MIDWIFERY

providers — direct-entry midwives. These nonnurse practitioners enter the field from midwifery schools or apprenticeships and rarely collaborate with physicians or hospitals.

Of the more than 400,000 out-of-hospital births attended by midwives in the past decade, nearly 60 percent involved those not certified as nurses, according to data from the Centers for Disease Control and Prevention.

But more than a dozen states, including Ohio, have no laws on the books concerning this type of midwife, creating a Wild West landscape where anything goes.

“The legislature didn’t really care about that population, and so it evolved without animosity,” said Virginia Buchanan, a Florida attorney representing the family of a child who died in an out-ofhospital birth. “They sort of snuck in and established a presence, and it just has sort of grown. Somewhere along the lines, it just got overlooked.”

In states where midwifery is still unregulated, non-nurse midwives have lobbied lawmakers for licensure. They want the legitimacy that comes with that status, as well as the ability to bill insurance.

But those same midwives fight restrictions Jackson Young

that come with state oversight, even helping kill legislation meant to protect families.

“They have been cowboys so long, they don’t want anyone telling them what to do,” said W. Gregory Wilkerson, chief of obstetrics and gynecology at University Community Hospital in Tampa.

Oklahoma state Sen. Ervin Yen tried for two consecutive years to regulate the practice amid opposition from midwives who bristled at some of the measures in his proposed legislation. Yen wanted to ban out-of-hospital breech deliveries, twin deliveries and vaginal births after cesarean sections, called VBACs. All carry extra risk and can lead to injury or death.

Yen’s efforts failed, and he lost his bid for reelection in June.

“How can we have supposed health-care professionals in the state dealing with life and death, and they’re not licensed or certified by any state entity?” asked Yen, who is also Midwife Faith Beltz, foreground, holds Aquila immediately after her mother, Liz Paparella, background, delivered her during a 2009 home birth. Aquila did not survive.

an anesthesiologist. “Hairstylists are licensed. This is life and death.”

Most out-of-hospital midwives are certified professional midwives, or CPMs. They require no nursing experience, health-related background or 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.

There are roughly 2,200 active CPMs in the United States, according to the midwives registry.

Many also hold state licenses, but hundreds live where non-nurse midwifery is unregulated or banned.

Many mothers told GateHouse Media they did not understand the distinctions among the different types of midwives and assumed all were alike.

“We honestly thought she was a certified nurse midwife,” said Bambi Chapman of Massillon, in northeastern Ohio, whose daughter, Mary Beth, died seven hours after a 2008 home birth involving a midwife. “We didn’t realize she was just a CPM. Knowing what I know now, I think that would have made a difference.”

Midwives fought restrictions in Alabama as legislation to regulate the practice worked its way through the statehouse in 2017. Although they had lobbied for more than a decade for state recognition, midwives balked when outside groups urged lawmakers to ban out-of-hospital VBACs, breech births and the delivery of twins.

The groups, including the American Medical Association and the College of Obstetricians and Gynecologists, also insisted the law require non-nurse midwives to carry malpractice insurance.

“The midwives were very much opposed to some of things we insisted being in the bill, but at the end of the day, they were willing to accept those things to get a bill passed,” said Mark Jackson, executive director of the Medical Association of the State of Alabama.

Alabama is now one of only three states with an insurance mandate. Indiana and Florida are the other two. But the minimum amounts required — $100,000 per incident and $300,000 aggregate — are far less than what physicians typically carry.

“The minimum amount for an obstetrician is $1 million per incident and $3 million aggregate,” said Lynda C. Gilliam, a physician and the chairwoman of the Alabama chapter of the ACOG.

Alabama’s new law called for the creation of a midwifery board to set rules, handle complaints and discipline licensees. But critics doubt its potential efficacy, citing a dearth of non-midwife members and a sparse calendar of meetings.

“I don’t have the confidence that this midwife board would properly investigate complaints or has the wherewithal to handle these issues,” Jackson said. “The board in Alabama said they’re only going to meet twice a year. How does a regulatory board meet twice a year?”

The Alabama Board of Medical Examiners, by contrast, meets monthly.

••• A GateHouse Media review of disciplinary cases handled in states that regulate midwifery show few resulted in license revocation — even when they involved numerous violations, injury or death.

In Florida, Lola Nelson failed to consult with a physician on a vaginal birth after caesarean delivery that resulted in a uterine rupture. The baby subsequently died and was delivered by C-section at a hospital. The mother required a partial hysterectomy. Nelson admitted the state’s allegations in a settlement. She received an 18-month probation during which she could still practice under supervision. She let her license expire in 2011.