How a burgeoning
industry fails to
A South Carolina midwife lost a baby during delivery at a freestanding birth center. A jury convened by the coroner ruled the boy’s death a homicide, and the midwife relinquished her license.
In Virginia, an unlicensed midwife pleaded guilty to felonies after losing a baby in a [evidence type="mixed" id="breech-home-birth" headline="Breech" symbol="W" definition="When a fetus’s bottom or foot enters the pelvis first, rather than head first. About 3 to 5 percent of full-term pregnancies will result in a breech baby." link="http://stories.usatodaynetwork.com/midwives/wp-content/uploads/sites/96/2018/11/breech.png" credit="Source: National Institute of Health" credit2="Herald-Tribune staff illustration | Jennifer Borresen"] breech [/evidence] home birth. She received cease-and-desist letters in at least two other states for practicing unlawfully there, too.
A midwife in Oregon lost a baby after attempting an out-of-hospital birth so risky few doctors would have performed it without a cesarean section. It was at least the second baby who died under her care.
All three midwives continue to practice today.
Across the country, midwives can dodge punishment for fatal mistakes, leaving empty-armed parents with few avenues for justice and a lifetime of loss.
Some states let midwives practice without rules or oversight. Others regulate them but rarely revoke credentials. Even in states where there are rules, midwives openly break them.
Dozens of U.S. midwives practice unlawfully, including a top official at the North American Registry of Midwives, the certifying body of the largest group of non-nurse midwives in the country.
As part of a nine-month investigation into out-of-hospital births, GateHouse Media and the Sarasota Herald-Tribune filed more than 150 records requests for complaints, disciplinary cases, licensing information and inspection reports of midwives and freestanding birth centers.
The records show how states have failed to safeguard an increasingly popular practice — deliveries in homes or birth centers unaffiliated with hospitals and overseen primarily by midwives without medical training or malpractice insurance.
Reporters also used the records to build a first-of-its-kind database to track midwives across the country.
Among the investigation’s findings:
- Midwifery laws and regulations vary so widely across the country that a criminal act in California is common practice in Oregon. Only 32 states regulate the midwives who oversee the majority of out-of-hospital births — non-nurse midwives. Four states and the District of Columbia ban them. They’re unregulated elsewhere.
- As the practice gains popularity, midwives lobby to be licensed like other health care providers. But they fight regulations aimed at protecting families. Midwives want the ability to oversee risky deliveries — like vaginal birth after cesarean section — but don’t want requirements like malpractice insurance.
- States with regulatory boards rarely take serious action against midwives, even in cases that result in death or permanent injury. The lack of accountability forces families into court to seek justice, but few midwives carry malpractice insurance, making them hard to sue.
- In the absence of state oversight, victims can turn to the North American Registry of Midwives to discipline its members, but the organization looks the other way when midwives practice unlawfully and punts punishment back to the states. It has revoked just seven certifications in its nearly 25-year history and limits who can even file a complaint.
“To be a home birth midwife, what an amazing career choice,” said Danielle Repp, a former home birth doula in California. “You get to reap all the glory when things go right, and you get to escape any accountability when things go wrong.”
Hospital doctors and nurses — including nurse midwives — have minimum educational and training requirements, must follow organizational protocols and are subject to performance reviews by their employers. Most carry liability insurance. And they’re licensed in every state — as are cosmetologists, barbers and school bus drivers.
But hundreds of non-nurse midwives who oversee life-and-death situations are not.
“The problems are rampant throughout the whole industry,” said Marla Rawnsley, a Florida attorney involved in a case against a midwife. “There’s no accountability when a mistake is made. The problem is we don’t have any kind of database. The public doesn’t know where to turn.”
A woman in Oregon can hire an untrained, unlicensed midwife to oversee her delivery. In California, the same midwife could face felony charges for practicing without a state license.
A woman who had a previous C-section in Tennessee can hire a midwife to deliver a baby vaginally at home. In Alabama, the same midwife could face state sanctions for overseeing such a delivery.
A woman in Missouri can hire a midwife to deliver her twins outside the hospital. In Florida, the same midwife could lose her license for handling multiple births.
