A years-long push to allow Maryland’s certified professional midwives to care for women who have had a previous Caesarean section and are seeking vaginal home births has come to a halt after state lawmakers withdrew draft legislation because of new safety concerns from regulators.
The legislation would have expanded the potential client base for such midwives, who are licensed by the Maryland Board of Nursing to provide care for pregnant women and deliver babies at home. Unlike certified nurse midwives, they do not hold advanced degrees or nursing credentials, instead learning primarily through apprenticeships.
Certified professional midwives had lobbied for the Maryland bill, saying that allowing them to take on the care of vaginal births after Caesarean section, commonly known as VBACs, could help reduce repeat C-sections. But physicians, hospital associations and patient safety advocates warned that the legislation could lead to life-threatening consequences for patients and their unborn babies due to the heightened risk of uterine rupture during attempted VBACs.
U.S. home births are on the rise despite having a more than twofold risk of infant death for planned home births attended by midwives when compared to hospital births, according to a recent Washington Post analysis of five years of data from the Centers for Disease Control and Prevention. State legislatures and health agencies across the country have taken a wide range of approaches to regulating certified professional midwives, who are responsible for the majority of the nation’s home births. In Maryland, nearly three dozen certified professional midwives serve as the primary caregivers for about 660 pregnant clients a year, according to state data.
Two state lawmakers said, in interviews that following a recent Washington Post investigation on several stillbirths and infant fatalities during attempted home births, they worried that the VBAC legislation could place more vulnerable clients under midwives’ supervision.
The Post revealed how the board granted a license to midwife Karen Carr despite her felony conviction in Virginia for child endangerment following the death of a baby boy after a breech home birth, and allegations that Carr refused emergency help in Southern Maryland for a newborn Amish baby who was struggling to breathe and later died. Carr, who defeated the state’s attempt to revoke her license following a stillbirth during a home labor in late 2021, did not respond to a request for comment. She remains licensed.
Early last year, the board’s president wrote to lawmakers to back the VBAC legislation with certain amendments, stating that, “when provided with full informed consent, the decision of the place and provider of birth should be left to the birthing mother and family.” Midwives, including Carr, wrote letters in support. “Many of the women I care for wish to have large families and are limited when the only option they have is repeated cesarean sections,” wrote Carr, who described her own successful VBAC in the 1980s.
In an about-face in January, the board unanimously voted to oppose the legislation. When asked why, the board’s executive director, Rhonda Scott, issued the following statement to The Post: “The Board believes that Direct Entry Midwives are valuable in caring for pregnant patients. However, many home deliveries occur in remote and resource limited settings which can pose a higher risk of complications for vulnerable patients like those seeking vaginal birth after a cesarean (VBAC).”
In early February, days after the board’s reversal, sponsors Sen. Arthur Ellis (D-Charles) and Del. Bonnie Cullison (D-Montgomery) withdrew their proposed legislation. Ellis told The Post that there was no path forward without the board’s backing.
“They said, ‘Well, we need to regroup,’” Ellis said of the board. “ … They’ve had, to be honest, major failures over the last few years.”
While Cullison did not respond to requests for comment about the withdrawal, she told The Post in December that she felt optimistic about the bill’s future. “This is a family choice issue,” she said then.
Lobbyist Caitlin McDonough, who represents the Association of Independent Midwives of Maryland (AIMM), said that the legislation would have included safeguards, such as requiring certified professional midwives to consult with a health-care provider before attempting a home VBAC. She said that, before moving forward, lawmakers wanted more discussions around ensuring smooth communication between midwives and hospitals during a transfer of care. McDonough would not speculate on next year’s legislative agenda but said that AIMM is open to edits that would increase access to VBACs in a “safe and accountable way.”
“There’s really not any circumstances where there’s zero risk,” McDonough said. “There still remains a high demand for out-of-institution VBACs in the state and the nation, frankly.”
The American College of Obstetricians and Gynecologists considers a previous C-section to be “an absolute contraindication” to planned home birth, meaning that it should not be attempted because of the risk of harm. It instead recommends that attempted VBACs occur in facilities with trained staff capable of performing emergency C-sections. While estimates vary, the risk of a uterine rupture during an attempted VBAC could be close to 1 in 200, according to studies.
Medical professionals have stated that, if such a rupture occurs at home, the time needed to transfer to a hospital could lead to fetal or maternal death.
In Arizona, Jordan Terry, a 28-year-old mother and registered nurse, along with her unborn son, Mack, died in December after a uterine rupture following an attempted home VBAC under the supervision of certified professional midwife Sarah Kankiewicz. The state’s health department has alleged that Kankiewicz did not immediately seek emergency help when Terry’s health began to decline and her lips turned pale, according to a notice of intent to revoke her midwifery license.
“I’m not anti-home birth by any means,” said widower Parker Terry, who shared his family’s story on social media in an effort to raise awareness. “If it makes sense and it’s safe, go for it. But these high-risk cases like this? It just doesn’t make sense.”
In text messages to a Post reporter, Kankiewicz said she informs her clients of risks and that Jordan Terry “knew full well exactly what she was getting herself into.”
Maryland’s Board of Nursing, meanwhile, has come under scrutiny for its sluggish pace at working through a staggering backlog of complaints.
One case, which The Post first reported on in December, took six years to resolve. In 2017, the board received a complaint from a physician regarding Tina Brown Overton, who supervised a VBAC attempt at a home in Crofton, Md., that resulted in the fetal death of Channing Puckett and a life-threatening infection to his mother, Naomi Puckett. Overton had held herself out as a trained midwife but actually had no credentials, the Puckett family later discovered. In March, Overton agreed to pay a $5,000 civil fine to the board for unlicensed practice of midwifery. Overton did not respond to a request for comment.
“Nothing will bring him back,” said Jeff Puckett of his deceased son. “Our motive really, from the start, is that we didn’t want this to happen to anybody else.”
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(c) Washington Post
The safest option is to create “birthing centres” with less intervention ~inside~ hospitals, in pre-screened, healthy mothers and babies but with immediate access should danger arise.
How will greedy doctors and greedy Big Pharma fill their pockets if experienced midwives can handle it?