Obstetrics Consultations and Midwifery Liability
Professional Interactions Between Women Physicians and Midwives
Maternal Mortality at the Hands of “Obstetricians”.
Unfortunately, during this turn-of-the-century time frame, maternal death was raging through hospital maternity wards, while newly-trained OB doctors were overreaching the limits of their knowledge and capabilities. Mortality statistics in American hospitals, during this stage, were significantly higher than those collected in Europe, which had always incorporated midwifery care in hospital settings. (Refer to the website: What Happened to Midwifery. (http://www.midwivesontrial.com/articles/what-happened-midwifery-1
Despite a White House study in 1925, which revealed unacceptable evidence of harm and death to women giving birth in hospitals, the Johns Hopkins Hospital’s fledgling specialty of Obstetrics prevailed. Despite overwhelming cases of maternal death in hospitals, conceding professional status to midwives was never going to happen. The safer alternative to obstetrics had always existed, but women practitioners of midwifery didn’t have a chance. The “medical men” were going to control women and their childbirth experience.
This scientific era of obstetrical care was nearly the end for midwifery in America. Physician-led public health campaigns against midwives were brutal and relentless. Efforts to obliterate American midwifery were, ultimately, successful and midwives were, without evidence, publically shamed and forced underground.
Campaigns against midwifery, starting at the beginning of the 19th century, set a table for strained relationships between physicians and midwives that have persisted over decades. Encouraged by the attitudes of J. Whitridge Williams (1912) and Joseph Bolivar DeLee (1915)*, anti-midwifery sentiments became commonplace. In that novel era of obstetrics and scientific medicine, hospital-based physician care was touted as the only modern and realistic choice for safe and healthy childbirth in America.
Midwifery Returns to American Hospitals
Beginning in the 1960’s, professional certified nurse-midwifery was re-introduced into hospital practice. Unfortunately, it was obvious that physicians’ attitudes toward midwives had not changed much from the 1920’s. Some well-meaning obstetricians were interested and supportive, but they were few. If a Certified Nurse-Midwife was able to find a supporting OB collaborator in order to practice in a given hospital, she was fortunate. Male physicians who were confident, and took the time to understand CNM scope of practice, made dedicated back-up consultants. Of course, many more were against midwifery presence in hospitals and were reluctant to have anything to do with them.
Liability Insurance Rates Through the Roof
Physicians in private practice were particularly concerned that working with midwives would raise their malpractice insurance, and it did, due to ignorance within the industry. In fact, industry hysteria that a nurse-midwife was going to draw innocent doctors into a vortex of expensive and career-ending malpractice claims were unfounded. Unfortunately, it remains difficult to convince insurance companies and individual physicians that midwives are not going to destroy them professionally. Obstetricians have always been known to face more malpractice claims than their non-OB colleagues. And they have accomplished this entirely on their own, without the help of “potentially dangerous” nurse-midwives. Then and now, medical misdeeds which drive obstetrics related lawsuits are rarely attributable to the individual malpractice of a midwife. Despite the absense of concrete proof, midwives continue to be considered malpractice liabilities.
Women Entered the Previously Male-Dominated Field of OB
As more women entered the profession of Obstetrics, professional relationships between physicians and midwives became, surprisingly, difficult. On the labor deck, it was unusual to have women OBs willing to even speak to, much less work with, a nurse-midwife. Demeanor toward CNMs ranged from confrontational and aggressive, to dismissive, condescending, or just rude. Women obstetricians, in contrast with their male colleagues, were tired and angry, impatient and disdainful, straight out of their residency programs.**
Stay in Your Own Lane
Many women OBs are, even now, unwilling to accept that there is even the tiniest overlap in MD/CNM scope of practice related to normal obstetrics. Nothing short of a medical school education confers a right to care for women experiencing normal, uncomplicated pregnancies and deliveries. Any concept of teamwork is only that; an opaque idea never translated into practice. Working relationships, today, may be problematic and entirely non-existent in some clinical settings. Hospital collaborating physicians, forced to cover nurse-midwives, can be angry if midwives call a consult, and angry if they don’t. This has been a confounding dynamic for decades.***
These statements may risk being interpreted as meritless or overwrought, but the point is for CNMs/CMs to understand that this unfortunate dynamic of woman-to-woman communication (or serious lack of) creates the potential for medical mistakes. Working and associating with some women physicians (or nurses) who do not support the concept of midwifery, or have general disdain for midwives, has real potential to invite legal liability. Animosity of this tenor can produce extreme stress and miscommunication, enhancing the risk for malpractice. Once midwives blunder into litigation, it will be a long and miserable journey before they are released from a lawsuit, vindicated, or found liable.
Are There Remedies For Sick Cultures of Care?
If midwives have attempted to rise above psychological stress in the workplace and nothing has changed, or the situation reflects a terminally ill culture of care, there are only a few options. Negative communications and behaviors need to be reported to hospital administration, along with personal documentation of specific events. If nothing is resolved, it is safer to leave a dysfunctional workplace. Making this difficult decision is, ultimately, for the benefit of career, professional sanity, and patients’ welfare.