Each state varies in its definition and oversight of out-of-hospital midwifery. The patchwork of laws and regulations makes it hard for families to know whom they can legally hire, what kind of deliveries they can have, and whether protections for them exist.
“You basically have 52 little countries, if you count the District of Columbia and Puerto Rico,” said Kate McHugh, director of global outreach for the American College of Nurse-Midwives.
No state bans out-of-hospital childbirth. Women can deliver their babies at home, on the side of the road or in a Chick-fil-A bathroom. Laws and regulations apply only when someone provides prenatal, perinatal and postnatal care under the banner of midwifery.
In states that do regulate the practice, midwives often play a central role in holding each other accountable. Many serve on oversight or advisory boards that help write the rules, hear disciplinary cases and consider licensure applications.
Some states have stricter standards than others.
When certified professional midwife [evidence type="mixed" id="karen-carr" symbol="D" headline ="Karen Carr" link="http://stories.usatodaynetwork.com/failuretodeliver/wp-content/uploads/sites/96/2018/11/Oversight_2_KarenCarr.jpg" credit="Source: Alexandria, Virginia"] Karen Carr [/evidence] applied for a license to practice in Wisconsin last year, the state denied her, citing her 2011 felony [evidence type="document" id="virginia-convictions" headline="Convictions" link="https://assets.documentcloud.org/documents/5029311/Carr-Karen-Plea.pdf#view=fitH" credit="Source: Alexandria, Virginia Circuit Court"] convictions [/evidence] stemming from a botched home birth in Virginia. Carr was unlicensed to practice in that state, and a baby died under her care.
Wisconsin also noted a 2011 cease-and-desist letter from Carr’s home state of [evidence type="document" id="maryland" headline="Maryland" link="https://assets.documentcloud.org/documents/5030727/Maryland-May-2011-Sanctions.pdf#view=fitH" credit="Source: Maryland"] Maryland, [/evidence] where she also had been practicing without a license. It did not mention another cease-and-desist letter Carr received the same year from the [evidence type="document" id="district-of-columbia" headline="District of Columbia" link="https://assets.documentcloud.org/documents/5029309/DC-CeaseDesist-Carr.pdf#view=fitH" credit="Source: District of Columbia"] District of Columbia [/evidence], which caught her practicing unlawfully there, too.
But the Delaware Midwifery Advisory Council unanimously approved Carr’s application for licensure just two months after Wisconsin’s denial. Council members knew of her past, [evidence type="document" id="delaware-minutes" headline="Minutes" link="https://assets.documentcloud.org/documents/5029310/Delaware-Midwifery-Council-Carr.pdf#view=fitH" credit="Source: Delaware Midwifery Advisory Council"] minutes [/evidence] show, but granted the license anyway. The council is housed within the state’s Division of Professional Regulation.
“The council is an independent body, and administrative staff of the Division of Professional Regulation cannot comment on the deliberations of the council, its decisions or rationale,” said Doug Denison, spokesman for the Delaware Department of State.
Carr did not return calls for comment.
It’s even easier for midwives with disciplinary problems to relocate to states without regulation.
Such was the case for Venessa Giron, who lost her license in Arkansas because of numerous violations before, during and after a 2014 home birth that resulted in the newborn contracting sepsis.
The little girl survived but developed cerebral palsy. She is tube-fed and “has so many doctors I can’t even list them all,” said her mother, Tiffany Nance.
Among Giron’s violations, [evidence type="document" id="state-records" headline="Order and notice of hearing" link="https://assets.documentcloud.org/documents/5029317/Giron-Venessa.pdf#view=fitH" credit="Source: Arkansas Department of Health"] according to state records [/evidence]: Failure to obtain documentation for Nance’s initial risk assessment, failure to submit a plan of care for Nance’s history of [evidence type="word" id="group-b-strep" headline="group B strep" definition="A bacterial infection found in the vagina or rectum. It occurs in 1 in 4 women. It’s not usually harmful, but it can be deadly if your baby contracts it." credit="Source: American Pregnancy Association"] group B strep [/evidence] — a disease that can be fatal to developing babies — failure to monitor Nance and her baby during labor, failure to recognize the signs and symptoms of group B strep infection during labor and failure to immediately transport the newborn for emergency care when she showed signs of respiratory distress.
