Patient safety, disciplinary action, and the marginalization of midwives

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

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 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 such a collaborative effort might look like. The Institute for Healthcare Improvement is sponsoring a webinar on April 8 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 analysisplease 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.

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  1. | #1

    Remember the story that GMA did last fall – “The Perils of Homebirth” – which accused the famous NY midwife of basically killing a couple’s baby? What is shocking and appalling is that nowhere in that article/segment did they mention that babies ALSO die in hospitals, and from the best evidence we have, babies die JUST AS MUCH in hospitals as they do at home. So why crucify the midwife? Ignorance, mistrust, sexism, drama, sensationalism… etc. etc. Now, maybe she was negligent – who’s to say – but certainly the stupid GMA didn’t find out the facts before tarnishing her name.

  2. | #2

    Once one of the doctors involved in the non-pregnant cesarean came forward with a crucial piece of the story that was not initially reported—that the induction was begun for an IUFD—the story became less about maternity care and more the tale of a tragic medical error that involved a whole lot of people caring for a woman that they thought had lost a baby.

    While “wrong leg” surgeries that go public always seem to garner shock and awe, unnecessary cesarean sections that happen everyday just seem to get rationalized away as a process alternative, with women being told to just be grateful, stop being selfish and not try to focus on some perceived “metaphysical” experience they’ve heard about that comes with a vaginal birth. Can you imagine shaming the poor woman in North Carolina who went through an unnecessary three day induction and followed by surgery for her situation? People have already blamed her for being conniving and deliberate in her effort to defraud the hospital into inducing her.

    I appreciate your perspective as a midwife in pointing out the politics of blame when it comes to midwives and doctors. Very interesting point of view.

  3. | #3

    I don’t see how a case of malpractice by two individual physicians justifies the licensing of grossly undereducated and grossly undertrained American direct entry midwives.

    Please explain why we should licensing a second, inferior class of midwife (in addition to highly trained certified nurse midwives) when no other country has a second, inferior class of midwife. Please explain why we should licensing midwives who do not meet the education or training requirements of ANY country in the industrialized world.

    In every other country in the first world, midwifery is a university degree or a masters degree. In contrast, the American direct entry midwifery credentials are post high school certificates.

    As regards malpractice, I’m curious to find out why you failed to mention that American direct entry midwives have a neonatal mortality rate that is triple that of hospital based nurse midwives. I wonder why you failed to express concern, let alone outrage, over the fact that Colorado licensed direct entry midwives have an appalling perinatal mortality rate of 8.6 per 1000 (7 deaths out of only 806 births), higher than the perinatal mortality rate for all Colorado deliveries including high risk and premature babies.

    Direct entry midwives do not keep women and babies safe. They lack the education and training that ALL other first world countries (including The Netherlands, the United Kingdom, Canada and Australia) deem necessary to keep women and babies safe. Instead of crying “persecution,” homebirth advocates should be working to improve the education and training of American direct entry midwives.

  4. avatar
    | #4

    I can’t help but be snarky…it’s too delicious:

    To quote Amy:

    “Please explain why we should licensing[sic] a second…” and followed by “Please explain why we should licensing[sic] midwives”

    Explain why? Um…perhaps it’s because there are MDs like you out there who appear to be as “grossly undereducated and grossly undertrained” as you appear to be.

  5. | #5

    @Amy Tuteur, MD
    I didn’t say anything about who we should license. This post is about figuring out the qualities of a system that reliably delivers safe care. I would agree with you that in the United States, all home birth midwives do not *reliably* deliver safe care, but many home birth midwives do, and the root cause of the bad outcomes we do see in home births should be analyzed. It is certainly possible that educational standards may play a role. Client selection may play a role. And hospital practices occurring after transfer may play a role. Since research from other countries shows that home birth *can* be safe, we should strive to ensure that it is as safe as it can be here in this country. Reflexively assuming that every bad outcome that happens is the midwife’s fault is unlikely to lead to better outcomes. Threatening midwives with prosecution for appropriately transferring a woman or baby or administering a lifesaving medication is certain to lead to poor outcomes.

  6. avatar
    | #6

    Regarding direct entry or professional midwives as ‘inferior’ with horrific neonatal mortality rates….

    Please refer to the founder of modern midwifery, Ina May Gaskin, CPM. The Farm Midwives are meticulous and transparent with their birth statistics which are as follows:

    Outcomes of 2,028 Pregnancies (1970-2000)
    Births completed at home 95.1%
    Cesarean section rate 1.4% (about 30% below the national average)
    Neonatal mortality rate (excluding lethal fetal anomalies) 8/2028 births or 0.39%

    Please get your facts straight before jumping to conclusions and perpetuating the fear mongering of women . Home birth with direct entry midwives is as safe or safer than hospital birth when the mother is low risk. With the U.S. maternal mortality rate at an abysmal 28th out of industrialized nations, we should not be chastising other professions, but working together to improve maternal and neonatal mortality.

  7. avatar
    Momma of 6
    | #7

    Unsafe. At least I have a choice. 5 out of 6 of my children born at home with one of those scary certified professional midwives and I never felt safer or healthier. If you enter doctor land, ie the hospital, you lose choice or have to endure WW3 just to have your baby without all the non needed “life saving” action cooked up by a poorly trained biased MD. TRained doctor= lousy care, no assistance to actually be healthy while pregnant other than tests. Hospital= mostly stuck in the dark ages of the 40’s and 50’s for archaic routines. Lay midwife= personal face time, detailed questioning of nutritional habits and how to minimize stress, lots of information about how your body works and how to keep it working well during pregnancy & labor, minor monitoring during labor and delivery because ‘gasp’ a woman’s body generally knows what it is doing but also stepping it up a notch when the signs point to something dangerous and dialing 911 for an ambulance(danger averted didn’t need to call after all). How if the world did the human race survive before doctors and “education”?

