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State protocol on births at home raises ire; exam rule snarls midwives, clients

by Andy Davis | May 9, 2018 at 4:30 a.m.

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.

Metro on 05/09/2018

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