Nurse midwife has license revoked, continues to practice

An Oklahoma midwife who lost her nursing license in November after back-to-back infant deaths continues to practice, the result of the state’s lack of regulations on out-of-hospital midwifery, GateHouse Media has learned.

The Oklahoma Board of Nursing revoked Dawn Karlin’s certified nurse midwife license on Nov. 8. One day later, Karlin changed her business title and kept practicing — this time as a certified professional midwife.

Oklahoma does not regulate certified professional midwives or any other non-nurse midwife. Anyone can call themselves a midwife and provide services without rules or oversight.

Karlin declined to comment. The Board of Nursing filed a complaint against Karlin of Moments of Bliss Midwifery Services in August, shortly after GateHouse Media began investigating the two fatal attempted home births she oversaw — one in November 2016; the other in January 2017.

The reporting was part of a ninemonth investigation called “Failure to Deliver” that found planned out-of-hospital births are more dangerous than those at the hospital.

As a result of the information GateHouse Media discovered about Karlin, the board was able to take action, said former state Sen. Ervin Yen, an anesthesiologist who first brought concerns about the midwife to the board in 2017. He was able to provide additional knowledge based on GateHouse Media’s reporting.

“If you hadn’t uncovered that,” Yen said, “there very well might never have been a hearing.”

Karlin denied responsibility for either death in her response to the complaint.

One day after the board revoked her license, Karlin launched a new website — Bliss Birth Services — and removed the word “nurse” from her title. She continues to provide out-of-hospital midwifery services as a certified professional midwife.

Certified nurse midwives — who are credentialed by the American College of Nurse-Midwives and hold a master’s degree in midwifery — are licensed in Oklahoma, just as they are in every state except Hawaii. Only 5 percent of certified nurse midwives practice outside of a hospital.

Certified professional midwives, by contrast, are credentialed by the North American Registry of Midwives and must have a minimum of a high school diploma and either attend a midwifery school or complete an apprenticeship, as well as pass a test. CPMs work mainly outside the hospital. Karlin’s website shows she obtained her certification in October, after the state filed charges.

Because Oklahoma does not regulate non-nurse midwives, Karlin was able to keep practicing without having to apply for a new professional license or answer to a new board. She has an office in Oklahoma City, according to her website.

A GateHouse Media analysis of Centers for Disease Control and Prevention data showed that outof-hospital births attended by nonnurse midwives have nearly double the infant mortality rate of those attended by certified nurse midwives.

The out-of-hospital birthrate in Oklahoma is 1.3 percent, which is less than the national average of 1.5 percent. It remains one of a dozen states where unlicensed, unregulated non-nurse midwives can handle out-of-hospital deliveries.

More than 5,000 babies were born outside a hospital in Oklahoma in the past decade, according to data from the CDC. Threefourths of them were delivered by a midwife, the majority of whom were not certified nurses.

The cases that led to Karlin’s license revocation began in the spring of 2016, when the midwife accepted two new home-birth clients. Both had previous deliveries by cesarean section, according to state records — making their deliveries high-risk.

Vaginal birth after C-section — or VBAC — carries a roughly 1 percent risk of uterine rupture, which is fatal to both mother and baby if not treated immediately. Nine states ban home-birth VBACs. Oklahoma is not one of them.

Neither mother got her home birth. The first one noticed signs of trouble more than three weeks before her due date and reached out to Karlin for guidance.

“Is the baby going to be OK?” the client asked her midwife in a text message at 4:47 a.m. on Nov. 7, 2016, as shown in state records.

After laboring in pain for days, the mother went to the hospital. The obstetrician, Nancy Bishop, couldn’t find the baby’s heartbeat and performed an emergency C-section.

Bishop later testified that the baby was “wedged” inside the mother, with his arm and knee positioned to come down the birth canal first, making it difficult to deliver the baby even by C-section. Bishop testified that VBACs should only be considered if the baby’s head is presenting.

When he was delivered, the baby was resuscitated. He was covered in thick meconium — an infant’s first stool — and the umbilical cord was wrapped around his neck five times. He was transferred to another Oklahoma City hospital and died the next day. Bishop testified that if Karlin had taken “timely and appropriate actions,” the baby would have lived.

Two months later, Karlin attempted a VBAC delivery for the second client. The mother was one week past her due date, according to state records. She showed signs of pre-eclampsia and labored for a total of 30 hours.

When Karlin couldn’t find the baby's heartbeat, she transferred the mother to the hospital, where the baby was delivered via C-section. But it was too late. The baby was stillborn. The mother’s placenta ruptured, which can deprive the baby of oxygen.

Karlin testified in the Nov. 8 hearing that she did not consider either mother high-risk. Karlin also told the board the first mother labored at home for days because she did not want to go to the hospital, but she “no longer accepts patients for a primary VBAC delivery.”

In both cases, the nursing board found that Karlin failed to “adequately and appropriately monitor” and “timely transfer” mother and baby to the hospital.

A certified nurse midwife who served as an expert witness testified in the hearing that in both cases, Karlin’s care for the patients fell below the minimum standard and contributed to both babies’ deaths.

Karlin denied that her care was outside the scope of her practice or “provided in an unsafe manner."

The back-to-back deaths at the time had caught the attention of Yen, who said he went to the nursing board with the information.

“The nursing board started investigating a year and a half ago,” Yen said. “But (it) didn’t have enough information to subpoena records until GateHouse Media uncovered some information that they were able to use.”

The board of nursing was not immediately available for comment.

The deaths also spurred Yen to introduced two pieces of legislation in 2017. The first bill would have made it unlawful for anyone who isn’t a certified nurse midwife to call themselves a midwife or practice as one. Four states — Kentucky, North Carolina, Illinois and Georgia, along with the District of Columbia — allow only certified nurse midwives to practice.

The second bill would have banned midwives from performing VBACs outside of a hospital.

He also introduced a third piece of related legislation in the 2018 session that would have regulated one type of non-nurse midwife and banned them from overseeing VBACs, breech or multiple births outside of a hospital.

None of the bills made it out of committee. Yen lost his re-election bid in the June primary.

“In my opinion, if there are babies dying, you’ve got to do something,” Yen said. “You’ve got to speak out.”

Less than one month after losing her license, Karlin announced on Bliss Birth Services’ Facebook page she had delivered her first baby under her new business. The Facebook account appeared to be deleted, however, shortly after GateHouse Media reached out to Karlin.

“Bliss Birth Services is super excited to have welcomed BlissBaby#1 in the early morning hours yesterday!” the now-deleted post said.