In the spring of 1999, Donna Cromie-Nguyen first visited with midwife Debra O'Conner. Cromie-Nguyen, a credit manager for a pharmaceutical company, and her husband, Truc Nguyen, an electrical engineer, were expecting their first child. Cromie-Nguyen chose the care of a midwife because she was interested in a water birth, which wasn't possible at the hospital where she had planned to deliver. She thought a water birth would be peaceful, having seen a video of one, and planned to have O'Conner attend her delivery at the midwife-run Puget Sound Birth Center in Kirkland.
O'Conner came recommended by other midwives as the best, Cromie-Nguyen later recalled. In practice for nearly 30 years, O'Conner was once named Midwife of the Year by the Midwives Association of Washington and teaches childbirth classes at the Seattle Holistic Center and Bastyr University. Over the years, O'Conner has also become known as a staunch advocate of what she considers "true" midwifery: natural, woman-centered care, as she sees it, which stands in sharp contrast to the "interventionist" model of the medical establishment.
Cromie-Nguyen's pregnancy dragged on past her due date, which O'Conner had first estimated to be July 25. When that date came and went, O'Conner changed it to Aug. 6, consistent with Cromie-Nguyen's first-trimester ultrasound examination at a medical facility. After that date passed, too, Cromie-Nguyen began to worry. On Aug. 10, having been off work for more than two weeks while waiting for the baby, she met with O'Conner. But the baby still wasn't coming. Cromie-Nguyen asked O'Conner about the possibility of being induced. According to Cromie-Nguyen, O'Conner told her that if "the baby wasn't coming, the baby wasn't ready." She suggested a natural remedy for bringing on labor consisting of castor oil, vodka, and orange juice.
O'Conner also photocopied for Cromie-Nguyen a chapter on induction from the book The Thinking Woman's Guide to a Better Birth by Henci Goer, a well-known critic of conventional childbirth medicine. In the chapter "Mother Nature Knows Best," Goer discusses the practice by some doctors of routinely inducing at 41 or 42 weeks of pregnancy because of an increased risk of stillbirth that kicks in a couple of weeks past a woman's due date. "Very rarely, a normally formed baby suddenly dies in the womb," Goer writes. "If it happens after the mother's due date, it appears that a routine induction would have prevented the tragedy. However, hindsight doesn't take into account the risks of induction. Because of these risks, while a routine induction policy would save some babies, other babies and even mothers would be lost."
Cromie-Nguyen chose not to seek induction. More than two weeks later, when the baby still hadn't come and Cromie-Nguyen had felt what she described as a swooshing movement of the baby and a leak of fluid, she had an ultrasound and discovered that her baby had died in the womb.
Feeling that O'Conner was to blame for her baby's death, Cromie-Nguyen filed a complaint with the state Nursing Care Quality Assurance Commission, which oversees nurse midwives like O'Conner and is part of the state Department of Health. After investigation, the commission agreed that O'Conner's care was negligent. Its findings of fact stated, in a footnote, that it was not alleging that O'Conner caused the baby's death. But the commission noted that O'Conner gave Cromie-Nguyen literature discouraging induction and said that O'Conner had "created an unreasonable risk" by failing to consult a physician and to properly monitor for fetal well-being as Cromie-Nguyen's pregnancy reached a critical stage. Cromie-Nguyen's case, along with another stemming from complaints against O'Conner, led the Nursing Commission to apply some of the strictest restrictions it has ever levied. O'Conner is required to have supervision over a three-year period; for the first year, she is forbidden from practicing independently as a midwife and must have a supervisor present at all times in the room.
Midwife Debra O'Conner (lower right) as featured on the Seattle Holistic Center's Web site.
It was not the first time the commission had disciplined O'Conner. While she was treating Cromie-Nguyen, O'Conner was on probation from another sprawling investigation that resulted in a finding of unprofessional conduct relating to four other cases. Two of them involved babies who had died, although, again, the commission did not blame O'Conner for the deaths.
O'Conner is unbowed. She has fought the state at every turn and is appealing the latest restrictions in King County Superior Court. Judge Anthony Wartnik has yet to issue a ruling in the case. As fervent in her beliefs as her Christian missionary parents were in theirs, O'Conner is an elegant 50-year-old with dark hair falling to her shoulders and an intense focus that alternately bestows great warmth and outrage. She passionately argues that she provided appropriate care in all cases, if not care that conforms to conventional obstetric management. She believes she is being persecuted for following the midwifery model of care that caters to women who opt out of a medical model that they believe causes more harm than good.
