Birthing center bill clears state Senate panel
By Emily Le Coz, Josh Salman and Lucille Sherman
A bill that would expand the scope of practice for freestanding birth centers has cleared a key committee in the Florida Senate despite pushback from hospitals.
The legislation would allow freestanding birth centers to begin offering cesarean sections and vaginal birth after previous C-section deliveries, which are not allowed under current birth centers rules. The measure swept through the Senate committee on Health Policy on Monday.
Oklahoma nurse midwife has license revoked, continues to practice unregulated
By Lucille Sherman, Emily Le Coz and Josh Salman
Dec. 21, 2018
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 nine-month investigation called “Failure to Deliver” that found planned out-of-hospital births with a midwife 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 certification body for members of the American College of Nurse-Midwives, the American Midwifery Certification Board, 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 located in Oklahoma City, according to her website.
A GateHouse Media analysis of Centers for Disease Control and Prevention data showed that out-of-hospital births attended by non-nurse midwives have nearly double the infant mortality rate of those attended by certified nurse midwives.
The out-of-hospital birth rate 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. Three-fourths 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.
Not one 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 on Thursday, however, shortly 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.
Correction: A previous version of this story said certified nurse midwives are credentialed by the American College of Nurse-Midwives. They are not. Certified nurse midwives are credentialed by the American Midwifery Certification Board.
Top NARM official under state scrutiny
By Emily Le Coz, Josh Salman and Lucille Sherman
Dec. 18, 2018
A top official at the North American Registry of Midwives – the credentialing body for the largest group of non-nurse midwives in the country – is under scrutiny by the state of Georgia after a GateHouse Media investigation found her practicing unlawfully.
The Georgia Board of Nursing confirmed Monday it is reviewing information reported in the series, called “Failure to Deliver,” to determine whether Debbie Pulley is in violation of the board’s law and rules. If so, it said it will issue her a cease-and-desist order.
Georgia Rule 511-5-1-.02 says “no person shall practice midwifery, or hold himself or herself out to the public as a midwife, unless that person has a current certification from the Georgia Board of Nursing to practice as a Certified Nurse-Midwife.”
Pulley is not a certified nurse midwife. She is a certified professional midwife, a credential provided by North American Registry of Midwives to those who complete a midwifery program or apprenticeship and pass a capability test.
Pulley, who oversees public education and outreach for NARM, 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 Georgia.
She did not respond to multiple requests for comment regarding her unlawful status.
Certified professional midwives are not required to have nursing degrees – most do not – and some have no more than a high school diploma.
Twelve states do not recognize or regulate certified professional midwives. Four states and the District of Columbia ban them. Yet several hundred of NARM’s 2,200 members are located in these states – including nearly 100 in areas where they are banned, according to the organization’s most recent annual report.
NARM shields those midwives by denying the public access to its roster. Pulley told GateHouse Media in a previous interview that releasing that information could jeopardize those who violate state laws or regulations.
“We don’t know necessarily where they’re practicing,” she said at the time. “We don’t care to find out.”
Planned births outside the hospital nearly doubled nationally in the past decade, but it’s a deadlier practice than hospital deliveries, and a loose patchwork of state laws leaves families little recourse when something goes wrong.
GateHouse Media, along with the Sarasota Herald-Tribune, spent nine months investigating the out-of-hospital birth industry. Reporters interviewed more than 100 mothers, midwives, physicians, attorneys, lawmakers and researchers. They read thousands of pages of disciplinary records, regulations, lawsuits and studies. They analyzed state and national birth and infant death data. They crisscrossed the country, visiting birth centers and hospitals, and even followed a mother through her home birth.
How a birth center delivery devastated a Florida family
By Emily Le Coz, Josh Salman and Lucille Sherman
Everything was coming together for Melinda Pino and her husband, Shawn McKee. The couple just settled into a new home with wide hallways and doors – perfect for the wheelchair their daughter would need.
Caring for a toddler with severe brain damage was tolling, but the little girl who wasn’t supposed to make it out of the hospital started to seem more alert. They began researching special needs schools, stem cell therapy and machines to help her walk. For the first time since Madeleine’s birth, the young parents could see a future.
They felt so confident about her progress that they turned off her precautionary breathing equipment one February night. She died in her sleep. Three days before her third birthday.
“She saw an opportunity and that was it,” McKee said. “Three years that felt like a lifetime.”
Maddie suffered from cerebral palsy , the result of oxygen loss during a delivery with a licensed midwife at a Florida birth center.
Maddie spent much of her life in and out of the hospital, racking up more than $1 million in medical fees. She ate through tubes that fed food directly into her intestines. She endured a dozen seizures every day and required round-the-clock care. A common cold would develop into pneumonia, then a collapsed lung and another eventual death scare.
