When a state senator in 2017 attempted to regulate out-of-hospital births for the first time in Oklahoma, a group of midwives reached out.
Representing the Oklahoma Midwives Alliance and the Midwives Society of Oklahoma, the women met with the lawmaker and brought their own statistics claiming just two deaths related to out-of-hospital deliveries occurred between 2012 and 2016.
But at least seven babies died during that time, according to a GateHouse Media investigation that spent a year counting fetal and newborn deaths related to midwife-assisted, out-of-hospital deliveries in the state.
GateHouse Media, which owns The Oklahoman, used information from obituaries, fetal and infant mortality review projects, medical examiners’ reports, state records and public social media posts to tally the numbers that the state otherwise does not track because it does not regulate the practice.
“Those were found through roundabout ways,” said John Stanley, vice chairman of the Oklahoma Section of the American College of Obstetricians and Gynecologists and an OBGYN. “There may have been more that you didn’t find.”
The midwives ultimately opposed and helped kill the legislation. A subsequent bill introduced in 2018 also failed.
Since then, at least seven additional babies have died during or after midwife-assisted out-of-hospital deliveries, GateHouse Media found. All occurred in 2018. Most were deemed preventable by medical experts who reviewed the cases at the request of reporters.
This is the second year that GateHouse Media has investigated the out-of-hospital birth industry. In the first year, it found the practice to be more dangerous than most midwives claim. It also found that the non-nurse midwives who dominate the business are loosely regulated in many states and not at all regulated in others.
In Oklahoma, they operate in the Wild West of legal landscapes.
They are unregulated, untracked and largely unaccountable.
As out-of-hospital births have gained popularity in the state, problems have continued unabated. Non-nurse midwives who oversee deliveries that result in babies’ deaths are not investigated or disciplined by any state agency. They continue to practice unmonitored and unchecked, putting mothers and babies in the state at risk.
A rare exception to the state’s anything-goes environment occurred in September, when the Oklahoma Attorney General Office’s filed for the first time charges against a non-nurse midwife for practicing medicine without a license — specifically, administering medication and performing an episiotomy. Midwife Debra Disch is set to appear for a disposition hearing on Oct. 30.
“In Oklahoma, we license and regulate people that do your hair,” said Ervin Yen, the former state senator who attempted to regulate out-of-hospital births.
“When somebody is doing your hair, I don’t think it’s a life and death situation,” said Yen, who is also an anesthesiologist. “But when we’re talking about delivering babies at home, it is a life and death situation.”
Most out-of-hospital midwives are certified professional midwives, or CPMs. They require no nursing experience, health-related background, bachelor’s or graduate degree. They can obtain certification by attending an accredited or non-accredited midwifery school — or apprenticing under another midwife — and passing a written test by the North American Registry of Midwives.
Neither the Oklahoma Midwives Alliance nor the Midwives Society of Oklahoma responded to requests for comment.
GateHouse Media made multiple attempts to reach the families whose babies died in 2018. The families did not respond, declined to comment or asked that their names not be used. Because of this, GateHouse Media has omitted their identifying information.
To be sure, few Oklahoma mothers choose to deliver their babies at home or in a freestanding birth center with the help of a midwife. Last year just 520 babies — or 1% — were born under such a scenario, according to birth data from the Centers for Disease Control and Prevention.
But that rate has more than doubled in the past decade, CDC data showed.
The number of babies who die during or after delivery also is relatively low regardless of birth setting or attendant.
Fewer than 30 of the 41,825 full-term, hospital-born babies in Oklahoma died within a week of delivery in 2017, according to the latest data available from the CDC. That’s less than 0.07%.
The CDC does not publish data for death counts under 10 due to confidentiality constraints. As such, it does not show Oklahoma’s midwife-assisted, out-of-hospital mortality rate among full-term babies that year.
But based on the seven fetal and infant deaths, all of which appear to have been full-term, GateHouse Media was able to confirm divided by the CDC’s count of 510 such births in 2018, it could be around 1.4%.
