Delivering safer birth outcomes

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Delivering safer birth outcomes

An unlikely group spent countless hours last year exchanging emails and meeting over coffee, seeking common ground on an issue they believed would give mothers in Kentucky more choices about how to deliver their babies — while also better assuring the safety of both.

The midwife, the mother and the doctor involved in hashing out that compromise paved the way for a state bill licensing and regulating non-nurse midwives in Kentucky. Signed by the governor in March, the law will allow midwives to openly handle out-of-hospital births after years of working in the shadows.  

In Oklahoma, where midwives are unregulated, untracked and largely unaccountable, at least seven state lawmakers from both parties expressed support for legislation regulating non-nurse midwives. Several legislators filed requests this month to author legislation for the session that kicks off in February. The deadline for introducing a bill is Jan. 16. 

An investigation by the USA TODAY Network, formerly GateHouse Media, found seven babies died during or after attempted out-of-hospital deliveries overseen by midwives last year alone.  The new legislation can’t come soon enough for those who want oversight of out-of-hospital births in Oklahoma.

“We continue to have bad outcomes, so I think the longer we wait, the more women and babies’ lives are at risk,” said John Stanley, an OBGYN and vice chairman of the Oklahoma Section of the American College of Obstetricians and Gynecologists. “It’s important to try to make some progress this year.”

Kentucky’s efforts may provide a road map for how to get there.

For decades, only Kentucky’s nurse midwives, most of whom work inside hospitals, were legally allowed to practice. Non-nurse midwives, who oversee the majority of out-of-hospital deliveries, have been unable to obtain licenses for years, effectively driving their practice underground. 

“When I started trying to learn about what types of midwives there were in Kentucky and how to find a midwife, it was very confusing,” said Mary Kathryn DeLodder, a mother of four and leader of the Kentucky Home Birth Coalition. “You had to know the right people and know the secret handshake.”

The state’s new law is changing that by establishing criteria for licensure of non-nurse midwives and setting up a system in which the state’s Board of Nursing will establish rules and restrictions for practitioners. The law went into effect earlier this year, but the board has not yet begun licensing non-nurse midwives. Stakeholders are still in the process of drafting regulations, but best-case scenario projections indicate that process will be completed and licenses issued as early as June, DeLodder said.

The law also includes measures that will require midwives to report their outcomes and disclose to clients whether they carry malpractice insurance.

“It will allow people an easier way to locate a midwife,” said DeLodder, who was among those who worked to compromise with other stakeholders. “It will allow them to know who they are hiring — that this person has at least the proper credentials. It also provides accountability and some sort of consumer protection, in that consumers, if they feel they have had a bad experience, it gives them a formal way to have recourse.”

For the Oklahoma lawmakers looking to draft midwifery legislation, Kentucky’s new law wouldn’t be a bad place to start. 

Tracking outcomes

Until a decade ago, out-of-hospital deliveries accounted for just 0.8% of all U.S. births. Now that number is double.

More than a dozen states have passed laws in the past 10 years recognizing, licensing or regulating non-nurse midwives, who oversee the majority of out-of-hospital births. These midwives enter the field from midwifery schools or apprenticeships, and they rarely collaborate with physicians or hospitals. 

In Oklahoma, out-of-hospital deliveries are increasing on pace with the rest of the country. But the USA TODAY Network found non-nurse midwives who oversee those deliveries are not investigated or disciplined by any state agency, even if deaths occur under their care.  

“Women need to know what the true risk is of delivering at home,” said Stanley, the Oklahoma OBGYN. “We don’t really have good information on what the actual outcomes are.”

When Kentucky’s new law is implemented, midwives will be required to file annual reports and separately report newborn and maternal deaths within 30 days. 

“If you have data that says we have a deficiency in this area, then you can go in and say what’s wrong and how do we fix it,” said Dr. Jeffrey Goldberg, legislative chair for the Kentucky Section of the American College of Obstetricians and Gynecologists who worked with DeLodder and others to pass legislation.

Kentucky will join other states with similar requirements. 

In Florida, a law passed last year now requires midwives to report adverse out-of-hospital delivery outcomes and mandates that midwives provide a medical summary of events for every adverse incident. 

Oregon goes so far as to require that all birth certificates include the planned attendant and place of birth. Other states require only the actual attendant and place of birth. 

Dr. Amos Grunebaum of the Zucker School of Medicine at Hofstra/Northwell Health in Hempstead, New York, said it’s the best way to collect such data. 

“Birth certificates in the United States should include where the original intent of delivery was,”  Grunebaum said, “so that for the woman who delivers in a hospital after she was transferred from home, there is a data point where we know this is a bad outcome.” 

Other countries have implemented such methods, said Saraswathi Vedam, a midwife who practices in both the U.S. and Canada.

“We have reliable systems of data collection in Canada,” said Vedam, who is also a professor of midwifery and principal investigator at the Birth Place Lab based out of the Division of Midwifery at the University of British Columbia. “There are a lot of claims of what’s safe and what’s unsafe (in the U.S.), but nobody really knows.”