  8. | #8

    “Please refer to the founder of modern midwifery, Ina May Gaskin, CPM. The Farm Midwives are meticulous and transparent with their birth statistics which are as follows:”

    Actually, The Farm statistics are horrible. In the only published study on The Farm (Durand, 1992) the perinatal mortality rate was an appalling 10/1000, more than twice the national rate for low risk pregnancies at the time. Durand hid that disturbing fact by comparing homebirth at The Farm to a mortality survey of high risk pregnancies.

  9. | #9

    Dr. Tuteur, I am a direct entry midwife. I started attending home births in 1979 and have attended approximately 2200 births. These births include nearly 200 VBAC’s, dozens of breech births, dozens of babies who weigh more than 11 lbs (largest was 12 lbs. 4 oz.), and 12 sets of twins. I have had 2 full term stillbirths (one was a fetal demise days before delivery and the other had a heart defect…autopsy confirmed…who died during delivery without any warning signs, one moment heart is beating normally without any signs of distress and 2 minutes later no heart beat of any kind) and 4 babies who have died within days of birth due to birth defects [2], intrauterine sepsis [1] or unknown causes [1]), and one baby who I transferred to the hospital because of poor breathing who developed hospital caused problems and died several years later [I will include this baby in my total even though home birth and midwife had nothing to do with this death], for a total of 7 deaths out of 2200 births. That would make my personal infant mortality rate at about 2.5 per 1000 births…about 1/3 the national infant mortality rate.

    My transport rate is between 1-2%, the vast majority of those transports are for failure to progress in labor and nearly all of those women have had a cesarean section, for a cesarean section rate of less than 2%. I have never had a woman die or suffer any kind of permanent damage due to pregnancy or childbirth. You might also be interested in knowing that I have done all these births without ever carrying or using pitocin or IV’s and some of these births were in communities that are 60 miles or more away from any medical help.

    I do not think I am anything special, particularly lucky or unique. I think I am a serious, watchful, self educating (I don’t use the word educated because I don’t think my education is finished quite yet) and caring woman. I took my apprenticeship of 3 years very serious and I learned everything I could find about pregnancy, labor, delivery and newborn care. I only accepted my own pregnant clients after I had attended/assisted at 140 births and had attended hundreds of prenatal examinations. I have come to expect normal and when abnormal rears its ugly head the mother, her family and I make decisions about how to proceed. I make it very clear to women at the beginning that this is their pregnancies and the final decision making is in their hands.

    Many people, mostly doctors, think that I am either lying or my results are due to taking on only the crème de la crème of the pregnancy crop. To this I laugh! Many of the women I take care of are poor, have horrible nutrition, some with mental and physical issues that don’t make them “high risk” but certainly wouldn’t make them low risk. In my early years of midwifery I had many cigarette smokers, some drug users, and some women in such emotionally disruptive situations that when I left their homes after the birth I wondered if any of them would survive for long. At one of these births the estranged father of the baby showed up with a gun demanding to see the birth and the teenage son and he came to verbal blows. I asked the man to please leave and he did, I caught that baby and got the heck out of that neighborhood ASAP!! I have had women with high blood pressure, a couple with pre-eclampsia, and a host of other situations where I would have felt best to transfer a woman to a doctor/hospital but the woman has refused. Only once did I pack up my bags and leave a home because the husband refused to take the woman to the hospital after she had been pushing for several hours without any progress. He got the message, took her in and she and the baby were fine.

    I also laughed when you said that direct entry midwifes where inferior and redundant since we already have CNM’s. Direct entry midwives preceded CNM’s by a few thousand years in all countries of the world. Other countries didn’t eliminate direct midwives and then develop a new kind of midwife but they took the midwives they already had and improved them. The US medical community used a serious smear campaign starting in the 1950’s to all but kill midwifery and then when women protested, the CNM was developed to “appease” the women who demanded midwives remain a choice. But, the new CNM that was offered to women where little more than junior doctors and physician extenders, they are technically nurses, only working under a doctor’s auspices and at the mercy of what the hospitals and doctors “allowed” them to do. If you want to look at other countries then you need to also look at how their licensed midwives are independent practitioners and how in some countries midwives are a woman’s first contact and are only referred to a doctor IF the midwife thinks it’s necessary.

    And, if you think that CMN’s are the answer then you need to open your eyes and look around you. You would see communities such as mine where there is a population of nearly 2 million people without a single hospital that allows CNM’s to handle childbirth; a community that doesn’t have a single freestanding or hospital connected birthing center; a community with a cesarean section rate nearly 40%. In our state as in the majority of states, a CNM is regulated by the state nursing board and hey are pretty much treated like any other nurse in that state, unable to do anything without a doctor taking full responsibility. If, as you stated, these CNM’s are so educated and capable, then why are they still treated as underlings of the birthing community? Why are they not allowed to practice midwifery as they see fit? Why are they not allowed to make serious pregnancy and delivery decisions and only call in physicians when they feel it’s appropriate? Why are they not allowed to do procedures that they feel skilled in, such as vaginal breech deliveries, even though the doctors they work with are not skilled with or comfortable doing? Why are they NURSES first and then midwives?

    I am sorry Dr. Tutuer if midwifery isn’t your cup of tea, but frankly me and the thousands of women just like me really don’t care what you and your kind think. I will continue to provide midwifery care until I feel I am no longer able and I will continue to fight for the right to choose home birth and midwifery care until I die. I will continue to train new midwives to take over when I am gone. And most of all I will educate women about pregnancy and childbirth so that at least the women I care for will no longer allow themselves to be bullied into thinking that the only way to have a safe pregnancy is to treat it like a disease with hospitals and doctors hovering over them to “protect” them and their babies from the horrors of it all.

