were developed in conjunction with the international Code of Ethics for a Midwife as well as traditional standards used world-wide in various jurisdictions. The primary purpose of these Standards includes consumer safety as well as advancing the professionalism of community midwives.

A secondary function relates to the legal status of these Standards as a measure of an individual midwife’s care as incompetent or negligent.

Two-fold nature of Standards of Care — to protect the competent and discipline the incompetent or negligent

In this regard the issue of Standards is two-fold — Standards should protect competent midwives as well as providing the structure for disciplinary action against incompetent / negligent midwives. Protection of the competent midwife is important as without this guide for midwifery practice and guarding of the individual midwife who adheres to the profession defined standard, there is no positive model to both protect consumer interests and the profession of midwifery.

In order to do this, such standards must be more than just a of contraindications and prohibitions. It also must establish what the specifics of standardized practice are so that we can identify midwives who have met that standard are thus to be held blameless in those circumstances in which they in fact provided “standard” care.

California midwives have been working with Senator Figueroa for the last 3 years in an attempt to amend the LMPA so that midwives would be able to be in technical compliant with their licensing law. Prior to the passage of the LMPA, non-nurse midwives in Califo worked for 17 years (with seven separate bills) to pass a midwifery licensing law.

Midwives want to be licensed and we want to be able to be in compliance with its provisions. Despite 25 years of earnest efforts to bring these things about, LMs in California cannot currently comply with the physician supervision provision of the LMPA as physicians uniformly and almost universally are unable to provided the mandated supervision (due malpractice carrier restrictions) or unwilling to to do so.

Legally, California licensed midwives have gone from criminal prosecution for practicing midwifery without a license, to administrative law charge of practicing licensed midwifery without a physician supervisor.

The Realities of Physician Supervision — a stumbling block, not a stepping stone

This is a deplorable situation brought about by organized medicine in its own self-interest and for its own economic advantage. At first glance, physician supervision seems to be a sensible and beneficent stepping stone to guarantee timely and appropriate access to obstetrical care.

Instead, the mandated supervision is instead a stumbling block that prevents childbearing women who have chosen the care from community-based midwives are refused preventative and essential services from physicians.

If you read the reports circulated by various obstetrical societies (ACOG and CAOG — see Ob.Gyn.News Sept 15, 1993), this political agenda becomes evident.

They state that the California Medical Association (CMA) successfully demanded a supervisory clause that created unnatural and unnecessary vicarious liability as a “disincentive to home birth“. Their hope was to prevent home-based midwifery care by making it imposable for LMs to be in compliance with their own licensing act via the legislative “poison pill” that mandated supervision clause which and is impossible for doctors to provide.

This of unlimited, uncontrollable liability is prohibited by virtually every malpractice carrier. However, the decision by Judge Roman calls into question the idea the physicians would inevitably be the target of this vicarious liability and opens the way for regulatory relief.

The original language of SB 1479 would have replaced the vicarious liability of supervision with the “firewall” of physician collaboration, in which no liability accrued to the physician unless and until the doctor him or herself actually provided care directly. As we all know was not to be. According to Senator Figueroa, the clause in SB 1950 establishhing a regulatory framework of an ìappropriate standard of careî and ìlevel of supervisionî was effort to promulgate regulations relative to standards and physician supervision reflectin administrative law Judge Roman’s decision in the Alison Osborn case.

According to Judge Roman:

“The effect of each model posited by the parties is to meet the Legislature’s primary interest in the implementation of license practice acts: protection of the public.

Sufficient evidence has been provided this tribunal to competently conclude that properly conducted midwife home births are as safe as births conducted by physicians in hospitals when affected within standards of practice.

Accordingly, without dismissing either model or deferring to either model, protection of the public can be effectuated, and the licensure of professional lay midwives promoted by this tribunal’s adoption of the midwifery model of practice to licence midwives as referenced in Findings 14, 17 – 21, and 23.” {emphasis added}

I included a complete copy of the Osborn Decision to make familiarity with it convenient. As you read it you will note that Judge Roman clearly acknowledges the du the midwife to fully inform and recommended medical care for any mother with identified risk factors. He simultaneously acknowledges the right of the fully informed childbearing women to formally decline in writing the medicalization of her pregnancy, even in the presence o significant risk factor such as frank breech.