When Baby Jozzie was finally transferred to a hospital, doctors discovered she had suffered a severe brain hemorrhage. They told her mother she likely wouldn’t make it. But she did.
“You carry this baby for nine months, and you think you’re going to have the rest of your life with this baby, and they’re going to surpass you,” Nance said. “It was the worst time of my life.”
Giron acknowledged she didn’t know as much about group B strep as she should have. She also said Nance probably should have “risked out” of a home delivery.
“But Tiffany was one of those women that said, ‘Regardless of whether you come or not, I'm not going to the hospital. I'm having my baby at home,’” Giron said. “The truth of the matter is I shouldn’t have done the birth.”
Nance denied ever refusing a hospital transfer. She filed a lawsuit against Giron in October. As of mid-November, Giron had not answered the complaint.
Arkansas initially suspended Giron’s license for her role in the incident and ordered her to complete additional coursework on group B strep. But Giron failed to meet the requirements. Only then, in 2016, did the state revoke her credentials.
Giron then moved to Oklahoma. She told GateHouse Media she practices there, as well as in nearby Missouri and Kansas. None regulate nor require licensure for non-nurse midwifery.
Such states are safe havens for midwives disciplined elsewhere. It’s one of the reasons Michigan passed a law regulating the practice in 2017. Before that, anyone could offer midwifery services without background checks or oversight.
“Michigan tended to be a magnet for midwives who had been in trouble in other states,” said retired certified nurse midwife Linda Johnson, who operated a freestanding birth center and did home births for 14 years in the state. “They could practice here without a problem.”
Non-nurse midwives in states that neither expressly permit nor ban them face no official oversight board to hold them accountable for mistakes. Midwife associations can attempt to fill that void, but they lack the legal authority to require colleagues to complete additional coursework or restrict their ability to practice.
“We have no teeth,” said Rachel Williston, chair of the Missouri Midwives Association.
It was the same in Michigan prior to the 2017 law. A professional association of midwives could conduct peer-review meetings after adverse outcomes, but they resulted in little accountability.
“It almost seemed like they didn’t want to discipline the midwife that had a poor outcome, because they all were taking the same risks,” said Johnson, who sat on the association’s board. “They never wanted somebody to come back and say, ‘Well you did the same thing. You should have the same punishment.’ So they’re protecting their own.”
The United States has failed to keep pace with the rising popularity of out-of-hospital deliveries, which until a decade ago accounted for just 0.8 percent of U.S. births but have nearly doubled since then to 1.5 percent.
During that time, more than a dozen states have passed laws recognizing, and in many cases regulating, the biggest group of out-of-hospital delivery providers — direct-entry midwives. These non-nurse practitioners enter the field from midwifery schools or apprenticeships and rarely collaborate with physicians or hospitals.
Of the more than 400,000 out-of-hospital births attended by midwives in the past decade, nearly 60 percent involved those not certified as nurses, according to data from the Centers for Disease Control and Prevention.
But more than a dozen states have no laws on the books for this type of midwife, creating a Wild West landscape where anything goes.
“The Legislature didn’t really care about that population, and so it evolved without animosity,” said Virginia Buchanan, a Florida attorney representing the family of a child who died in an out-of-hospital birth. “They sort of snuck in and established a presence, and it just has sort of grown. Somewhere along the lines it just got overlooked.”
In states where midwifery is still unregulated, non-nurse midwives have lobbied lawmakers for licensure. They want the legitimacy that comes with that status, as well as the ability to bill insurance.
But those same midwives fight restrictions that come with state oversight, even helping kill legislation meant to protect families.
“They have been cowboys so long, they don’t want anyone telling them what to do,” said W. Gregory Wilkerson, chief of obstetrics and gynecology at University Community Hospital in Tampa.
Oklahoma state Sen. Ervin Yen tried for two consecutive years to regulate the practice amid opposition from midwives who bristled at some of the measures in his proposed legislation. Yen wanted to ban out-of-hospital breech deliveries, twin deliveries and vaginal births after cesarean sections, called VBACs. All carry extra risk and can lead to injury or death.
Yen’s efforts failed, and he lost his bid for re-election in June.