  10. avatar
    | #10

    Choice – It should be about choice. If women choose to have their babies at home, they should be attended by providers who are trained to provide care at home. Nurse-midwives are wonderful, however although they can, and sometimes do attend home births, their training is not specific to it.
    Most of them cannot afford to attend homebirth and still pay off the student loans they needed in order to obtain that post-graduate education.

    I am a midwife who has practiced in a licensed state. I currently live (not practicing) in an illegal state. In my licensed state, let me tell you some of the things a midwife can do that make homebirth more safe. Order prenatal labwork and ultrasounds as needed. Request records of prior care. Consult openly with an M.D. as needed. Consult during labor as needed. Call an ambulance without fear of prosecution. Admit a baby directly to the NICU without an unnecessary and possibly dangerous admission through the ER. Administer lifesaving antihemorrhagic drugs. Administer medical oxygen. Do labs for Rh negative women and administer RhoGam if needed. File a birth certificate for the baby.

    In the state I am living in right now a midwife cannot do any of these things legally. There is NO WAY that licensing CPM’s makes homebirth less safe. The CPM credential is competency based, it is not based on a particular educational model. As a mother who home-schooled her three children, I tease my daughter, who is working on her M.A. that she might be the only librarian ever who doesn’t have a high school diploma. It is a piece of paper, not a measure of her education.

    This is a free country, and Dr. Amy can be as bothered as she likes about it, but she will not stop women from having their babies at home. I think she would save more lives by starting a campaign to feed children healthy foods in public schools. We have to keep the numbers in perspective here.

  11. | #11

    “I do not think I am anything special, particularly lucky or unique.”

    You’re none of the above. You, like most direct entry midwives have a neonatal death that is double that of CNM hospital births, and you don’t even realize it.

    With 2200 births, you should expect no maternal deaths (since maternal deaths are measured per 100,000) and it is entirely possible to have no neonatal deaths since the expected neonatal death rate for low risk deliveries is less than 0.4/1000. Instead you’ve had 2 neonatal deaths (sepsis and unknown cause) for a neonatal death rate of 0.9/1000; that’s double the neonatal death rate for CNM attended hospital birth.

    You’ve demonstrated what I have pointed out; direct entry midwives have higher rates of neonatal death than expected in low risk pregnancies.

  12. avatar
    Momma of 6
    | #12

    @Margie Dacko, Midwife
    Don’t let the birth haters or trolls get to you.

  13. avatar
    | #13

    I can’t help but notice that this article is about marginalizing midwives….and Dr. Amy steps in for the kill. Sometimes it’s not about the rate of neonatal dealths or even the percentage of cesarean sections. Sometimes it’s about chosing a provider that cares enough to empower you to make your own decisions rather than just belittling you into chosing their way by pulling out facts that often have nothing to do with quality of care. Dr. Amy has helped demonstate what we’ve been pointing out all along…and she probably doesn’t even realize it : )

  14. | #14

    Margie, that was wonderful! *clap clap clap*

    Amy, thanks for this post. I wish I had made a comment last night when I read it for the first time, but I needed some time to process it. I still don’t know if I can articulate a good thought, but I’ll try.

    This is why I left midwifery and went to medical school. I was training with a direct entry midwife. She was being investigated for delivering an IUFD. It was a known IUFD. The father of the pregnant patient was a practicing ob/gyn in another state. He sat in on an ultrasound, and talked with his daughter about inducing at a hospital or waiting to go into labor and going ahead with a delivery at the birth center. She wanted to deliver naturally at the birth center, and did with his support, blessing, and presence.

    The problem came when the midwife needed someone to sign the death certificate. She called around to physicians and the medical examiner, and one of them called in a complaint to the health department.

    Apparently, state law requires that a midwife in Florida only participate in the delivery of what should be a healthy, uncomplicated labor and delivery of a healthy, normal baby. Although there was no question as to whether the prenatal care was adequate or if the IUFD could have been avoided, she is still being investigated four years later.

    Yes, their constant probing has uncovered disgruntled former employees with dirt to dish, irregularities of paperwork, and the like. But, as my medical jurisprudence professor taught us, anyone can be busted for paperwork or charting errors. Anyone. They will find a technical error. It doesn’t matter what the complaint is about, they will pull years worth of charts (like they did with her – 5 years worth) and pore over them to find any charting error.

    She has had to continue to try to run a birth center with all of her charts missing, various inspections and raids, and scrutiny of her past patients and anyone who has ever worked with her. All for delivering a known IUFD with compassion the way the patient wanted it to be, with no complications.

    There are a lot of reasons why I decided to go to medical school. I had planned on it before midwifery school, actually. But, this was the event that led me to leave midwifery, especially direct entry midwifery, and go to medical school. I did not want the scrutiny, the bizarre overregulation, (at least in Florida – mandatory transfer of any postpartum patient with total blood loss of more than 500cc, for example), the lack of respect, or the hostility from the mainstream obstetrical community. I didn’t want to sit there with an impending investigation for what I would consider good care, going over five years of charts, terrified that I made a mistake, tempted to go back and “fix” items here and there on charts of uncomplicated, healthy, successful deliveries, to make sure that there were no holes or oversights that would cause me to lose my license.