It should be noted here that the mortality for breech births in the large multi=center study, including footling breech babies ) was identified in a recent study as (n=5 or 1 1/2 % ) for CS and (n=13 or 5% ) for vagnial birth. The already small number of vaginal breech mortality included two SIDS deaths (not attributable to route of delivery) and did not include any of the excess maternal mortality morbidity from Cesarean surgery.

Delivery by CS triples Maternal Mortality

While a theoretical advantage of 3 1/2% by virtue of Cesarean surgery, this statistic does not factor in ANY of the post-cesarean complications occurring downstream in future pregnancies, especially infertility, miscarriage, abnormal placentation (previa, abruption and accreta/percreta) and emergency hysterectomy. According to one researcher, a baby in future pregnancy is lost for every 500 cesareans performed. (ObGyn News ~ get title & date from my SBB.com website)

Unfortunately there is no “zero risk” option in regard to these choices. Informed consent theory, and the legal aspects of parental autonomy, acknowledge the right of a childbearing couple to decline treatments like “prophylactic” Cesarean surgery. This “option” puts the mother’s life and future pregnancies at risk for a statistically small gain that the parents have no guarantee they will be one of those few that benefit.

The current ACOG policy against singleton vaginal breech births is a legal strategy chosen by their organization (without input from childbearing women affected) as the best protection for obstetricians against litigation by a childbearing population. In regard to breech birth, they are exacerbated by the fact that obstetrical residents are no longer trained in the management of vaginal birth.

Since the majority of doctors do not attend vaginal breech births anymore, it becomes substandard care under current tort law for physicians to provide care for a vaginal breech delivery. The same type of physician-centric restrictions have recently prohibited the majority of doctor from providing care for VBAC labors.

Families are forced to choose between an unwanted, medically unnecessary cesarean, or driving as much as a 100 miles while in labor to one of the few hospitals that “permit” a natural VBAC labor. Again this denies the childbearing family the normal rang options and results in women with identified risk factors choosing home-based midwifery as their only option to avoid the risks of major abdominal surgery.

I’m including a copy of ACOG’s own policies that acknowledge the rights of childbearing women to decline recommendation by obstetrical providers:

ACOG Official Opinions on Reproductive Rights of Women

ACOG’s Committee Opinions #166 — Informed Refusal, 1995 & #214 — Patient Autonomy: The Maternal-Fetal Relationship“, 1999 were published in ACOG’s 2000 Compendium (pgs 134 & 160).

These policy opinions, among many other similarly supportive statements, say that:

Abiding by the patient’s autonomous decision will provide the best care for the pregnant woman and the fetus in most circumstances.
In the event of an emergency … the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the patient’s wishes regardless of the consequences.
When a patient’s autonomy is violated, the woman is wronged and may be harmed, whether physically, psychologically or spiritually.
The patient’s subsequent loss of trust in the healthcare systemmay reduce the health care provider’s ability to help her and may deter others from seeking care.

ACOG’s Statement of Policy #1067 on Abortion says, among other supportive statements:

The diversity of beliefs should be respected
Informed consent is an expression of respect for the patient as a person; it particularly respects a patient’s moral right to bodily integrity, to self-determination regarding sexuality and reproductive capacities and to the support of the patient’s freedom with caring relationships
The pregnant women should be fully informed in a balanced manner about all options … the professional should make every effort to avoid introducing personal bias

EDITOR’S NOTE: Source material for ACOG’s Committee opinion #108, #166 and #214 can be found in ACOG Committee Opinion #108, 1992 Ethical Dimensions of Informed Consent [ref #1]

Judge Romanís ruling in the Osborn case also established that an appropriate standard care for community midwives includes specific criteria that must be met in regard to the special circumstances of an identified risk factor. This category of exceptional circumstances is not a free pass, but a category that falls within a regulated framework of responsibility on the part of the midwife and included advanced-practice training.

