Delivery dilemma

Local nurse AJ Edmondson gave birth to her son at home and plans to do so again with her daughter, who’s due imminently. On the occasions when this experience becomes a topic of conversation, she finds herself dispelling a range of misconceptions.

“Even people in the medical profession ask me, ‘Is it just going to be you and your husband?’ No, it’s fully assisted; they monitor you very closely,” Edmondson said. “It’s not just that you run out to a tree and deliver your child. It’s very medical—the same attention, but without this big, heavy-duty equipment.”

Welcoming newborn Weston was Dena Moes, a certified nurse-midwife (or CNM). Like Edmondson, Moes is a registered nurse. That RN designation distinguishes Moes from licensed midwives without that training, but also places her under the jurisdiction of a separate agency—one with a recent pattern of actions suggesting her profession may be in jeopardy. The California Board of Registered Nursing has brought charges against a series of Northern California CNMs in home birth practice, including Moes, who is currently defending herself against allegations from 2010.

Nonetheless, Edmondson remains as passionate about her midwife as she is about home birth.

Seeing The Business of Being Born, Ricki Lake’s documentary about American obstetrics, Edmondson says “the seed was planted” for a home birth before she and her husband, Walker, were ready to start their family.

Their decision didn’t stem just from a movie; nor from biases against modern medicine, the local hospital or Chico’s physicians. Edmondson works at Enloe Medical Center. Her choice practically defines the term “informed consent”: permission granted to practitioners by patients with full knowledge of the risks and benefits.

She knows others—nurses and nonpractitioners alike—who feel the same way.

“I support Enloe and am very proud of Enloe,” Edmondson told the CN&R. “I just want to promote home birth and promote the idea of options, other choices, and it doesn’t always have to be one way or the other.”

Indeed, Edmondson developed a plan with Moes for transport and admission to Enloe had complications arisen during the delivery of Weston, who’s now 3. The Edmondsons have the same arrangement for the birth of their daughter, who could come any day now (perhaps entering the world as you read this story).

“I’m open to the idea of transfer as needed,” Edmondson said. “It’s definitely a conversation I’ve had with Dena; that if there are any yellow flags, we will definitely go to Enloe.”

Otherwise, she will give birth at home. Privacy is one consideration, albeit minor: Edmondson works at Prompt Care, not in the Nettleton Mother & Baby Care Center, but Enloe is still a relatively small community of colleagues. Primarily, she embraces the midwifery model of maternity care, which includes “monitoring the physical, psychological and social well-being of the mother throughout the childbearing cycle” and “minimizing technological intervention” (per Moes’ website).

With Weston, she began early labor around 10 p.m. and called for Moes around 2 a.m. The Edmondson home already was set up for delivery, with a birthing tub and supplies; once Moes arrived with her assistant, they began monitoring Edmondson’s condition.

Edmondson moved from room to room, gauging where she felt most comfortable. She spent “a huge chunk” of her labor in the tub—“I loved the water, but I would get in and out, in and out”—before deciding to deliver in the family bedroom in the rear of the house. She gave birth on a birthing stool, then nestled in bed with Walker and Weston.

“It’s really a beautiful thing,” Edmondson said, encapsulating her home birth experience.

The baby Edmondson is carrying now potentially could be one of the final babies Moes delivers in a Chico home.

Moes faces disciplinary action by the Board of Registered Nursing (BRN), which could revoke her RN license or place her on probation with conditions that preclude her from practicing home birth midwifery. The board has done the latter in several recent instances, including the cases of Bay Area CNMs Yelena Kolodji and Kavita Noble.

Kolodji is challenging her sanction, as is Ruth Cummings, a CNM in Sacramento with 34 years’ experience.

Meanwhile, Nora McNeill, a CNM in Redding for 39 years, has found herself in a comparable predicament as Moes. She, too, must answer charges at a BRN hearing this summer.

Moes says she learned the BRN filed a formal complaint—called an “accusation”—against her approximately 2 1/2 years after she met with state investigators in 2012. The accusation (dated May 2, 2014) centers on her care of two patients transferred for hospital care. Each mother developed complications at home; the state contends that both patients were “high risk” and labels one “beyond the scope of patients a nurse[-]midwife can treat.” Obstetricians delivered their babies via Caesarian section.

