Part 3 of 3

Editor’s Note: This is part 3 of 3.

The North American Registry of Midwives represents the nation’s largest group of out-of-hospital delivery providers — certified professional midwives.

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 certified professional midwives, also known as CPMs.

The organization counts nearly 100 of them 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, which restricts midwifery to certified nurse midwives only. 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 informed consent document 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, including Ohio, don’t regulate non-nurse 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 breech position and had a prolapsed umbilical cord, 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, according to a May 2014 letter 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 re-open the case. 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.”

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The United States differs from other industrialized countries in its recognition and regulation of midwifery.

In countries such as Canada and the Netherlands, where out-of-hospital outcomes are better, all midwives must have at least a bachelor’s degree 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 only five states — 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 between groups like the ACNM, NARM, other professional midwife groups.

The groups, which began meeting in 2013, released suggested measures for states to address issues such as insurance, complaints and education requirements.

The regulatory goals outlined, if met, would inch the United States 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 Grunenbaum, 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,” Grunenbaum continued. “They don’t have adequate training. They don’t have enough experience. And they’re performing dangerous procedures outside of a hospital.”