Complaints about home birth midwives languish amid Maryland backlog

They filed a complaint with the Maryland Board of Nursing, which oversees midwives.

“She is illegally practicing midwifery care, putting mothers and babies at risk,” Naomi Puckett wrote to the board on Sept. 11, 2019. “She has devastated our family.”

More than four years later, Naomi and Jeff Puckett are left wondering if the board will act on their complaint.

Their hope for accountability rests with a board facing a backlog of over 6,200 unresolved complaints filed about some of the nearly 115,000 nurses and tens of thousands of other care providers the board oversees. A Washington Post review of board meeting transcripts, annual reports, a legislative audit and other records reveals the Board of Nursing has struggled for years to perform its two most critical functions: issuing licenses and investigating complaints.

Public concerns about the board’s shortcomings have focused on the delay in licensing nurses, some of whom have lost job offers or even left the state as a result. But the board’s failure to investigate complaints means that nurses, midwives and others accused of harmful behavior may continue to practice for months or even years until the board decides their cases, putting more people at risk.

“Public Safety is in jeopardy as serious cases remain uninvestigated,” board leaders wrote to the Maryland General Assembly in 2021, conceding that they were unable to investigate complaints in a timely manner.

The board, which is headquartered in a Baltimore strip mall, has blamed its struggles on staffing shortages, a decades-old information technology system and a debilitating 2021 ransomware attack.

“The Board is dedicated to its mission to protect public safety and continues to prioritize efforts to reduce the number of outstanding investigations, including by hiring additional investigative staff,” Rhonda Scott, executive director of the board, said in a statement. “The Board focuses its resources on investigating complaints that pose a potential risk to the public.”

The Maryland Board of Nursing licenses certified professional midwives, referring to them as direct-entry midwives. Distinct from certified nurse midwives, who have graduate degrees and nursing credentials, certified professional midwives have no hospital privileges and primarily learn through apprenticeships. They attend the majority of home births in the United States.

According to the board’s 2023 annual report, there are 36 such midwives licensed in Maryland. Thirteen of the board’s open complaints are related to direct-entry midwives, which a board spokesman said would include allegations against unlicensed providers of this type of midwifery care. The board declined to comment on specific investigations.

Direct-entry midwives have the highest rate of open complaints among the professions the board regulates, according to a Post analysis. For example, the rate is more than 12 times that of nurses.

A recent Post investigation revealed a patchwork of state regulations that govern certified professional midwives and showed how a lack of national standards makes it difficult to hold midwives accountable when home births go wrong. It also found that planned home births attended by midwives are twice as deadly for infants than hospital deliveries.

The Post reported on certified professional midwife, Karen Carr, who had been granted a license by the Maryland Board of Nursing in 2020 despite a felony conviction for child endangerment in connection with an infant death following a home birth in Virginia. She continues to practice.

Since then, seven additional families have spoken to The Post about their experiences with home birth midwives in Maryland, alleging that the Board of Nursing puts the public at risk by failing to properly vet midwives and investigate complaints. The families’ accounts span eight years — from 2015 to as recently as October.

“When you have a backlog like this, that is significant,” said state Sen. Clarence K. Lam (D-Anne Arundel and Howard), a physician who chairs the legislature’s Joint Audit and Evaluation Committee, which reviewed a 2021 audit that drew attention to the backlog. “That means that nurses that are trying to get their license can’t. That means that individuals that need to be reviewed aren’t … We are dealing with people’s lives here.”

In April, Maryland Gov. Wes Moore (D) signed an emergency bill that directed the Secretary of Health to take over the board’s administrative functions for two years. The intention, lawmakers have said, was to allow board staff to focus on licensing, investigations and discipline. But it is unclear if the changes will result in more timely investigations.

Each of the board’s handful of investigators takes on roughly 30 new cases each month but closes just five, according to an August consultant’s report mandated by the new legislation. “This trend suggests the backlog of investigations will continue to grow,” it said.

Nursing boards in comparable states issue discipline at higher rates than Maryland, according to the report, which did not disclose Maryland’s rate. It added: “The National Council [of] State Boards of Nursing indicated that eliminating this backlog of investigations should be the ‘No. 1 priority for Maryland.’”