Moes will head to Sacramento tomorrow (May 15) for a mandatory settlement meeting, where her attorney and state attorneys may negotiate a resolution. If not, Moes will mount a defense before an administrative judge at a hearing expected to be scheduled late next month, then appear in front of the BRN at its following meeting. Board members consider the judge’s ruling in determining the verdict.

“It’s been a whirlwind of emotions for me,” Moes told the CN&R last week. “It’s been difficult and stressful. On the other hand, I’m learning a lot about how things work in a system like the one we’re operating under.

“It feels pretty emotional because of the strong likelihood I may have to close my business, so I feel a lot of loss and grief about that. It’s been a wonderful way to earn a living and support my children while being of service to the community.”

Edmondson and others worry about the void that would materialize should Moes lose her ability to practice. Chico has several licensed midwives who perform home births, but Moes is the only nurse-midwife doing so locally. (Chico’s other CNMs deliver babies at Feather River Hospital or offer care under the auspices of Enloe-affiliated OB/GYNs.)

“It would create roadblocks for people who want to access home birth [midwifery] if you have fewer options,” Edmondson said. “And, just like with doctors, not all home birth midwives are going to be the best fit for you. I interviewed midwives and made sure I felt comfortable in their care.

“Dena is a really wonderful person. She provides excellent care. She’s smart. She has great education [two degrees from Yale, including a master’s in nursing]. The fact that she’s a nurse-midwife really makes a big difference, too.

“So I think if Chico were to lose her as a home birth midwife, it would definitely be sad to the community.”

Edmondson is among the supporters organizing a fundraising campaign for Moes’ legal defense. (See “Rallying to her defense,” page 25.) Moes has retained an L.A.-based attorney, Peter Osinoff, with expertise in health care litigation. Should the BRN rule against her to any extent, Moes could be responsible not only for Osinoff’s fee but also expenses accrued by the state throughout the five-year proceeding.

Mounting any appeal, she said, “gets more and more expensive.”

Ironically, Moes’ professional peril comes during a period of progress for the home birth community in Chico.

Edmondson, Moes and other proponents have coalesced into an informal group called the Chico Birth Network. More formally, Enloe administrators and staff have met with midwives and doulas (nonmedical maternity assistants), as part of a conscious effort to improve relations between the hospital and home birth practitioners; and Enloe also has opened the Mother & Baby Care Center to parents who choose home birth, offering tours to familiarize them with facilities and services.

Tracy Weeber, the center’s director, says these orientations—scheduled upon request—have proven to be “a really nice bridge to make the providers feel more comfortable coming to us, as well as some of their patients who could end up here. Instead of seeing us for the first time when they’re in labor, they get to see us a little bit beforehand.”

Added Connie Rowe, Enloe’s vice president of patient care services: “We just want to support them if they should need to make a change to their plan.”

That sentiment underscores the discussions between home birth midwives and hospital staff, who would like to develop protocols for the smooth transition of care. Smooth Transitions is, in fact, the title of an initiative adopted in the state of Washington and under consideration locally for home-to-hospital transports.

“I think [midwives] do feel a little vulnerable when we go into the hospital,” said Paula Emigh, a home birth midwife in Chico. “Our goal is to access medical attention for these families who have chosen to give birth at home … and I think sometimes the focus can go toward the midwife instead of just access for the family.”

Emigh, a licensed midwife, cares for an average of 20 expectant mothers a year through her practice, Birth Dance Midwifery. She began training in Chico in 1996 and practicing on her own in 2001. While the tone of her reception at Enloe varies “case to case”—most notably, whether she’s arriving due to an emergency transfer—“the majority of the time it’s been cordial between the doctor [on duty] and myself.”

Weeber anticipates an upswing in interactivity, saying: “I’m glad we have great communication with them. It makes it so much better for women in this community to have this open dialogue.”

Joc Clark has been both catalyst and conciliator for the hospital/home birth conversations. Clark is a facilitator who helps organizations with team-building through his firm, Collaboration Works Consulting. A resident of Paradise, he owns property in Chico that neighbors the Moes household and became acquainted with Weeber through a leadership course he taught at Butte College. (He also is an instructor in the Kinesiology Department at Chico State.)

Clark volunteered to facilitate discussions. The next is scheduled for Monday (May 18).