"You know what, I'm going to always be different than they are," she says in one of a series of interviews, her voice rising with agitation after discussing the details of several cases for which she has been sanctioned. "You know why? Because the patient comes to me and I have a fiduciary duty to give them something different. They didn't come to me because I'm an obstetrician. They didn't come to me because I'm a nurse. They came to me because they wanted midwifery care. . . . They didn't want what they offer in the hospital. And until people start getting this through their thick brains . . . " She begins to enunciate each word slowly and sharply: "The women do not want what's being offered there."
"It's a big damn risk to walk in the hospital," she says in a later conversation. Almost 99 percent of births take place in a hospital in this country, yet the U.S. is only the 28th-lowest country in infant mortality. She attributes this dismal showing to interventions common in obstetric care like C-sections, epidural analgesia, and inductions, all of which, O'Conner believes, carry unacknowledged risks. "We're the worst of most industrialized nations, we're the fucking worst!" she exclaims. "So I have to find a way to buy out of that." O'Conner has found a way by practicing her noninterventionist philosophy in homes and birth centers, free, for the most part, of the domineering hands of doctors.
No One Standard of Care
In early February, O'Conner stood in a narrow hallway of the King County Courthouse, warmly greeting supporters who arrived to hear oral arguments in her case. Inside the courtroom, O'Conner's lawyer, William Bishin, reiterated to the judge, "We don't look at this as a case about negligence but as a conflict between two different ways of looking at the birth process."
During a break, I talked with some of O'Conner's supporters. Some were women who had delivered with O'Conner, acting as a midwife or, after the latest restrictions, as a "doula," providing labor support without being the primary care provider. A few had brought along their babies or young children. Lisa Port, who used O'Conner as a midwife for one baby and doula for the next, told me that Bishin's remarks had been "right on. The reason we chose her was because we wanted her standard, because of what she represented."
Also present were aspiring midwives who participated in a weekly study group with O'Conner. They planned to be lay midwives, according to one, because they didn't want the regulation that comes from state licensing. The state licenses two types of midwives. There are nurse midwives like O'Conner, who have been to nursing school and who tend—unlike O'Conner—to practice in hospitals. And there are those known merely as "licensed midwives," who complete an accredited midwifery program and almost always practice in homes or birth centers. Un-regulated lay midwives can legally practice as long as they don't advertise or charge a fee.
O'Conner served as a midwife for Lisa Port (above): "The reason we chose her was because we wanted her standard, because of what she represented."
The midwifery community, however, is far from united in support of O'Conner. In fact, one of the complaints that led to the latest investigation of O'Conner came from another midwife, Ann Darlington. She treated a patient of O'Conner's who needed to transfer to Group Health Hospital from a planned home birth. Another midwife, Fra Na Ready, wrote to the state in 1998 that she shared an office with O'Conner at the Northwest Hospital campus until O'Conner "was asked to leave in 1995" because she "pushed the limits of our practicing protocols," refusing, for example, to do diabetic screening.
"I feel she's trying to make this a midwifery issue, and a lot of this is a Debra issue," says Peggy Thurston, co-president of the state Midwives Association. "Debra O'Conner does not represent the standard of care in the greater Seattle area, and she does not represent the opinion of licensed midwives in the greater Seattle area," agrees Heike Doyle, a midwife who is an owner of the Puget Sound Birth Center. O'Conner, while not an owner or employee of the center, used to have "privileges" to deliver there, much like doctors have privileges at hospitals. After the latest state investigation, the center revoked those privileges. "We do not want her practicing out of the Puget Sound Birth Center—and that includes working as a doula," Doyle says. Unwilling to elaborate, Doyle says simply: "We believe in a different standard of care."
At the same time, some midwifery advocates who don't necessarily support O'Conner say they agree with aspects of her case. "I think Debra raises some important issues," says Jo Anne Myers-Ciecko, the former executive director of the Seattle Midwifery School and a nationally known figure in midwifery. One, she says, is the question of who regulates midwifery. O'Conner argues that she has not been judged by her peers, because no midwives sat on the state panel that disciplined her, which consisted of three nurses and a public member. The state did hire a midwife as a consultant, but O'Conner holds that even she is not satisfactory, because she worked in a hospital. She thinks hospital midwives have been co-opted into the medical, interventionist model and therefore are not in a position to judge out-of- hospital midwives.
