The Lowdown on Lawsuits: An Interview with Premier Speaker Mamie Guidera

Last month, a National Institutes of Health (NIH)-convened panel urged greater access to vaginal birth after cesarean (VBAC) for low-risk women. However, many clinicians have noted since that access to VBAC is not likely to expand until the “elephant in the room” is addressed—fear of malpractice lawsuits. ACNM Communications Manager Yolanda Landon had a chance to chat with Annual Meeting Premier Speaker Mamie Guidera, CNM, MSN, about this growing reality that affects midwives and access to midwifery care. Read on for an inside look at what to expect during Mamie’s co-presentation at the ACNM 55th Annual Meeting. And don’t forget—Early Bird Registration ends today!

Yolanda: Through the media, we keep hearing about an increase in lawsuits against both midwives and physicians. What do you think accounts for this increased attention?

Mamie: Suits are more public now. We need tort reform! The costs have gotten out of control….If you look at ACOG’s ongoing litigation surveys and studies, you’ll notice that nearly 90% of physicians have been sued at least once in their lifetimes. Bill McCool and I did our first midwives and litigation survey in 2005, and we recently wrapped up another one. Among midwives who responded to our surveys, the percentages are close to 30%.These numbers have increased only slightly over the past few years; however, lawsuits affect practice in a major way because of malpractice insurance costs.

Really, there are four factors that can predict the likelihood of a lawsuit: the number of years in practice (the more years of practice increases the likelihood of litigation), the number of births done, your age, and the region of the US where the midwifery practice is located. For example, I’m at high risk because of my years of practice…it’s all about exposure. It’s not about skill, it’s about numbers.

Yolanda: A midwife is there to help women and families. So, s/he might get discouraged after the threat of a suit. Any advice for midwives to stay in the profession and not give up?

Mamie: First, there is a professional liability resource packet posted on the ACNM website. Part 4 is called “What to Do If You Are Named in a Lawsuit,” and provides practical advice. One of the most important things midwives should do is process. By that, I mean they should share their feelings with a professional counselor or religious/spiritual leader or [share the] details of the event with a formal morbidity and mortality committee where they work. These three places are “non discoverable.”

Most literature suggests getting back on the horse, stay in practice, and keep moving forward. And this [being named in a lawsuit/litigation] is part of our practice. This is just part of what happens. It’s as basic as carrying a Blackberry/pager device or assisting with a birth in the middle of the night.

Lastly, remember that a lawsuit is not usually because you did something bad. It tends to be about money. We live in a country where the system doesn’t take care of disabled children well. People need money [to take care of their families].

Yolanda: What will attendees learn during your session?

Mamie: They will learn the results from the midwives and litigation survey, which was distributed to all ACNM members in 2009. We asked members how litigation has affected their practice and what helped them cope. Attendees will also learn some lessons from closed claims analysis, which means we will review cases that are closed and try to learn lessons from them.

Yolanda: What are the take-away messages from the presentation? Please provide 1 or 2 pieces of advice that our attendees should always remember.

Mamie: Understand litigation and embrace the issue! Know why midwives get sued, and what kind of malpractice insurance you need and have. Get involved in your professional organization or your hometown to support tort reform…and if you get named in a suit, know you are not alone.

Guidera will co-present the Joint Risk Management Session Monday, June 14, at 5 pm with William McCool, CNM, PhD, FACNM, Tina Johnson, CNM, MS, and Israel Teitelbaum of Contemporary Insurance Services. Look for the expanded version of this interview in On Location, the newsletter that will be distributed to attendees at the ACNM 55th Annual Meeting & Exposition in Washington, DC.

The Case for Choice in Labor Pain Management

by Melissa Garvey, ACNM Writer and Editor

Early this year, ACNM released a new Position Statement on the use of nitrous oxide for managing labor pain. Unless you are a midwife or other clinician, it can be hard to understand why nitrous oxide and the ACNM Position Statement is such an exciting topic. I just finished combing through a thorough, informative post at Science and Sensibility that helped me realize why—as a 29-year-old woman hoping to someday experience pregnancy and birth on my own terms—my enthusiasm has piqued. Nitrous oxide has the potential to expand access to choice related to one of the most sensitive issues around birth—pain management.

As certified nurse-midwife Judith Rooks so aptly articulates in the Science and Sensibility post, “Every woman and labor is unique. There is no single best method of labor analgesia. Every method has advantages and disadvantages, and different women value different things.” Just as women need options in where and with whom to give birth, women need to be able to choose which methods of pain control best match with their beliefs, experiences, health status, and stage of labor.