‘Vbacs r not legal’

A physician had delivered Naomi Puckett’s first child via Caesarean section in 2012. When she became pregnant again in late 2014, she wanted “bodily autonomy, and a natural birth.”

Through an advocacy group that promotes access to vaginal births after C-sections, or VBACs, she heard rave reviews about Tina Overton, who had a business called Birthlilly Childbirth Services. The Pucketts said Overton told them she was a certified professional midwife with years of training.

Maryland law prohibits certified professional midwives from attending VBACs at home because the delivery can pose a greater risk. Puckett said she did not know this at the time.

In August 2015, Overton successfully delivered the Pucketts’s second daughter in a birthing tub at their home. After the Pucketts learned they were expecting their third child, they hired Overton in early 2017.

Early in her pregnancy, Naomi Puckett also saw certified nurse midwives affiliated with a local hospital, which is common for home birth families who want ultrasounds and other tests.

Upon learning about her home birth plans, a nurse midwife asked who her midwife was, Puckett said. Puckett told her she wanted to keep the information private. “I don’t know why you’re hiding it. It’s legal in Maryland,” Puckett said the nurse midwife told her.

After the February appointment, Puckett texted Overton about the exchange, according to messages reviewed by The Post.

“For what it’s worth she’s mistaken,” Overton wrote. “Vbacs r not legal.”

During an interview with The Post, Puckett began to cry when asked about Overton’s comment. She said that at the time she had glossed over it, saying she “wholeheartedly” trusted Overton. “Hearing this again, it’s like, ‘Oh my God. What the hell did I miss?’ ” she said.

On Sept. 10, 2017, Puckett went into active labor. Overton soon arrived, along with Puckett’s doula, a support person for labor.

By the early morning hours of Sept. 11, Puckett’s labor stalled. Puckett said hours passed without any checks of her vitals or the baby’s heart rate.

The couple said Overton repeatedly went into the bathroom to phone her “mentor” for counsel — and told the Pucketts that she was talking to midwife Karen Carr, who was then unlicensed in Maryland.

Around 9 a.m., Overton used an ultrasound known as a Doppler to try to listen to the baby’s heart rate, and her eyes widened, Puckett said. The couple asked if they should call an ambulance, but according to Puckett, Overton told them they should drive themselves to the local hospital, then Anne Arundel Medical Center. Puckett had been in labor for over 24 hours.

Hospital staff pronounced the baby dead in utero. Shortly after, Overton entered the room. She hugged Puckett and introduced herself to staff as “the doula.” When staff asked Puckett about her midwife, Overton leaned over and said to Puckett, “I thought we said we weren’t going to talk about the midwife,” according to Puckett’s account. A physician later performed a C-section. The Pucketts named their son Channing.

Naomi Puckett was diagnosed with preeclampsia — a condition with high blood pressure — and chorioamnionitis, indicating an infection within her uterus. She spent several days recovering in the ICU. The fetal death certificate listed Channing’s causes of death as chorioamnionitis and maternal preeclampsia. The family did not want an autopsy, citing their Jewish faith.

“If I had not been under her care, my baby would be alive,” Naomi Puckett said of Overton.

Overton responded to an email from The Post saying she wanted to “reply accurately” to questions but needed to “locate the evidence” in texts and other online exchanges. She did not respond to further calls or emails.

Carr, who through her attorney declined to comment, lists Overton on her website as a resource for Maryland parents-to-be, describing her as a “Childbirth Educator/Doula.”

Months after their baby’s death, Naomi Puckett shared her story in a Facebook group, “Birth Circle of Baltimore.” A commenter replied that Overton had no credentials to work as a midwife. The Pucketts searched online for evidence of a license, but they found nothing.

Maryland law requires direct-entry midwives to have credentials from the North American Registry of Midwives (NARM) and a license from the Board of Nursing to practice. Ida Darragh, NARM’s executive director, told The Post that the organization has no record of Tina Brown Overton having ever been credentialed as a certified professional midwife. The Board of Nursing’s public database lists no licensed midwife with that name.