    I figured I could go into medicine and get away with a helluva lot more. I am not going to jump on a physician bashing bandwagon or anything – I respect many, many obstetricians and other physicians, and think that it is a wonderful field, or I wouldn’t be joining it. That being said, after being to a lot of hospital births, either as transfers from our center or as a doula or friend of the patient, I saw just how unsupervised and unscrutinized a private obstetrician with hospital attending rights can be. As long as you are not violating a major policy, like allowing trial of labor for VBAC *eye roll*, or letting patients and fetuses die, or majorly abusing the staff, there is an awful lot of pure, unadulterated autonomy. For all of the malpractice complaints, obstetricians should be happy that their practice patterns and standards of care just have to meet a bare minimum (baby comes out) to not get investigated by the licensing board. If every doctor I know who didn’t give informed consent before an episiotomy, (much less did one as a routine practice!) or had more than 500cc of blood loss without calling in a specialist had to worry about losing their license, it would be a very different atmosphere. Not that I think that is the answer. I just didn’t want to live with that spectre looming over me. I took the malpractice boogeyman instead. (which midwives still have to deal with, too.)

    I completely agree with Amy. Punitive measures aren’t the answer. I am not asking to have these obstetricians run out of town, tarred and feathered. I think the whole system needs to be examined, focusing on the needs of the pregnant women, first.

    That means recognizing and treating mental illness without doing an unnecessary induction and surgery, and then blaming and ridiculing her afterward. No sane woman goes through a two day induction and cesarean without being pregnant. Sane women who are pregnant want to avoid that! That means not investigating their practitioner for delivering their IUFD in an environment that was safe and good enough for a live fetus. That means allowing near miss reviews and apologies from physicians without placing them in legal jeopardy. That means not pitting obstetricians and midwives on opposing sides of a battle, where it seems women and babies are the ones caught in the crossfire.

  15. avatar
    | #15

    Amy –

    Amen, sister!

  16. | #16

    I’ve read all the posts. I’ve been working with women, their families and helping with birth since 1974. I’m a mother, sister, daughter, wife, Lamaze educator, Lamaze faculty, doula, assistant midwife and RN (BSN if you need to know).

    Can’t we all just get along? Can’t we all remember why we are in the “business of birthing babies” in the first place? Don’t we all want the best for the woman and her child(ren) and family? Isn’t that what is best for all of us? Anyone going into the arena of birth certainly doesn’t do it because the hours are good and your life can be scheduled!

    Shit happens at the best of times. And blessed events happen, too. And Birth is on the spectrum of life which also includes Death. Why are people surprised that things like this occur? and what is the point of assigning blame?

    It makes me want to cry, in fact I am now, listening to the continued divisiveness that has been going on for as long as I can remember, certainly for two hundred years if not more. Read Martha Ballard’s diary. She, at least, was respected in her time. Why cannot midwives have the respect of, and a role in, their communities in this day and age? Why does one profession need to pit itself against another?

    I’m not stupid-very idealistic maybe, even as I approach my 59th year on this planet. I know the answers to these questions that I ask as they can be, and are, answered in this day and age.

    What I am hoping, REALLY hoping, is that we, as a nation beginning to look at how health care has been delivered (BADLY) for the past century, can begin to put humane practices in place that provide good care for everybody. Beginning with Birth, for where else do we start? I have a son and a daughter and hopefully, one day, grandchildren. I want the best for them. Doesn’t everyone want that for their own?

    Please, Please, can we just stop pointing fingers at each other and take those first steps in working together for the common good? I will never, ever, stop asking for that.

    Thanks for listening.

  17. avatar
    AJ C.
    | #17

    Amen Margie! Your comment was inspiring! Keep up the good work.

    I am the mother of 2 and have been delivered by both an OB and Midwife. I will NEVER leave my care to an OB again and will educate my daughters to do the same unless major changes are made in US maternity care.

    Mom TFH thank you for your post. I’m sure many women would feel differently about using an OB with your perspective and midwifery background.

    It’s disappointing how differently midwives and doctors are treated if their is any question about how they handled a patients care. Its extremely unfair, I know from seeing one of my own, beloved CNM’s was treated recently, here in Omaha.

  18. | #18

    I hope they did a root cause analysis too. I also wish it was made public, similar to how England handles their maternal mortality outcomes. But I also worry about the standardization of care that can occur. My hosptial just recently responded to the increase of thrombosis complications with pregnancy/labor and immediately postpartum, with the plan that anyone admitted in labor with moderate risk (an increased BMI plus one more risk factor) should have TED stockings and venodynes on, so much for ambulation in labor! What about decreasing the C-section rate instead? Oh well, the simplist answer just seems too easy doesnt it?

  19. avatar
    | #19

    @Amy Tuteur, MD

    @ Amy Tuteur: but her stats aren’t on low-risk births. So you’re wrong, and you probably do realize it.

    Get some help, angry doc.

  20. avatar
    | #20

    I agree with Kris Avery- it is so unfortunate there is a war between obstetrics and midwifery. Imagine a healthcare system where an ob/gyn could have faith in a midwife’s work, and a midwife could freely practise with the support of her local medical community, and know that if she needs to refer a client, that can all happen smoothly and professionally. And if there was a need for them to collaborate in providing care, they wouldn’t feel competitive, and maybe they could debrief together over a cup of tea…
    And here’s the kicker- in this scenario, women might also be able to feel that they received the best care possible, and the mental health of our new families would be improved also.
    Idealistic, maybe, but really I think this is a possibility (where there’s life there’s hope), and if everyone could stop slinging mud at each other we might be able to get started.
    So who’s first?

  21. | #21

    @AJ C.
    You’re welcome, AJ C. I am going to be one of those “midwives in disguise”.

  22. | #22

    “it is so unfortunate there is a war between obstetrics and midwifery”

    There is no war between obstetrics and midwifery.

    Homebirth advocates like to muddy the waters by pretending that direct entry midwives, with their self-conferred post high school certificates, are representative of midwifery. They are not; they represent only a tiny fraction of practicing midwives.

    Homebirth advocates also like to pretend that homebirth represents a significant proportion of births. They are only a tiny fraction of US births.