LM Osborn completed the same ALSO (Advanced Life Support in Obstetrics) course in management of breech birth as attended by family practice physicians. The mother was informed and declared her official decline of medical care in writing. The criteria for home-based care was specified, including the experience level of the midwife and the results of a recent ultrasound confirming an average weight baby in a frank breech position with flexed head. Judge Roman commented that:

“A midwife’s assistance in a breech presentation that fails to meet such specific criteria violates the midwifery model’s standard of care and/or practice and would be unprofessional conduct … particularly where, as here, the Legislature failed to specifica preclude breech presentation, and relied instead, and consistent with its deference to developing healthcare models, on professional standards of care.”

Judge Romanís ruling recognizes the legal difference between the practice of medicine (which is statutorily prohibited) and the practice of midwifery. For example his ruling stated:

“Unlike physicians, physician assistants, physician assistant midwives, registered nurse certified nurse midwives who practice within the context of a medical model, licensed midwives practice within the context of a midwifery model.

Complainant {i.e. the MBC} contends that that medical model should function to define the scope of a midwife’s practice.”

Judge Roman rejected that opinion of the MBC. His decision established that:

1) Midwifery is a separate and distinct discipline from that of the practice of medicine

2) Midwifery standards of practice are unique from that of medicineís

3) It is inappropriate for midwifery practice or its practitioners to be judged by medical doctors imposing medically-based standards

The parties readily acknowledge that “supervision” as set forth in Business and Profess Code section 2507(c) does not “require the physical presence of the supervising physic and does not purport to involve, as set forth in Business and Professions Code section 2 (f), the overseeing of activity or acceptance of responsibility for services rendered by licensed midwives as required by such physicians for licensed physician assistants. Clearly a different standard was intended by the Legislature; however undefined.”

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Note, when I imported this document from an older version of Windows, the last 1, 2 or 3 letters were left of many words and every apostrophe or quote (‘ or “) is replaced by a lower case “i”.

I’m very slowly and painstakingly correcting these problems!

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Situations of physician referrals which are primarily for the purpose of providing access to appropriate monitoring or diagnostic technology, in which case midwives with direct access to monitoring equipment would not be required to refer the client as long as criteria monitored were within the normal range. This would apply to EFM during labor and pulse oximetry values for newborns

Managing situations in which the midwife is being directed by the regulation ìconsultî with physicians but local physicians refuse to provide any such phone conversation

I have a copy (enclosed) of a letter by Norcal which very specifically forbids physician u contract with Norcal to provide any advise at all to midwives either by phone or in perso Lest they be ìaccusedî of having a defacto supervisory relationship and thus create vica liability. This particular letter specifically addresses emergency situations by saying that only advise that insured physicians may render in an obstetrical emergency is to call 91 Period. If regulations require the midwife to consult with a doctor, we need to either hav doctors who will answer their phone or the regulation needs to include instructions for fil an ìincident reportî by the midwife to establish her good faith attempt to comply and the medical professionís refusal to participate.

As you may or may not be aware the LMPA as sponsored by Senator Killea, was descri as containing ìboth the statutes and the regulations for certified nurse midwivesî (Nov 1 letter from Sen Killea to Dr. Trestail, then president of the MBC). The LMPA defines the profession of licensed (direct-entry) midwifery to be ìequivalent but not identicalî to certi nurse midwifery. For that reason we obtained a copy of the ìstandards of practiceî ascri to by California nurse midwives, which were developed by their national organization — American College of Nurse Midwives (ACNM). A copy of that text by the ACNM is includ While it could conceivably be modified to serve for LMs it is clearly more appropriate to utilize an ìequivalent but not identicalî document developed by our state organizations (California Association of Midwives & ACDM/California College of Midwives) in conjunct with the Osborn decidion.

All of these documents (ACNM, ACDM, CAM and Osborn case) develop general standa of conduct rather than consisting of specific prohibitions. The wisdom of this method res the ever-changing nature of evidenced-based health care in which the advance of scien discovery continuly changes the most effective science-based response to specfic medi situations. For example the CDC changed its recommendation relative to antepartal test for GBS just this last June. In August, they modified those protocols yet again. By the tim specific diagnoses are identified and regulated the situation had often already changed.