Ali Toperosky, another owner of the Puget Sound Birth Center, is sympathetic to that point of view. "Hospital and out-of-hospital births are completely different," she says. Adds Thurston of the Midwives Association: "Midwives are very concerned with the safety and health and well-being of babies. But the medical model and the midwifery model have different ideas of what constitutes safe practice. Doctors think home births are crazy." True. Both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have issued statements portraying out-of-hospital births as unsafe.
But if, as many midwives believe, there is not one standard of childbirth care, that makes for a nebulous world in which expectant mothers like Cromie-Nguyen are trying to judge the best course of action for themselves and their babies.
Midwifery Goes Mainstream
In the 1970s, the practice of midwifery underwent a rebirth in Washington and across the country. It was a by-product of the natural childbirth movement of the decade before, when the ideas of Fernand Lamaze and Grantly Dick-Read made their way here from Europe. Natural childbirth advocates saw unmedicated childbirth as healthier. And, by reducing the role of drugs and doctors, it also promised women a greater degree of control during birth, an experience that came to be seen as an opportunity for empowerment.
Midwifery took that a step further by taking doctors almost out of the picture entirely, putting care firmly in the hands of women—the midwives, almost all of whom are female, and expectant mothers themselves, who in the midwifery model are given greater responsibility for their own care. "We were inventing a new feminism," pioneer midwife Suzy Myers recalled at a recent meeting of the state Midwives Association. In 1982, Myers acknowledged, midwifery underwent a setback after Karen Lustig, laboring with a midwife at a local birth center, experienced a cerebral hemorrhage. Lustig and her baby died, prompting a flurry of press coverage.
The practice of midwifery continued to grow nonetheless. In 1975, midwives attended fewer than a half of 1 percent of births in this state. In 2002, the latest year for which records are available, midwives attended almost 11 percent of all births. The national average is 8 percent.
Even fewer births take place on the frontier of midwifery—in the home and at birth centers. But the number is not insignificant. In 2002, there were 1,588 out-of-hospital births in Washington, amounting to 2 percent of all births. And just as midwifery has entered the mainstream, so too have home births and those at birth centers. Thurston, of the Midwives Association, who attends home births herself, recalls that 30 years ago the clientele for out-of-hospital births "were really sort of alternative, marginal types. They were the people who were recycling when nobody else was, people who were joining and creating food co-ops. Now you have all kinds of people wanting to have home births, including those who have a much more mainstream mentality. You might have a Microsoft person or a businessperson or doctors or chiropractors." Those clients, Thurston says, might not reject mainstream medicine in the same way that the old clients did.
As interest in home births and birth centers has grown, they have served as a lightning rod in the culture clash between doctors and midwives. "It's incredibly contentious. None of us want to talk to you," says Robin De Regt, medical director of women's and children's services at Evergreen Hospital. Talking anyway, she tells me, "Most of us physicians don't even remotely understand why you would want to deliver outside a hospital. When things go bad, they go bad very, very quickly. By the time an ambulance is called, the situation is potentially not as safe as it was." For example, she says, "there is not the capability for resuscitating a baby adequately" outside the hospital. (Midwives say they are usually able to stabilize a baby with an oxygen bag and mask until they can get more help.) Among obstetricians, De Regt says, "everybody has a story to tell" of a patient who was transferred to a hospital from a home birth after receiving what the doctor considered to be inadequate care.
Like many doctors, De Regt admits that her view is skewed because she only sees the cases that turn problematic. And the encounters between her and patients who wanted midwives, not doctors, caring for them can be unpleasant. "It's almost a setup to be a hostile relationship," she says.
The University of Washington Medical Center gets more home-birth transfers than most hospitals because it houses a group of midwives and has welcomed such transfers. Still, Tom Easterling, an obstetrician there, says the UW doesn't condone home births, which he maintains carry risks that women need to be aware of. "Personally, I wouldn't have a baby at home," he says. "I've seen too many things happen."
