As the number of home deliveries increases, midwives practice legal gray areas: shots

Bethany Gates, a certified professional midwife in Iowa, examines her client Mandy King. The king has three children and this will be his first home birth.

Natalie Krebs / Side Effects Public Media

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Bethany Gates, a certified professional midwife in Iowa, examines her client Mandy King. The king has three children and this will be his first home birth.

Natalie Krebs / Side Effects Public Media

Mandy King Ivar lay down on a large, brown couch in Vifton’s Shifrah Birth Service, with soft piano music playing from a TV in the background. Her three young children – ages 3, 5 and 7 – her midwife Bethany Gates was playing next to her, examining her pregnant abdomen, applying pressure with her hands to various parts to locate the baby.

On this first day of spring, the king was 38 weeks pregnant.

“His head isn’t really moving very much,” Gates said. “She’s settling in the pelvis a bit, but it’s good. That’s what we want her to do.”

The king is planning to give birth in his first home. As a self-described homebody, King stated that he did not like giving birth in a hospital away from the comfort of his home and children.

“The experience of being at home is going to be amazing for my mental health,” he said. “[In previous births] There was just a lot of crying, a lot of ‘I miss my other kids. I want to be together as a family. ‘ So I’m really excited about that. “

King says he found Gates through a Facebook group.

Gates is one of about 12 certified professional midwives in Iowa. These are non-nurse midwives who specialize in home births and are certified through a program approved by the North American Registry of Midwives.

Iowa is one of more than a dozen states where midwives like Gates work in legal gray areas. The current law is working to change that by creating a license board for certified professional midwives.

In recent years, more people – such as kings – are choosing to give birth at home instead of in a hospital In 2019-20, the number of home births in the United States increased by 22% – to more than 40,000. According to the US Centers for Disease Control and Prevention, after a steady increase since 2004, home births now make up 1.3% of all births in the United States.

Home births are on the rise in rural America due to the closure of maternity facilities. In Iowa, eight hospitals closed their labor and delivery units in 2020-21, according to the state Department of Public Health.

Midwives like Gates say licensing homes in Iowa will help address the growing demand for births and address the growing desert of maternity care. But home delivery lawyers and hospital administrators are at odds over the issue.

High demand, little supervision

Gates has supervised nearly 100 home births in the last five years. He said before the epidemic, he never had to take back clients because of the high demand. But last year, she said requests for her center’s home birth services had increased.

“Like us, there were 120 searches from potential clients and we couldn’t take even half of them,” Gates said.

Following the nationwide trend, the number of home deliveries in Iowa has increased by more than 30% in recent years – from 512 in 2019 to 674 in 2021, according to state health data.

Bethany Gates’ desk has a certificate from the North American Registry of Midwives, an organization that approves courses for certified professional midwives.

Natalie Krebs / Side Effects Public Media

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Natalie Krebs / Side Effects Public Media

Bethany Gates’ desk has a certificate from the North American Registry of Midwives, an organization that approves courses for certified professional midwives.

Natalie Krebs / Side Effects Public Media

Gates said that unlike nurse midwives who work primarily in hospitals, certified professional midwives like themselves tend to focus on home births for less risky pregnancies.

“We’re specialists in out-of-hospital, normal, low-risk births,” Gates said.

Fifteen states, including Iowa, Nebraska and Kansas, do not license certified professional midwives. Gates says without a license, midwives are unable to get the drugs and lab tests they need to practice.

“I am not illegal to practice, because there is no state law to ban my practice,” he said. “However, there is no law that I can say, and that’s where we get into the issue of accusing midwives.”

This is taking skilled midwives underground, he said, even outside of unlicensed states like Iowa.

At a recent legal hearing, Melanie Peterson, a certified professional midwife who has worked in Iowa for more than 30 years, said she was charged in 2006 with drug use without a license.

Peterson said he took an application contract and the allegation was removed from his record.

“I’ve had hundreds of deliveries, especially in Cedar County, where there’s no gynecological, no maternity, no hospital,” she said. “So rural women are giving birth at home. There is no opportunity to take care of them.”

