Southwest Missouri midwife case draws scrutiny to state laws

Tuesday, December 28, 2010 | 1:26 p.m. CST; updated 2:46 p.m. CST, Tuesday, December 28, 2010

SPRINGFIELD — As Amanda Gardner spent more than 48 hours in labor in her Springfield home, Elaine Diamond, her midwife, came to Gardner's house frequently to check on her — and repeatedly told her she did not need to go to a hospital, according to Greene County prosecutors.

On Oct. 26, 2009, two days after Gardner's water broke, Diamond said she should go to a hospital, according to Springfield police.

The baby, a boy named Raheem, was partially delivered on the way, but when they reached the hospital, he wasn't breathing. He was born with the umbilical cord wrapped around his neck, 17 minutes after he had stopped breathing. He suffered brain damage and died Oct. 30.

Diamond, 53, of Schell City, was charged in Greene County with involuntary manslaughter.

Missouri has almost no regulatory authority over lay midwives such as Diamond, who are not required to be nurses and may not have a college degree.

Most learn under the supervision of other midwives. Diamond's credentials come from a group that calls itself a traditional Native American organization.

"She flat out lied to us and said she was registered," said Josh Gardner, the baby's father. He said he and his wife thought Diamond had medical credentials. "She said she was certified."

What Diamond did have was a work history that included an earlier brush with authorities. She was barred from practicing as a midwife in Colorado in 1997 after she left a woman who had given birth bleeding uncontrollably.

According to court documents, Diamond, who was not registered as a lay midwife in Colorado, called 911 and fled.

"I'm surprised there haven't been more of these incidents," said Jeffrey Howell, legal affairs director for the Missouri State Medical Association. "It comes down to how many babies do you want to end up like (the Gardners') baby? The answer should be zero."

State Rep. Mike Talboy, the House minority leader, said he plans to introduce bills next year that would outlaw lay midwifery or regulate lay midwives. He said that when problems arise with lay midwives, there is no recourse except criminal charges.

"We regulate the people who take the trash away from your curb," said Talboy, D-Kansas City. "We regulate the people who cut your hair. If you're a professional and want to be held as a professional, you want to have a regulatory environment so you know who's doing it right and who's doing it wrong."

Some midwifery advocates also say more regulation is needed.

Katherine Prown, campaign manager of a group called The Big Push for Midwives Campaign, said most other states that allow lay midwives to deliver babies have some type of oversight. Her organization wants to see certified professional midwives legally able to practice in every state.

Prown said the Diamond case is "a good example of the need for oversight and regulation."

Mary Ueland, a spokeswoman for the Missouri Midwives Association, said Missouri's current law regarding midwives would not have prevented what allegedly happened in the Diamond case.

"The current law didn't prevent this situation because the parents in the case chose to hire a midwife outside of the current state standard for midwives — CPMs and CNMs," Ueland said. "No matter what the state standard (law) is for midwives or veterinarians or plumbers, there will always be some people who may choose to hire someone who does not meet that standard or carry the license/certification approved by the state."

Diamond is outside the current law because she was not credentialed by the two groups that review lay midwives under Missouri law, the North American Registry of Midwives and the American Midwifery Certification Board.

Certified nurse-midwives, registered nurses who have completed graduate-level training in midwifery, are overseen by the State Board of Nursing in Missouri. Lay midwives are not overseen by any regulatory body in Missouri.

Although lay midwives are not required to be nurses, some undergo rigorous training. The requirements of the North American Registry of Midwives include helping during at least 20 births, doing at least 75 prenatal exams and taking an eight-hour written exam.

Ueland said parents need to think about what type of birth they want and research who will deliver the baby.

"We all like to see good outcomes," Ueland said. "The truth is that babies die in the hospital and that babies die at home."

Fewer than 1 percent of babies born in Greene County in 2009 were delivered by a certified nurse-midwife, according to the Missouri Department of Health and Senior Services.

Five babies were delivered by an "other" midwife — how the state records births delivered by lay midwives — in Greene County in 2009.

The baby whose death Diamond is charged in was delivered by medical staff in a vehicle outside St. John's Hospital.

Missouri became one of about two dozen states to allow lay midwives to deliver babies in 2007.

John Loudon, a state senator whose wife had been helped by Ueland, slipped a sentence using a Greek synonym for obstetrics, "tocological," into a bill. The law legalized midwivery by midwives who aren't certified nurse-midwives without setting up provisions to oversee them.