"Part of the problem," he says, "is that there is no one community delivering at home. There are some excellent people out there. And then there are some that are out of the mainstream." That is something to keep in mind when looking at the research on the subject.
Obstetricians point to a high-profile study by a group of doctors at the University of Washington, including Jenny Pang and Thomas Benedetti. The 2002 study, which analyzed birth and infant-death certificates in Washington over a seven-year period, found that women who planned to deliver at home had twice as much risk of their babies dying, though it was still an extremely small risk of less than one-half of 1 percent. Midwives roundly attacked the methodology, in part because state certificates don't specify which births were intended to occur at home and which happened as a result of emergencies.
That same year, a study came out of British Columbia after a two-year project requiring every woman who planned to deliver at home to participate in an evaluation. This was the kind of "prospective study"—collecting data in advance of looking at outcomes—that scientists like to see. Examining 862 home births, it found no associated risks of infant or maternal mortality. By phone from Vancouver, lead researcher Patricia Janssen, an obstetrical nurse who is a professor at the University of British Columbia, allows that one potentially important point is that British Columbia— like Holland, which is known for its good outcomes with home births—regulates the conditions under which a home birth can occur. Vaginal birth after cesarean, known as VBAC, which carries a risk of uterine rupture, is not allowed at home. Nor are breech births, in which the baby is positioned coming out bottom-first, rather than headfirst, making it more difficult to push the baby out. Nor are prolonged pregnancies of more than 42 weeks.
In Washington, birth centers are subject to similar regulations. But not home births, partly because the state can't regulate what you do in your home. "Guess what?" O'Conner says. "There are VBACs being seen by midwives all over this town. Sorry if the doctors don't like it."
When Cromie-Nguyen passed her 42nd week of pregnancy, according to her testimony before the Nursing Commission, O'Conner told her that she would not be able to deliver at the birth center but could still do so at home. Cromie-Nguyen left O'Conner's office with a list of home-birth supplies to buy.
Whether or Not to Induce
Cromie-Nguyen seems to have been one of midwifery's new mainstream clients, drifting into an alternative world without really knowing what she was getting into. In O'Conner's court brief for her appeal of the state sanctions, she describes Cromie-Nguyen and the other client involved as patients who "wished to avoid medical intervention if at all possible." But Cromie-Nguyen's testimony at a hearing before the Nursing Commission in 2001 paints a different picture. State Assistant Attorney General Robert Hargreaves asked her why she chose a midwife. Cromie-Nguyen said she had been to a meeting where she heard doulas talking about the benefits of midwifery. "I believed I was going to get better care. I believed that I would have more attention, more time with the health-care provider."
"Were you necessarily adverse to doctors and medical intervention?" Hargreaves asked.
"No," Cromie-Nguyen replied, adding that she had started with an obstetrician and switched to a midwife primarily because of her interest in a water birth.
What happened to her baby? After 42 weeks of pregnancy, according to medical studies, the risk of stillbirth and neonatal death doubles, to between 4 and 7 incidents per 1,000 deliveries. The risk increases fourfold at 43 weeks and sevenfold at 44 weeks. "As you pass the due date, the placenta ages, and it doesn't feed the baby as well," explains De Regt, the Evergreen obstetrician. Because the fetus is taking in less, it is peeing less, and fetal pee serves as amniotic fluid. Diminished amniotic fluid can create problems. The baby has less of a cushion around it, leaving it more vulnerable to umbilical cord compression, which in turn decreases the baby's oxygen supply. If the baby poops, the resulting substance, known as meconium, is not diluted as much as it would be if there were more fluid. That leaves a greater chance that the meconium could get stuck in the baby's lungs; although the baby doesn't breathe in the womb, its lungs take in the substances around it.
While the risk of death from such problems does not even reach 1 percent at 42 weeks, many practitioners, both doctors and midwives, consider it significant. "The standard of care for the most part is to deliver the patient by 42 weeks," De Regt says, expressing the standard for doctors. Midwives might not induce. But a "reasonable and prudent midwife" would be expected to conduct several tests for fetal well-being, according to Kathleen Jones, the hospital midwife used as a consultant by the state who testified at the 2001 hearing. One is a "nonstress test" that measures the baby's heart rate. Another is something called a "biophysical profile" that entails an ultrasound and assesses, among other things, the amount of amniotic fluid.