    Across the US, doctors and CNMs collaborate on caring for tens of thousands of women each and every day. There is no war on midwifery. There’s only a campaign against direct entry midwives and their practices, which fail to meet the standards of midwives in ANY other country in the industrialized world.

    An American CPM would not be allowed to practice in The Netherlands, the UK, Australia or Canada. Are those countries conducting a “war” on midwifery? If they won’t allow the practice of direct entry midwives, considering them undereducated and undertrained, why should the US allow it?

    Canada recently barred the practice of direct entry midwives, mandating that they must obtain more education and training to be licensed. Why shouldn’t we demand the same?

  23. | #23

    @Momma of 6
    Dr Amy Tuteur – I would like to say – contry to your statement – I am a fully registered midwife in the UK practising as a homebirth midwife employed directly by women and also under the health system of the UK – I am direct entry and I do not hold a degree – where do you get your facts from?

  24. avatar
    | #24

    “Direct entry” means entering directly into midwifery studies without first being licensed as a nurse. Nursing and midwifery are two distinct professions and there is no reason to require midwives to first be licensed as nurses. In fact the American College of Nurse Midwives offers a direct entry credential, the Certified Midwife. Midwives throughout Canada and Europe are direct entry midwives.
    True midwifery is an autonomous profession. While CNMs in the United States are a valuable part of maternity care, and I wish they were more prevalent considering the difficulty in accessing midwifery care here, they are not autonomous practitioners, and are subject to the oversight and authority of physicians. This is not the type of care offered by midwives in other parts of the industrialized world.
    What other countries have is not a different *type* of midwife than the direct entry midwives who in this country are credentialed as CPMs, but a different, more formalized, university-based system of education for direct entry midwives. Many aspiring midwives in the United States would love to be educated in this way, but because of the supression and virtual elimination of direct entry midwifery, such an option is largely inaccessible.
    Since it is impossible to believe that Dr. Tuteur is not aware of the meaning of “direct entry” midwifery, one must conclude that she is being purposely misleading in declaring that other industrialized nations disallow direct entry midwives. This declaration is untrue and disingenuous.

  25. | #25

    “What other countries have is not a different *type* of midwife than the direct entry midwives who in this country are credentialed as CPMs, but a different, more formalized, university-based system of education for direct entry midwives.”

    In other words, “direct entry” means something different in the US than in other countries, just as I pointed out. CPMs lack the education and training of ALL other midwives in the industrialized world. It is disingenuous to pretend that they are representative of midwifery when they would be considered undereducated and undertrained in ANY first world country.

    That lack of education and training is reflected in neonatal mortality rates nearly triple that of CNMs. Indeed, MANA, the trade union for CPMs, won’t even release the safety statistics they’ve collected over the last decade. What are they hiding and how can they ethically justify hiding the truth?

  26. | #26

    @Amy Tuteur, MD
    Dr. Amy, I will believe the Lancet over you, sorry. Feel free to post any evidence that midwifery is well supported by the obstetrics community to contradict the expert opinions offered.

  27. avatar
    | #27

    I would challenge Tuteur to put up her own OB stats here, if I thought she’d be honest about it.

    But it really doesn’t matter, because she’s fighting a losing battle, and *she and those like her will lose.* Women will have our choice, we will have good evidence-based care, we will break the stranglehold of those like her who care more about power and control than about their patients, and we will have access to midwives, whether she likes it or not. We know it is possible; it’s only a matter of time before we make it happen.

    Keep scolding us and trying to derail us, Tuteur, if it makes you feel better. It won’t change the outcome.

  28. | #28

    People have already blamed her for being conniving and deliberate in her effort to defraud the hospital into inducing her.

    Not conniving, delusional. Its not her fault that she was delusional, but that doesn’t make it not so. Women in some delusional conditions do present themselves as pregnant, and often are quite convincing. The docs were negligent to not follow proper protocol in this case, and these errors led to a very bad mistake in their practice.

  29. avatar
    | #29

    “In other words, “direct entry” means something different in the US than in other countries, just as I pointed out.”

    It actually doesn’t mean something different. The fact that persecution from the obstetrical community has made it difficult for women to access the kind of midwifery education they would recieve in other countries does not justify continuing to deny childbearing women access to these types of midwives. We should be seeking to improve education of and access to direct entry midwives, not declaring them an invalid type of birth attendant. The fact that the prevailing system denies direct entry midwives a recognized, integrated role in maternity care is the *cause* of the difficulty in obtaining a standarized, formalized program of education in direct entry midwifery. The obstetrics community is itself to blame for refusing to acknowlege a non-nurse, autonomous class of midwife as a valid type of birth attendant, and that refusal is what makes it difficult or impossible for direct-entry midwives in this country to obtain the exact kind of training midwives get in other countries. However, most graduates of MEAC-accredited programs would be eligible to practice in British Columbia, for example, after an evaluation process similar to what most health care professionals must undergo to practice independently in a country other than the one they trained in. Three months to a year of supervised practice is sufficient to bring these midwives up to speed in a system that actually includes hospital practice, while CNMs and CMs usually require two to six months of supervised practice, meaning that while most CNMs qualify faster than most CPMs, some CPMs can qualify to practice in British Columbia faster than some CNMs. That says to me that a lot of direct entry education programs are actually doing a pretty good job relative to the standards both of other countries, and of CNM programs here, especially considering the efforts of the obstetrics community to marginalize and suppress the direct entry type of midwifery.

  30. | #30

    I just typed a long comment that got lost and I can’t imagine typing it all again, so here it is in short.

    The numbers for neonatal death for homebirth with midwives are arguable, but in my opinion homebirth is associated with a higher rate of fetal death. Given the various reasons that a baby would die, that’s just not hard for me to believe. A number of the deaths reported by Ms. Ms. Dacko certainly sound like they may have been prevented, particularly the deaths associated with heart defects, which diagnosed antenatally would typically not lead to a fetal death.

