Babies and Bathwater
March 31, 2010 2:48 PM   Subscribe

Should I stay with my midwife practice, given a trustworthy account of a mismanaged case? This gets long, sorry.

This is both long and somewhat vague. For liability reasons, I've tried to leave out searchable terms; I didn't want to go anon because I suspect I might need to follow up on questions.

I am 8 weeks pregnant with what I hope will be my second child. I've had four miscarriages, but we've seen the heartbeat on the embryo now, and the only time that's happened, I was holding a living baby seven months later. My first child was born in a hospital in a really great experience, but the recovery and aftercare was, meh, not so hot. Additionally, my previous OB left her practice, and my new family care doctor (I'll call her Dr. D, there are many names in this story) can only deliver babies at the University hospital, which is up to an hour away in traffic. My first labor was very fast, and Dr. D decided that it would be a bad idea to risk the journey. She also strongly recommended midwife care, in case this labor is SO fast that I don't want to leave the house. OBs, she explained, rely a lot on nursing support, and so aren't really equipped to attend a homebirth. Midwives are much better trained for that situation.

So, with all this in mind, I picked out a midwife practice -- I'll call them Local Midwives. They are in residence at the Local Birth Center which is six minutes from my house, and half a mile from a major hospital that does maternity care. I attended a birth as a labor support assistant that was overseen by these midwives, and they were fantastic, even when a somewhat worrying complication arose. They have also worked extensively with Dr. S, who was the OB who delivered my first child -- she observed upwards of fifty births with them. The Local Birth Center offers a very different recovery experience than I had with my first birth, which is strongly attractive to me.

When I told Dr. D that I was working with the Local Midwives, she became concerned, and ended up calling me at home, from her home phone, outside of business hours. She said she had a colleague who had recently a patient who was poorly managed through the Local Midwives, with a very poor outcome. I ended up speaking with this colleague directly; without going into too many details, she told me that the one of the midwives in the practiced missed a fairly common and very severe complication of late pregnancy, resulting in a crash pre-term C-section and a mom with a stroke. I've spoken to some other midwives, off the record, and they all knew about this case (it was a Big Damn Deal locally) and confirmed the essential facts of the case.

I am so torn as to what to do. I could find another area midwife who is privileged at the birth center, but I'm reluctant to hire a licensed midwife / direct entry midwife who doesn't come with the same recommendations as these folks, and there are exactly two nurse-midwives in the county who deliver babies at birth centers at all; mostly they do either hospital births or homebirths. I could go with the midwifery center at the nearby hospital, but then I'm losing the birth center. I know, realistically, that providers make mistakes, and that any 20-year practice of any kind is likely to have at least one colossal fuckup in it, but this is a REALLY BIG FUCKUP, and also it was just last month.

My first pregnancy was textbook -- I delivered on my due date after 4 hours of freight-train labor. I turn 35 next month. I have a family history of clotting disorders, but no real personal history. I desperately need some opinions from someone who isn't trapped inside my own head. Help!
posted by KathrynT to Health & Fitness (22 answers total)
is it possible that you can request not to receive care from that midwife that messed up? Or is there only her as the option?

I've never had a child, so I don't know and can't offer personal advice. I would have my baby in a hospital - just in case. More eyes on you, your vitals, and your baby.
posted by royalsong at 2:57 PM on March 31, 2010

Response by poster: Sadly, I've signed up with the practice, not with any individual midwife. Everyone agrees that the head midwife of the practice is frickin' amazing. I get care from all three folks in the practice, but when I go into labor, I get whomever is on call that day.
posted by KathrynT at 3:01 PM on March 31, 2010

IANAD just a mom. I agree that mistakes happen in all medical situations, and I doubt that you'd find a medical center anywhere that hadn't made some mistake at some point. But having said that, I really think that it is very important to have peace of mind. Do you want to worry for the next 32 weeks about what is going to happen at the end of the 32 weeks? I wouldn't. Pick a place that gives you peace of mind. Can you get peace of mind and still use this recommended midwife practice and Local Birth Center? Perhaps, think about it this way: They just recently really fucked up, and they know it. Maybe they've newly reviewed procedures and renewed medical training for employees because of this incident. Maybe they are going to be extra careful and extra prepared because of the screw-up. Maybe this is the best time to go to that particular midwife practice!
posted by molasses at 3:07 PM on March 31, 2010 [1 favorite]

Is there any way you can ask them about this incident and what they are doing to address the mistake that was made? You could see how you feel after they respond and decide then.
posted by cabingirl at 3:12 PM on March 31, 2010 [2 favorites]

Can you stay at a hotel or a friend's house near the University hospital near your due date? I know it's not ideal, but I have friends in rural areas who tend to have fast labors who've done it, and friends with high-risk pregnancies who've gone to stay near their preferred hospital.
posted by Eyebrows McGee at 3:16 PM on March 31, 2010

Response by poster: Eyebrows -- not with a three-year-old and a working husband, no. Particularly not when there's a hospital just as good five miles from my house. If I went with a hospital birth, I'd go there.