Jeff Puckett said he drove to a county police station to file a fraud report but left after he said an officer told him it was not a criminal matter. The couple contacted a law firm but said attorneys showed no interest in a lawsuit against an unlicensed practitioner who likely carried no medical malpractice insurance.

In March 2018, they wrote to Maria Mayzel, a certified nurse midwife who had treated Naomi Puckett in the hospital. She encouraged them to file a complaint to the Board of Nursing, adding that the hospital’s director of obstetrics, Eugene Morris, had already done so.

“Dr. Morris reports receiving an acknowledgment of the complaint from the MBON and was informed it would take some time for a formal investigation,” Mayzel said in an email to the Pucketts. “They are aware she was portraying herself as a midwife within the community; we believe your complaint will further confirm this.” Morris has since died. Mayzel did not respond to a request for comment.

On Sept. 11, 2019, on the second anniversary of Channing’s death, the Pucketts filed their complaint. That October, they met at the board office with an investigator, Sara Tongue, to give recorded statements.

‘Our team is burned out’

Two months later, in December 2019, the Maryland Board of Nursing reported a staggering single-year rise in the number of open complaints: 3,081 to 6,724. The board had discovered paper files that had not been uploaded to the electronic case tracking system, a board spokesman recently told The Post.

By contrast, the Maryland Board of Physicians has 75 open complaints despite handling twice the amount of complaints and conducting six times more investigations, records show.

By 2022, the nursing board’s enforcement team had dwindled to just four investigators, down from a previous total of 11, the board would later report. One person was assigned to investigate approximately 2,800 cold case files. The remaining three handled between 400 to 500 cases each, and their manager had taken on another 600.

The board’s workflow for intake and investigation of complaints is “manual and slow,” according to a recent report by an external consultant, Ernst & Young. Those seeking to file a complaint must download and sign a form from the website, then email it to the board. A staffer then retypes that information into a Google Sheet, the report said.

Lead investigators then print out the complaints and present them to a triage committee, which meets twice a month to review between 120 to 160 complaints, according to the board.

The committee can recommend several options, including that the complaint be closed with no further action, referred for settlement discussions or assigned a priority number for investigation. A board report noted that roughly 30 percent of the board’s recent cases were given the highest priority because they posed an “immediate” or “imminent” threat to the public.

If an investigation proceeds, case data is entered into Microsoft Excel. Investigators compile interview notes and evidence in Microsoft Word. By the time a case comes to the board for review, information has been pulled from three different programs.

The public only learns of a complaint if the board issues a public order for disciplinary action, such as a fine or suspension of a license. Otherwise, those who file complaints may never know the outcome.

The complaint backlog was revealed in early 2021 by a Maryland legislative audit that examined 22 boards overseen by the Department of Health Regulatory Services and found that the Board of Nursing “did not provide sufficient oversight of complaint investigations.”

The audit found 2,790 complaints that had been open for more than a year.

Some of the board’s investigative evidence and interview recordings were lost after a December 2021 ransomware attack against the Maryland Department of Health.

The attack may have affected files from the investigation into Overton. The Pucketts later filed a public records request for the recordings of their 2019 interviews. They received a letter saying no such files could be found.

“The Board suspects that the recordings may have been lost during a data security incident that occurred in December 2021,” it said.

In 2022, the board’s problems spilled into public view, when nurses spoke out after waiting months to receive a license despite calling, emailing and driving to the board’s offices to beg for help, even as Maryland leaders warned of a nursing shortage.

Nearly three years after filing their complaint, the Pucketts emailed their investigator, Tongue, in August 2022 for an update. Tongue had since been promoted to director of the board’s enforcement division and told them she had assigned the case to a different investigator.

Almost three months later, at an October 2022 board meeting, Karen Evans, then the executive director, said that in recent years the goal for the time frame to investigate and close complaints had grown from 270 to 540 days. Robin Hill, a registered nurse and board member, presented a hypothetical scenario of a complaint about a nurse suspected of drug diversion.

“They could literally be practicing for 540 days?” Hill asked.

“Absolutely,” Tongue said. She spoke bluntly of the plight of investigators. “Our team is burned out. I am burned out. We need help, and I’ve been screaming it from the top of my lungs for a very long time.”