Restricted deliveries

Oklahoma lawmakers will also have to consider whether they will restrict the types of deliveries midwives can oversee. 

Former state Sen. Ervin Yen, an Oklahoma City anesthesiologist, tried for two consecutive years to ban out-of-hospital breech deliveries, twin deliveries and vaginal births after cesarean sections (known as VBACs), all of which carry additional risks. 

Midwives opposed Yen’s legislation, and he lost his bid for re-election in 2018. 

Several midwives interviewed by USA TODAY for its October investigation said they would support legislation regulating their practice and establishing reporting requirements. But they would not comment on whether legislation should include restrictions on high-risk deliveries like those that Yen tried to ban. 

In Kentucky, lawmakers chose to exclude restrictions in legislation. Instead, they will be established by the state’s Board of Nursing. 

That’s also how restrictions are implemented in Arkansas, where the state’s Midwifery Advisory Board advises the Board of Health on regulations.

“We do have some organizational structure that provides a framework,” said William Greenfield, medical director for the Arkansas Health Department’s Family Health program. “For us, we have certain things in place to ensure that we are able to track and monitor certain activities.” 

Under the board’s rules, Arkansas non-nurse midwives are banned from overseeing VBAC, breech or twin out-of-hospital deliveries.  

Compare that with Oregon, where licensed midwives are not banned from overseeing such deliveries, but midwives who seek reimbursement from Medicaid cannot oversee VBAC, breech or twin deliveries, according to the state’s Health Evidence Review Commission. 

In Kentucky, Goldberg said he would have preferred writing some restrictions into law but that midwives opposed it. So they left it up to the nursing board — with input from the Licensed Certified Professional Midwives Advisory Council — to decide what kinds of complications require that midwives refer patients to higher levels of care.

“We had several meetings where we would sit down and go through the proposed bill, and line by line, issue by issue, have a conversation about why we wanted (something) in or why we wanted it out,” Goldberg said. “We came up with some compromise, and we were able to edit the bill to something that was acceptable to all stakeholders.”

Malpractice insurance

While only three states — Florida, Alabama and Indiana — require non-nurse midwives to carry malpractice insurance, it’s another issue Oklahoma legislators will need to consider.

Kentucky did not pass such a requirement, though its midwives must disclose whether they carry insurance. 

The absence of a requirement makes it difficult for clients to sue midwives, even if they are at fault. 

“If you’re delivering babies, your insurance needs to be on par with other individuals who deliver babies,” said Oklahoma malpractice attorney Kenyatta Bethea. 

But in those states that do require that midwives carry malpractice insurance, the minimum amounts are far less than requirements for physicians, and in particular, OBGYNs. 

In Florida, midwives are required to carry at least $100,000 per claim, or an annual aggregate of $300,000. 

“I’ve never had an OB that had less than a million dollars in coverage,” Bethea said. “One hundred thousand isn’t enough to take care of a brain-damaged baby. Regardless of whether we’re talking about a baby that dies or a baby that survives with injuries, $100,000 is woefully insufficient.” 

Coming together

Kentucky isn’t the only example Oklahoma lawmakers might consider when drafting legislation. 

The U.S. Midwifery Education, Regulation, and Association — a coalition of midwifery organizations — drew from international standards to create model legislation and regulation in 2015, addressing issues such as insurance, complaints and education requirements.

While Kentucky implemented some of the measures recommended by the coalition, other provisions differ from the coalition’s model. For example, non-nurse midwives will be overseen by the state nursing board, rather than by a midwifery-specific regulatory authority, as the coalition recommends. 

Given Oklahoma’s failed attempts to pass legislation in previous years, the most important lesson from Kentucky’s success in passing midwifery legislation may be how midwives, doctors, legislators and mothers all came together. 

Goldberg pointed to stakeholders’ respect for each other and their willingness to collaborate as the key to getting a law passed. 

“If you look at the history of attempts to pass this type of legislation for multiple years and you ask, ‘What was different in 2019 that brought this about?”’ Goldberg said, “I would say that for the first time the stakeholders really sat down in a room in a small group and worked out compromise legislation.”

Oklahoma legislators pursue midwife regulations

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Oklahoma legislators pursue midwife regulations

Lecye Doolen plays with building blocks with her son Dutch Lippoldt at her home. Sarah Phipps | The Oklahoman

After at least two failed attempts to regulate Oklahoma’s non-nurse midwives in recent years, two state legislators told GateHouse Media they plan to author bills in the upcoming session to do just that.

At least three others said they would support the effort.

“We need to be more aware of who we’re choosing to deliver our babies,” said state Sen. Brenda Stanley, R-Midwest City.

Stanley and Sen. Mark Allen, R-Spiro, both plan to author legislation. They are backed by Rep. Lundy Kiger, R-Poteau, Rep. Jason Dunnington, D-Oklahoma City and Rep. Collin Walke, D-Oklahoma City.