    That being said, the attributable risk to home birth / midwifery is very small, and for people that choose homebirth there are lots of benefits that they may want to trade that small risk for, not least of which is a substantially decreased rate of cesarean delivery. There are also potential non-measurable benefits to women, that only they can measure the importance of.

    It is a shame that midwives are under attack. Many lay/direct-entry midwives are quite experienced. I know some that are very experienced, and I often have very thoughtful discussions with them about all kinds of topics in obstetrics, and have rarely found their knowledge lacking. In fact, I have learned quite a few things from them over time. That being said, I also have had experience with a few midwives that really didn’t seem to have the knowledge base to practice safely, and they didn’t seem to know what they didn’t know. They did dangerous things, didn’t transport appropriately, and often failed to diagnose significant complications. These folks are not so well respected in the community I used to be in, including by the more respected midwives in the community. In fact, I’d say they get more scorn from the better midwives than from anybody else.

    But as I would hope that people did not paint physicians with a broad brush based on the actions of a few people, midwives shouldn’t be either.

    Windy Acres >> Choice – It should be about choice. If women choose to have their babies at home, they should be attended by providers who are trained to provide care at home.

    YES. Ultimately patients should decide. The risks are small either way, and to get the benefit of hospital birth you have to accept a higher cesarean rate, which has its own risks. People should do what they are comfortable with.

  31. avatar
    | #31

    The family who lost their baby are friends of mine:
    Here are some facts that seem to constantly be overlooked/not brought to the fore-
    It was the TODAY SHOW not GMA.
    The writing has been on the wall about Cara Mulhahn (sp.) for years
    There is another complaint against her pending with the NY dept. Of Professions- this makes TWO- (when is enough enough?)
    She uses her WPA in a hit or miss fashion, and this was an avoidable midwifery/medical error which her practice and she are responsible for
    She has settled ANOTYHER personal lawsuit ($950,000) where she was found negligent
    The NY midwifery Guild and Cara were invited to respond and CHOSE not to-
    The ACNM STILL has her on their web page all glitzed out- promoting her despite the fact that she is fairly questionable in her practices-
    A BABY DIED. No one seems to connect to that. A baby died, someone is responsible and all those involved are being held accountable according to the LAWS of NY and the ethics of her profession.

    Most, if not all of these are matters of public record at this point.

  32. avatar
    | #32

    Thank you AGAIN Dr. Fogelson: (seriously)
    This is the tone we need for a dialogue to begin about how we fix this mess.

    “It is a shame that midwives are under attack. Many lay/direct-entry midwives are quite experienced. I know some that are very experienced, and I often have very thoughtful discussions with them about all kinds of topics in obstetrics, and have rarely found their knowledge lacking. In fact, I have learned quite a few things from them over time. That being said, I also have had experience with a few midwives that really didn’t seem to have the knowledge base to practice safely, and they didn’t seem to know what they didn’t know. They did dangerous things, didn’t transport appropriately, and often failed to diagnose significant complications. These folks are not so well respected in the community I used to be in, including by the more respected midwives in the community. In fact, I’d say they get more scorn from the better midwives than from anybody else.”

    I feel the collective “we” those interested in birth matters- generally speaking are getting into a tail wags dog argument about homebirth. I am constantly astounded when I see CONSUMERS insist that home birth midwives do not NEED a standard credential, regulation and statutes. I have seen this by and large that they are concerned about their midwives being unable to practice in a fashion that they want- if they are regulated- it is a perplexing case of and I doubt I am using it 100% correctly but- parens patriae-applies here. I feel like such a conservative for saying so- but after hearing of the behavior of a *SMALL* number of DEMS (most stats. Although elusive are that only 1-4% of people choose home birth- so we are talking about a very small pool of people- and I know the stats. Are willy-nilly) in some states and some are by and large worse than others- I feel like the only way to stop this tide of substandard home birth midwifery is to agree on a credential that is acceptable- The CPM is an acceptable educational standard in over 27 states, create regulations that define the scope of practice and FORCE PHYSICIANS TO COLLABORATE. It is the last house on the left. People will continue to have homebirths, we need to have babies and mothers safe from egregious practice, not regulating health care opens the door top egregious practice.I have very wonderfully debated this with my OBs and I think we have reached a middle ground. I understand that he believes obstetricians should deliver care to mothers and babies. (I don’t know his take on CNMs- just DEMs, not CPMs)- However, ACOG delegates and members digging in heels opposing legislation as a lobbying group and actively undoing efforts of CONSUMERS to regulate midwifery again- tail wags dog. Want to end bad practice? Regulate it. Do you want to work with mothers and babies? Get educated. The days of the self trained, oppressed profession midwife are as far as I am concerned in the wind, and no longer appropriate. (and I consider many amongst my mentors and friends- even they agree.)
    Insofar as midwives who serve the Mennonite/religious community- for every ethical, well trained, and CREDENTIALED provider of care to religious communities- there are wing nuts who lose babies knowing that they can use the God’s will argument to somehow gloss over their tragic errors in judgment. In my State we had two families lose babies at homebirths, two non CPM midwives, two religious midwives (One Christian Scientist- one Muslim midwife), and a vacuum of legislation.

    Conversely on your point Dr. Fogelson- there are many bad health care professionals in all aspects of health care. Here is a silly case in point, I saw on some national news program a bunch of nurses were fired for being trashy about their hospital on a facebook page, but these docs in the non-pregnancy c-section were given letters of concern-. Hmmmmm.
    I don’t mean that as a statement to make a doctor bristle with antagonism. I have six doctors right now who I am so confident in and I feel so well cared for- I need medicine to get to the finish line, midwifery is not an option for my high risk pregnancy. Other women might assume the risk I will not. There is a huge difference between midwifery and medicine. I say this a lot- this is at the core of reform to me- looking at best practices and why as a nation we are unable to adhere to them in ALL medical specialties. I feel like I understand the polarized nature of birth matters at this current time. It is because we are in a nadir. I don’t first and foremost blame doctors- and midwives. I blame $$$$ which when you follow it is always driving the bus of bad practices.