Our suggestions in regards to mfry regulations are two fold. First the acknowledgement MBC sponsored regulation that the professional standands as developed and adopted b the California College of Midwives, which is the state chapter of the American College o Domicilairy Midwives would be identified as defining both the professional and the unprofessional practice of licensed, community-based midwifery.

Second is that a specific regulation be developed by Mfry Task Force in conjunction with the major stakeholders — LMs and consumers — that identify pregnancy and birth-relate conditions that represent a level of risk above the lowest level. This would include condi which are not actual medical complications for either mother or baby and for which ìnorm birthî is the anticipated and is the statistically most frequent outcome. This is quite a diff category than medical diseases or complications of pregnancy included in the MBCís October 6th memo in which the mother or baby actually need medical care. The conten list would be included in the information made availale to the parents on the MBC web s and when interviewing the midwife.

A document developed for this specific purpose would inform the prospective parents th the identified conditions included a higher risk of developing complications during labor birth and that such complication would be more successfully treated or even prevented acute care hospital. For this reason it is recommended that those with any of the listed conditions plan to labor and give birth in an appropriate medical facility under the care o professional midwife or physician. The form should permit up-to-date evidenced-based information specific to the clientís siutaiton and require the mother/parents to sign an ìinformed decline of standard medical careî should they decline the advise to plan intrapartum care in an institution. Another situation that needs to be established in regul is some type of provision for care under the ìGood Samaritian Principleî.

While there are many different situations in which parents may seriously contimplate ho based care in the presence of less than idea circumstances, the ones that are of the mo interest to consumers (and their families) are relative to those conditions that the obstet community currently declines to offer the option of a normal vaginal birth.

In the last decade or so, the standards and guidelines published by the American Colleg Obstricians and Gynecologist

Typically the family is faced with a choice of an extremely medicalized vaginal delivery o many areas of the state, an automatic ìprophylacticî cesarean delivery. There is a very w developed consumer factions that have become very knowledgable about dangers of Cesaren surgery and are very committed to avoiding non-emergent operative deliveries

Tort law conventions as applied to obstetical medicine looks to the obstetricial professio define the professional standard. Once the industry standard is established, the profess cannot be forced to offer forms of care that are, in his or her professional opinion, ìsubstandardî, as doing so would expose the practitioner to the judgement of negligent malpractice suit. This ìindustry standardî is not required to be science-based or even to advantage of the public. In general, tort law cannot compel individuals to bear specific professional risks or provide services they feel may somehow disadvantage them or the industry or for which they may not be economically compensated. Obstetricians are quit open about their motives in refusing to provide anything other than cesarean surgery as managment for women with a breech baby, twins or a previous cesarean. They cite avoidance of malpractice litigation and unwillingness to ìlabor sitî (see LA Times artice o VBAC).

Three years ACOG, under then president Ben Harer, MD (who avidedly promoted the ìmaternal choiceî cesarean on ìGood Morning Americaî) has actively promoted a policie

that virtually garenteed to replace a VBAC labor with not-so-elective repeat Cesarean a did so under the banner of ìfreedom of choiceî on the part of the childbearing women. ACOGís story was that HMOs were forcing doctors provide a trial of labor to all post- cesarean mothers, which they characterized as a violation of the motherís ìright to choo repeat Cesarean. What ACOG did was use ìcategory threeî evidence — consensus and expert opinion — to construct such a tight protocol for VBAC labors that it became more expensive for HMOs to pay for management of a spontaneous labor than a scheduled repeat surgery. This represented an arugument for suprimacy between HMOs and orga medicine in which ACOG trumpted the bean counters.

As is true for many conventions of obstetrical medicine, this policy was not based on scientific evidence for two reasons. One is that many of the studies on the topic do not actually contain the type of data that would permit the formulation of solid conclusions. O example of this problem is the relationship between the adminsitration of artifical labor accelerating hormomes (oxyhtocin and prosteglandincs) and the issue of increased rupt rates. At present, a labor is classified as ìspontaneousî if it is not ìinducedî even though Pitocin was used to ìaugmentî labor. A convention of obstetrics is that ìinductionî only applies if the mother has not yet had any contractions. If she is in very early labor or ìfal labor, then it is considered an ìaugmentationî and does not show up in the statitsitcs for induction. Midwives who use NO artifical hormones at all, the safe and successful condu post-cesarean labors (in women with low transfer incision) is statistically better than outcomes for medical management.

