One of my favorite new bloggers, Public Health Doula, posted about a New York Magazine article called Extreme Birth about midwife Cara Muhlhahn. The article is well-researched and thorough but perhaps better suited for a personal blog where an author can let their biases run wild. The use of the word “extreme” in the title leads me to believe that a splash of sensationalism was added to the article to make it better link bait in the same vein as Hanna Rosin’s recent article in The Atlantic. Or perhaps I am just reading it through my own biased lens.
Regardless, The Feminist Breeder mentioned that she was having technical difficulties yesterday while trying to comment on the article and I got sucked into reading 73 comments. This one wouldn’t have caught my eye unless the author of the article hadn’t stepped in to defend his work.
I can’t respond to the article itself because it is full of twisted logic, half-facts, and an amazing bias, all wrapped in a sensationalist tone, beginning with the EXTREME headline. It is interesting to note that if one actually knows the person being discussed in such an article, it is easy to see where the bias picks up and the truth leaves off in service of the author’s own agenda. I can see how awful Cara Muhlhahn’s practice would look if this article was the only thing you “knew” about her. Please understand that you don’t “know” anything about her based on this article. For instance, the practice agreement thing isn’t as simple as you might think. For one thing, just because a midwife doesn’t have one doesn’t mean she is not collaborating with physicians; it just means she can’t get one to SIGN one. There are many physicians who are happy to take transfers from midwives but who do not want to sign anything, for understandable reasons—they are afraid they will be held responsible for something that happens while they are at home asleep! What they fail to realize is that the same thing can happen to them with the residents they “supervise” at a hospital. As my mom used to say, the proof is in the pudding. Cara’s statistics speak for themselves. Her outcomes are better than those of the hospitals who accept her transfers, who have their own in-house “train wrecks” every day, which they do not blame on the practitioner.
By MAIRICNM on 03/25/2009 at 8:49am
Then Andrew Goldman, the author of the article, steps in:
I’ll let you vent about my bias; the story speaks for itself. You haven’t challenged any of the facts, just the tone, and it’s pointless to get into a back and forth on something as subjective and mushy a term as ‘tone.’ I will however, say this. I don’t think there’s any arguing that hospitals produce “trainwrecks” [sic] of their own; this story is not about St. Vincent’s. The difference is that anybody delivering babies at that hospital must carry malpractice insurance; Muhlhahn chooses not to, and also chooses not to have a discussion about it with clients I’ve interviewed. If that baby that Muhlhahn delivered at the maternity center were injured today, what recourse would the parents have to get help with longterm [sic] care of their kid with Erb’s palsy? [emphasis mine]
BY ANDREW GOLDMAN on 03/25/2009 at 9:34am
The “train wreck” paragraph of the article is the one in which an unidentified resident says that Muhlhahn dumps her laboring clients there and runs out the door.
Muhlhahn calls St. Vincent’s her “backup hospital.” About 10 percent of her patients end up transferring there during labor. But her relationship with the hospital is not exactly formal. “St. Vincent’s is her dump,” says one former obstetrics resident who’s treated Muhlhahn’s transfers. “She could say any hospital is her backup, because no hospital is ever going to deny a woman care. She’d bring her patients in, holding their hands, find out we were going to have to do a section, and then she’s out the door. To me, that’s a dump.” Other doctors on the floor have referred to her transferred patients as “train wrecks.”
The “maternity center” to which Goldman referred is Muhlhahn’s former birth center, mentioned in this article:
For all her home-birth successes—she has delivered more than 700 babies—Muhlhahn has also had some tragedies. In 2003, she and her former birthing center settled a $950,000 malpractice suit brought by the parents of a child who was injured during delivery. As the baby’s head was crowning, he suffered a shoulder dystocia, when a baby’s shoulders get stuck behind the mother’s pelvis. It was imperative to get the baby out quickly, because he couldn’t breathe in that position. “Cara was crying and saying that she thought she was going to lose the baby,” Yvette Garcia, the boy’s mother, said in a deposition. The child survived, but the cervical nerves in his neck were damaged, rendering his right arm paralyzed, a condition called Erb’s Palsy. According to Garcia’s deposition, when she first brought the boy to the family pediatrician, the doctor took one look at the lame appendage and “knew that the baby was yanked out.” Garcia’s complaint argued that Muhlhahn should have known that the baby would be too large for a vaginal delivery.
Put a pin in Goldman’s question, “If that baby that Muhlhahn delivered at the maternity center were injured today, what recourse would the parents have to get help with longterm [sic] care of their kid with Erb’s palsy?”
Without knowing anything about the case other than that which was covered in the article, I can tell you with no hesitation that the old Should Have Known How Big the Baby Was and Therefore Should Have Performed a Cesarean argument is usually total and complete crap. It reflects both a complete disregard for evidence and an unrealistic attitude toward pregnancy and birth.
Furthermore, Cesareans do not prevent Erb’s Palsy! It is extremely rare, but so is Erb’s Palsy. Some indirect evidence suggests that maternal propulsive forces can be just as damaging as provider traction to the infant’s head. In addition, there is no way to accurately fetal weight prior to birth. Besides, one half of all cases of permanent brachial plexus injuries occur in infants weighing less than 4,500 g (9 lb, 15 oz).
From the American Family Physician article, Management of Suspected Fetal Macrosomia:
[U]p to one fourth of infants with shoulder dystocia experience brachial plexus or facial nerve injuries, or fractures of the humerus or clavicle. Brachial plexus injuries, such as Erb-Duchenne palsy, are ordinarily attributed to delivery complicated by shoulder dystocia; however, approximately one third of these injuries are not associated with a clinical diagnosis of shoulder dystocia. The most feared complication secondary to shoulder dystocia is asphyxia, which is rare.
And even if a midwife or doctor were to magically foresee with total accuracy the weight of the baby prior to delivery, guess what is not recommended for suspected fetal macrosomia. Elective cesarean section. Neither is elective induction. In fact, inducing a woman carrying a “macrosomic” fetus with Pitocin makes it 23 times more likely that shoulder dystocia will occur.
Yet induction to prevent the baby from getting too big, which will supposedly help prevent shoulder dystocia from occurring, has become a standard of practice. Unfortunately, it’s a practice that makes it 23 times more likely that the very thing the doctor or midwife is trying to prevent will actually happen.
How shoulder dystocia is handled in the moment is seems to be the one area where we almost always see physicians and midwives on the same page. It is universally terrifying when the infant’s head turtles and the clock starts ticking.
The authors of another American Family Physician article discuss the management of shoulder dystocia and note the following:
Among the most common fetal complications are brachial plexus palsies, occurring in 4 to 15 percent of infants. These rates remain constant, independent of operator experience. Nearly all palsies resolve within six to 12 months, with fewer than 10 percent resulting in permanent injury.
Rare. Rare. Rare.
The big question, though, is why Goldman argues that home birth midwives should carry malpractice insurance to ensure that their clients will have access to a huge payout in case they need it. Are private insurance and Medicaid not adequately covering care for disabilities? Are we as a society not adequately supporting and accommodating the needs of persons with disabilities? That sounds like the real issue to me.
I read a comment one time on a story about unassisted birth that asked, “Who will the family sue if something goes wrong [at an unassisted birth]?” At the time, I thought it was a joke.
I’m not so sure anymore.
As Public Health Doula puts it, “It’s comforting to think about handing over all the responsibility to someone else, but I think ultimately it’s unrealistic.”
Edit: Unnecesarean reader Leigh was actually interviewed for the New York Magazine article. She shares her experience on her blog, Marvelous Kiddo.