    I am also certain in the time that it took me to write this post- several hundred people in America were privy to a medical error of some kind whether in “maternal health” via a doc or midwife, or other doctor in another specialty- medicine is not magic, nor is midwifery.

  33. | #33

    @Nicholas Fogelson

    The situation was discussed on many forums all over the internet. Some who didn’t understand that women with false pregnancies actually believe they are pregnant which is reinforced by physical changes in their bodies. As you know, with weight gain and cessation of menstruation, a woman who is not mentally ill might actually believe she was pregnant in the same vein as women who don’t realize until they give birth on their toilet that they have been pregnant for nine months.

    I’m not a fan of one comment section bleeding over into another. I’ll just say that my comment on this thread was not directed at you, as you were certainly not the only person on the internet to comment that this woman was tricking doctors with a faked pregnancy, okay?

  34. avatar
    | #34

    Oh hold up- I had to reread more astutely this thread- to point out one little irksome quality I find with doctors coming to regular people/patient advocacy discussions, I am hoping the first part of your post was not an “appeal to authority” because you are a doctor.:

    I have read so many varying statistics about the numbers for “neonatal death” and seath during home birth from so many different types of organizations representing a myriad of special interests- I really don’t think anyone in either community (medical or midwifery) has up to date or ACCURATE stats. about the actual rates. Even my doctor misquotes stillbirth rates per 1000 births that I read in other sources. He also referred to the Dutch system of home birth which I found fascinating because well- it’s the Dutch system- not our system-like comparing apples and bacon. (Bear in mind, I LIKE MY DOCs I am not a doc basher.)

    A lack of reporting accurate stats. punctuates the need for regulation, with regulation you can require stats. reporting by professionals.

  35. | #35

    OK – but you’re the one that brought that up in the first place. No worries anyway.

  36. | #36

    I really don’t think anyone in either community (medical or midwifery) has up to date or ACCURATE stats. about the actual rates.

    You are right of course – but we do have to work with the best stats we have, right?

    I have to wonder if there is any reporting bias in homebirth stats. It seems to me that there is a much greater opportunity for an adverse outcome to go unreported in a homebirth situation than in an in-hospital birth. Do any of the midwives have comment on this? What are the mechanisms to ensure that outcomes in homebirths are reported?

  37. avatar
    | #37

    @Nicholas Fogelson
    Dr. Fogelson:

    I know we have to work with the stats. we have- agreed. I have growing concern (naturally) as stats. are cited pro and con that reasonably cannot be accurate that serve as “death knells” to these important pieces of legislation that serve to protect mothers and babies. Legislators are not statisticians, nor are the general public. We can always slant things as we see fit to craft our arguments pro and con.

    Again- a slam dunk to the regulation argument IMHO. Additionally- I am sure there is some massaging of the reporting in home birth stats., yet another compelling argument for regulation. I would also guess reporting errors abound in vital stats. on a state by state, locale by locale basis as well.

    I will email a midwife I have become acquainted with, who is in a state where all birth options are regulated and see if she will weigh in on how she reports her stats.

  38. avatar
    | #38

    CPM’s are more educated, trained AND experienced in normal, natural childbirth than any OB doc I’ve known. For normal, natural childbirth give me a midwife at home any day. If (and only if) I should require medical attention then I would be grateful for the expertise of an OB for truly abnormal circumstances or surgery – but only then. Dr. Amy discusses how in other first world countries they require college educated midwives. In Canada they did develop a college program for midwifery but it is NOT nursing based. Even nurses must go through the full midwifery course and they do not come out as CNM’s – they all come out equal and the same. Unfortunately the U.S. has not put the priority on midwifery to develop such midwifery based university programs. Also those countries Dr. Amy discussed (and as someone else mentioned) use midwifery as independent practitioners for primary care of pregnant and birthing women. Women only see the OB when necessary due to a true abnormality in their pregnancy or birth course. If Dr. Amy wishes for midwives to become “educated and trained” to how she feels would be “safe”, what is she doing to make sure that happens here in the U.S.? If she supports “safe” midwifery practitioners – is she ready to support primary autonomous midwifery care with OB’s being utilized only when a pregnancy becomes high risk and/or requires surgery? As an RN if I chose to go to midwifery school today I would personally choose to become a CPM and not a CNM. Nurses work under doctors – period. We take orders from doctors and are not seen as autonomous practitioners. My experience with CNM’s has been that their practices are dictated by physicians either directly or indirectly. If I were to choose midwifery – I would choose it to answer to the families not the doctors.

  39. | #39

    I totally agree. Root cause analysis, like all scientific approaches, can still be influenced by bias and medical model-context. That’s why we need more midwives and consumers involved in hospital committees – to bring a diversity of perspectives including the wellness/prevention/cost containment/common sense/patient centered perspective.

  40. | #40

    From the cases I’m aware of, I can’t see how deaths would go unreported. Typically, the baby would end up at the hospital because 911 would be called when either fetal distress or a precipitating event (cord prolapse, abruption, etc.) occurred or when the baby was born not breathing. Once the woman and/or baby are at the hospital, it would be hard to not report the death. Most of the time, the midwife goes through some sort of formal review or scrutiny, or just flat out gets arrested. The exception here might be antepartum fetal demises, which may get reported as planned hospital birth if the woman chooses to birth her baby in that setting after the death is diagnosed. But the potentially preventable cases in that group would have to do with prenatal care and decision-making, not planned places of birth.

