On today’s podcast, we’re going to talk with Mary Kathryn DeLodder about licensing certified professional midwives in Kentucky.
Mary Kathryn DeLodder (she/her) is a consumer advocate and leader of the Kentucky Birth Coalition. From 2012 through 2019 she worked on efforts to license certified professional midwives in Kentucky. She is now working on legislation to improve access to birth centers in Kentucky.
We will talk about how Mary Kathryn first became interested in helping pass the midwifery licensure bill in Kentucky and the beginnings of forming the Kentucky Home Birth Coalition. We will also talk about the challenges that were against legalizing certified professional midwives to practice in Kentucky and the wave of collective support that helped to push the bill to get passed.
Rebecca Dekker: Hi, everyone. On today’s podcast, we’re going to talk with Mary Kathryn DeLodder about licensing certified professional midwives in Kentucky. Welcome to Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.
Today, I am so excited to welcome Mary Kathryn DeLodder to the Evidence Based Birth® Podcast. Mary Kathryn is a consumer advocate and leader of the Kentucky Birth Coalition. From 2012 through 2019, Mary Kathryn worked on efforts to license certified professional midwives in Kentucky. She is now working on legislation to improve access to birth centers in Kentucky. Mary Kathryn is the mother of four children, and she and her family live in Louisville, Kentucky. Welcome, Mary Kathryn, to the Evidence Based Birth® Podcast.
Mary Kathryn DeLodder: Thank you, Rebecca.
Rebecca Dekker: It’s so fun to talk with you because, in some ways, it’s really fascinating to relive a lot of what you worked on because I got to watch it from the sidelines and a little bit in person as well. Can you tell our audience how you first got interested in helping pass the midwifery licensure bill? Because you are not a midwife yourself, correct?
Mary Kathryn DeLodder: I am not. I get asked that question a lot. Are you a midwife? Do you plan to become a midwife? I say, “No, I’m a mom who wanted to have home births in Kentucky,” and when I started trying to figure out that process, I realized you can’t just go to your computer and search for home birth midwives, or at least at that time, you couldn’t. It was so confusing to try to read and learn about the different types of midwives, and I thought from the beginning, this is crazy, this is not how you would find your pediatrician or your dentist or any other provider. Climate in Kentucky then was that you had to know the right people who knew the midwives, and it was like you had to know the secret handshake. After my first child was born in 2011, he was a planned home birth but he came early, and so we needed to go to the hospital instead. My midwife appropriately advised us to go to the hospital.
I hadn’t actually had the home birth experience, even though I planned one at that time. I didn’t feel like I really had any legitimacy, so to speak, to talk about home birth. But unbeknownst to me, there was some other folks, some other home birth parents and midwives who were working at that time to start what was then called the Kentucky Home Birth Coalition, and one of them was someone who was a childbirth educator and I had taken her class. She thought of me, and she called me up out of the blue one day, and said, “Hey, we’re working on this, and we thought you might be a really great person to be involved with it,” and so I got invited to come to a meeting at the house of someone who I didn’t know. I went to a meeting in someone’s living room, and just started regularly attending the meetings, and that’s how it started, somebody thought to invite me.
Rebecca Dekker: That was the beginnings of the Kentucky Home Birth Coalition. What were they looking at doing at that time when you started attending the meetings?
Mary Kathryn DeLodder: Their goal was really to change the law in Kentucky by getting a bill passed to allow certified professional midwives to be licensed here. There were a couple of midwives involved, some home birth mothers, and one of the midwives who was involved, she had gotten her training in Texas and practiced as a CPM there. She was originally from Kentucky and had moved back to Kentucky, but was choosing not to practice here because she didn’t want to take any chances of putting herself or her family in jeopardy by practicing what was technically illegally at the time. She really was putting her efforts into trying to change the law so that she could practice in Kentucky. That’s really what they were focused on, was mostly how do we figure out this process? All is completely novices to the political process. How do we do this? How do we change the law? That’s what they were really working on when I came in.
Rebecca Dekker: You mentioned that it was illegal to practice as a certified professional midwife in Kentucky, which might strike some people as odd because Kentucky is the home of the frontier university where nurse midwives all over the country are educated. But can you explain a little bit more about what was going on in Kentucky, what are certified professional midwives, and how come they couldn’t practice while certified nurse midwives could?
Mary Kathryn DeLodder: In Kentucky, our certified nurse midwives are licensed as advanced practice registered nurses. They are considered APRNs. They are licensed that way. They have for years been licensed providers, and so they can practice in the hospital or out of the hospital. Although very few, in modern times, choose to practice outside of the hospital for various reasons.