Altogether, Oklahoma has the fourth highest infant mortality rate in the country, according to CDC data. Many counties in the state don’t have a single birthing hospital.
“In Oklahoma, we’re at the bottom of the barrel as far as outcomes for mothers and babies,” Stanley said. “We have a lot of limitations.”
But without accurate information about out-of-hospital birth outcomes, he said, it’s hard to understand the true scope of the problem. And Oklahoma lacks data on the fastest growing birth trend in the state.
“It’s maddening how poor this information is,” said Sandra Braun, an epidemiologist for the Tulsa Health Department.
Baby T died three days after he was delivered at the now-closed Edmond Birthing Center in March 2018.
In the hospital, such newborns go directly to the neonatal intensive care unit due to risks associated with low birth weight, including respiratory issues, jaundice and an inability to regulate blood sugar and body temperature, several hospital experts said.
A nurse visited Baby T once daily after he was born, according to the medical examiner’s report. It’s unclear if that nurse was Karlin, who at the time was licensed as a certified nurse midwife.
The report attributed low birth weight in full-term babies to intrauterine growth restriction. The condition is often diagnosed during prenatal visits, said former Oklahoma labor and delivery nurse Jessica Smith, who reviewed the case at GateHouse Media’s request.
“That would be anticipated by anyone with any amount of training,” Smith said.
The medical examiner’s report also noted the baby was jaundiced and showed potential signs of fetal lung immaturity — a cause of respiratory difficulty. And it stated both mother and baby received limited medical care.
Baby T died from “sudden unexpected infant death,” the report states, noting contributing factors of low birth weight and an unsafe sleeping environment — the baby was found in a portable sleeping dock inside a bassinet, against manufacturer warnings.
“I would classify (this death) as probably or possibly preventable,” said Robert Yelverton, a retired Florida OBGYN who chairs his local Fetal Infant Mortality Review Committee and who reviewed the case at GateHouse Media’s request.
Yelverton said Oklahoma should adopt regulations to protect low birth weight babies born outside the hospital.
“At that weight, if this was a home birth, by some rule or statute in the state of Oklahoma, they should be required to transfer to the NICU for assessment for at least 24 to 48 hours,” Yelverton said.
Two previous cases
Baby T was not the first to die under Karlin’s care. A little more than a year earlier, Karlin lost two babies in attempted home VBACs — vaginal births after previous cesarean sections — a risky practice banned in other states that regulate midwife-assisted, out-of-hospital deliveries.
These appear to be the two deaths in the statistics midwives gave Yen in 2017, and they ultimately cost Karlin her nursing license.
Oklahoma licenses and regulates certified nurse midwives through the Board of Nursing. Most of them deliver babies in the hospital, but some, like Karlin, deliver in homes or birth centers.
In November 2018, the Board of Nursing held a hearing into Karlin’s handling of the fatal deliveries, one of which happened in November 2016; the other in January 2017.
Karlin denied responsibility for either death. She also testified that she had no concerns about her practice.
But the board determined Karlin had failed to “adequately and appropriately monitor” and “timely transfer” both sets of mothers and babies to the hospital. It revoked her nursing license.
Among those at the hearing was Oklahoma City OBGYN Nancy Bishop, who was working at the hospital when one of those two mothers was rushed in for an emergency C-section.
In addition to testifying about that case, Bishop also described another fatal attempted home birth occurring just days before the hearing. She testified that the same student midwife who assisted Karlin during the first fatal incident — Brandy Harris — was involved in the most recent one, the transcript shows.
Bishop told the board that earlier that week, Harris had accompanied a laboring client to the hospital because the mother was suffering from cord prolapse. The condition occurs when the umbilical cord becomes trapped against the baby’s body and can block blood and oxygen flow.
Bishop performed an emergency C-section and found thick meconium — the baby’s first stool and a possible sign of distress. Both the umbilical cord and the baby were stained green from it, Bishop said during the hearing.
Hospital staff attempted to resuscitate the girl, but their attempts were unsuccessful.
