It’s hardly surprising that homebirth midwives have a serious problem with obtaining informed consent. That’s because selling homebirth midwifery services implicitly depends on being dishonest about the risks of homebirth: minimizing them, lying about them or omitting disclosure altogether.
Simply put, if homebirth midwives had to honestly disclose risks, they’d have very limited employment opportunities.
Therefore, homebirth midwives have devised a variety of strategies to avoid obtaining informed consent.
1. Delay
Melissa Cheyney and the Oregon homebirth midwives are masters of this strategy. They simply didn’t obtained informed consent for homebirth and when forced by the legislature to begin doing so, they stalled, and stalled and stalled again.
As I wrote two years ago, the legislature mandated informed consent by June, 2011:
… [I]t is remarkable that Oregon homebirth midwives have still not begun obtaining consent for these high risk situations, arguing repeatedly that they need “more time” to create consent forms. Homebirth midwives petitioned for and were granted an extension until October 15, and as the date drew near, they petitioned to postpone the requirement for informed consent until January 1, 2012. That request was formalized on 9/26/11. A little over a week later, having postponed compliance with the requirement for 6 months, Oregon homebirth midwives petitioned to postpone it a further 6 months.
The idea that they needed any extension at all is bizarre. The increased risks posed by VBAC, breech, twins and postdates pregnancy are well known and have been quantified for years. For example, obstetricians have been obtaining informed consent for VBAC for at least 20 years. The Board of Direct Entry Midwifery could easily assemble and print the information in one day.
But Oregon homebirth midwives depend on their friends in the legislature to protect them from even the most basic requirements for consent. I’m not sure that they have yet begun obtaining consent for high risk situations.
2. “More research is needed.”
Homebirth midwives will do just about anything to avoid acknowledging risks. Hence the inane claim by MANA executive Jeannette McCulloch, in a recent post on the blog of the Midwives Alliance of North America, that “no one knows” how to tell the difference between low risk and high risk.
More research is needed into what constitutes low-risk for home birth. It is critically important that mothers and their care providers have accurate, evidence-based information so that they can make true informed consent. Risk factors that need further examination include breech, multiples, post-dates, and a variety of different VBAC circumstances.
That’s funny. MANA’s official stance is that:
…[F]or low-risk women with a skilled midwife in attendance, home birth is a safe option for newborns with lower rates of interventions and complications for mothers.
Well, which is it MANA? Does “research show” that homebirth is safe for low risk women or do we need more research to figure out just what low risk really means?
Now you or I might think that statements like these represent confusion on the part of MANA about what constitutes low risk, but that’s not true. The EXPLICIT policy of MANA is that each homebirth midwife can “decide for herself” what constitutes low or high risk. That makes no sense at all until you remember that the entire point of MANA is to provide intellectual cover for homebirth midwives, who are nothing more than lay people, to do whatever they want to do.
Standards apparently are only for real medical professionals, not for homebirth midwives.
3. An “informed consent” form that doesn’t obtain informed consent
Some homebirth midwives, like Mountain View Midwives in Charlottesville, VA, have come up with an informed consent that doesn’t obtain informed consent:
Each woman must weigh for herself the risks of birthing outside an emergency facility against the risks of in‐hospital birthing, where the risks of unnecessary interventions, emergency‐mentality, and hospital born infections present their own dangers. Babies (and very rarely, mothers) do sometimes die in spite of the best care and great love. It happens at home and in the hospital.
Evidently the folks at Mountain View Midwifery don’t know what informed consent actually is. They have written a release, not an informed consent. This is probably going to come as a huge surprise to them, but medical care is not the same as going to a water park or going skiing. In those situations, the park or the ski slope is not required to enumerate all possible risks of swimming or skiing. They simply need you to acknowledge that you are willing to proceed at your own risk.
Informed consent is something else entirely.
The first and most important element of informed consent is:
… [D]isclosure by the [provider] to the patient of adequate clear information about the patient’s diagnosis; the alternatives available to treat the patient’s problem, including surgical and nonsurgical management; the benefits and risks of each alternative, including nonintervention … and a frank explanation of those factors about which the medical profession, and the individual [provider] in particular, are uncertain and cannot provide guarantees…
In other words, informed consent REQUIRES enumeration and disclosure of risks SPECIFIC to the individual patient’s diagnosis and proposed treatment.
Those are the three major ways in which homebirth midwives avoid obtaining informed consent for their services, but the real issue is not how, but why. The reason homebirth midwives are strenuously resisting informed consent requirements is that their financial success depends on HIDING the risks of homebirth. They are frightened to the core of informing patients of the risks of homebirth, because they know that the risks are real, substantial (particularly in the case of high risk situations), and frightening. Better to just hide them and wash their hands of all responsibility for the disasters that occur why they enjoy their birth junkie hobby.
The key to homebirth advocacy is NOT an informed patient. It’s a gullible patient who doesn’t know the real risks, but has been flattered into thinking that she is “informed.”