Rebecca Dekker: Yeah. About how many at the time were attending home births, of the certified nurse midwives who could practice legally?
Mary Kathryn DeLodder: The time that I’ve been involved in this movement, it’s been anywhere from four to six nurse midwives at any given time, and mostly, they were in Central Kentucky. Unless you lived in Central Kentucky and had access to one of those four to six, depending on the time, you didn’t have access to a licensed provider. Kentucky had a law that dates back to the 1950s that said that what they then termed lay midwives are required to have a permit from the state, and so the state did issue permits to the “lay” midwives, as the law called it, from the 1950s until 1975. The actual statute wasn’t changed, but the regulation was changed in 1975 to say we will not issue any new permits after the certain date in 1975.
We still had a law that said to practice direct entry midwifery, what they were calling in the law lay midwifery. You needed a permit, but we’re not going to give out any permits. Everyone after that time who was practicing had no way to get the permit, so they were technically practicing without the permit, which was against the law. There were some folks in the ’80s who brought a lawsuit against the state that was unsuccessful. Throughout the years, I’ve met and talked to different folks who have tried different iterations of trying to get things changed and they weren’t successful at that time. I’ve always just felt that we definitely didn’t start this. We were just running the next leg of the race that other folks started before us.
Rebecca Dekker: Can you explain the difference between a statute and a regulation for people who are new to the whole process of state legislation?
Mary Kathryn DeLodder: A statute is a law that gets passed by the legislature. When they pass a bill, most of the time, it’s to put a piece of statute into place in Kentucky, and I think most states are similar in this way. The administrative regulations are the next step of that that go into a lot more of the details to implement the laws. They are the law also, but they are dictated by the statute. The statute may dictate what’s going to be in the regulations, and then the regulations go into deeper detail as to how it gets implemented. The regulations are put into place by different agencies in the state, and they have to correspond with the statute. They get their authority from the statute.
Rebecca Dekker: Okay. Regulations are a little bit easier to change, because to change a statute, you actually have to get a bill passed through both sides of the legislation plus signed by the governor. But a regulation can be shifted or adjusted through other processes.
Mary Kathryn DeLodder: Yes. The regulation process is still cumbersome, but it is easier than getting a bill passed, for sure.
Rebecca Dekker: Okay. Take us through a timeline of how this legislation was passed. You said you started attending these meetings. When did you start getting more involved in the leadership of the group?
Mary Kathryn DeLodder: It was sometime in 2012 when I started getting involved, and some point, the midwife who was the primary leader, the one that had been trained in Texas, she and her family decided they were going to move back to Texas. It was probably about a year after I had been involved, and so I had just been listening and learning and taking it all in and learning the lingo and starting to feel more confident in my knowledge about the whole process. When she was leaving, it just left a void and I just assumed the role. It was just sort of a natural progression, I think. I just stepped up into that role and things kept going. As I mentioned, we were just running the most recent leg of the race. The timeline really starts back in the late ’70s when they no longer were giving out permits.
There have been different attempts at passing bills throughout the decades, but this most recent effort under Kentucky Home Birth Coalition really started in 2012. The first two bills filed in 2013 and some of the volunteers looked at bills that other states had, laws that they thought were good for other states, and tried to pull together pieces, not reinvent the wheel. One person who was involved said, “I know my state senator. I can ask him if he would sponsor a bill for us,” and it was really that simple. She asked him and he said yes. He had no particular connection to our cause, but because his constituent asked him, he agreed and he was our sponsor for all the years that we worked on it. He got invested in wanting to see us get this passed as the battle went on over several years…
Rebecca Dekker: Did he think it would be fairly simple in the beginning?
Mary Kathryn DeLodder: I don’t know what he thought, but I’m pretty sure he didn’t think that it would take as much as it did or that it would…
Rebecca Dekker: Encounter as much opposition?
Mary Kathryn DeLodder: As controversial as it was. I used to joke that I don’t think he knew what he was getting into when he said yes to us, but I was so grateful that he always stuck with us and was willing to fight with us. After that experience in 2013 with our first bill, we were so excited. We got connected with a bill drafter, who that’s their job, is to help you put the bill into the right language, and had this bill. It got filed. It was so exciting. We have bill number, it got assigned to the Health Committee.