“How can we have supposed health care professionals in the state dealing with life and death, and they’re not licensed or certified by any state entity?” said Yen, who is also an anesthesiologist. “Hairstylists are licensed. This is life and death.”
Midwives fought similar restrictions in Alabama as legislation to regulate the practice worked its way through the Statehouse in 2017. Although they had lobbied for more than a decade for state recognition, midwives balked when outside groups urged lawmakers to ban out-of-hospital VBACs, breech births and the delivery of twins.
The groups, including the American Medical Association and the American College of Obstetricians and Gynecologists, also insisted the law require non-nurse midwives to carry malpractice insurance.
“The midwives were very much opposed to some of things we insisted on being in the bill, but at the end of the day, they were willing to accept those things to get a bill passed,” said Mark Jackson, executive director of the Medical Association of the State of Alabama.
Alabama is now one of only three states with an insurance mandate. Indiana and Florida are the other two. But the minimum amounts required — $100,000 per incident and $300,000 aggregate — are far less than what physicians typically carry.
“The minimum amount for an obstetrician is $1 million per incident and $3 million aggregate,” said Lynda C. Gilliam, a physician and the chair of the Alabama Chapter of the ACOG.
Alabama’s new law called for the creation of a midwifery board to set rules, handle complaints and discipline licensees. But critics doubt its potential efficacy, citing a dearth of non-midwife members and a sparse calendar of meetings.
“I don’t have the confidence that this midwife board would properly investigate complaints or has the wherewithal to handle these issues,” Jackson said. “The board in Alabama said they’re only going to meet twice a year. How does a regulatory board meet twice a year?”
The Alabama Board of Medical Examiners, by contrast, meets monthly.
A GateHouse Media review of disciplinary cases handled in states that regulate midwifery show few resulted in license revocation — even when they involved numerous violations, injury or death.
In Florida, Lola Nelson didn't consult a physician on a VBAC delivery that resulted in a uterine rupture. The baby subsequently died and was delivered by C-section at the hospital. The mother required a partial hysterectomy. Nelson admitted the state’s allegations in a settlement. She received [evidence type="document" id="final-order" headline="Final order" link="https://assets.documentcloud.org/documents/5029319/Nelson-Lola.pdf#view=fitH" credit="Source: Florida Department of Health"] an 18-month probation [/evidence] during which she could still practice under supervision. She let her license expire in 2011.
The Florida Council of Licensed Midwifery “is a loosely run playroom,” said Wilkerson, the Tampa obstetrician-gynecologist. “I think the public is ignorant to what they’re getting with a licensed midwife. It has gone on for way too long.”
The council operates under the Florida Department of Health and helps the agency develop rules and address complaints. Although physicians sit on the board, midwives serve as both chair and vice chair.
Required to convene three times a year via conference calls, the group meets with no regularity. In 2017, members met on Sept. 13, Sept. 25 and Oct. 23. Their next meeting was more than a year later, on Nov. 16.
In the past decade, Florida formally pursued discipline against just 36 of the 170 midwifery complaints — at least 10 involving fatal incidents. It revoked only one license during that time, although six other midwives voluntarily surrendered theirs after facing allegations.
During that same time period, the Florida Department of Health counted 66 full-term stillbirths at home, in a freestanding birth center or en route to the hospital. An additional 19 full-term babies died during or within a month of an out-of-hospital delivery assisted by midwives, CDC data show.
But for years, it was voluntary for midwives to submit annual reports counting fetal deaths and hospital transfers, according to a GateHouse Media review of the reports. Some of those submitted were incomplete or inaccurate, the analysis showed.
Florida passed a law this year requiring better tracking of hospital transfers and adverse incidents from attempted and completed out-of-hospital deliveries.
“The bill we passed is not going to solve this problem in and of itself,” said Sen. Dana Young, R-Tampa, who chaired the Health Policy Committee and sponsored the legislation. “But it does require that these birthing centers staffed by licensed midwives must do what hospitals already are doing, which is reporting adverse incents.”
Kama Monroe, executive director of Florida’s Council of Licensed Midwifery, declined interview requests for this story but answered questions via email in August. She defended the state’s oversight of midwives and the home birth industry.