The Nursing Commission's subsequent findings of fact took O'Conner to task for failing to arrange for Cromie-Nguyen to have a biophysical profile by 42 weeks. By the time she had one, Cromie-Nguyen was 42 weeks and five days pregnant and had felt the swooshing movement and the leak of fluid. It was then she learned her baby had died. "The autopsy indicated that the cause of death was unknown," read the findings of fact. But it noted that O'Conner's expert testified that the death occurred because of meconium in the baby's system. While that's a classic post-due-date complication, O'Conner does not think she subjected Cromie-Nguyen to undue risk. Indeed, she has a very different interpretation of what the risks were in this case and why it ended badly.
The Right to Choose
At her white-walled bungalow, with an expansive view of Lake Union and the Seattle skyline, O'Conner sits in the living room, surrounded by art, potted plants, and a coffee table upon which sits a copy of Mothering, self-described as the "natural family living magazine."
"First of all," she says, as we turn to Cromie-Nguyen's situation, "you do not have a statistically significant number of dying babies from postdates pregnancies until completion of the 43rd week." She does not take issue with the mortality numbers from medical studies but says that those numbers should be weighed against the risks of induction. For one thing, she says, there's a greater chance of the need for cesarean sections with inductions, and that carries risks of fetal distress and maternal mortality.
Even though Cromie-Nguyen had not yet reached what O'Conner considered a high-risk stage, she contends that she did monitor for fetal well-being—just not in the way that the state would like. O'Conner and her attorney have repeatedly pointed out that she did a nonstress test. As for the biophysical profile, she says: "They wanted it done at 42 weeks. I have a problem with that. If the American College of OBGYN (Obstetricians and Gynecologists) says that an NST (nonstress test) is as effective as a biophysical profile, then why would you have to schedule one any sooner than the other?" As she frequently does to make her points, she hauls out the textbook Williams Obstetrics and reads aloud, with rapid-fire speed, summaries of studies that illustrate the limitations of the biophysical profile.
But it turns out that even the type of test that O'Conner did perform raises questions. To do a nonstress test, according to the testimony of Jones, the state consultant, "a reasonable and prudent midwife" uses what's known as "electronic fetal monitoring," which produces a tape that tracks the baby's heartbeat over a period of time. O'Conner used a portable Doppler monitor, which allows you to hear the heartbeat but doesn't produce a tape. According to Jones, a Doppler monitor does not produce as accurate a result as other monitors. Toperosky of the Puget Sound Birth Center agrees. Seemingly taken aback, Toperosky says of the Doppler procedure: "You can't call that a nonstress test."
When I call O'Conner back to ask her about it, however, she asserts that a nonstress test using a Doppler is "an acceptable standard in nurse midwifery" and is cited in literature disseminated by the American College of Nurse Midwifery. "Now the bottom line is, it doesn't make a difference if we did the friggin' test or not. The studies say that the tests don't improve outcome." It is, in fact, noted in medical literature that fetal monitoring in prolonged pregnancies has not been proven effective, even though health care providers consider it prudent to do such testing.
O'Conner's stance raises interesting questions about the practice of health care: Do you follow an established standard of care, heavily influenced not only by medical but by liability concerns, or do you follow your reading of scientific studies, even if those studies are cutting edge or have not led to a new consensus about how to proceed? Should every procedure that seems reasonable to a doctor require studies that prove its effectiveness on the ultimate outcome of a patient?
In any case, O'Conner has a bigger point to make about Cromie-Nguyen's case, one that gets to the heart of her beliefs about midwifery. O'Conner says she presented Cromie-Nguyen, like all her clients, with an informed choice to make. She says she gave Cromie-Nguyen information about the risks and benefits of induction as well as about the risks of a prolonged pregnancy. "Going so long was her choice," she stresses. And, she says, "you cannot crucify midwifery for allowing women the right to choose"—even if their choices buck conventional medical beliefs.
Cromie-Nguyen, she claims, "reneged on her personal responsibility." O'Conner blames Cromie-Nguyen for failing to self-monitor her baby's movement in the womb and for waiting a day before calling to report the swoosh and the leaking fluid. "I can tell you, if it were me, I would have a tough time living with myself if I thought that I had sensed something and didn't call," O'Conner says. "Is she having a hard time accepting responsibility for her baby's death?"