The chair of the Health Committee at that time happened to be my state senator, and I got together a group of eight people and we went and met her at a Panera one morning to talk about the bill. She really had no concept of home birth, she did not have natural births with her children. It was really out of her realm of understanding why we would even want such a thing. We had this meeting, and then the bill never got a hearing. Essentially, it died in committee that year. The first year, we made a lot of progress.
Rebecca Dekker: Who decides when a bill gets a committee hearing? When you say a bill died, it means nothing happened. It just never got action. But it has to be heard in order to get any kind of action. Who decides that?
Mary Kathryn DeLodder: It’s a combination of the chairperson of the committee and the leadership of the chamber. In this case, the bill was in the senate because our sponsor was a senator. It’s a mixture of the leadership of the senate plus the committee chairperson. She chose not to hear the bill that year, and we realized there was a lot about this process that we just did not know. But before this, I like to say that the most political thing I had ever done was just to go vote every four years. I don’t think I’d ever visited our state Capitol, I had no idea how the process worked. We just realized we don’t know what we don’t know and we really need some professional help. We started looking for a lobbyist. We were told that you really need to have a constant presence here so people know who you are and remember you. With most of our volunteers being parents of young children or midwives with active practices, it wasn’t really feasible for us to be there a lot. We started…
Rebecca Dekker: Plus you’re spread all over the state, right? How far do some people have to drive to get to the Capitol, which is Frankfort?
Mary Kathryn DeLodder: For some folks, they came four or five hours to get to the Capitol, and so they could only maybe at best make it once a year. Whereas folks who live closer, unfortunately, I live about 45 minutes away from the Capitol. In later years as I got more involved, I was able to go pretty frequently. But not everyone can do that. It’s just a nice coincidence that I lived within driving distance. I didn’t have any idea how do you find a lobbyist either. Can you just go Google lobbyist? I asked some folks, I asked a legislator who had been supportive of our bill, I asked our bill sponsor, and they gave us some names and some recommendations, and so I reached out to a few of lobbying firms, and many of them were way too expensive.
Some of them had conflicts of interest because they had other clients. Maybe they represented a hospital or some other medical organization that they felt it was a conflict of interest. We spent a few years just raising money until we felt that we could afford a lobbyist, and then we finally got connected with a lobbyist who wanted to work with us and was going to charge a rate that we felt we could afford, and so we signed a contract and have been working with that lobbyist ever since, and that was immensely helpful for us. I lovingly call him our legislative doula because he really helped guide us through the process and let us know here are your options, what do you want to do? This is my advice. It’s been a really great partnership to work with professional lobbyist.
Rebecca Dekker: Okay. You had this barrier of not being able to be there in person, financial barrier, needing to raise funds just to even to be able to hire more affordable lobbyists, and this is in contrast to the medical establishment in the state, which just is able to throw tons of money at the legislative and lobbying process. You were definitely an underdog at this point?
Mary Kathryn DeLodder: For sure The next time we had a bill was in 2016, it was I think almost identical to the bill we had had in 2013. But we had taken that break to find a lobbyist to raise the money. We came back in 2016, we had more of a game plan. We planned a lobby day for the first time and got people to sign up from all around the state to come on one day and set up meetings with their own senators, and we had lots of meetings. We asked everyone we met with, “Will you co-sponsor the bill?” That’s something that we wouldn’t have known to even ask for without our lobbyists telling us what you should ask. We very quickly got 16 or 17 co-sponsors. Almost half of the entire state senate co-sponsored the bill very quickly.
Rebecca Dekker: And it was bipartisan?
Mary Kathryn DeLodder: It was.
Rebecca Dekker: Co-sponsorship.
Mary Kathryn DeLodder: It was. People didn’t see an issue with it. The legislators thought this just makes sense. People are having home births, they should have access to licensed providers. Well, of course. We hadn’t really gotten the attention of the medical groups in the state yet because our bill had never moved before. By this point, we had a different state senator who was in charge of the Health Committee. When it got assigned to that committee, she did give it a hearing that year. We had a hearing, I think. Maybe you…
Rebecca Dekker: I think I was there. I think I spoke at it. Yeah.
Mary Kathryn DeLodder: Yeah. We had-
Rebecca Dekker: I testified.
Mary Kathryn DeLodder: We had you and Robin Weiss, who’s got a Ph.D. in Public Health to come and talk about the bill, and it passed out of committee. I think it was nine to two was the vote. There were only two no votes. That was pretty good odds. After it passed out of committee, then the medical groups such as the Hospital Association and the Medical Association paid attention, and they suddenly…
Rebecca Dekker: In other words, they freaked out.