Recently a study published in the NEJM on VBAC labors was given a great deal of publ in the lay press and media. The advise by a Dr Green of Massachutes Gen that what wa ìsafest for the baby was a repeat Cesareanî and that ìonce a Cesarean always a Cesar was to become the new mantra for the 21st century. Sadly, the historical phrase of Dr Craignís ìOnce a Cesarean Always a Cesareanî has been taken out of context. As used Dr. Craign in the early 1900 its purpose was to caution physicians against the use of Cesaren delivery in all but the most dire of circumstance because the initial Cesaran (at time done with the many times more dangerous ìclassical incision) would make the mot into a reproductive cripple in need of subseqent surgeries.

The NEJM study on post-cesarean delivery had many serious flaws — for instance, all d was predicated on ICM codes and those codes did not distinquish between beigein dehistance and catastrophic rupture. Not one of the 91 charts coded for uterine rupture pulled to check for accuracy, predisposing factors and extenuating circumstances. The did not contain any new information except for revealing a vastly increased rate of uterin

rupture when prostaglandin and Pitocin were used to induce labor in post-cesarean pregnancies (21 times greater than a spontaneous labor with an intact uterus, 18 greate than natural VBAC labor).

It was identifying the increased dangers of induction of VBAC women that should have b the studyís big news. Instead of the media promoted the notion that natural labors were extraordinarly dangerous and should be relaced by elective Cesareans. This was predic on a curious manipulation of the statistics for perinatal mortality in the post cesaean coh as a direct result of uterine rupture.

The non-uterine rupture group included 20,004 women with 100 case of perinatal morta a rate of 0.5 percent. Amoung the 13,115 women attempting VBAC were 91 uterine ruptures with only 5 perinatal deaths for a mortality percentage of 0.038. Obviously the important question is the odds that natuural labor after cesarean will result in the death baby. The answer is that the risk of of a baby dying in association with VBAC labor was times lower than the risk of a baby dying from other cause having nothing to do with the VBAC status.

When the rate of uterine rupture in intact uteri and dishiscence of a beign nature are bot subtracted from the generally quoted 1 %, the actual danger of VBAC labor is .25% — th to say that 99.75% of natural labors will have no problems associated with the motherís VBAC status. When post-cesarean women learn this, they are frequently unwilling to tak all the associated risks of an extremely medicalized VBAC labor in a hospital with a Cesarean rate of 25% to 40%. Or worse yet, many women find themselves being forced a repeat Cesarean against their wished, with a double or triple maternal mortality and al long-term complication such as placenta previa, percreta and emergency hysterectomy uterine rupture in a subsequent pregnancy. when the likelyhood of a normal outcome w 99.75% (Robert Silver, ìVBACî, in Ob Gyn Secrets, Helen L Frederickson and Louise Wilkins-Haug, eds, 2nd edition)

In one of the most recent and largest studies (Scotland) the neonatal mortality rate subsequent to both induced and spontaneous multip VBAC women is 1 per 1000 — exa the same as for primagravidas mothers.

Elective Cesarean increases a womanís risk of hysterectomy in both the current and fut pregnancies (53, 54) and more than doubles the risk of death campared to vaginal birth

The most frequent immediate post-op complication of Cesarean is infection. Other complication include 7.3% incidence of massive hemmorrhage (42), blood transfusions 6.4% (43), ureter and bowel injury in about 0.5% (44, 45) and incisicional endometriosis 0.1 to 1% of cesareans (46, 47). Compared to women who have a vaginal birth, those undergoing Cesareans have twice the rate of rehospitalization for reasons such as uteri infection (2.0 relative risk), urinary tract infections (1.5 RR), surgical wound complication (30.0 RR), cardiopulmonary conditions (2.4 RR) , thromoembolic conditions (2.5 RR). Several studies were unanimous in finding that women who delivered by Cesaeran were less satisfied with their experience thatn women who had normal spontaneous vaginal births.(49-52