Licensed midwife Deborah Jacobs Marin noticed signs of distress during the February 2010 delivery. But she let the first-time mother push for four more hours without calling for help, even after losing the baby’s heartbeat, according to a lawsuit filed by the family .
Marin denied the allegations in a court document but agreed to a settlement for an undisclosed sum . She did not return three calls for comment.
Despite those legal woes and a previous, unrelated reprimand from the Florida Department of Health, Marin still works at the same South Florida birth center.
After Maddie’s death, the family moved to Arizona, where they’re raising three healthy children.
But pictures on the beige walls are all Isabella, Adeleine, and Christopher have to remember their oldest sister.
“I still don’t compute in my head how this happened,” Pino said. “Thank God we had my daughter for three years.”
Maddie’s birth came on one of those rare mornings Miami drops below 50 degrees. A week overdue, Pino took a hot shower to help ease the contractions.
During her 45-minute ride to the Hollywood Birth Center in Broward County, Pino was passing hospitals and remembered wanting to just stop. By 8 a.m., she was 8 centimeters dilated. At the birth center, she got right into the warm tub to labor.
But Pino’s progression slowed.
She forgot breakfast, and by now, she was hungry. But she couldn’t swallow. She couldn’t even catch her breath. The pain was unbearable.
Three hours later, Marin – the midwife leading the delivery – broke her water. Pino could not stop pushing. The baby was turtling, her head popping in and out.
“She said, ‘You can’t have this baby here – we need to go to a hospital,’” Pino said. “I didn’t want to move, it was too painful.”
But the midwife didn’t call 911.
“She gave us 15 more minutes – that turned into a few hours,” Pino said. “You hire these people to guide you. I’ve never done this before. I don’t know what point the situation becomes an emergency. That’s not the job of the mother.”
She went down on all fours – and the baby started to come out.
Maddie’s hand was stuck near her face. The newborn was covered in thick, pea soup meconium, which stained her fingernails yellow. She didn’t cry. She was purple and not breathing. The only thing keeping the infant alive was a beating heart.
When paramedics arrived, they loaded Maddie into an ambulance, her father by her side.
An annual report filed with Florida’s Agency for Health Care Administration confirms the birth center transferred a newborn in poor condition on Feb. 26, 2010, for breathing problems and ingested meconium.
Back at the birth center, Pino started nodding off and said the midwife slapped her to wake up.
She remembered getting up to use the bathroom, a trail of blood leading back to the bed. The sheets were soaked and stained.
“It looked like a murder scene,” she said.
Joe DiMaggio Children’s Hospital was five minutes away. Maddie’s eyes were twitching back and forth; her breathing sporadic. But medical staff estimated she would be home by the end of the weekend.
The next day brought devastating news. The baby had seizure activity from apparent brain damage. The official diagnosis was hypoxic-ischemic encephalopathy, according to provided medical documents . During the prolonged delivery, the fetus lost her supply of blood and oxygen, killing vital brain cells.
Maddie would never live a normal life.
Physicians prescribed Phenobarbital, a powerful and sedative seizure medication. The mother and her daughter shared skin-to-skin kangaroo time, and took newborn pictures. Then they stuffed Maddie’s face with more tubes.
“The recommendation from doctors was just to let her die,” Pino said. “They told me to let her be an angel.”
Maddie spent the first six weeks of her life in the neonatal intensive care unit. There was a lot of testing, trial and error. They would constantly switch medicines and tinker with doses. Several times, physicians urged the family to sign a do-not-resuscitate order.
“That was not an option for us,” Melinda said. “We couldn’t just let her go.”
The doctors at Joe DiMaggio Hospital told the family there was nothing else they could do, but the parents wanted a second opinion, so they worked with insurance to have Maddie transferred by ambulance to Miami Children’s. Physicians at the new hospital gave them more time.
The couple lived in in their daughter’s hospital room. No social life – their daughter’s nurses, doctors and specialists became their only friends. In the hospital’s pharmacy, they’d be confused for employees. They knew the good pastries were kept in the surgery center and which floors stashed the best coffee.
At Pino’s suggestion, doctors eventually took Maddie off the seizure meds.
All of a sudden, she gained reflexes. They started oral feeding therapy. And speech therapy. And pulmonary therapy. Anything to get her to latch or swallow.
They battled pneumonias, a collapsed lung and acid reflux. A good stretch would mean five days without a death scare.
“There were no options – at least, no good options,” McKee said. “The first year to 18 months was pretty much survival mode. It’s like being in a war zone, real life or death situations, and you’re just trying to make it to the next milestone. There was no end in sight.”
By July, Maddie stabilized. The first-time parents could finally bring home their daughter. But not without feeding pumps, an oxygen tank, suction machines and nurse care.