Cabingirl -- I forgot to mention, I plan to do exactly that at my next appointment.
posted by KathrynT at 3:19 PM on March 31, 2010

Which feels more important to you, the choice of midwife or the ability to deliver at the birthing center? I know the answer is "both", but if you had to choose? The birthing center is close to your house, and you didn't like the followup care at your previous hospital experience, but is the followup care at the hospital midwifery center likely to be at all similar to the birthing center, or just traditional hospital style? Is the hospital the same one you delivered at before, and didn't like? Not all hospitals are the same on followup, although I don't know details of what you disliked.

Most importantly though, have you talked to the midwife practice about the huge fuck-up, what they have done to address the issue, and hear their side of the story? I'm not suggesting that it isn't a huge issue, but as molasses intimated above, maybe they are aware they messed up big-time and have changed things, and can put your mind at rest somewhat. The way they react to your question will probably be very telling too. I would want them to be very honest and open. If they were defensive I would probably run away.

What does Dr S say about them and the incident?

You say you're reluctant to hire another midwife who doesn't come with the recommendations this practice does, but then again this practice also comes with a huge black mark! Presumably the other midwives have some recommendations and history you can look into. Maybe they are just as awesome, but aren't the big name in town.

Would hiring an experienced Doula to assist you help put your mind at rest? Essentially having another experienced person there to look after you (rather than monitor the birth itself).
posted by Joh at 3:28 PM on March 31, 2010

I feel for your situation as you try to make the best decision. It's not easy when so much is at stake. I can only tell you something of my experience and hope that it helps you sort through this in some small way.
First baby delivered by great OB in hospital. No meds no complication. I was 28. Baby born healthy. So -so aftercare, as there was a bleeding issue a few weeks post partum that drs weren't really on top of. Emergency D and C followed.
Second pregnancy 3 years later. After much research and thought, decided on a homebirth with midwife for baby number two. Found great midwife and had a wonderful, peaceful, healthy pregnancy. Birth went well also, until the 3rd stage, delivery of placenta. Without warning I had a life threatening complication, enormous blood loss, emergency transfer to hospital. Surgery and transfusions followed. Baby and I now fine.
Most people who heard my story immedeately siezed upon the home birth aspect of this and felt that because of where I was when this disaster occured, I was lucky to be alive.
But that same year, a dear friend's cousin, lost her life to the same complications ( to be sure, it is very rare ) right in the middle of the hospital. The dr ( with many years experience) and the ob nurses missed the signs of what was going on and mismanaged the 3rd stage in light of that. Despite being in what many consider the safest of all places to deliver a baby, this woman did not receive the care she needed. Sometimes even the most experienced professionals can make a series of mistakes, with just the right/wrong circumstances lining up to cause a one in a million disaster.
When I look back on my experience, I see how my midwife was so focused on me that she spotted the early signs of this problem straight away, and took immedeate and successful steps to save my life, including calling an ambulance without delay. I live in a suburban area, so I was in the operating room within about 20 minutes from the 911 call.
If someone were to hear about my birth locally, they might wonder if the midwife did something wrong. An OB might retell the story with a slant towards the dangers of emergencies during a home birth, or suspicion of the management by the midwife. A client might not get the full picture without speaking to the midwife herself about the incident.
I think the most important factor in choosing a provider is that you feel you can trust them, both with your care ( your life and your baby's life) as well as to admit to their professional mistakes if asked, and discuss how they have learned from them. When I interviewed midwives initially , I interviewed about 10 , and most interviews lasted 15-20 minutes. I asked them several questions about their most difficult cases. I think if you really want to go with this practice of midwives, you would have to feel comfortable with the details of how this tragedy occured as it relates to your chances of a similar mistake happening to you. You would need, I think, to speak to the midwives directly for their account of what happened. It might not be exactly as you have heard through second hand sources.
As to giving birth in birth center, I can understand the appeal of such a birth to you, especially if you had a smooth first birth. You would probably be considered a good candidate for that type of birth. That is how I was classified before my second birth.
My complication was very much unforseen.
I personally would not put as much focus on the location of birth (birth center vs hospital) as I would put in my trust in the provider. Whether it turns out you choose an OB or a Midwife, I would try to interview both as in depth as you are able to ( they tend to be so busy its hard to get the time from them I know)and ask the OB similar questions about how they have handled difficult complications. Its not so much their litteral answers that will be telling ( all medical providers given enough time in their professions with have had some unfortunate mistakes) but their general way of communicating these answers to you that may make it clear to you on a gut level which provider you can place your confidence in. It may be that many providers in your area have made similar mistakes at some point in their careers, but that the timing of this midwife's mistake is why it is front and center for you right now as you are pregnant and needing to make a decision. Good luck to you!
posted by Rapunzel1111 at 3:33 PM on March 31, 2010 [9 favorites]