“This just happened Sunday,” Bishop told the board.
Cord prolapse is considered an obstetrical emergency, even in the hospital, but babies rarely die as a result, several experts told GateHouse Media.
Because Oklahoma does not regulate non-nurse midwives, Karlin could continue to practice despite losing her nursing license. She removed the word “nurse” from her title and changed her business name shortly after the board decision, according to archived versions of her website.
Harris, who told GateHouse Media in October that she plans to graduate from midwifery school this year, faced no discipline for her involvement in either fatal case. She declined to comment on any cases she was involved in, citing client privacy.
In addition to the March and November deaths, another baby died after an attempted home birth overseen by a different midwife in the late summer of 2018, according to social media posts by that baby’s mother, the midwife and a midwife’s assistant.
The mother suffered complications during labor and needed an emergency C-section. Following the delivery, the baby underwent brain cooling, the mother wrote on Facebook.
Brain cooling — when a baby’s temperature is reduced to about 91.4 degrees for three days — is standard treatment for newborn brain damage caused by oxygen deprivation and limited blood flow.
The infant died a week later, the mother wrote on Facebook. The midwives also made social media posts about the death.
“Midwives should be able to practice to the full capacity of their scope and be part of an integrated system,” Goodwin told GateHouse Media in an October interview. “I am looking forward to support (sic) well-thought-out laws and fair regulations relating to midwifery care. I have no opposition to that.”
She refused, however, to answer questions about whether that legislation should include restrictions on high-risk deliveries such as those involving twins, breech babies or babies born vaginally after previous C-sections.
‘We don’t really have good information’
Due to lack of state regulations, Oklahoma midwives delivering babies outside the hospital do not report outcomes to any official state oversight body — nothing on births, deaths, injuries or hospital transfers — as is required in other states.
The only statistics come from birth certificates, which in every state must include the place of birth along with the attendant — whether a physician or a midwife or someone else. And death certificates, which are linked to the birth certificate if the baby dies in less than one year.
But linked birth and death certificates don’t capture hospital transfers. Babies who experience complications during an attempted home birth but who are delivered or pronounced dead in the hospital count in these statistics as hospital deaths.
“When it’s blamed on the hospital and not on the home deliveries, it doesn’t allow women to make an educated decision,” said Stanley, the Oklahoma City OBGYN and vice chairman of the Oklahoma Section of the American College of Obstetricians and Gynecologists. “Women need to know what the true risk is of delivering at home. We don’t really have good information on what the actual outcomes are.”
The Oklahoma State Department of Health keeps its own state-level birth and death data, not all of which is publicly available. And it contains numerous inaccuracies regarding birth attendants, according to Braun, the epidemiologist at the Tulsa Health Department.
“It’s just not collected in a way that’s conducive at all” for tracking and analysis, Braun said.
The Tulsa Fetal Infant Mortality Review Project has its own records showing five deaths between 2012 and 2017 involving non-nurse midwives, who can practice only outside the hospital. An additional 42 cases involved nurse midwives, most of whom handle deliveries inside the hospital.
The state’s other FIMR Project, located in central Oklahoma, does not differentiate between nurse and non-nurse midwives, making it impossible to determine which of the at least 37 midwife-assisted deliveries ending in death between 2012 and 2017 happened inside or outside the hospital. The data is therefore useless for tracking out-of-hospital birth outcomes.
In addition to Baby T, Baby M and Baby S, at least four other babies died during or after midwife-assisted deliveries outside the hospital in 2018, according to medical examiners’ reports.
One of them was Baby C, an otherwise healthy girl delivered at home in early October but without a pulse and “in agonal respirations,” according to a medical examiner’s report.
Agonal breathing, in which someone sounds like they are gasping, often denotes an underlying condition such as cardiac arrest.
The full-term baby was transferred to an Oklahoma City hospital where she was pronounced dead, according to the report.
An autopsy revealed no fatal trauma or abnormalities nor any evidence of alcohol or drugs in her system.