“Our intention is to get together and have dialogue about what can be done to build trust,” Clark said. “This is a five- to 10-year scope; we’re not expecting it to turn on a dime or be resolved in the next year or two even.”

Moes has grown accustomed to waiting for resolution.

In 2010, she marked the fifth year of her practice, Sacred Ways Homebirth. She previously worked three years for the Paradise Midwifery Service at Feather River Hospital, which she joined after moving to the North State in 2002.

“I have nothing against hospitals,” she said. “I [just] personally really appreciate the benefits of home birth midwifery care.”

Under provisions of the nursing board, nurse-midwives must obtain a supervising physician. (Licensed midwives no longer have this requirement.) Moes says none of the local obstetricians would provide supervision; the closest physician she could retain in this capacity was Dr. Stuart Fischbein, an obstetrician in Los Angeles known for his support of midwifery.

Fischbein remains her supervising physician, though Moes says an Oroville obstetrician (who prefers to go unnamed in this story) has agreed to see her patients for single visits. Proximity of supervision is one of the matters at issue in the nursing board charges. Moes refers to this as a “gray area” in nurse-midwifery regulations, which have not been modified for 30 years by a board that mothballed its Nurse-Midwifery Advisory Committee in 2011.

Home birth mothers who require hospitalization become the responsibility of the obstetrician on call. This is not a frequent occurrence; Moes, who like Emigh delivers around 20 babies a year, says only two or three of those mothers get transferred. “This is what happens all over the country,” she said.

Moes emphasizes that “the nursing staff at the Enloe mother-baby unit are exemplary in every way. They’ve been extremely kind to both me and my clients.” From the start, Moes says, she’s had challenges with some obstetricians: “I assumed I’d be treated collegially … and then it was very surprising that this is not how I was responded to by physicians at times.”

Moes says doctors at Enloe filed the complaint that led to the BRN accusation. Had she been able to develop a better working relationship with doctors, such as having the opportunity for case reviews, she believes the complaint might not have been filed.

Both Enloe and the obstetricians on Enloe’s medical staff (through Enloe’s communications department) declined to comment beyond a statement: “Enloe Medical Center reports matters that we are ethically or legally required to report. It is then up to the state or other agency to make a judgment on these matters.

“Following the complaint process outlined by the Board of Registered Nursing, Enloe Medical Center will not be able to discuss the complaint against Dena Moes.”

The Department of Consumer Affairs, which includes the BRN, referred the CN&R to the accusation, a single public document that does not include the original complaint nor investigative files. Russ Heimerich, an agency spokesman, explained that “the case we develop may not directly stem from the complaint”; according to Jacqueline Cummings, public information officer from the Department of General Services, Moes’ attorney can call and cross-examine witnesses, “subject to any relevant laws and rules” that may distinguish an administrative hearing from a court trial—so whether Enloe and doctors remain parties in the process is unclear.

Moes also is limited in what she can discuss, due to patient privacy laws. In the charges against her, the accusation identifies the patients only by initials. Moes could not disclose their identities and was unable to put them in contact with the CN&R.

What she could discuss were overarching issues in the accusation: supervision by a remote physician and accepting into her care women who previously had Caesarian sections.

Vaginal birth after Caesarian (or VBAC) is a sensitive issue. Some hospitals permit these deliveries, some ban them, and some vacillate. The medical concern is whether the scar tissue from incision during the previous procedure, or procedures, has weakened the uterine wall to the extent that it could give way during delivery. The ethical concern is whether denying VBAC or TOLAC (trial of labor after Caesarian) forces women into surgery.

Moes feels strongly that the VBAC debate “is a human rights issue” and until last year attended VBAC deliveries. She stopped last summer, on the advice of her attorney, pending the hearing.

Both patients in the accusation previously had C-sections, and the accusation says no hospital in the area “was staffed or equipped to offer obstetric services” for a VBAC. The latter is a point of contention that Moes will raise in her defense.

Enloe’s stance on VBACs has softened—“Everything goes full circle,” said Rowe, hospital vice president—but even in 2010, doctors wouldn’t force a mother to undergo a Caesarian against her will.

“People felt like if they showed up on our doorstep, we would somehow strap them to a table and do a C-section,” Weeber said. “That’s assault and battery; we’d never do that.”