Yeah, mistakes happen. In the most traditional settings, and in the non-traditional settings. Recently a beloved family member almost lost her life in delivery, and her baby did die. That was at a top hospital, at the end of a normal pregnancy, with no warning signs. Another family member had an easy home delivery. I had a great hospital experience that ended in a necessary c-section. There are just so many factors that make this a tough, tough decision.

So like every pregnant lady, you'll have to decide what makes you feel the most comfortable. I vote for starting with a conversation with the folks at the birthing center. You may find that their response indicates that they've analyzed what went wrong in that previous case, and have taken steps so that it won't happen again. Or perhaps their response will indicate something negative -- that they appear secretive, or unable to respond in a manner that assuages you. Luckily you do have a bit of time.

Only you can make this choice, I'm afraid.
posted by BlahLaLa at 3:34 PM on March 31, 2010

This is probably flawed reasoning, but I would think having made such a colossally huge fuck-up recently would mean the Local Midwives (LMs) are now focusing extremely hard on delivering babies as perfectly as is possible. That leads to two scenarios:

--If the mistake was a fluke event, something that resulted from one of the LMs not paying attention or not being focused, then I think their concern for their reputations will solve the problem.

--However, if the mistake was symptomatic of a larger lack of knowledge/competence, then the LMs' resolve to do better won't fix things.

From what you say in the post, it seems other medical professionals who had directly observed the LMs really trusted them and held them in high regard. What are the chances of a doctor observing the LMs more than fifty times and coming to this conclusion if the LMs lack knowledge/competence? I would think pretty low. This suggests to me that the first scenario is the correct one--that this error was a fluke error, and one ended horrifically, but one that the LMs will avoid in future because they will be uber-focused on making sure nothing like it happens again.

You'll learn more when you meet with the LMs. Absolutely demand to know what they are doing to rectify this, and if you aren't satisfied, let them know.

Lastly, I am not a mother, but even just thinking now about what I would do gives me unease. This, unfortunately, is one situation where there is no right answer, there is no real way to assuage all your concerns and make you feel perfectly secure, and there is no way to be 100% sure that everything will go well. You need to do what will make you most comfortable, and do it realizing that you're making an informed and well-thought-out decision, and that if something were to go wrong (I knocked on wood), it's not because of the choice you made but because that's life.
posted by sallybrown at 3:41 PM on March 31, 2010

There's no way for anyone here to answer this, but as someone who had a homebirth with licensed midwives, and also apprenticed with midwives, and also has interacted pretty extensively with the hospital system too, I can throw in some ideas for how to think about this:

- Everyone makes mistakes, and further, some births have very negative outcomes no matter how good the care.
- Many doctors feel very negative about homebirth and the midwives who practice it. I'm not clear how this is impacting your situation since it sounds like Dr D is generally supportive of homebirth midwives, just not these midwives. Is that correct?
- Are Local Midwives LMs or CNMs? Speaking again in general terms, MDs tend to view LMs and CNMs quite differently, so I'm also wondering if Dr D is supportive of LMs generally or not.
- I would take very seriously the perspectives of Local Midwives peers. I would take this feedback more serously than the perspectives of MDs or former clients. Of course you should consider that feedback too - but fellow midwives will have the best sense of the standards of care for their own profession.
- Birth centers vary a lot. Some birth centers are very much like home. They offer little additional technology. If the birth center you want to use is of this style, there may be no particular benefit of the center over your home. On the other hand, some birth centers are like little free-standing hospital rooms, only without the ability to perform C-sections. So identifying what it is about the birth center might be of value.
- With a really great doula, you may be able to mitigate some of the crappynes of the hospital post-partum experience.