Mary Kathryn DeLodder: They were like, “Oh, this is getting traction, and we don’t like this bill.” It seemed that they made a few well-placed phone calls, and our bill got assigned to a second committee, which I did not … I wouldn’t have even known it had gotten reassigned for a few days, but our lobbyist immediately called and said, “This has happened, it’s not a good sign.”
Rebecca Dekker: It’s another way of killing the bill, right?
Mary Kathryn DeLodder: Yeah.
Rebecca Dekker: By kicking it back to another committee.
Mary Kathryn DeLodder: In Kentucky, it’s not common to get reassigned to a second committee after passing a first committee, and so that signal that your bill’s not moving forward. The second committee it was assigned to was the Licensing and Occupations Committee. Of course, this was a licensing bill, and the chair of that committee seemed pretty willing to work with us in between time, between sessions. It was a barrier, but we had gotten farther than we got the previous year. Every year was a little win and a little step.
After getting moved to that committee, we went back and forth between these two committees and had different senators who were working with us to have meetings outside the process and getting the other groups to come to the table. We just went through several years of back and forth and having bills and making changes to try to compromise with other groups, and just went back and forth like that until we finally got to a place where we’re able to pass it in 2019. From 2016, ’17, ’18 and ’19, we had a bill every year.
Rebecca Dekker: Yeah, and you had to make compromises, you also had to stick to your guns, so to speak, and some issues. I think we passed in 2019, but there were a lot of big barriers that happened in that three-year period where we felt like the bill was going to pass and then something would always happen that was usually related to a power play by another organization that wanted to block the bill. Can you talk about some of the tricks that were used to try and stop the bill from passing?
Mary Kathryn DeLodder: Yeah. One year, we decided to introduce a bill in both chambers, so one in the House and the Senate, and we had a House member who was actually a home birth parent himself, and so he was willing to introduce the bill in the House. We had one in the House and one in the Senate.
Rebecca Dekker: That increases your chances of getting it through faster, especially in a shorter … Our Kentucky sessions are pretty short.
Mary Kathryn DeLodder: Yeah. You can start a bill in either chamber in Kentucky. The bill still has to make it through both chambers, but you have two shots at it versus one. We thought, why not? We’ve got a willing sponsor, we’ll give it a try. The chair of the Health Committee in the House that year, she said, “I’m working on something for the bill,” and the bill sponsor, he wasn’t really sure what she was working on, and it turned out that she had been having meetings without us with all the medical groups, so the hospitals, the Obs, the Medical Association, and essentially getting their wishlist of what they would want to see in this bill. The medical groups always said, “Yes, we think these groups should be licensed. They shouldn’t be out there just doing whatever they want,” is the way they viewed it, but they wanted it on their terms, and they wanted the restrictions on practice that they wanted.
She took their wishlist and totally rewrote the bill. Myself and our lobbyists in the bill sponsor came in for a meeting, it was a few days before our lobby day that year, and basically said, “Here’s your new bill. You’re going to like it, you’re going to take it and this is what we’re going to do.” I looked at it and it had things in it like a ban on VBAC, ban on breaches, ban on multiples, and so many other things that were in there. The term that it used for the licensees was lay midwives. They were going to call them licensed lay midwives, and I’m like, “This is the craziest thing. They did not understand that lay means untrained. We’re not talking about untrained people here. This is a insulting term to use,” and I had to explain that to her.
We went over her bill, and I came back two days later with our lobbyists. I had a baby at that time, and she was not yet crawling, so an infant, and we were in the legislators office. Our lobbyist, who was a father himself, he stood beside me and held my infant while I was sitting at this commerce table talking to the legislator. I said, “Here are the things that we would suggest to change in your bill draft respectfully,” and when I got to the section on the things that she wanted to ban, such as VBAC, she closed her papers and said, “No, that’s non negotiable. It’s going to be this way.” I said, “We can’t accept that. We can’t accept a ban on VBACs at home,” and she said, “Well then. We’re done here and I’m going to be filing something that’s going to put a stop to this illegal practice.”
I felt like all the air got sucked out of my lungs and hearing my heart pounding in my ears thinking, “Did she just threatened to put all of our midwives in jail?” I said, “Well, just a minute. Can we just table the bill and work on this in the interim, or what can we do?” She was just angry at that point and was trying to shoo us out of her office. She gets us over to the door, and I said, “Well, can you just clarify me, you said you’re going to do something to stop the midwives from practicing?” She took a breath and paused for a moment and said, “I’m just saying it’s not going to go unnoticed anymore, and someone is sure to do something that’s going to stop this.” At that point, I knew she was bluffing a little because it’s been no secret that the midwives have always practiced. The medical community knows, the hospital knows…
Rebecca Dekker: Not all of them choose to, but some of the CPMs were choosing to practice without a license in Kentucky.