Severe and potentially fatal placental complication are greatly increased by a history of previous cesarean. Abnormal placentation such as placenta previa is otherwise quite ra only a 1/4 of one percent in an intact uterus. It rises to 1.87% after one previous cesarea (56) This risk rises expodentially so that it is 7.4 x after two CS, and 6.5x after three CS an astonishing 45 times greater after 4 previous cesareans.(57) A low-lying placenta is more likely to lead to the most severe placental complication — an accreta or percreta. Placental percreta is associated with a maternal mortality rate of 10% and virtually a 100 hysterectomy rate. This catistrophic complication is greatly increased in post-cesarean pregnancies and is cumlative, going up from 5% (for an intact uterus), to 25% for one, 4 for two and up to 70% with four previous cesarean. (60). Placental abruption is also significanntly increase with post-cesarean pregnancies with a rate of 0.17 to 0.49 with perinatal mortality of about 10%.

Increased rates of secondary infertility have been reported after prior cesarean and also higher rates of miscarriage and etopic pregnancy. Babies born by cesarean have triple t rate of devbeloping asthma in childhood and as adults.

Compared to these serious complicatons of post cesarean pregnancies, the rate of uter rupture, which is identified in the NEJM article was .6 and in the Scotland study only .3 w perinatal demise of 1 in 20 of this already small number, must be looked at in a whole n light. These are the many reasons that a significant number of post cesarean women, w they begin to reseach this topic on their own, are horrified to learn of this long list of extremely serious ìdown-streamî complications. Already upset about a possbilely unnecesary CS, they feel betrayed by the medical profession for failing to give them the story. They are often extremely angry about this and refuse to return to what is to them ìscene of the crimeî during subsequent pregnenaices.

These mothers will choose to labor and if their labor is normal and progressive, to give b at home — with or without professional attendants. Regulations prohibiting LMs to attend natural VABC labors is counter-productive, and only deprives both mother and baby of a professionally trained, skilled, experienced and equipted midwife, to be replaced by the baby’s father, a women ìfriendî or other unskilled, unexupted helper. This is a human ri issue for the baby who has a every right to have its mother receive care at the highest le she will permit so as to protect her and so as to provide a skilled first responder should a complication of any kind occur.

And for me as a religious practitioner (in addition to my status as a state licensed midwi would be a violation of my conscience and the obligation of my religion to fail to respond the genuine needs of this mother and unborn or newborn baby. If the mother can face th small but real risk of her situation as a laboring women, then it behoves me to face the s but real risk to myself as a guardian of the wellbeing of her and her unborn/newborn bab While this may seem unusual, one must considewhat we would think of fire fighter who declined to enter an occupied building in which someone reported smelling smoke, base the fire fighter’s fear of his /her personal safety. Laboring women and thier babies are al safer with an educatored observor with emergency respone capasity providing care than they will be alone with only family members or an untrained, ill-equpted and inexperienc lay provider.

(copy text on tort law — no responsibilty after last stitch, informed consent does not exte inlcude

note that at present there is a bias that the recommendation o OB docs are more profes or of a higher level of value than those of LMs. But physicians do not teach learn or utiliz pysiiological management which is the core of the discipline of professional midwifery ca In regard to physiological managment, phhysician are uneducated and unskilled. Note t LTM survey that report ìvirtually no natural childbirth in our survey respondant except o small number (under 1%) who had home birth (under midwifery care) ffor women giving in last 24 months.

At present a crucial peice of information has been unavailable to us. In order to intellege craft of appropriate relulation, the Califnornia College of midwives need to know the num and nature of current complaints, investigations and disciplinary actions agasint midwive

In particular, we need to know the following:

(a) The total number of complaints filed against LMs since the implementation of th LMPA in 1997

(b) The origins of those complaints — ratio filed by client or immediate family, by extended family, neighbors, by-standers (or anonomously), number filed by physicians a those by other medical or hospital personal

(c) The nature of the circumstance or problem triggering the complaints – number cases involving stillbirth, neonatal mortality or significant maternal or neonatal morbidity (d) those relating to absence of physician supervision, those involved in disputs o

definition of the midwiveís scope of practice, quality of care
(e) Those involving non-quality of care such as insurance fraud, substance abuse

criminal behavior

In order to develop a regulatory framework that is protective of consumer safety we mus know what types of circumstance are currently implicated in quality of care cases.