Rather, if a laboring mother with a previous Caesarian gave the hospital permission to perform a vaginal delivery, signing informed consent documents acknowledging the risks, an obstetrician would commence with her vaginal delivery.

What Enloe and the local obstetricians did—and still do—is refer nonlaboring mothers seeking VBAC delivery to higher-acuity hospitals in Sacramento or the Bay Area.

“We can’t do something to a patient that they don’t agree to,” Weeber added, “but we don’t seek out people to do vaginal births after Caesarian.”

Moes says nurse-midwives are permitted to attend VBAC deliveries, contrary to what’s indicated in the nursing board’s accusation, because it falls within the scope of practice of a CNM as established by the American College of Nurse Midwives and approved by the American College of Obstetricians and Gynecologists. She calls that point “one of the things that [will be] cleared up in my hearing,” necessary because the board no longer has midwives as advisers.

Heimerich confirmed that the nursing board has not allowed the Nurse-Midwifery Advisory Committee to convene in four years. The committee is supposed to offer guidance to the board on CNM practices and education. A joint report from two legislative oversight committees, which notes the NMAC’s hiatus (made for budget reasons), states that the board is “statutorily authorized” to appoint this advisory panel, including at least one CNM and one RN “familiar with nurse-midwifery practice.”

Lacking midwives’ advice, Moes asserts, the nursing board has regulations with “these gray areas that are very open to individual interpretation”—allowing for decisions beyond the letter of the law, gauging the spirit of the law. Those areas include physician supervision and VBAC deliveries, for which Moes says that “legally I should be protected, but it’s really unclear.”

What is clear is the financial stake. Heimerich also confirmed that Moes would be assessed all the costs incurred by the state for investigating and adjudicating her case should the board’s ruling not clear her completely. That tab could run $30,000.

Though the agency stands to gain from guilty verdicts, Heimerich disputes the surface-level notion that the nursing board has a fiscal incentive or conflict of interest.

“If the implication is that cost recovery for investigations is a money-maker, it’s not,” Heimerich said. “The vast majority of cases, we have trouble collecting from the subjects of our discipline … and it’s only money we expend to conduct the investigation and attorneys’ costs for the Attorney General, because, as the winning party, we’re entitled to receive those.”

For Moes, just the defense lawyer’s fees are significant. Her husband, Adam, is an acupuncturist. They live in the Chapman neighborhood, own a 12-year-old car, work to support their children.

“I do [accept] partial payments, and people have mended my fence, built me a chicken coop, given me babysitting—home birth is an affordable option,” she said. “I’m not in this for the money.”

Talia Scherquist is another Chico mother with a deep connection to home birth. While pregnant with her first daughter, she initially considered a hospital birth with midwives in Paradise before enlisting Moes’ services.

“I’m not ‘anti-’ anything except misinformation,” said Scherquist, whose husband, Mishu Cioban, is a nurse. “For some people, safety is in the hospital…. Whatever a person’s choice is, as long as they’re able to get there, to me that’s the goal: to feel good about your birth.”

She does—times two. The birth of Livia, now 5, was “textbook,” she said, and Moes delivered second daughter Adina, 4, at home as well. “During both births,” Scherquist added, “my husband was able to be dad, rather than ER nurse.”

Cioban, like Edmondson, works at Enloe. Scherquist said opting for home birth “wasn’t even an anti-Enloe choice” but rather a decision for her comfort, including privacy. While she preferred not to be hospitalized, “knowing that we were five minutes from Enloe, if needed, was also a factor for us in our personal decision,” she continued, “and knowing that Dena would make the call to take us there if that needed to happen.”

Scherquist echoes the concern of Edmondson regarding the potential loss of Moes’ practice, declaring that “the option to have a home birth with a certified nurse-midwife is critical to the health of our families and our community.”

Emigh, too, is concerned. While she and other midwives could accept more mothers into their practices and “lean on” colleagues from out of the area, access poses a problem, and she fears some women may attempt home births unattended rather than start labor in a hospital.

“Something for the community to think about,” Moes said, “is that obstetricians are surgeons, and they are experts in caring for complicated pregnancies. Eighty to 90 percent of women having babies are healthy, young women without complications. That’s why there’s a need for midwives in our community, because midwives are experts at caring for normal, healthy pregnancies. That’s to differentiate why wouldn’t everyone want an OB?”