“This issue needs to be looked at,” Dunnington said. ”And policy (should be) put in place to be more protective of women and newborn children.”

The lawmakers’ remarks come one week after an investigation by GateHouse Media and The Oklahoman found seven babies had died during or after attempted midwife-assisted out-of-hospital births last year alone. Four of those deaths were deemed preventable by experts.

Oklahoma does not license or regulate non-nurse midwives, so anyone can call themselves a midwife and practice as one. They are not required to report their outcomes to any state agency, nor is there an official oversight body to set standards or investigate incidents, the investigation also found.

It’s among some one dozen states without such regulations.

Non-nurse midwives also provide prescription medication to mothers and babies, even though they are not licensed medical professionals, GateHouse Media also uncovered. The Oklahoma attorney general filed felony charges against one such midwife, Debra Disch, in September.

Other states that regulate non-nurse midwives have established minimum education and qualification standards for licensure, created oversight bodies to set rules and procedures to discipline midwives for violations. Most also require midwives to report annual outcomes on deliveries, hospital transfers and deaths.

Oklahoma lawmakers are not yet sure what will be included in the legislation. Stanley said she plans to include language requiring midwives to report their outcomes, but nothing that would deny mothers the choice of a home birth overseen by a midwife.

“I don’t want to limit anybody’s choice,” Stanley said. “It’s about helping people make good choices.”

Legislators must request to draft a bill by Dec. 13. The legislative session begins Feb. 3.

A group of Oklahoma women also launched a Facebook page called “Regulating HOME BIRTH in Oklahoma” to educate the public and start a discussion about regulation.

The page has received more than 300 likes since its launch Tuesday.

The Oklahoma Midwives Alliance, the Midwives Society of Oklahoma and the National Association of Certified Professional Midwives Oklahoma State Chapter did not respond to email requests for comment. None of the organizations list phone numbers on their websites.

The organizations worked to block previous attempts to regulate out-of-hospital births.

‘This isn’t about politics to me’

Stanley, a former educator, said she decided to author legislation after learning that Lecye Doolen lost a baby during an attempted home birth. Doolen was a student at the elementary school Stanley taught at.

“What guided me through my whole career is I always made decisions based on what’s best for children,” Stanley said. “This isn’t about politics to me. This is about protecting babies and mothers.”

Doolen’s son, Shepherd, was delivered via emergency cesarean on Nov. 7, 2016, and died the next day. Doolen had hired then-nurse midwife Dawn Karlin for the planned home delivery, and the midwife’s nursing license was later revoked in part due to her handling of it.

Oklahoma licenses and regulates nurse midwives through the Board of Nursing. But because it does not regulate non-nurse midwives, Karlin was able to keep practicing. She removed the word “nurse” from her title, changed her business name and continues to deliver babies in the state.

Doolen’s story was also detailed in GateHouse Media’s investigation.

“I’m eternally grateful that people are understanding that our goal is to protect mothers and babies in the state of Oklahoma,” Doolen said. “I don’t want another mother to have to go what I went through, if it is avoidable.”

As for Allen, he said his decision to spearhead legislation came after hearing about a constituent’s traumatic out-of-hospital birth experience. Oklahoma mother Suzie Bigler’s account of her botched home birth went viral after she posted her story on Facebook in August. Her baby survived.

“We’ve got to protect the mothers and the children from what happened over here,” Allen said. “We’ve got to take care of the babies and mothers.”

Bigler’s midwife, Debra Disch, began delivering babies in Oklahoma after running into trouble for practicing without a license in Arkansas, which regulates non-nurse midwives. Bigler said she did not know about Disch’s past troubles.

She now is calling on the state to regulate non-nurse midwives like Disch.

Beyond legislation

Oklahoma City midwives Dawn Karlin and Taryn Goodwin told GateHouse Media in October that they support regulation despite having opposed previous legislative attempts.

“Midwives should be able to practice to the full capacity of their scope and be part of an integrated system,” Goodwin said. “I am looking forward to support (sic) well-thought-out laws and fair regulations relating to midwifery care. I have no opposition to that.”

Goodwin refused, however, to answer questions about whether a legislation should include restrictions on deliveries such as those involving twins, breech babies or babies born vaginally after previous C-sections, all of which are against American College of Obstetricians and Gynecologists — or ACOG — guidelines for home deliveries.

John Stanley, an Oklahoma City obstetrician and vice chairman of the Oklahoma Section of ACOG, said he plans to assist the legislators. He is unrelated to the lawmaker with the same last name.

“I think legislation is really to help to get information and help prevent the problems that we’re having now,” Stanlely said.

But Stanley said legislation alone isn’t enough.

“You still have to find a way to serve these women,” Stanley said. “Knowing there’s a large number of women that want the low intervention birthing experience puts the impetus on us to work with hospitals to find a way to offer that experience.”