Mary Kathryn DeLodder: Yes, they were. There was maybe 15 or so CPMs and then there were other non-credentialed midwives who were practicing as well. It was the day before our lobby day. I went home and then we had a Facebook Live in our Facebook group that night to tell our folks we have some stuff that we need to … really important to talk about. We said, “This is what she’s proposing, this is the restrictions that are in this bill, such as banning VBAC and other things. Tell me what you all think. Do we try to compromise with this, or is this a line in the sand that we will not cross?” Overwhelmingly, our supporters said, “No, we are not willing to negotiate on that point. We’re going to hold them, as the VBAC is definitely the thing that we are not going to give away.” We came into our lobby day with a strategy of…
Rebecca Dekker: This is in contrast to several other states where they’ve been trying to pass legislation and they did end up giving up home VBAC, correct?
Mary Kathryn DeLodder: Yeah. Having been the person in those negotiations, I know that sometimes it just depends on what is the scenario in your state, and the truth in Kentucky was that our midwives were practicing underground, but nobody was going after them. They weren’t being prosecuted or put in jail. Whereas in some other states, it may have made more sense for them to negotiate on those points, because maybe their midwives were under attack. While in certain places you had access to an unlicensed midwife and nobody was bothering the midwife at that time, in other places your midwife was maybe at a real risk of going to jail. They could have, in theory, been in risk of going to jail in Kentucky, but because it hadn’t happened, it was a little bit of a different level of confidence that we had more ability to negotiate on those points. If we had midwives sitting in jail, we might have felt differently about the things we wanted to negotiate on.
We essentially went in and told all the House members, “We don’t like this bill. We don’t support it. It’s been rewritten, and vote no on that version.” Then when we met with the Senate members, because we had two bills, we just said, “Support our Senate bill.” We had two different messages depending on who we met with. We ended up making a lot of noise, having a lot of phone calls, lots of meetings, and the bill was scheduled to be heard in the House Health Committee two days later. We ended up making enough commotion that the member who had rewritten our bill decided to take it off of the agenda and the bill died. Essentially, we lobbied to kill our own bill because it had been hijacked. That was a big really scary situation really, that for one moment, I thought she was threatening to put the midwives into jail, and then we had to lobby against our own bill that had been turned into something we did not want any longer.
Rebecca Dekker: Do you know why this particular House representative was so intent on adjusting the bill? Was she closely…aligned with the medical groups?
Mary Kathryn DeLodder: She was a nurse, was her profession before being in the legislature, and I believe that she truly felt that she was helping. She thought, “You know what? I’m going to go in, I’m going to go talk to these medical groups, and I’m going to tell …” She was going to get them to agree to it as well, and by putting their requests in the bill. It’s just that we were left out of the discussion process and we weren’t able to really voice that, no, these are not compromises, this is just us having to give in to something. She was really trying to help negotiate out a bill that could pass. It just was that it wasn’t a bill that was acceptable to the consumers, or for the profession that it was going to be regulating. It wasn’t acceptable for the midwives either.
It was just a case of someone trying to be helpful, but they weren’t. They were being hurtful, actually. We ended up working with that legislator more over time, and having a meeting with her during the interim with some other legislators present trying to negotiate, true negotiation about some of the things she had put into the bill. She wanted to add a moment of levity to the meeting by saying you’ll find this funny. Something that we did during our lobby days is we would bring cookies to give to the legislators because our lobby day was always around Valentine’s Day. We started off with a we’re going to bring Valentine’s cookies type of thing. The first year, people made cookies themselves, and then after that, we started using a bakery, and it was much easier to have the bakery package the cookies.
One of our supporters has a bakery. But that first year, this legislators said that … She started telling other members, “Those midwife cookies, they made those with breast milk.” I just looked at her, and I said, “But you told them the truth, right?” She’s like, “Oh, no. I just let them think it.” She’s like, “Those guys were so freaked out,” and I just sat there looking at her and mortified like, “I can’t believe she told people that,” and people actually-
Rebecca Dekker: She told all the state senators and House representatives that the cookies that we’d been passing out had been cooked with breast milk, and that wasn’t a joke, that she was serious?