Legislators had no idea that the bill they were voting on legalized midwives, according to news accounts. Doctors groups have been trying unsuccessfully since then to get the law repealed or to get lay midwives regulated. The Missouri Supreme Court upheld the law in 2008.


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Derrick Fogle December 28, 2010 | 7:31 p.m.

Before Louden's addition to that bill, Missouri had some of the most restrictive midwifery laws in the US. Basically, a midwife could only practice if she was sponsored by an obstetrician. That's like having to be sponsored by a business competitor before you can open up shop. Several doctors that were willing to provide backing for midwifes found their hospital privileges threatened. I know this first hand; both of my children were born at home with the assistance of a certified nurse-midwife before that bill passed, and I was still very involved in midwifery advocacy at the time.

There was actually widespread support for sensible midwifery legislation well before Louden's action. In fact, there was only one Missouri rep who consistently filibustered every midwifery bill: Chuck "Double DUI" Graham. He was Missouri's filibuster king, partly because he was allowed to sit during his filibuster, instead of having to stand. Louden's action was an end-run around Graham's beholden-to-the-medical-industry recalcitrance.

A lot of people get really wound up about birth: "OMG you can't take ANY chance!" But the stark reality is that obstetrician-attended hospital births have statistically worse outcomes than midwife-attended home births and birthing center births. Just the drive to the hospital - especially in such a distracted state - carries a risk. A hospital-based birth exposes moms and babies to all kinds of foreign germs that they would not be exposed to at home. The probability of needing surgery - a cesarian - increases tenfold in hospital delivery setting. There's a difference between real risk assessment, and taking actions that appear to avoid risk.

Certified Nurse Midwifes actually must have as many years of medical training as obstetricians. But there's some difference in training: midwifes are focused on childbirth as a natural process of the human body; obstetricians are trained to treat pregnancy and birth as a disease to be treated, medicated, and surgeried.

When there are complications, modern medical procedures are a lifesaver. But the natural birthing process is slow, for a reason. Competent midwifes can sort out the high risk from the low risk, and almost always transition a laboring mom in trouble to the hospital in plenty of time. It's too bad the medical community so reluctantly takes these referrals, heaping all the scorn and liability accusations that they cry about when they get sued onto the parents.

If it weren't for the midwife witch-hunt the medical community invariably engages in every time this happens, the midwifes wouldn't be dialing 911 and running. They would be sticking with their patients.

(Report Comment)
Derrick Fogle December 28, 2010 | 7:32 p.m.

I don't want to defend this particular midwife. Mistakes were made that probably cost the life of that baby. But OBGYN's make mistakes too, and babies die even when even hospital deliveries are planned from the start.

I do want to staunchly defend midwifery in general. Midwife-assisted delivery is just as safe as a hospital based, obstetrician-assisted delivery. Midwifery based prenatal care is more extensive, more tailored to the mom and family, more personal. Postnatal care is excellent too. The delivery itself allows the laboring mom to maintain control, and the birth stays in the realm of "miracle from God." How many bad outcomes have there been from midwife deliveries since 2007 in Missouri? This one? You know every time it happens, the medical industrial complex will do everything they can to parlay the parent's grief into an advertisement for them.

One other aspect that must be brought up is the cost. Midwifery is as safe as OBGYN care, but half the cost. If we're looking for cost savings for health care, this is an effective way to accomplish that.

Not everyone can use a midwife, but most can. From both my wife and I's perspective, midwifery care was the best, most incredible, most wonderful experience imaginable. My son even had the dreaded 'cord wrapped around the neck' problem during delivery. It's actually fairly common. The midwife deftly unwrapped it. When he had transitional apnea because of the cord (he didn't start breathing right away), an oxygen tank was within arm's reach of the midwife. In a hospital, the oxygen is usually in a different room, down the hall. If you're worried about seconds counting, the midwife had the hospital beat.

We absolutely should NOT go back to the Graham days where midwifery was all but illegal. Hoever, I do agree with the need for more sensible certification and regulation. Make sure midwives are certified, but let them run free-standing businesses, without the requirement of OBGYN 'sponsorship.' And, make sure hospitals accept the occasional transfer with grace and enthusiasm, instead of scorn and derision. That should fix it.

(Report Comment)

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