Peer Review: a midwife stands up for accountability

I was recently forwarded this letter and was given permission to share it with a few identifying details removed. This letter really spoke to me, further convicting me of things I am guilty of that I have not yet really explored, including the referring of clients to midwives who I knew would take on their risky births. I applaud the author for stepping out, stepping up, and saying hard things that must be said. She reports that she has received numerous supportive replies from midwives in her community who acknowledge the truth of what she is sharing.

Boldface emphasis is mine: 

An open letter of resignation [organization redacted]

May 11, 2015

Dear fellow midwives, students and former midwives

This is an open letter of resignation as Peer Review Coordinator for [organization redacted]. Because this community is so important to me, and because I believe that Peer Review is critical, I feel compelled to write this difficult letter of explanation instead of simply quitting.

I have been a member of the birth community since late 2006. Over the last nine years, our home birth community of [Midwestern U.S. location redacted] has experienced at least nine intrapartum or neonatal fetal deaths. I have personally coordinated or facilitated Peer Reviews for seven of these deaths. Some of these babies may have died in another birth setting or with a non DEM. Most would have survived. During peer review, I have watched and participated in this community’s utter failure to hold each other accountable. Instead of challenging each other to do better and change, we have tended to soothe ourselves with false statistics, false logic and comforting ideas and support.

The fact is that these deaths are not a statistical blip. As a midwifery culture/community and as a Peer Review group, we have failed to hold each other accountable for egregiously risky behavior that has resulted in the deaths of many babies and countless unnecessary morbidities.

I recognize my part in this. I recognize that I have participated in many, many unsafe situations and made risky clinical decisions as a midwife and as a student. I was not held accountable and I have not held you all accountable for similar mistakes. I know that I am simply very lucky that my past actions or management did not result in anyone’s death.

I say this with much understanding and compassion in my heart for my fellow CPMs and DEMs. We are immersed in a birth culture that valorizes risk and avoiding intervention, minimizes danger, and which mis-represents statistics and research to a group of people – ourselves and our clients – who are not trained to interpret research. We are organized by institutions (MANA, NARM, MEAC) that send undertrained and undereducated women to care for families with almost no guidance or standards. We are told only to stick to our own practice guidelines while our organizations fight for our right to do whatever we want. Even while their own research shows that there should be standards, that there are risks CPMs should absolutely not be taking. Our organizations leave us powerless to stop even the most dangerous midwives. There is no institutional accountability or institutional support for better standards. I understand why things are the way they are. I no longer want to be complicit.

Midwives, I have been listening to your stories and telling my stories for almost ten years. You are all amazing, intelligent and endlessly compassionate people who work hard and care deeply for your clients and your work. But we have some incredible blind spots. I urge us to read the statistics, to look closely at our own outcomes and protocols. I want us to support each other for taking only low-risk clients and to celebrate each other for conservative transfers, transports and consults instead of cheering another crisis averted.

I want to encourage everyone (including me!) to take some important steps – stop considering breech, twin or VBAMC births. Stop referring clients to dangerous midwives who will do these risky births. Adhere to more conservative guidelines on the length of time in different stages of labor, ROM and length of gestation. Test your mamas for GDM and GBS and share evidence based research with them when they screen positive. Do labs.

I want to share that I am working with a group of midwives and former DEM midwives from around the country on a response to the failures of our midwifery culture and institutions. We hope to publish a set of guidelines and organizing principles for midwives to agree to and get support from. If you would like more information, please let me know. I would encourage everyone to read the newly published blog honestmidwife.com with an open heart and mind. There is so much uncomfortable truth in what Leigh is saying there.

I don’t seem able to steer our group toward more accountability and less risk. I hope that a future Peer Review coordinator will be better able to do this. I look forward to participating in our group a little less and in a different capacity. I hope we can elect a new Peer Review coordinator on [date redacted] who will bring fresh energy, objectivity, compassion and strength to our process.

With compassion and love,

[name redacted]