Tragic cases bring scrutiny of midwife-attended home births

The babies, one born in June, the other in January, had several things in common.

Both their mothers wanted to deliver at home, attended by Virginia Beach midwife Kristina Zittle, rather than in a hospital. Both mothers were obese. Both babies were turned the wrong way in the womb, according to records.

Still, their births might not have gained any attention from the public, except that both babies arrived in the world gray and lifeless.

Zittle has been accused by the Virginia Board of Medicine of handling high-risk pregnancies she wasn’t qualified to take on, and her license has been suspended. She is scheduled for a hearing Oct. 24.

Meanwhile, her case has brought attention to a movement that has been quietly growing in the state since a 2005 law legalized the practice of home-birth midwifery.

The number of home births has increased during that time. However, some in the health field say certain women are poor candidates for delivering at home because of risk factors that put their babies in unnecessary danger.

Other doctors and health care providers have questioned why there aren’t more restrictions in the law.

And one Board of Medicine member, Dr. Juan Montero, a retired Chesapeake surgeon, described the law as “irresponsible, egregious and truly reprehensible.” He said he was ready to resign from the board if the law was not repealed.

To some midwives, however, the Zittle case is an important step in the development of their profession because it demonstrates there’s a process to discipline and weed out those who practice unsafely.

“It should not reflect on all midwives any more than a bad outcome by a doctor reflects on the whole practice of medicine,” said Brynne Potter, a Charlottesville midwife and policy coordinator for the Commonwealth Midwives Alliance. “Reviewing and revoking licenses shows the system is working. I want them to judge fairly, and if there are problems, I want them corrected. That improves the profession for me.”

Potter helped draft Virginia’s licensed-midwife law, which was sponsored by Del. Phillip Hamilton, R-Newport News.

Until then, only certified nurse midwives – registered nurses with additional midwifery medical training – were allowed to supervise births. Nurse midwives practice legally in all states and work in consultation with a doctor. That means most of their deliveries are performed in hospitals or birthing centers because of malpractice insurance requirements.

Across the country, though, there’s been a push during the past few decades from women who want to have their babies at home. They view home birth as a natural event and want it to be free of the medical tests and interventions common in hospitals.

Supporters of this movement have lobbied legislators across the country to license non-nurse midwives. These practitioners get credentials through a midwifery certification board, most commonly the North American Registry of Midwives. The certification, established in the 1990s, includes education in core areas, either from midwifery institutions or through distance learning; the practice of skills under the supervision of a licensed midwife; and a licensing test.

The 2005 Virginia law requires that certification for licensure. The midwives don’t have to have malpractice liability insurance, but they need to inform clients whether they do, as well as how to file a complaint. According to the Midwives Alliance of North America, 26 states have some kind of licensing or permitting process.

Home birthing still accounts for less than 1 percent of births in Virginia and the United States, but it’s enough that the American Medical Association has raised concern. A resolution by the organization earlier this year stated that hospitals are the safest setting for birth and that physicians and midwives with a nursing background are best qualified to deliver babies.

After Virginia’s law took effect, the number of home births in the state grew by 19 percent between 2005 and 2007, to 592 last year. That compares with an increase of 4 percent for all births.

Twenty-two non-nurse midwives with Virginia addresses are licensed to deliver babies in the commonwealth. Dr. William Harp, executive director of the Board of Medicine, said eight complaints have been filed against licensed midwives.

Complaints about three midwives were serious enough that they advanced to the Board of Medicine or are scheduled to be reviewed by the board later this year. All those cases involve women who were morbidly obese and pregnant with large babies that during birth were either in a breech position – feet-first instead of headfirst – or experienced “shoulder dystocia,” in which the baby’s shoulders are caught on the mother’s pubic bone.

The case that has generated the most attention in Hampton Roads is that of Zittle.

Action against her is the strongest the board has taken – suspension of her license on Sept. 9 pending a hearing of the full board next week. Zittle declined to comment for this article.

Information she has posted on a personal Web site called “His Grace Herbals” said she is a retired midwife and sells herbs and homeopathic products.

She had four children in hospitals when she and her husband lived in Pennsylvania, and then three children in home births with the help of a midwife, according to the Web site.

She started studying midwifery herself before moving to Virginia. Her eighth child was born in a birthing center in Norfolk. She wanted to return to home birth for her next pregnancy but went into premature labor when she was 24 weeks pregnant. The twins died shortly after birth in a hospital. According to the Web site, that made her more determined to deliver her next baby at home in 2007, this one unassisted except for her 16-year-old daughter and a friend.

After she had obtained her midwife license, Zittle took on the care of a woman in January of this year. The client was in the last third of her pregnancy, according to Board of Medicine records.

The 25-year-old woman was overweight and had been treated by an obstetrician-gynecologist earlier in her pregnancy, at one point taking a test suggesting she might have gestational diabetes.

At 9:30 p.m. Jan. 23, the patient informed Zittle that her water had broken, which usually triggers the onset of labor.