Such a list of identified risk status would of course include post-cesarean pregnancies a other controversial categories, in particular those situations in which parents are current forced to choose between unwanted Cesarean surgery or a higher than average risk for vagnial birth.

the requirement placed on California’s professional healthcare practitioners, including licensed midwives, to exercise restraint when compelled to do so by patient safety.

Old growth forest of the mind
non-emergent operative deliveries.

Tort law conventions looks to the obstetricial profession to define the professional stand Once the industry standard is established, an individual professional cannot be forced to offer any form of care that is, in the opinion of his/her professional organization, substandard, as doing so would expose the practitioner to a judgement of negligence by courts and or his regulatory agency.

If the MBC’s currently proposed regulation prohibiting lic midwives from providing care t healthy mothers with certain identified risk factors were to be implimented it would give to a whole new inferstructure of non-professional midwifery under SB 577, and the relig

exemptions clause and the emergency exemption of Section 2063. But far more disturb than the resurgence of lay midwifery, this policy would also vastly increase the number women who fail to seek professional care during labor and thereby give birth with a professional attendant. The perinatal mortality rate of nurse or direct entry midwife was determined by one researcher (Burnett, North Caroline, 1980) to be 3 per thousand whe as the rate of infant death in unattended birth was between 30 to 60 per 1000.

An recent textbook on midwifery –“Professional Studies for Midwifery Practice” publishe Britian — contains a lengthy chapter on midwifery ethics and ethcial decision making. It makes an interesting distinction between a problem and a dilemma. The authors define problem as a situation with a straightforward solution. However difficult, expensive or tim consuming that solution may be, what needed to be done to met the need was still clear mutually agreed upon. A dilemma is a situation that has instead two or more possible conclusions, each of which presents only a partical solution or solves the identified prob by introducing a secondary problem. Depending on the perspective of the decision mak these downstream issues may be egually undesirable, leading to considerable controve and difference of opinion as to what the best choice is.

The topic of identified risk factors is a dilemma for childbearing parents, their midwives a your agency. Unlike a problem with an easily identified solution, this situation presents everyone with a uniguely difficult situation with no obviously superior conclusion. The m who finds herself being swept into non-consensual obstetrical intervetions such as non- emergent Cesarean for a breech, twin or vbac pregnancy is often distrubed to discover our current tort system happily exposes her to painful riskly surgery without any acknowledgment of the many well-known risks and downstream complication in order to shieled obsterical providers and institutions from litigation. The BJM/Lancet recently published a study revealing institutionalized violence against women in reproductive ser which identified the performance of surgery for the convinience or betterment of the physician to be a form of violence.

Compared to these serious operative and post-operative complicatons and complication post cesarean pregnancies, the low rate of uterine rupture, which is identified in the NEJ article was .6 and in the Scotland study only .3 with perinatal demise of 1 in 20 of this already small number, must be looked at in a whole new light. These are the many reas that a significant number of post cesarean women, when they begin to reseach this topi their own, are horrified to learn of this long list of extremely serious ìdown-streamî complications. Already upset about a possbilely unnecesary CS, they feel betrayed by th medical profession for failing to give them the full story. They are often extremely angry

about this and refuse to return to what is to them the ìscene of the crimeî during subseq pregnenaices.

Many women discuss their relationship with a midwife as their decision as to wheter or n “invite” her to be present during their labor. This is quite a remarkably different from the medical model in which it it the doctor who decides when or even if he or she will provde or her presence.

The dilema for the MBC is two-fold. THe first dilema is where to stand, officially, on the issue of non-consentual obstetrical interventions. Does the MBC think it apporpriate to b part of a system that forces women into non-consentual medicalization or that triggers women deprived of other safer options to choose professionally unattanded labor and b How can one square that with the legislative mandate to protect and provide for consum safety? How does the BMJ study of institutionalized violance against women in regard to reproductive services relate to the issue of non-consensual medicalization relative to identified risk factors?