“Licensed midwives are medical professionals and the department regulates and investigates their work using the same methods we use for every other medical professional,” Monroe wrote. “This has been true since we began regulating the profession in 1982 and remains true today.”
Oregon revoked just two direct-entry midwife licenses in the past decade despite investigating at least nine incidents in which a baby died, according to a review of disciplinary records.
One of them involved licensed midwife Jennifer Gallardo, who didn’t call 911 despite several signs a VBAC baby was in distress during a 2010 home birth, [evidence type="document" id="state-records-two" headline="State records" link="https://assets.documentcloud.org/documents/5029321/Gallardo-Jennifer.pdf#view=fitH" credit="Source: Oregon Board of Direct-Entry Midwifery"] state records show [/evidence].
At one point during the difficult labor, the midwife failed to distinguish the difference between the baby’s heart rate and that of its mother.
Gallardo “admitted that she questioned whether these were fetal heart tones at the time, and thought the baby was either fine or dead,” state records show. The midwife “did not call 911 to transfer to care to EMS, did not document discussion of need to transport with client, nor is there a signature from client refusing transport to the hospital during this time.”
The complaint counted more than 50 violations of Oregon statutes and regulations leading to the baby’s death.
Gallardo, who had four prior disciplinary actions in Oregon — one stemming from a fetal death — was ordered this time to participate in a peer review and receive direct supervision for her next five clients. Her current license status is active.
The chair of Oregon’s Board of Direct Entry Midwifery, Colleen Forbes, declined to comment on the disciplinary process, saying it’s a confidential proceeding. She further declined to offer general insights into how the board protects the public’s safety or holds midwives accountable.
“We do an excellent job of keeping the public safe,” said Forbes, a licensed, certified professional midwife based in Eugene. “But this is certainly not information for the media.”
Not everyone agrees the board does a good job.
“The board exists to protect the midwives,” said Martha Reilly, chief of women’s and children’s services at McKenzie-Willamette Medical Center near Eugene. “Midwives cover for other midwives like you wouldn’t believe.”
Two decades ago, the board’s then-chairwoman resigned over similar concerns.
Kate Davidson cited her fellow members’ failure to revoke the license of a midwife who left a mother without delivering her placenta after childbirth. A retained placenta can lead to infection and blood loss and can be fatal in some cases.
The board placed the midwife on probation. Davidson said it wasn’t sufficient punishment.
“I do not feel I can honestly continue to serve and maintain my own personal integrity,” Davidson wrote in her [evidence type="document" id="resignation-letter" headline="Resignation letter" link="https://assets.documentcloud.org/documents/5029322/Davidson-Kate.pdf#view=fitH" credit="Source: Sharron Fuchs"] May 1999 resignation letter [/evidence]. “I feel this was an aggregious (sic) act and failure to revoke the license conflicts with the Board’s duty to protect the public.”
The [evidence type="document" id="surrendered" headline="Midwife license" link="https://assets.documentcloud.org/documents/5301898/Loprinzi.pdf" credit="Oregon Health Authority"] midwife [/evidence] voluntarily surrendered her license one year later – after the board received a second complaint; this time about a baby who died under her care, state documents show.
Davidson, a certified nurse midwife in Salem, hasn’t been involved with the board since then and couldn’t comment on its current performance. But she said midwifery in Oregon is safe and that not all fatal outcomes are the fault of the midwife or should result in license revocation.
When a midwife’s negligence is to blame for a death, however, Davidson said the board needs to hold her accountable. Failure to do so does the public a disservice, she said.
It also further aggrieves families who, after experiencing a birth trauma, endure an emotional complaint process that ends with few results.
Liz Paparella spent two years seeking justice for the death of her daughter during a December 2009 home birth in Austin, Texas. In the end, she said, she felt cheated by the system.
The young mother filed a complaint in March 2010 with the now-defunct Texas Board of Midwifery against her former midwife, Faith Beltz. When the board held a hearing into the matter in September of that year, some two dozen spectators packed the small room in support of the midwife.
Some of them booed Paparella as she testified, she recalled.
“It was awful,” Paparella said. “I felt like I had done something wrong, like I’m having to defend myself.”