Sorry this is a little disjointed, but feel free to mefi mail me. I may be able to give some more specific ideas that way.
posted by serazin at 4:55 PM on March 31, 2010 [1 favorite]

Seems like you may not get much of an answer from the local midwives because of #1 HIPPA rules which pretty much mean they can't talk about another patient's care and #2 ongoing litigation if the case hasn't been settled. That being said, I would suggest a hospital birth with a doula due to your age and family history (IANAD). People have babies in their bathroom by themselves and mom and baby turn out fine while others have their baby in the best hospital in the state and massive complications arise--there are no guarantees no matter where you choose to have your baby.
posted by MsKim at 5:16 PM on March 31, 2010

It was unprofessional of the Doctor to tell you this, and the interpretation of the events should be taken with a large grain of salt. Further, you are left to question the local midwifery practice but even though any 'mistakes'/complications associated with the hospital setting are conveniently obscured, leaving the hospital in an empowered position and you left vulnerable in the middle. This is unfair, and not supportive of you making informed decisions about your care.

I would go to the Local Midwives and say: "I really would like to work with your practice, but to do so requires a relationship of trust. The Doctor told me of this incident and framed it this way. I would like to hear your interpretation of these events, because I would hate to have a one sided misunderstanding affect our relationship. These are my concerns about the whole situation around my birth plan". Hear the response and then decide.
posted by kch at 5:23 PM on March 31, 2010 [3 favorites]

You should call the Local Midwife office, and discuss your concerns. If Midwife w/Bad Outcome is questionably competent, you don't want her delivering your baby. Be honest; they've likely had this conversation several times and they can handle it.

I'd take the time to investigate other options at the Birthing Center or closer hospital. Statistics help; find out what the C-section and infection rates are. I had a very necessary c-section, but the post-surgical infection and return stay in the hospital sucked, and should have been avoidable.
posted by theora55 at 5:48 PM on March 31, 2010

In my experience doctors really dislike midwives and the independent (i.e. non-hospital) practice of midwifery. You can put this down to the docs being territorial, but I think it's more than that. Doctors are trained for years, and part of the result of that training is the belief the training and the methodology and the accoutrements are all very important.

Another factor is that most doctors only see the out-of-hospital births that don't work out, the ones that get transferred to the hospital. So they end up with a very skewed picture of the outcomes of midwife-facilitated birth.

By contrast your former ob --- who had witnessed many births at this midwifery practice --- was enthusiastic about them.

You'll need to trust your, er, gut and go with what you think is right. But I wouldn't let this one story push you too far.
posted by alms at 5:52 PM on March 31, 2010

Response by poster: Some more followup:

The Local Midwives are 2 CPMs and an LM. No CNMs.

The peer feedback from other area midwives has been that 1) this was an aberrantly colossal fuckup and 2) that the events of the case were basically just as I heard them. One CNM said that as shocking as the events were, it doesn't disturb her faith in the practice at all.

Dr. D. is not generally terribly supportive of direct-entry midwives. I have a call in to Dr. S, who worked with these midwives extensively, to ask her opinion.

The single greatest thing about the birth center to me, honestly, is the fact that they have one big queen-sized bed rather than a hospital bed. Being separated from my husband and child during recovery was excruciatingly awful -- and, I mean, they were in the room with me, but we couldn't all climb into bed and collapse exhausted.

I strongly disagree that it was unprofessional of the doctor to tell me this, though I do agree that the source has to be considered as regards the framing. I feel like it would have been seriously unethical for her to keep this information from me, in fact. She has never acted to obscure anything hospital-associated from me, and she stressed that the Local Midwives have a stellar reputation and that their statistics back them up.

Keep it coming. . . all of these questions are helping me clarify some things. . .
posted by KathrynT at 5:52 PM on March 31, 2010

I wouldn't have gone as far as to say the doc was being unethical, but I doubt she would have called you at home to warn you against a fellow MD. Just something to consider.
posted by serazin at 6:40 PM on March 31, 2010 [1 favorite]

I absolutely agree with the advice above to have an honest and frank discussion with LM about the mistake and their response to it. My experience with midwives is that they really want the moms they care for to feel comfortable and safe, so they should be willing to give you the answers you seek. And, as someone already said, trust your gut. Not because it will necessarily be a reliable indicator of the kind of care you'll get from that practice, but because your stress levels and level of trust in your practitioners are really important. If you don't feel safe with them, it doesn't matter if they're the safest practitioners in the world, because your experience will still be one of stress and worry. That said, it sounds like the general reputation of this practice should outshine the single mistake, which (though horrible), can and does happen in any birth setting.