1. Lynette A. Ament, PhD,CNM,RN,FACNM. Professional Issues in Midwifery; specificChpt. 1, p. 23. Relationships Between CNMs and CMs and Other Midwives, Nurses, and Physicians (Judith P. Rooks, CNM, MPH,MS,FACNM).. Jones and Bartlett Publishers. Copyright 2007 .by Jones and Bartlett Publishers, Inc.
*Attributable to DeLee in 1915: “the evils natural to labor” and . . .” If the profession (obstetrics) would realize that parturition (childbirth) viewed with modern eyes is no longer a normal function, but has imposing pathological dignity, the midwife would be impossible even of mention”). In re Williams: Dr. Williams was a lead professor at Johns Hopkins (and first author of Williams Obstetrics). It was his opinion, based on The Flexner Report on Medical Education, and his own survey in 1911, that most women were safer with midwives than general physicians. To improve the training of obstetricians, Dr. Williams advocated for hospitalization for all deliveries and “gradual abolition” of midwives, who should be replaced by obstetrical charities which would serve as “training sites” for budding obstetricians.
** It is an old and tired joke among midwives that there must be a class in medical school for women students entering obstetrics, warning them of the evil and incompetence of midwives that they may encounter in practice. I’m confident that a syllabus exists out there, somewhere.
If it were not for a few, completely wonderful, supporting and brilliant women OB’s I have worked with, and considered friends, I would have left midwifery sooner than planned. I consider myself fortunate to have concluded my career with an obstetrical hospitalist group that I will never forget. The doctors (male and female), midwives, nurses, and amazing young residents were some of the finest people I’ve known and I was fortunate to end a long career, with gratitude, that I was lucky enough to have worked alongside them.
***Attempting to understand unfortunate relationships between midwives and OBs, particularly the doctors who are the most critical of midwifery, it is surprising that many of these individuals have never met, much less worked with, a midwife. I also would like to think that OB attitudes against midwifery may be connected to the pressures of OB practice and the stress of simultaneously raising young families. Midwives can relate to this! This does not explain, however, the vitriol of many older women in OB.
I am encouraged to hear of a growing number of private practices where midwives, and women OBs, are working together. One practice I am aware of seems to have created the best of all worlds for the women and families that they care for. If this represents a growing trend in obstetrics and midwifery, I hope that it prospers and becomes accepted practice in women’s healthcare.
Relevance For Practice:
Situation
There are published, and unpublished, legal cases involving consulting or collaborating physicians who have failed to respond when a midwife has asked for consultation or referral. These failures were deliberate and the result of paranoia and avoiding collaboration with an unfamiliar midwife. Failures, such as these, occur most often when the midwife’s established consultant is not available or has signed out to hospital laborists or hospitalists. Some details cannot be disclosed due to confidential settlement agreements, but failures by contractual consultants have resulted in bad outcomes for mothers and babies. It appears that the majority of the failed/delayed responses involved non-reassuring fetal monitor tracings, placental abruption, arrest of labor, or mal-presentations. In these cases, both midwives and physicians were named in the lawsuits.
Vulnerability
Unfortunately, cases exist where the midwife has appropriately consulted, and a consultant physician has either delayed or failed to respond. In one case, the midwife’s back-up physician could not be reached and the laborist on deck declined to get involved. The midwife acted appropriately but the laborist was responsible for an unacceptable delay in responding to the obstetrical emergency. Both the midwife and laborist were named in the personal injury lawsuit. Infants involved in these types of cases were injured as a result of delay in treatment, oxygen deprivation, hypoxic-ischemic encephalopathy, cerebral palsy, and a need for life-long supportive care.
Expectation/Duty
Some form of consultant contingency planning, prior to any emergency in OB, is essential. This is especially true in situations involving rural hospitals or birth centers where a consultant physician may not be in house. In these instances, consultation/collaborative agreements must include planning for alternative assistance in unexpected emergencies. Communications between the midwife and consultant must be undertaken according to pre-approved, written plans where both individuals understand their roles in emergency situations.
Naturally, in the midst of an emergency, you cannot be taking notes at a computer. In every emergency situation, make whatever notes you can (on scrubs, glove packages, random pieces of paper, etc.) so you can more accurately transcribe events, later. Being able to provide real-time information will be helpful in the event that a claim is filed against you. Time passes and memories fade. Documentation of conversations and events, as close in time as you can manage, will be helpful in case of adverse events.
Remedies/Protection
Discuss the issue of back-up availability with your consultant and reach an understanding regarding other options for times when he/she may not be available. Work these details out in advance and have it in writing. If the hospital where you deliver has laborists, determine whether any of them have problems with stepping in to assist a midwife. From a legal standpoint, hospitalists and laborists do have a duty to respond to requests for emergency assistance, no matter whether the requesting provider is OB or CNM.
Finally, if it were not for a few, completely wonderful, supporting and brilliant women OB’s I have worked with, and considered friends, I would have left midwifery sooner than planned. I consider myself fortunate to have concluded this career with an obstetrical hospitalist group that I will never forget. The doctors (male and female), midwives, nurses, and amazing young residents were some of the finest people I’ve known and I was fortunate to end a long career, with gratitude, that I was lucky enough to have worked alongside them.
http://www.midwivesontrial.com