Board members said during the hearing that Beltz appeared to have missed signs of an infection, including Paparella’s high fever and the baby’s soaring heart rate, according to a [evidence type="document" id="transcript" headline="Transcript" link="https://assets.documentcloud.org/documents/5029294/Paparella-Liz.pdf#view=fitH" credit="Source: Liz Paparella"] transcript [/evidence]. Beltz should have called 911, they said, instead of letting the mother continue to labor at home.
Beltz told the board she suggested a hospital transfer but that no one listened to her. Paparella and her husband, Gabriel, denied that; saying Beltz merely suggested they think about a transfer without providing any indication they were in an emergency situation.
The board gave Beltz a six-month probated suspension during which she could continue practicing. It informed Paparella of its decision in a February 2011 [evidence type="document" id="board-letter" headline="Letter" link="https://assets.documentcloud.org/documents/5046665/TX-Midwifery-Board-Decision-Beltz.pdf#view=fitH" credit="Source: Liz Paparella" ]letter [/evidence], and closed the case.
For Paparella, the board’s decision was a punch in the gut. Her baby was dead, but her midwife got to keep practicing.
State lawmakers voted to abolish the Midwifery Board in 2015 and transferred its regulatory duties to the Texas Department of Licensing and Regulation the next year. A new Midwives Advisory Board was then created to assist the agency.
In the meantime, Paparella filed a complaint with the North American Registry of Midwives, which certified Beltz. She spent an additional year submitting paperwork and testifying before its grievance committee.
Paparella was disappointed with NARM’s conclusion. The organization [evidence type="document" id="noted" headline="NARM decision" link="https://assets.documentcloud.org/documents/5046666/NARM-Decision-Beltz.pdf#view=fitH" credit="Source: Liz Paparella"] noted [/evidence] that Beltz already complied with Texas’ recommendations and that it had nothing more to add beyond requiring Beltz to complete some additional training. NARM did not respond to requests for comment on the case.
“They did nothing. No sanctions. No findings of guilt. No reprimands,” Paparella said. “And (midwives) never carry any malpractice insurance, so you can’t sue them.”
Beltz said she no longer practices midwifery and declined to comment for this story.
The North American Registry of Midwives represents the nation’s largest group of out-of-hospital delivery providers — certified professional midwives, or CPMs.
Its credentials are a path to licensure in most states that regulate non-nurse midwives, and it stands as the only defense against bad actors when states fail to take action.
Yet NARM does little to discipline its more than 2,200 active CPMs.
The organization counts [evidence type="document" id="nearly-hundred" headline="CPM location" link="https://assets.documentcloud.org/documents/5219088/CPMs-by-state.pdf" credit="Source: GateHouse Media"] nearly 100 of them [/evidence] in states that ban non-nurse midwifery. NARM further shields those midwives by denying the public access to its roster. One of its top officials, Debbie Pulley, said releasing that information could jeopardize those who violate state laws or regulations.
“We don't know necessarily where they’re practicing,” Pulley said. “We don’t care to find out.”
Pulley herself practices unlawfully in Georgia, one of the states that [evidence type="document" id="georgia" headline="Rules and regulations of the state of Georgia" link="https://assets.documentcloud.org/documents/5029323/GA-RR-511-5-1.pdf#view=fitH" credit="Georgia Rules and Regulations"] restrict midwifery to certified nurse midwives only [/evidence]. Pulley is not licensed as a nurse midwife in Georgia, according to state records.
She advertises her services under the name Atlanta Birth Care and acknowledges in her bio and her [evidence type="document" id="informed-consent" headline="Informed consent document" link="https://assets.documentcloud.org/documents/5141569/Debbiepulleyinformeddisclosure.pdf#view=fitH" creditlink="http://gamidwife.com/meet-the-midwives/" credittext="Source: gamidwife.com/meet-the-midwives/"] informed consent document [/evidence] that her credentials aren’t recognized in her state.
Pulley did not respond to multiple requests for comment regarding her unlawful status.
Despite the fact that many states don’t regulate midwives — and many of its own members fight efforts to do so — NARM says it’s up to the states to set rules and discipline violators.
“If there are problems in a state with a CPM, then it is the state’s responsibility to do something,” said Pulley, who oversees public education and outreach for the organization. “They’re the ones who are dropping the ball.”