I won’t even try to rival Judith Rooks’ overview of what nitrous oxide is, how it is used, and how it works. Instead, I leave you with four ways nitrous oxide has the potential to expand access to choice.

1. More Options for Pain Management in Homes and Birth centers. While midwives can help women manage the pain of labor through a variety of options like massage, emotional support, and water immersion, many women find it comforting to know that their midwife can order pain medication if they end up needing it. In homes and birth centers, that drug could be nitrous oxide rather than an epidural, which is only available in hospitals.
2. More Options for Pain Management in Hospitals. If a woman decides that she wants an epidural, she has to wait until labor is well established and for the anesthetist or nurse anesthetist to administer the epidural. That same woman can use nitrous oxide to take the edge off the pain while she waits to be able to have an epidural. Depending on her response to nitrous oxide, she may even decide she does not need the epidural.
3. Freedom to Move. If delivered through portable equipment, nitrous oxide can be used without sacrificing movement during labor. Women can still change positions, walk, go to the bathroom, or soak in a tub.
4. Freedom to Change Your Mind. If a woman decides that she does not like how nitrous oxide makes her feel or decides she no longer needs it, her body will be completely free of it in less than five minutes from the time she stops inhaling it.
   

According to Judith, only two hospitals in the US currently offer nitrous oxide for labor pain management. Most birth sites in the US do not offer the drug largely due to lack of equipment and manageable concerns over the risk of nitrous oxide to health care workers. The new ACNM Position Statement addresses some of the concerns related to nitrous oxide, and a new company is preparing to make the equipment. Let’s hope this is the start of a growing wave of support for more choice in how laboring women cope with pain.

Public Citizen Spotlights Unnecessary Cesarean Sections in New York State

by Melissa Garvey, ACNM Writer and Editor

Some of you may remember Public Citizen’s 1997 report “Nurse-Midwifery: The Beneficial Alternative.” Yesterday, the group released a new report called “Guide to Avoiding Unnecessary Cesarean Sections in New York State.”

They chose to spotlight New York not because of its high rate of cesarean births (At 33.7%, only nine states have higher rates than NY), but because it is one of only two states that tallies intervention rates for obstetric procedures all the way down to the facility level.

What they found is that the cesarean section rates vary widely throughout the state and nearly a third of cesarean sections may be unnecessary. That estimate is based on the fact that the state’s 10 hospitals with the lowest cesarean rates had an average rate of 20.8%—more than one third lower than the average rate for all New York hospitals.

The report contains a myriad of useful information, including birth statistics by county, tips for women who want to avoid an unnecessary cesarean section, and even guidelines for health departments and hospitals seeking to reduce unnecessary cesarean sections. Before you dive in, I’d like to highlight one of my favorite quotes from the Public Citizen press conference, which was held yesterday morning. This comes from Dr. Jacques Moritz, an obstetrician at St. Luke’s-Roosevelt, Roosevelt Division:

“The model of obstetrical care in this country is all wrong. The model of an overtrained obstetrician attending to a normal birth is all wrong. The proper model is for all low-risk mothers to be managed by a certified midwife with a midwife-friendly obstetrician as back-up. This works in other industrialized countries, but not in ours.”

Susannah Donahue-Negbaur, CNM, MPH, a midwife at Roosevelt Hospital, New York City, drove the issue home:

“Choosing a midwife is one good way a woman can reduce her chance of a cesarean section. Research shows that low-risk women who use midwives are more likely to have a safe and healthy birth for themselves and their babies, and are less likely to undergo an induction of labor, cesarean or episiotomy than low-risk women who use doctors.”

Read more of Susannah’s comments about how maternity care works best as a partnership between midwives, physicians, and families here.

What do you like most about Public Citizen’s latest report?

Evidence in Action at Midwife Connection

by Melissa Garvey, ACNM Writer and Editor

We’ve been pretty silent at Midwife Connection lately, but this week we’re getting back to normal. Yolanda Landon, our communications manager, is back from maternity leave with baby Kennedy in tow (yes, ACNM has the best mother-friendly, baby-friendly work policies I’ve ever encountered!), and we’re gearing up for the ACNM 55th Annual Meeting scheduled for June 12 – 16 right here in Washington, DC. In honor of this year’s theme—Midwifery: Evidence in Action—let’s kick off the week with another post in Andrea Lythgoe's excellent “Becoming a Critical Reader” research series.