The second dilema for the MBC what the model to use to determine the basis and acceptable risk ratio — some theretical number or rate of perinatal or maternal risk whic would “Permit” a laboring women to “qualify” for care by California licensed midwives. Y see, this mathical formula would have to account for the risk ratio of the entire spectrum pregnancy-related conditions and medical interventions. For example, the fetal loss rate amniocentisis is approximately 1%. In general, society recognizes the right of the childbearing family to decide to have this procedure performed. Would this be the bench mark that we would use to measure identified risk factors such as vbac which is, in spontaneous labor (no Pitocin, Cytotec or prostaglandins) only a quarter of this rate (1:4 We would have to also assign mathical values to to the tripled rate of maternal deaths, emergency hystorectomies, and other complications of the “maternal choice Cesarean a well as the risk ratio associated with elective inductions, off-label use of Cytotec and the vastly increased rate of Cesareans with their associated complications that accompany use of continueous electronic fetal monitoring and epidural anesthesia.

December 15 2002 * Volume 37 * Number 24 Obstetrics: ob.gyn.news

Behind 50% of emergency hysterectomies
Last 50 Years Show 10-Fold Rise in Placenta Accreta

Kate Johnson

Contributing Writer
INDIANAPOLIS – Placenta accreta is a growing cause of postpartum hemorrhage and an increasing cause of emergency hysterectomy, according to Dr. Gary Dildy III.
“The incidence of placenta accreta is increasing, and it’s thought this
may have to do with the increasing rate of cesarean sections since the 1960s,” he said at the annual meeting of District V of the American
College of Obstetricians and Gynecologists.
Research has shown that the incidence of placenta previa and accreta correlates highly with the number of prior cesarean sections that a
woman has had. In addition, while placenta accreta accounted for only
about 10% of emergency hysterectomies in the 1950s, it accounted for 50% of these procedures in the mid-1980s.
Currently, the incidence of placenta accreta is about 1 per 2,500 pregnancies and has increased 10-fold in the past 50 years, said Dr.
Dildy, professor of ob.gyn. at Louisiana State University, New Orleans. Although placenta accreta remains one of the rarer causes of postpartum hemorrhage, Dr. Dildy urged physicians to be aware of it. Occasionally,
the condition can be diagnosed prenatally, which can be highly advantageous.
“It is always nice to know ahead of time whether a problem like this
exists. Although nothing that we currently have available is exact,
including ultrasound or MRI, it can at least give us a heads up in many cases,” he said, adding that a combination of the patient’s history of a previous cesarean section plus ultrasound imaging is probably the most reliable means of investigating a suspected placenta accreta.
Other risk factors for placenta accreta include placenta previa with or
without previous uterine surgery, prior myomectomy, prior cesarean
delivery, Asherman’s syndrome, submucous leiomyomata, and maternal age older than 35 years.
Women who have had at least two cesarean deliveries with anterior or central placenta previa have nearly a 40% risk of developing placenta accreta in the future.
“By using ultrasound and assessing risk factors, we can identify
patients that require a greater degree of advance preparation,” he said
in an interview.

The ACOG Committee Opinion No. 266, issued in January 2002, recommends that when placenta accreta is suspected prenatally, appropriate measures need to be taken to acquire blood for transfusion, arrange for Cell
Saver technology when available, arrange a preoperative anesthesia consultation, and recruit the appropriate backup expertise.

“If you have vascular involvement, you may need a vascular surgeon; if you have urologic involvement, you may need a urologist or a gynecologic oncologist,” he explained.

The ACOG committee opinion states that “profuse hemorrhage can occur when attempting to separate the placenta. If the clinician is extremely confident in the diagnosis, it may be prudent to complete the delivery
of the infant and proceed with hysterectomy while the placenta remains attached.”

Cell Saver technology is starting to gain popularity in obstetrics and can greatly reduce the need for blood transfusions in the case of placenta accreta. The device suctions blood out of the pelvic cavity, filters it, and reinfuses the red cells into the patient.

“It’s relatively new to obstetrics, and in the past, we’ve always been afraid to use it because of concerns about putting amniotic fluid and
fetal cells back into the maternal circulation. But the filtration
system seems be effective against this, and the cases that are published thus far, although the numbers are small, suggest that Cell Saver is

safe in pregnancy and [that] the benefits probably outweigh the risks,” he said.
40 per million, 160 each year, plus