Pro­to­col on births at home raises ire

Exam rule snarls mid­wives, clients

Arkansas Democrat-Gazette - - ARKANSAS - ANDY DAVIS

Arkansas mid­wives and their clients are com­plain­ing about a new pro­to­col used by the state De­part­ment of Health for de­ter­min­ing whether a woman can safely give birth at home.

Since Oc­to­ber, the de­part­ment has re­quired women to re­ceive vagi­nal ex­ams as part of the preg­nancy health as­sess­ments per­formed by nurse prac­ti­tion­ers at de­part­ment clin­ics. Some women who ob­ject to the exam as in­va­sive and un­nec­es­sary have agreed to sub­mit to it any­way. Oth­ers have re­fused.

Lit­tle Rock mid­wife Mary Alexander, chair­man of the state’s mid­wife ad­vi­sory board, was found in vi­o­la­tion of the de­part­ment’s rules af­ter she delivered a baby in Novem­ber for a woman who re­fused the vagi­nal exam. She has ap­pealed the find­ing.

State reg­u­la­tions bar a li­censed lay mid­wife from de­liv­er­ing a baby un­less the mother has passed two as­sess­ments: one shortly af­ter the mid­wife be­gins pro­vid­ing care, and the other at or near the 36th week of preg­nancy. The as­sess­ments are meant to de­ter­mine whether the mother has any med­i­cal con­di­tions that would make a home birth dan­ger­ous or re­quire con­sul­ta­tion with a doc­tor.

In the past, women could de­cline the vagi­nal exam but still com­plete the as­sess­ment. That isn’t the case now.

In some cases, mid­wives say they have been forced to drop clients who re­fused the vagi­nal exam. Those clients went on to give birth at home with­out a mid­wife’s

help, put­ting the woman and baby at a higher risk for com­pli­ca­tions, the mid­wives say.

Alexander said she won’t aban­don clients over their re­fusal to sub­mit to the exam.

A com­mit­tee of the state Board of Health is set to hear her ap­peal of the rule vi­o­la­tion find­ing on Thurs­day. In the mean­time, an­other of her clients who re­fused the exam is due to give birth next month.

“We don’t think that these vagi­nal ex­ams are nec­es­sary,” Alexander said. “They don’t give in­for­ma­tion that would de­clare the woman high risk for home de­liv­ery or not.”

Wil­liam Green­field, the med­i­cal di­rec­tor for the Health De­part­ment’s fam­ily health ser­vices, said the pro­to­col was de­vel­oped by a panel of de­part­ment nurse prac­ti­tion­ers to en­sure stan­dard prac­tice across dif­fer­ent health units around the state.

The vagi­nal exam al­lows the nurse to as­sess whether the woman’s pelvis is large enough for a vagi­nal de­liv­ery, to spot ge­netic con­di­tions that could pose risks for such a de­liv­ery and to look for in­fec­tions that could be passed on to the baby, he said.

“This is about our health care con­sumers — that they get a stan­dard and safe health ex­pe­ri­ence,” Green­field said.

State reg­u­la­tions don’t re­quire the risk as­sess­ments to be done at the de­part­ment. But mid­wives say few clin­i­cians out­side the de­part­ment will per­form such as­sess­ments for women who plan to give birth at home.

One man said that af­ter his wife re­fused a vagi­nal exam and ul­tra­sound from a Health De­part­ment nurse, he called four doc­tors in Lit­tle Rock in an un­suc­cess­ful search for one who would per­form such an as­sess­ment.

About two weeks later, af­ter his wife went into la­bor on a Satur­day in De­cem­ber, the cou­ple made one last at­tempt, vis­it­ing two hos­pi­tal emer­gency rooms and three ur­gent-care clin­ics in Lit­tle Rock, Ben­ton and Bryant.

Fi­nally, they went home, where the man — us­ing in­for­ma­tion he had read on­line and ad­vice given by an un­cle who had delivered chil­dren — delivered the baby him­self that evening with help from his mother-in-law.

“It was not fun,” said the man, who asked not to be iden­ti­fied. “My wife will tell you that for our other two chil­dren, I wasn’t even in the room.”

One of Alexander’s clients — Stephanie Wol­marans, 32, of Lit­tle Rock — said she re­fused a vagi­nal exam dur­ing her first risk as­sess­ment at the Health De­part­ment’s Faulkner County Health Unit in Jan­uary and was is­sued a form say­ing her as­sess­ment was in­com­plete.

She isn’t sure where she’ll go for her sec­ond as­sess­ment, due in a few weeks, but she plans to give birth at home in any case.

“If it comes down to it, we’re just go­ing to do it unas­sisted,” she said.

Arkansas has 28 li­censed lay mid­wives. They delivered 250 of the 38,721 babies born in the state in 2015, the most re­cent year for which fig­ures were avail­able.

The mid­wives have long com­plained about the risk as­sess­ments, say­ing they du­pli­cate checks the mid­wives al­ready do.

Among the 31 states that reg­u­late mid­wives, Arkansas is the only one that re­quires such as­sess­ments, said Ida Dar­ragh, a mem­ber of the mid­wife ad­vi­sory board who is also di­rec­tor of the North Amer­i­can Registry of Mid­wives, which sets the stan­dards for a pro­fes­sional mid­wife cer­ti­fi­ca­tion.

State reg­u­la­tions that take ef­fect June 1 will al­low a mid­wife to con­tinue car­ing for a woman who re­fuses cer­tain tests, but the woman must still un­dergo a risk as­sess­ment. The reg­u­la­tions don’t re­quire a woman to get a vagi­nal exam, but the Health De­part­ment does re­quire one as part of an as­sess­ment that it per­forms.

Last year, 17 women were is­sued forms in­di­cat­ing that their as­sess­ments were in­com­plete be­cause of their re­fusal of a re­quired med­i­cal ser­vice or test, up from four in 2016, Health De­part­ment spokesman Meg Mirivel said.

As of late last month, six women who re­fused tests or ser­vices had been is­sued such forms this year, she said.

Deb­o­rah Phillips, a North Lit­tle Rock mid­wife and mem­ber of the mid­wife ad­vi­sory board, said three of her clients ended up giv­ing birth at home, with­out her as­sis­tance, af­ter she was forced to drop them as clients be­cause they re­fused the vagi­nal exam.

Oth­ers have driven to Fayet­teville or Cam­den to see pri­vate clin­i­cians who will do the as­sess­ments with­out the vagi­nal ex­ams.

“Most women hate them,” she said of the vagi­nal ex­ams. “They hurt, and they make them cramp af­ter­ward. It’s just no fun.”

In a let­ter to the Board of Heath, the mid­wife ad­vi­sory board said mid­wives shouldn’t be re­quired to drop a client just be­cause the woman re­fuses the exam.

Board Pres­i­dent Cather­ine Tapp said at a meet­ing last month that she would ap­point a com­mit­tee to study the is­sue.

“We need moms and babies who are safe and healthy — I think we’re all in agree­ment on that,” said Arkansas Sur­geon Gen­eral Greg Bled­soe, a Board of Health mem­ber.

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