I also have one little comment on this:

Some birth centers are very much like home. They offer little additional technology. If the birth center you want to use is of this style, there may be no particular benefit of the center over your home.

Since you've given birth before, you probably already know that it's messy. Not to get too graphic, but it can be really nice to have somebody else do all the laundry, clean the floor, deal with a bed that probably has a water-proof casing on it, etc. Just sayin'.
posted by vytae at 7:59 PM on March 31, 2010

I personally would not want to deliver with a midwife who is not a CNM. This is because I know when I see the CNM after someone's name that he/she has had appropriate medical training. I would like to note that I'm not saying that all DEMs or CPMs are unqualified, just that I know that a CNM has had a nursing education, but I don't know what kind of qualifications a CPM or DEM has until I specifically inquire.

That said, I think if you've done your research and determined that the Local Midwives are qualified (by whatever your standards are) to assist your birth, then that's great. You certainly should talk to them about your concerns, and pay close attention to how they address them. It's still early enough in your pregnancy to explore other options if you aren't satisfied with the Local Midwives.

If you decide for whatever reason not to go with the Local Birthing Center, then my advice would be to go with the hospital. At least, that is what I would do. If you decide to go the home birth route instead, then you should certainly put a lot of work into vetting your potential midwife. Above all, make sure that you're dealing with someone who you trust, who is more than competent, and who has your interests and the interests of you baby at heart.
posted by lexicakes at 9:14 PM on March 31, 2010

My main thought is that just because your first birth went very quickly doesn't necessarily mean your second one will.

I used to want to be a doula and so I've heard a lot of very strong opinions both for and against home birth. If I were having a child, I would want to be in the hospital simply for the fact that if some crisis happens, I'm already in a great hospital with a NICU and don't have to waste any time getting there.

I know you said it was hard not being able to collapse into bed right away with your family, but perhaps you could work something out with a doctor or midwife at the hospital that if the baby's all right, you can go home the same day? (Be careful about leaving AMA - against medical advice - if you do, your insurance may decline to pay for the birth.) Or many hospitals now have those reclining chairs with popup footstools and it's about as close as getting into bed with someone as you can get if you pull it up next to the bed and put down the rails... I know it's not quite the same.

Again, these are just my thoughts and feelings... you really have to do what you feel is right in your heart. It's important to trust in whichever care provider you choose. I am lucky in that my GYN already saved my life once (when I was 20 I needed emergency surgery on an ovarian cyst the size of a canteloupe) and I have a lot of faith in her, and I hope you find someone you trust as much.
posted by IndigoRain at 10:20 PM on March 31, 2010

I would be really hesitant to make decisions based on one mistake. A pattern of substandard care? A pattern of miscommunication and maltreatment and unprofessionalism? I'd be a little more hesitant then. But one instance of a mistake? Unless that mistake was because they have a systematic reluctance to do certain tests or perform to certain levels of care, I'd probably interview then go with my gut.
posted by geek anachronism at 10:45 PM on March 31, 2010

Response by poster: Update! I have a resolution!

I had made a "meet and greet" appointment with one of the two nurse-midwife practices in the county that delivers at the birth center -- coincidentally, the same practice that delivered my doula's little boy -- and there was an IMMEDIATE click there. I liked the Local Midwives just fine, but these other folks are really, like, my kind of people. The two licensed midwives did extensive work in the Phillipines, which means they've been exposed to a much, much broader range of pregnancy and maternity experiences than midwives in the US typically get, because they were the only real providers of maternity care in their area -- OB backup was very rare. The other group, to be honest, largely works with upper-middle-class low-risk white ladies. Now, I mean, I AM an upper-middle-class low-risk white lady, but still, I'm really attracted to the diversity of experience represented by this other practice.

So, I went ahead and transferred care, and I could NOT be more thrilled. This is the best possible resolution for me, that I would have a good reason to go with another group that has nothing whatsoever to do with the information I got!
posted by KathrynT at 11:53 AM on April 7, 2010 [1 favorite]

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