In some parts of the United States, labor and delivery services are more important than ever. According to a 2017 survey published in the Journal, between 2004 and 2014, 1 in 10 rural counties nationwide lost all hospital maternity services – and a further 45% had no hospital maternity services in rural US counties. Health issues.

“We’re not going to open an OB unit, but we’re going to have extra manpower to help,” Gates said. “If an OB unit closes in a county where there is a midwife, that midwife will automatically become much busier. So more midwives may come to the state to help fill that void as a result of licensing.”

Disagreement on the way to the license

In early March, Iowa lawmakers echoed Gates’ sentiment when the Iowa House passed a bill that would establish a licensing board for midwives. It has received bipartisan support.

“This is rural access to healthcare that many young families need,” said Mary Mascher, a Democrat from Iowa City. “And one of the most important parts of this bill is the fact that many birth centers are closed in hospitals across our state and so it opens up access for them.”

If the measure passes, Iowa will join 35 other states, including Washington and DC, which have already passed licensing laws for certified professional midwives.

But the state’s main hospitals and healthcare providers have objected to the bill, saying it does not require a strong enough transfer agreement and coordination between midwives and hospitals. They argue that this could lead to problems with medical liability for the hospital and could have serious consequences for mothers and children.

“We’re setting up a scenario here where, if there’s a complication, we’ll drop women off at the emergency department without a warm handoff, and that’s not a scene we’re comfortable with,” Dennis said. Tiben, a lobbyist for the Iowa Medical Association, at a Iowa Senate subcommittee hearing in March. “We believe this is a very dangerous situation.”

Professional organizations such as the American College of Obstetricians and Gynecologists, or ACOG, have a more subtle perspective.

Lindsay Jenkins, an OB-GYN of Des Moines and chair of the ACOG’s Iowa legislature, said the agency wants to see the bill limit midwives’ practice to carefully define low-risk pregnancies before endorsing them.

Jenkins said, “The problem with obstetrics is that everything goes well until it suddenly happens.”

A hospital or a recognized birth center is always the safest place to give birth, he said. But if a woman wants to give birth at home, it should be carefully planned with a trained professional.

“This includes a midwife who meets the minimum required standards of training to be able to provide care during and outside the hospital. Someone who is willing to accept the limitations of their practice opportunities,” she said.

The ACOG’s latest statement on birth settings, published in 2020, warns against home births, stating that “planned home births are associated with fewer maternal interventions than planned hospital births,” adding that they are more than twice as likely to die in childbirth (1 in 1,000). -2) and the risk of neonatal seizures or severe neurological dysfunction is tripled (0.4-0.6 per 1,000). “

Research suggests that limiting home births designed for low-risk individuals may be a safer option. A 2021 peer-reviewed study in the journal ACOG, Jn Shag Shadg DogIt has been found that low-risk mothers who are born prematurely have a lower rate of adverse outcomes in the state of Washington, where there is a well-established practice of community midwifery.

Licensing can be difficult to compromise

To address the concerns of hospitals and healthcare providers, some states, such as Indiana, have imposed additional restrictions on midwives. Indiana passed the Licensing Act in 2013 and has 17 actively licensed certified professional midwives, according to state data.

The law requires midwives to bear medical liability insurance and to have written cooperation with a physician.

This has created new challenges for licensed midwives like Mary Helen Ires in Bloomington, Industry. He said a few insurance companies cover home delivery midwives, and it is difficult to find a physician who would sign the cooperation.

“Doctors are very aware of their responsibilities and don’t want to extend it, so I don’t blame them,” he said. “In exchange for legitimacy, we are understood by a requirement for liability insurance; we are understood by the need for cooperation.”

Ayers said the additional restrictions made it more difficult for midwives to practice in his state.

This comes from a partnership in the story Iowa Public Radio And Side effects Public media – A public health news correspondent based in WFYI. Follow Natalie on Twitter @natalie_krebs.

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