Zittle waited more than 12 hours from that time to examine her in her office on Jan. 24, according to records. Zittle instructed her to go home. The woman began having contractions at 6:45 p.m. Zittle arrived at the patient’s house at 9:40 p.m. She did not perform a vaginal examination until 12:30 a.m. Jan. 25, records show – almost six hours after contractions began and 27 hours after the membranes had ruptured. By 5:02 a.m. Jan. 25, the left foot, shin and thigh of the baby were showing through the birth canal.

“Even though Ms. Zittle had never before performed a breech delivery, she opted to continue with a home delivery after obtaining the parent’s informed consent to do so,” the Board of Medicine report reads.

She didn’t call 911 until after the baby was born at 6:42 a.m., lifeless.

An autopsy revealed that the baby’s liver had ruptured, and the baby tested positive for infection. A medical examiner noted, “A c-section would have been life saving in this case.”

It was not the only Zittle case that went awry this year, according to the Board of Medicine. The second one involved a 42-year-old woman.

The Board of Medicine report states that the case was beyond Zittle’s abilities because of the mother’s risk factors – her age; that she was Rh negative, which can cause blood disease in the baby; and that she had delivered two overweight babies in the past.

A March 7 ultrasound showed the baby was in a breech position. Zittle, according to records, didn’t order another ultrasound closer to delivery. Rather, she determined the infant was in a head-down position based on “external palpation” in early June, records show.

The woman’s contractions began at 4 p.m. June 9 and intensified around 10 p.m., yet Zittle “ did not leave to go to Patient B’s home to attend her labor and delivery until approximately 12:34 a.m. on June 10, 2008, notwithstanding the 45-50 minute drive anticipated to Patient B’s home and the fact that Patient B was located approximately 17 miles from the nearest hospital and lacked transportation at that time.”

The baby was stuck halfway out of the mother’s womb in a breech position. An emergency medical services crew arrived before Zittle and called her to ask for the go-ahead to transport the mother to the hospital.

Zittle, though, instructed them not to leave and to instead help deliver the baby in the woman’s birthing tub and wait for her arrival, estimated to be 30 minutes, records say.

State licensing requires midwives to “transfer care immediately in critical situations that are deemed to be unsafe to a client or infant and remain with the client until the transfer is complete.”

Zittle arrived, and the mother was transported to a local hospital, where the baby was delivered and pronounced dead.

It is perhaps because these cases sometimes end up in the hands of obstetrician-gynecologists that some of these doctors have expressed growing concern about home deliveries.

The Medical Society of Virginia and the Virginia Obstetrical and Gynecological Society opposed the legislation that passed in 2005.

Dr. Bonnie Dattel, an associate director of maternal-fetal medicine at Eastern Virginia Medical School, said that during the past year she has noticed an increase in the number of pregnant women who had planned home deliveries but ended up at the hospital or in the care of high-risk obstetric specialists because of complications. Dattel said she’s seeing several a month.

What most concerns Dattel, who also oversees labor and delivery at Sentara Norfolk

General Hospital, is that in the cases she’s handled, the patients were clearly high-risk, she said, and should not have been accepted by midwives for home birth.

Four certified nurse midwives in Virginia also have lodged concern about the acceptance of high-risk patients by midwives.

In a January letter to the Board of Medicine, they said that they were not opposed to home birth or to non-nurse midwives practicing in Virginia but that stronger guidelines are needed to screen out high-risk patients.

They pointed out that some states’ laws prohibit non-nurse midwives from taking on the care of women with gestational diabetes, those who are morbidly obese, those pregnant with multiple babies, those who want a vaginal birth after having had a Caesarean birth, and those pregnant with a baby that is not in a headfirst position.

When a midwife “transfers a patient to a hospital who they clearly should not have provided care for, it compromises the integrity of our profession as midwives,” the letter read.

In February, the Board of Medicine voted to begin a “regulatory review” of the law with a focus on high-risk pregnancies, a request currently before the state’s executive branch.

Potter opposes stricter regulations, saying that the current guidelines are sufficient and that any restrictions would cause women to seek unlicensed midwives. A hallmark of midwifery, she said, is individualized care, and competent midwives are best qualified to determine who is able to have a home birth.

Potter said licensed midwives are trying to build better alliances with health care providers, since – even in the best of worlds – a small percentage of their cases will need to be transferred because of complications.

“We don’t want to all be judged by the one bad outcome,” she said. “We want accountability and transparency. The reason why obstetricians oppose us is they only see the 10 percent that get transported to hospitals and not the 90 percent that go beautifully.”

That’s a perspective that Virginia Beach mother Jennifer Green can provide.

Her three sons – each weighing in at more than 9 pounds – were all born in her Virginia Beach home in experiences Green describes as beautiful and empowering to her as a mother.

For her most recent pregnancy, Green hired Jennifer Derugen, a licensed midwife who moved to Norfolk from Pennsylvania two years ago.

Green, who is 33, said she believes in women’s right to give birth at home. She said she views childbirth as a natural process that too often gets interfered with by doctors in a medical setting. That said, she also recognizes that in high-risk pregnancies, the physicians are “a godsend.”

“If I were high-risk,” she said, “I would not be at home. There’s too much at stake.”

Elizabeth Simpson, (757) 446-2635, elizabeth.simpson@pilotonline.com