Becoming a Critical Reader: The Five Basic Questions

by Andrea Lythgoe, LCCE (Originally published on Science and Sensibility for Lamaze International)

Since it has been a while since we’ve had any articles in this series, you may want to refresh your memory by rereading the first and second installments in the “Becoming a Critical Reader” series. I promise it won’t be so long of a gap before the rest of them!

OK, having reviewed and identified your own personal biases, you are ready for the second read-through, where you can more critically read the article. We’ll spend the next few posts in this series going through the various types of articles and the things you’ll want to consider when doing this more critical reading. Some questions will be pretty universal, no matter what type of article you are reading. Others will be more specific to the various types of articles. We’ll cover those specific questions over the next few posts.

The basic questions to ask as you read:

1. What did the authors set out to do? Hopefully you’ve already figured this out in your preliminary run through. If you’re not clear on that, make that the first thing you look for. When you find it, write it down so you don’t lose sight of that aim in the remainder of your reading.

2. Did the article really do what it set out to do? Look for the “conclusions” or “results” sections to see what the authors say about a study. Sometimes what is written here will have nothing to do with their original intent. Not that this makes the conclusions invalid, because sometimes studies do make important and interesting discoveries in tangential information. Ideally, the authors should at least address the original aim of the study, even if it was to say “we did not find what we expected to find.”

NOTE: This question is NOT the same question as “Did the study show what I think it should have shown” or “Did the study look at what I wanted it to study?” Sometimes I hear people disparage a study by saying “They looked at the wrong thing! Instead of studying ‘when is the best time to do an induction?’, they should have studied whether to do them at all!” This is unfair. The study is no less valid because it addresses a different issue than you would have chosen to research. The question is “Did they do what they set out to do?”

3. Did the article use appropriate methodology? Some methods might not be a good way to study a particular question. Other methods might be a better approach. While some are fond of saying that only a double-blinded, randomized controlled trial can give you sufficient answers, it’s not always realistic or ethical to do research in this way. We’ll go more into detail on that in our next series on methodology, so don’t worry if you don’t know enough to make a good judgment on this aspect right now.

4. Did the author show undue bias or influence? Many studies will have a disclosure on the first or last page of a study that tells who paid for the study or if the researcher has any conflicts of interest. While I wouldn’t necessarily dismiss a study because of a potential conflict of interest, I certainly would be using a VERY fine-toothed comb in my perusal of the study!

5. Do the conclusions match the data? Sometimes there is a pretty obvious mismatch between the two. I once read a study where the author concluded that a vaccine for GBS would save lives. However, the aim of the article was to find out if prenatal screening for GBS would reduce the incidence of serious GBS infections. Vaccines were not mentioned anywhere in the article, except in the conclusions area. It seemed an obvious mismatch to me.

Sometimes the mismatch might be more subtle. This is why you’ll want to jot down that answer to the initial question, “What did the authors set out to do?” At this point, go back and see if both their data and conclusions answer that.

These five questions are a good place to start as you review articles. I suggest that you take some time this week to find the full text of a study and read through it, answering these questions as you go.

Patient safety, disciplinary action, and the marginalization of midwives

by Amy Romano, CNM (Originally published on Science and Sensibility for Lamaze International)

It sounded like an April Fools joke, except the story broke two days early. Doctors in North Carolina induced and ultimately performed a cesarean on a woman who wasn’t pregnant.

The case happened in 2008 but we all learned about it this week because the North Carolina Medical Board finished their investigation and issued “letters of concern” to the doctors involved. Public letters of concern appear to be the least punitive disciplinary action performed by the state Medical Board, according to their list of published board orders (PDF).

To which I respond: Letters of concern? Seriously???

The consensus on Facebook and around the web was that if midwives had been involved in an incident of this magnitude, they would have had their licenses revoked post-haste. Why? Because all kinds of disciplinary actions are made against midwives, whether they are practicing safely or not. Very often, the complaint is issued by a physician rather than a patient. It’s all part of what Marsden Wagner, perinatal epidemiologist and former director of Women’s and Children’s Health in the World Health Organization, in an editorial in the Lancet, called:

a global witch-hunt…the investigation of health professionals in many countries to accuse them of dangerous maternity practices. This witch-hunt is part of a global struggle for control of maternity services, the key underlying issues being money, power, sex, and choice.