Where midwives are regulated, those who lose their licenses don’t always lose their NARM certification as a result. That contrasts with the American Midwifery Certification Board — the certification body for members of the American College of Nurse-Midwives — where state discipline can be grounds for revocation.
NARM has investigated 42 complaints and revoked just seven certifications in its nearly 25-year history, according to its most recent annual report. Pulley would not say how many complaints it chose not to investigate.
It disciplines its members for a short list of reasons. Among them is a breach of informed consent guidelines, Pulley said. Those guidelines require midwives to inform their clients of the potential risks and benefits of the evolving plan of care — even if that plan deviates from acceptable standards.
“We don’t tell them we can’t do a birth at 42 weeks. We don’t put together those regulations,” Pulley said. “The mother has to know what the risks are.”
Missouri mother Andrea Smith said she didn’t understand the risks when she hired certified professional midwife Joann Falcon to deliver her identical twin daughters outside the hospital.
Smith started having contractions around 9 p.m. the night of her May 2013 home birth. She informed Falcon by phone, but Falcon was more than two hours away and sent a backup midwife, according to medical records and notes from both midwives.
“At that moment in time, she should have just been, like, ‘I’m too far from you right now,’” Smith said. “Why didn’t you ever just tell me to go to the hospital? We took her lead with what she told us to do.”
Smith and her husband delivered the first girl alone in the bathtub with Falcon on the phone. When the backup midwife arrived, she determined the second girl was in a [evidence type="mixed" symbol="W" id="breech-position" headline="Breech position" link="http://stories.usatodaynetwork.com/midwives/wp-content/uploads/sites/96/2018/11/breech.png" definition="When a fetus’s bottom or foot enters the pelvis first, rather than head first. About 3 to 5 percent of full-term pregnancies will result in a breech baby." credit="Source: National Institute of Health" credit2="Herald-Tribune staff illustration | Jennifer Borreson"] breech position [/evidence] and had a [evidence type="mixed" symbol="W" id="prolapsed-umbilical-cord" headline="Prolapsed umbilical cord" link="http://stories.usatodaynetwork.com/midwives/wp-content/uploads/sites/96/2018/11/Prolapse.png" definition="When the umbilical cord drops through the open cervix before the baby, which can cause the chord to become trapped against the baby’s body." credit="Source: Cleveland Clinic" credit2="Herald-Tribune staff illustration | Jennifer Borreson"] prolapsed umbilical cord [/evidence], which can block blood and oxygen flow, according to notes from the backup midwife.
The cord “was pale, cold and flaccid, no pulsing felt,” the backup midwife wrote.
Falcon, who was on speaker phone, instructed them to call 911. Paramedics arrived shortly before the second baby was delivered. They rushed the girl to the hospital, where doctors determined she suffered severe brain damage from oxygen deprivation, records show. The family turned off life support three weeks later. The other twin survived.
“I never got to hold her when I delivered her. They just took her from me,” Smith said. “I still try to tell my twin daughter that she’s a twin.”
Because midwifery is unregulated in Missouri, Falcon violated no state rules in her handling of the case. So Smith turned to NARM.
NARM has a two-part complaint process whereby a group of local midwives first reviews the case and makes non-binding recommendations focused on education rather than punishment. If the matter remains unresolved, a second complaint is required to trigger a case review by NARM members that could result in suspension, probation or revocation of CPM credentials.
“The fact that it requires a second complaint by a first-hand witness makes it difficult if a specific midwife is doing something that other midwives don’t think is appropriate or safe,” said Rachel Williston, chair of the Missouri Midwives Association grievance review board. “But the clients don't want to complain.”
Members of the Missouri Midwives Association reviewed the case on behalf of NARM and, in conclusion, recommended Falcon learn documentation and charting skills, research and write a paper on twins and update her practice guidelines.
But Falcon failed to implement these suggestions, [evidence type="document" id="narm-letter" headline="NARM letter" link="https://assets.documentcloud.org/documents/5029326/NARM-AndreaSmith.pdf#view=fitH" credit="Source: Andrea Smith"] according to a May 2014 letter [/evidence] NARM sent to the midwife and copied to Smith. NARM urged Falcon to follow through on the recommendations and warned that not doing so could prompt a second complaint by Smith or the Missouri midwifery group.