‘This is the holistic approach’

Four days after Tongue’s remarks, a couple who, like the Pucketts, also lived in Crofton, were preparing for the home birth of their first child.

Jenell and David Burns, a Black couple in their 30s, were concerned about the disproportionately high rates of maternal mortality for Black women in hospitals. They said they hired Kai Parker, a licensed certified professional midwife and the former chair of the state’s midwifery advisory committee, because of her credentials and her promise to them that, as a Black midwife, she could provide them with better care. They paid her $7,500.

“Healing Starts Here,” read a large banner on Parker’s website. “Naturopathic Doctor. Homebirth Midwife. Doctor of Oriental Medicine.” But her Maryland license as a naturopathic physician, which allows the practice of alternative medicine, expired during the Burnses’ pregnancy, state records show. And, in 2021, Parker had been arrested for driving under the influence of alcohol and sentenced to a year of probation as part of a plea deal, according to court records.

At the time, the Burnses knew none of this. The couple said Parker conducted most appointments virtually, asking David Burns to use a Doppler even after he told her he was not trained to listen to a fetal heart rate. At one point, Burns said he confronted Parker about what he viewed as lax care. “She kind of dismissed it as basically, ‘This is the holistic approach and this is how it goes,’” he said.

Jenell Burns went into labor the morning of Oct. 29, and Parker arrived at their home around 11 p.m. She was alone, according to the couple. Maryland regulations require certified professional midwives to have an assistant present for delivery. Burns labored into the next day.

Midday on Oct. 30, Parker could not find the fetal heart rate and wondered out loud if her Doppler was broken, the couple said. After David Burns frantically put a second Doppler on his wife’s belly, Parker reassured them that she could hear the baby’s heartbeat, although she said it was weak, according to the couple. She advised Jenell to drink apple juice, they said.

Maryland midwifery regulations state that a “nonreassuring fetal heart rate” is cause for immediate emergency transfer. The family said Parker did not call 911 until about an hour later, when she reported seeing meconium, which is fecal matter that can indicate fetal distress.

Parker’s records, provided by the family, show that she only noted being unable to hear the fetal heart rate right before she called 911. EMTs arrived within minutes, according to records. Just past 2 p.m., Jenell and David Burns’s son was delivered stillborn. They named him Onyx.

An autopsy by the Maryland Office of the Chief Medical Examiner found a placental infection known as chorioamnionitis and noted that the skin on Onyx’s body had begun to peel — a process that doctors say indicates the death likely occurred at least six hours before delivery.

Parker did not respond to requests for an interview or answer a list of questions sent by email.

In late March, an Anne Arundel County law enforcement official assisted the Burns family by contacting the state assistant attorney general assigned as counsel for the Board of Nursing. The official requested dual investigations by the Board of Physicians and the Board of Nursing, given the family’s allegations that Parker had misrepresented herself as a licensed physician and had negligently cared for them as their midwife, according to a person with knowledge of the outreach who spoke on the condition of anonymity because they are not authorized to speak to the media.

Jenell and David Burns said the Board of Physicians interviewed them in June. The couple recently learned they will sit for an interview in January with a Board of Nursing investigator.

“We don’t want Onyx to have died in vain,” said Jenell Burns. “So I do hope that years down the line, we are able to make some changes with policy and the rules and guidelines to be able to protect families in the future.”

Five other families told The Post about troubling experiences after hiring Parker during pregnancies from 2018 to this year. Their babies were born healthy, but after finding each other through online reviews, the families meet virtually to commiserate.

Two recently filed complaints with the Board of Nursing.

Parker’s two-year midwifery license was due to expire in October. Earlier this month, the board’s licensing database showed Parker’s status as “active.” After a request from The Post for comment, her status changed to “non-renewed” — meaning Parker is no longer licensed in Maryland.

An annual board report submitted to the legislature discloses deaths under the care of certified professional midwives. But the report shows none for Anne Arundel County, where Onyx Burns was stillborn. A board spokesman said midwives are responsible for submitting accurate information.

“Our son did die,” said David Burns, upon learning from a Post reporter of the omission. “Do these people think they’re going to get away with brushing him under the rug?”

Hayden Godfrey, Steven Rich, Alice Crites and Erin Cox contributed to this report.