Cromie-Nguyen, who with her husband sued O'Conner and settled out of court, declined, through her attorney, to be interviewed. But she made clear in her testimony before the state that she thought O'Conner was calling the shots. The information she provided was all slanted toward eschewing intervention, Cromie-Nguyen said. "And when your health care provider is telling you, don't do something, that it's not a good idea, I was afraid that I was making the wrong decision to not go along with what she was saying." What Cromie-Nguyen said she did not know at the time, and what made it seem even worse to her later, is that O'Conner had already been disciplined by the state. "This wasn't her first time. It wasn't an oversight. It wasn't a mistake," she said. "I believe my baby died because Debra made a deliberate decision to not seek care for my child sooner."
'Intensely Staying With Me'
O'Conner has been charged with failing to seek medical intervention soon enough in other cases, too. In one, which was considered in her most recent disciplinary proceeding, O'Conner's patient continued to push at home for almost four hours despite signs of a possible infection and the presence of thick meconium in her amniotic fluid, according to the findings of fact. Because thick meconium presents a greater risk of asphyxiation for the baby, health care providers usually recommend that the baby be delivered at a hospital, where doctors can immediately suction the baby's lungs upon birth. Characteristically, O'Conner challenges the conventional wisdom, presenting studies that question the efficacy of suctioning. And she holds that it was the patient's choice to continue pushing at home, a fact that the patient backed up in her testimony.
Eventually, the patient was transferred to a hospital, where her baby was born with respiratory distress and required seven days of hospitalization. Standing by O'Conner, though, the patient at a December hearing testified that she thought the hospital was to blame for her baby's poor condition because Darlington, the midwife there, failed to recognize a placental abruption, a charge Darlington denied.
O'Conner has frequently alienated other health care providers. "Her professional attitude toward the pediatricians was that it was her role not only to critique our care, but to protect 'her' patients from what she considered to be our unnecessary and intrusive interference," wrote a Northwest Hospital pediatrician in a 1997 letter to the state. A similar letter came from Providence Medical Center. O'Conner does not deny the charge. "I'm pretty aggressive about how I advocate for my clients," she says. "I'm paid to do that."
One of the most compelling dramas revealed in O'Conner's voluminous file concerns an encounter between O'Conner and a Kirkland paramedic. O'Conner had called for paramedics after helping to deliver a baby, according to the mother's statement, who was "covered with meconium" and was barely breathing. The paramedic, James Pierce, wanted to suction the baby's lungs, but O'Conner objected. How vociferously depends on who's telling the story, but Pierce, under the agitated eye of the father, ultimately decided he couldn't proceed and went to the hospital.
Although O'Conner questions the need for suctioning regardless of the baby's condition, she says that in this case, the baby was stable by the time the medic arrived. She also says she was worried about the medic making mistakes while attempting to perform what is a tricky procedure. Pierce, now a paramedic lecturer at Central Washington University, contends that he knew what he was doing. And he insists that the baby was far from stable. "The baby was limp, grossly blue," and had "not just trouble breathing but severe trouble breathing," he recalls. "This kid was dying." According to a statement by a physician at Evergreen Hospital, where the baby was taken, doctors there suctioned meconium from below the baby's vocal cords, at which point the baby's condition began to improve.
Despite the long list of allegations against O'Conner, many of her former clients remain adamant supporters. One is Kelly Meinig, a 38-year-old mechanical engineer who had a home birth last year with O'Conner acting as a doula. "Debra was phenomenal at my birth," Meinig recalls. Though another midwife was present, it was O'Conner whom Meinig felt brought a spiritual quality to the birth. "Debra would be locked onto my hands, looking into my eyes and just intensely staying with me," Meinig says. "As ferocious as my contractions were, she was ferocious right back. I've never had that experience with any other human in my entire life."
That connection held up for the five long days in which Meinig was in labor. During that time, O'Conner essentially moved in, sleeping on a mattress by the hot tub in which Meinig eventually gave birth. Before she left, O'Conner made "refrigerator soup" so that the Meinigs would have food to eat while they were taking care of their newborn.
As O'Conner awaits a court ruling, Meinig is watching. So strongly does she feel about O'Conner that she says, "I will not have another baby unless Debra is my doula—or hopefully my midwife."