The cause of death was listed as sudden unexplained infant death. And it was probably preventable, according to at least two physicians who reviewed the report at the request of GateHouse Media.
“This would have probably been preventable had she been monitored continuously during her labor,” said Yelverton, the retired Florida OBGYN. “It’s rare in this day and age to see an unexplained surprised stillbirth in a hospital. It still happens, but it’s rare.”
Another retired Florida OBGYN, W. Gregory Wilkerson, former chief of obstetrics and gynecology at University Community Hospital in Tampa, said Baby C might have survived if born in a hospital with access to immediate resuscitative efforts.
Wilkerson also disputed the cause of death, saying it was most likely a case of neonatal or in-utero oxygen deprivation.
Another death occurred less than two weeks before Christmas. Baby R was 12 pounds and in the breech position when he experienced difficulties during a midwife-assisted delivery at a home an hour south of Oklahoma City.
“He was kicking and pushing and helping with the labor and was trying to pull his little feet back in when he started coming into the world,” the father wrote in a public Facebook post a day after his son’s death. “Our midwives were unable to get his little lungs to take in air.”
The baby was rushed to the hospital where he was pronounced dead, according to the medical examiner’s report, which otherwise noted no apparent abnormalities or trauma.
The medical examiner determined the cause of death as “stillbirth,” with the breech delivery listed as a contributing factor. But Wilkerson disagreed.
“This is a neonatal death,” he said. “Probably caused by entrapment of the head at delivery with resultant asphyxia.”
Both Wilkerson and Yelverton deemed Baby R’s death preventable.
“If they knew it was a breech, the providers should never have tried to deliver it at home,” Yelverton said. “If they missed the fact it was breech, they were negligent in their exam of the patient. Either way, this is why breeches should not be delivered vaginally at home.”
Two additional fatal attempted out-of-hospital deliveries occurred just three days apart in September in more rural parts of the state. Both babies were delivered by midwives to mothers who did not seek prenatal care due to religious beliefs, the medical examiners’ reports note.
Baby F was delivered stillborn when his mother was 38 weeks along. The umbilical cord was tightly wrapped around his neck and deprived him of oxygen, according to the medical examiner’s report.
Three days later, another Baby R was delivered stillborn. CPR was performed, the medical examiner’s report notes, but the girl never responded.
She showed no signs of fatal trauma, and was otherwise well-developed and well-nourished, according to the report.
‘We haven’t done a good job’
In John Stanley’s mind, the solution is clear: Everyone in the state must collaborate to solve poor out-of-hospital birth outcomes.
“I don’t think there’s a lot of respect or understanding on either side of the issue,” said the Oklahoma City OBGYN, who has practiced for 25 years. “The only way to make it better is for everybody to work together.”
Midwives, physicians, nurses and other public officials interviewed by GateHouse Media said they support legislation regulating out-of-hospital midwives and requiring them to report their outcomes for tracking purposes.
Midwives Goodwin, Karlin and Harris said they, too, want regulation. But they declined to elaborate on what exactly it should entail or how much it would have to differ from Yen’s previous attempt to win their support.
“I think accountability is important,” Karlin told GateHouse Media.
Beyond that, Stanley said, hospitals and physicians have a lot of work to do, too.
“I think that hospitals and physicians in the state of Oklahoma need to look at the group of women that strongly desire low-intervention births and obstetric care, and they need to offer services to those women that are compatible with their desires,” Stanley said. “I think we haven’t done a good job of that in Oklahoma.”
Harris, the Oklahoma City student midwife, said there should be improvement in collaborations with hospitals and physicians.
“Access to midwifery care is immediately improved with strong integration in the community care system,” Harris said. “It allows for healthy, collaborative relationships and that also leads to healthier outcomes.”
At least two state legislators — Lundy Kiger, R-Poteau, and Brenda Stanley, R-Midwest City — have expressed interest in pursuing legislation.
“Something has to be done,” Brenda Stanley said, “because we’re losing children.”