Within six months, she was back in the hospital with a cold. The family went straight from New Year’s Eve fireworks to the emergency room. This time, she was intubated for 11 days and put on life-support.
During Maddie’s hospitalization, McKee was laid off from his job at a dietary company.
“I remember thinking, ‘Good – that’s great,’” Pino said. “‘We’re going to need this time because we might not be taking a baby home with us.’”
The couple also used the opportunity to get married. During a shift change at the hospital, they dashed to her father’s house, where their stepmother wed them in the kitchen. That night, the family celebrated with an impromptu dinner at Red Lobster.
But there was no honeymoon. The newlyweds spent the rest of the night with their daughter in intensive care.
Maddie’s condition eventually improved. Physicians prescribed Methadone to wean her off some of the other medications, and the strong narcotics were working. At one point, Maddie grabbed her father by the ears and pulled him toward her face. It was the most interaction they’d ever seen.
In February, the family celebrated Maddie’s first birthday at home.
She was never hospitalized again.
“We started a new life at home – with a kid with severe medical needs,” Pino said. “We just isolated ourselves.”
The oxygen levels often dipped in their bedrooms, so on most nights, Maddie slept in the living room, her mother on an air mattress beside her.
The family moved out of their townhome and purchased a new house – with wide doors and hallways – planning for Maddie’s future in a wheelchair. The new place was right down the street from a hospital and 10 minutes to therapy.
They tried to assimilate into a normal life. They took Maddie to the park, picked out a Christmas tree together and spent a day at the beach.
When Maddie was 18 months old, Pino and McKee also got pregnant with their second child, Isabella. They went to Stephanie Fink, a certified nurse midwife, who is married to an obstetrician, and delivers in a hospital. She became close with the family.
“When you see red flags, that’s when you transfer a patient,” Fink said. “You don't wait for the emergency. You've got to see the writing on the wall. It sounds like there was definitely red flags during (Maddie’s) delivery. She didn't get transferred early on, when she needed to be.”
“It was a very difficult situation, but I've never seen a family so connected and caring,” she said. “It was almost like she didn't have special needs, the way they loved her.”
When Isabela was born, they laid her on Pino’s chest, and the baby lifted her own head.
Ten seconds into life, she accomplished something Maddie barely could.
“You don’t have time to think about it or be sad,” Pino said. “You’re just so focused. We just went minute to minute, hour to hour, trying to string a few good days together. You don’t see the big picture.”
Pino started blender diets using fresh vegetables and eggs from free-range chickens kept in their backyard. That worked for some time, but when Maddie started aspirating, they had to go back to partially-digested formula.
Maddie would seem more alert, even attempting the push buttons on a toy.
The family looked into stem cell therapy and medical marijuana. Insurance approved coverage for a wheelchair and a walker.
“There’s so much stuff that goes into keeping someone alive,” Pino said.
Maddie was almost 3, and no longer needed her breathing equipment all the time.
She strung together several good days. And then one night, McKee woke up panicking. Maddie was dead.
“She had been doing so good that day,” Pino said. “There was so much momentum, and then you just hit a brick wall. It was nonnegotiable. Until then, I had been able to negotiate every moment of her existence.”
Melinda and Shawn already ordered Maddie’s birthday cake from the bakery.
They decided to keep it, celebrating their child’s third birthday at her own wake.
Friends started a crowdsourcing page and raised enough money to buy them a headstone.
The experience was the exact opposite of glowing stories they read about online – and recalled from Ricki Lake’s “Business of Being Born” documentary.
By all indications, the baby was perfectly healthy. She had all of the ultrasounds done, and there were no high risks. Melinda was 29 years old and fit, with no medical issues in her life.
“You don’t want your kid to get the side effect of an epidural,” she said. “Looking back, if only it was just that – the side effect of an epidural. If only.”
After Maddie’s death, the couple had vivid nightmares of their daughter’s resurrection.
Pino says she is not religious. But when caring for Maddie, she felt bigger then herself.
“I felt plugged in, and Maddie was the plug,” she said. “I know it was her because she’s gone now, and I don’t feel it anymore.”
Mother’s home-birth death turns ‘greatest day’ to ‘worst day’ in family’s life
Eric Dexheimer, Austin American-Statesman
In the spring of 2013, Amanda Garbacz was on top of the world. A standout student, she had recently graduated from the University of Arkansas with a civil engineering degree and become engaged to another engineer. Now she was about to become a new mother.
The previous fall, Amanda, then 23, learned she was pregnant. Her early prenatal checkups showed her to be in generally sound health, but raised several concerns. She had seen a cardiologist for a rapid heartbeat and arm numbness. In October, an obstetrician also had noted her asthma and labeled her pregnancy “high-risk.”