But when Smith inquired about filing a second complaint a year later, NARM told her it was too late and it would not reopen the case against Falcon, Smith said. NARM did not respond to requests for comment on the case.
Falcon could not be reached for comment. GateHouse Media could not confirm whether she continues to practice.
“If women really realized what’s behind birthing at home,” Smith said, “they wouldn’t be doing it.”
The United States differs from other industrialized countries in its recognition and regulation of midwifery.
In places like Canada and the Netherlands, where out-of-hospital outcomes are better, all midwives must have at least a bachelor’s degree in education and must be licensed. They are integrated into the health care system, have hospital admitting privileges, collaborate with physicians and adhere to internationally recognized standards.
“The integration is huge — the ability to recognize the need to transfer and to transfer seamlessly — it’s crucial to the care that’s provided here,” said Louise Aerts, registrar and executive director of the Canadian Midwifery Regulators Council. “That’s why all midwives have to offer both home and hospital birth here. There is no such thing as a home-birth-only midwife in British Columbia or anywhere in Canada.”
Only one province and one territory do not regulate midwifery in Canada, Aerts said, but she’s unaware of anyone practicing in those places.
Compare that to the United States, where midwives lack consistency on a number of things: training and education, laws and regulations, hospital admitting privileges, collaboration with physicians, and adherence to international standards.
Some midwives have no formal training. Others practice without any license or registration. Some even practice unlawfully.
“We don’t have standardization for what it means to be called a midwife in the United States,” said Kate McHugh of the American College of Nurse-Midwives. “There are international standards on what it means to be a midwife, but a number of people in this country who use the term midwife don’t meet the international definition.”
The international definition, set by the International Confederation of Midwives, requires practitioners to complete an ICM-recognized midwifery education program, be legally registered or licensed to practice, and demonstrate competency.
Health care experts believe out-of-hospital birth outcomes would improve if all U.S. midwives adhered to international standards and if all states adopted similar laws and regulations governing the practice and the practitioners.
Two types of midwives in the United States — certified midwives and certified nurse midwives — already meet international standards. Both are credentialed by the American College of Nurse-Midwives — its certification requirements adhere to ICM standards — and both have at least a master's degree in midwifery.
The American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives both have pushed for universal adoption of ICM standards for years. But [evidence type="document" id="five-states" headline="Five states" link="https://assets.documentcloud.org/documents/5031725/CPM-Licensure-Laws-EDUCATION-STANDARDS.pdf#view=fitH" credit="Source: American College of Obstetricians and Gynecologists"] only five states [/evidence] — Alabama, Delaware, Maine, Maryland and South Dakota — have a licensing process that meets the educational component of those standards.
“Everyone agrees the basic floor should be ICM criteria,” said Hal Lawrence, who was executive vice president and CEO of the American College of Obstetricians and Gynecologists when GateHouse Media interviewed him in August. He retired in October.
“State legislators should require that midwives meet these criteria before they get licensed,” Lawrence said. “That’s the answer.”
Midwife groups are working to amend this. The U.S. Midwifery Education, Regulation, and Association is a collaboration among groups like the ACNM, NARM and other professional midwife organizations.
The groups, which began meeting in 2013, [evidence type="document" id="model-language" headline="Midwifery legislation & regulation statement" link="https://assets.documentcloud.org/documents/5029328/US-MERALegislativeStatement2015.pdf#view=fitH" credit="Source: U.S. MERA"] released suggested measures [/evidence] for states to address issues such as insurance, complaints and education requirements.
The regulatory goals outlined, if met, would inch the U.S. closer to meeting international standards and have the potential to better protect mothers and babies.
Until then, the United States remains a riskier place than other countries to deliver babies outside the hospital.
“The majority of midwives who perform these are not certified by international standards,” said Amos Grunebaum, a New York-based obstetrician-gynecologist who has published peer-reviewed studies of out-of-hospital birth outcomes.
“They wouldn’t be allowed to work in other countries,” Grunebaum continued. “They don’t have adequate training. They don’t have enough experience. And they’re performing dangerous procedures outside of a hospital.”