    The stickier situation, in my opinion, would be the categorization of perinatal deaths as potentially preventable or not. Every death that occurs at home is presumed to be preventable by hospitalization, if not by those of us involved in this conversation, then certainly by the public and others in the maternity care field. Some of the deaths in planned home births certainly are preventable by earlier hospitalization – not necessarily routine hospitalization at the onset of labor, but maybe reducing delays in diagnosis, referral, transport, or acceptance of a referral, or by better care in the hospital after transfer. Ideally, close scrutiny (including disciplinary action, changes in policy/practice/training, etc.) should be reserved for those cases that might have been preventable. That goes for hospital births and home births alike. The results of the scrutiny should inform efforts to improve care, not just punish people.

  41. avatar
    | #41

    @Amy Romano

    “Typically, the baby would end up at the hospital because 911 would be called when either fetal distress or a precipitating event (cord prolapse, abruption, etc.) occurred or when the baby was born not breathing. Once the woman and/or baby are at the hospital, it would be hard to not report the death. Most of the time, the midwife goes through some sort of formal review or scrutiny, or just flat out gets arrested.”

    An unscrupulous or scrupulous but terrified midwife (I’m being nice here) can conceivably present at a hospital with a client in a sad state of affairs- and claim to be a doula. 911 can and may NEVER be called. Trust me when I tell you that is no accident on the part of lousy midwives. This practice is so egrgeious but does happen in ILLEGAL home birth states. There is no arrest-unless the state is bent on wasting the taxpayers’ dollars on mounting a trial rather than creating statutes and regulations designed to make home birth safer much more money and life saving in the long run.(I love to say it at the risk of being a broken record: Mothers and Babies collateral damage for bad policy!) A couple of states come to mind-the legislators and lobbyists are more inclined to hold onto the monopoly and deny public safety rather than protect mothers and babies it becomes clearer as new legislation is introduced gets a little footing toward making hb illegal and consumers push back. We must perservere! Some states dileneate the transport by private car for this reason in their statutes- for a non-emergency transport for this reason and dileneate when 911 MUST be called. If you are a midwife and you ignore that regulation- you are tempting silver handcuffs and justifiably so if you ask me. States that choose to keep home birth illegal at this point are just archaic- what they are saying to their constituents is: “your lives is not worth protecting.” I say this because despite all the foot stomping by opponents for home birth, people birth at home routinely- and it needs to be safe whether people object or not. I guess it’s keep your non-laws off my body…or some such.

    A midwife has to be an unbelievably ethical person to practice in a state where their literal freedom is at stake and STILL follow the “law” as if there will be a punitive action (loss of freedom/arrest/court trial/sanction/peer review etc.) I have been lambasted in the blogosphere for suggesting BTW that a peer review can be a very worthwhile and meaningful tool for sanction in illegal states. I figure once your peers know you’re inept you are more likely to be slowly ostracized.

    I have to say that docs refuse to discuss outcomes honestly and vilify home birth because it serves them- yeah, I know it’s like come on down from the choir loft. The mothers I know who lost babies at hopsitals had preventable, discernible and treatable conditions.Docs say by and large- we don’t know why this happened (hello autopsy)and this is priceless- my friend was told she just had “bad luck.” (nope, bad medicine.)The Moms I know by and large were the victims of bad insurance, poorly trained docs who withheld care b/c of really ridiculous reasons mostly hubris, or poor timing. Sometimes literally I want to “sick” them on docs who narrow their focus on the dangerous nature of home birth while refusing to acknowledge that no one can say they are 100% in the right. They would regret having 100 hospital birth/ob attended emotionally gut wrenching tales thrown in their faces.

    “Every death that occurs at home is presumed to be preventable by hospitalization, if not by those of us involved in this conversation, then certainly by the public and others in the maternity care field.”

    This is a great quote- and I just have to say- home birth deaths are not always preventable by hospitalization- but snowball’s chance in you know where getting people to be honest about it.I have seen first hand docs LIE in public about home birth transfers-and deaths and legislators take it in. There is one doc I love to publicly throw word daggers at for her dishonesty- b/c I know the family whose home birth death she lies about. She couldn’t have saved their baby either- no amount of medicine or midwifery could have- but she hauls it out when she needs it. Once in a while you have a doc who will put their foot so eloquently in their mouth and say something to the effect of- well we can’t always get to do an emergency c-section in time either- a rare admission but once in a while someone will break rank.

  42. avatar
    | #42

    oops a funny grammar gaffe-

    “your lives is not worth protecting.” (sounds so podunk.)

    should say:

    “your lives are not worth protecting.”

  43. | #43

    Amy Tuteur, MD :
    I don’t see how a case of malpractice by two individual physicians justifies the licensing of grossly undereducated and grossly undertrained American direct entry midwives.

    Wah-wah-wah. Same tune, same lyrics. Anything new to offer, Dr. Amy? No? I thought not. Once again, dodging the issue at hand.

  44. | #44

    SaanenMother…I think your first quote with the hick accent was good!

  45. avatar
    Sheryl Cronk
    | #45

    @Amy Tuteur, MD
    Dr. Tuteur wrote “Canada recently barred the practice of direct entry midwives, mandating that they must obtain more education and training to be licensed. Why shouldn’t we demand the same?”
    This comment has a date of April 6th, 2010 at 08:57.

    Today is April 9, 2010. I am a practising direct entry midwife in Ontario, Canada. I am a Registered Midwife, registered by the College of Midwives of Ontario. My practice has not been barred. My practice is legal by the laws of Ontario.

    The statement is completely false.

  46. avatar
    Laura Nyman
    | #46

    But the version I heard does make it sound like the woman came into the hospital asking for induction while knowing she wasn’t pregnant. What details am I missing?

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