Midwives practicing in states that refuse to license direct-entry midwives are the most vulnerable. Consider the case of Ohio Mennonite midwife, Freida Miller, who was jailed for appropriately administering a life-saving medication, pitocin, to a woman experiencing a postpartum hemorrhage. For cultural and religious reasons, the women in the community Miller served would be unlikely to accept routine hospitalization for childbirth unless the benefits clearly outweighed the risks, which for many women they don’t. Rather than equip the midwife with a drug (pitocin) that is considered so essential for women’s safety that it is given routinely to all women birthing in hospitals, the government removed the community’s midwife altogether. In the name of public safety.

Even when midwives are licensed, they are not immune from predatory disciplinary action. A licensed midwife in California was issued a cease and desist order at gunpoint and ultimately had to surrender not just her midwifery license but her licenses to practice as a registered nurse and a nurse practitioner. The complaint was made by a physician in the community, not a patient. Among the board’s findings: she performed a vaginal exam before labor (routine practice in most obstetric offices), failed to obtain informed consent before performing an episiotomy (true of approximately 25% of all episiotomies performed in hospitals, according to the Listening to Mothers II survey), and failed to clearly chart the course of treatment for a patient (Didya ever hear the one about the doctor with bad handwriting?). To be fair, the investigation revealed evidence of other, more serious transgressions, but the scale of the disciplinary action seems out of proportion with the evidence, especially when we consider what obstetricians have to do to have their licenses revoked. (Seriously, googling “obstetrician license revoked” yields surprisingly few cases and most include drinking on the job, having sex with patients, or having a pattern of many preventable bad outcomes.)

Midwives who have avoided disciplinary action by state boards may be arbitrarily deemed unsafe by hospital administrators. By publicly citing safety concerns but keeping the details sufficiently vague, hospitals succeed in forcing midwives out. Cases that have been analyzed in the research literature reveal economic motives, however. A hospital in California recently suspended the privileges of a group of nurse-midwives, stating that the absence of a neonatal intensive care unit at the hospital rendered its patients safe only in the hands of obstetricians. Never mind that the only randomized, controlled trial reporting admission to a special or intensive care nursery showed higher rates in the physician group than the midwife group (9.4% vs. 7.9%).

Photo courtesy of Birth Action Coalition

Is Disciplinary Action the Best Way to Protect Patient Safety?

We need to stop the predatory use of state and hospital disciplinary action against midwives, and equalize the process for all categories of care providers. But whether disciplinary action is against midwives or physicians, is punishment the best way to deal with breaches in patient safety? After several high-profile cases in which health care professionals went to jail for making medical mistakes, the patient safety community is rallying around alternatives to punishment, and producing evidence that these alternatives are in fact more effective.

As nurse and patient safety expert, Barbara Olson, argues in one of the posts that made me fall in love with her blog (the other post being her birth story), punitive actions, especially when they are the only actions taken, do not address the root causes of unsafe care, nor do they make care safer.

We can and will argue about what constitutes the safest kind of care. But perhaps we should instead be asking what kind of maternity care system can most reliably deliver safe care. Achieving such a system will take a collaborative effort among all types of health care professionals and the women they care for. Fortunately, some brilliant minds have been hard at work determining what kind of collaborative effort might produce a safer maternity care system. The Institute for Healthcare Improvement is sponsoring a webinar on April 8 to discuss the findings, titled, “Momentum for Maternity of the Safest Kind.” The speakers, who include Maureen Corry and Rima Jolivet from Childbirth Connection, will discuss the recent work of the Transforming Maternity Care Project. If you have been eager to hear more about this work, this is a great opportunity.

So, should the doctors who performed the ultimate in unnecesareans have gotten more than letters of concern? Probably. Maybe. It’s hard to know without knowing what the root cause analysis – please tell me they did one - revealed. But there must have been other opportunities for such a breach of safety to have been avoided. A system that can so completely lose sight of patient safety desperately needs to have its assumptions, routines, and safeguards examined.

When preventing avoidable harm is a fundamental aim of a maternity care system, the logical strategy is to address the root causes of injury, and to arrange care and resources to keep women and babies safe. That’s exactly what midwives do, yet instead of embracing them, our system marginalizes them.

The Evidence is In: Texting Helps Teen Moms

by Melissa Garvey, ACNM Writer and Editor

In February, ACNM signed on as an outreach partner with Text4Baby and I posed the question, “Do you expect Text4Baby to make a meaningful difference in the lives of women and their babies?” I found the answer this week on MTV’s 16 and Pregnant. Watch the clip below for an inside look at how Text4Baby is, without a doubt, making a difference.

MTV Shows

Text “BABY” to 511411 to sign up for free.