Mary Kathryn DeLodder: She did. One House member who was supportive of us, his wife, who would go with him to the Capitol, and she’s a very, very staunch breastfeeding supporter. When she heard about it, she was livid. Like, “How dare you all be spreading these rumors?” She told us about it as well, like, “Yes, it’s actually true. There were people who really believed this and were really freaking out that they thought they ate your cookies.”
Rebecca Dekker: Is that really weird passive aggressive form of sabotage? Because in on one hand, it’s a funny joke, right? But she didn’t reveal the punchline, so all these legislators were starting to feel really grossed out by our group, like, “Ew, they put breast milk in our cookies. We’re not going to support them.”
Mary Kathryn DeLodder: Luckily, we had people like our supportive bill sponsor in the House, and we had people like the very pro breastfeeding wife of another House member who went around and doing damage control saying that’s not true. We found out through our allies that this rumor of the cookies lived on even after we started using professional bakery made cookies that came with the ingredient label. It became a joke that other legislators would tell new freshmen legislators, “Well, you know those cookies are made with breast milk,” and, of course, people would be astonished by that and believe it. But I think now, I don’t know how many years later we are after that rumor, I hope that maybe it is finally died. But it’s still our inside joke, and every now and then someone brings it up, that the joke still lives.
Rebecca Dekker: The joke that was not meant to help?
Mary Kathryn DeLodder: No, it was not meant to help.
Rebecca Dekker: Yeah. Were there any other events that happened before the year it passed in 2019? I feel like there was another year where we got really, really close in several things. I think there were several years where it felt like we were getting close, and then something happened at the last minute, a strategy from the Hospital Association or the Medical Association, who always seem to be opposed to the bill up till the very end. Can you talk about what some of the events happened where we were like, “Oh, we’re going to make it this year,” and then we didn’t?
Mary Kathryn DeLodder: Once more and more legislators got on board and saw that we were … I think that some legislators thought that we were really being unfairly opposed by the medical groups, and that we were going to need advocates, them as the legislators. They really helped to bring the other groups to the table. They weren’t able to necessarily make them cooperate, but they at least got them to participate in the discussions. I know one year we had a huge meeting at the Capitol around a huge conference table when you were there…
Rebecca Dekker: I was there. Oh, my gosh.
Mary Kathryn DeLodder: We had every group represented in the room. We had ACOG and the Hospital Association, the Medical Association and us.
Rebecca Dekker: Pediatrics.
Mary Kathryn DeLodder: Yes, a neonatologist was there, and we had-
Rebecca Dekker: And the Nursing Association. Yeah.
Mary Kathryn DeLodder: Yeah. APRMS and midwives and several legislators, and so it was just big back and forth. We started having regular meetings with ACOG with some of their state level leadership and their lobbyists. Because the Medical Association took a stance and said, “We’re just going to defer to whatever our specialists say.” For them, that was the obstetricians and ACOG. They said, “We’re going to let you duke it out with ACOG to figure out what … If ACOG’s okay with it, then we’ll be okay with it.” We started having regular meetings with ACOG for a long time. In the beginning, the folks that were in their state leadership for their state level ACOG weren’t really interested so much in it, and those people changed over time. A person who came into the role of the legislative chair for ACOG, he was more interested in really working with us.
Wasn’t necessarily supportive per se in the beginning, but he was more willing to hear what we had to say and actually truly negotiate. That made a difference who the individual people were that were involved. In every year, we might get a little step closer. We get it through the committee, that was a positive step forward. Another year, we actually got it to pass through the Senate. But it was at the very, very end of our session, and there wasn’t time at that point for it to actually go through the whole process in the House. It was such a monumental thing to pass the Senate. But yet, then it didn’t have time to actually fully pass because it couldn’t go through the House. That was an example of feeling like we had made a lot of progress, but yet, we still have to keep coming back.
Rebecca Dekker: I remember you being really encouraging to the coalition members like, “This is a huge achievement. This is a really positive sign. It’s like, yes, we have to come back next year and start all over again. But the fact that we passed the Senate is going to make everybody take it more seriously this next year.”
Mary Kathryn DeLodder: It was always disappointing to get to that point where you realized it’s not going to happen this year. We worked so hard. Having to keep telling yourself, this is positive, we’ve made progress, we’re going to keep going, and try not to waste any of that time between the sessions knowing that was valuable time to continue to educate legislators and to continue to try to get the best possible bill that we could. The final year that we passed the bill, the bill made it through the Senate, and I think that some of the opposition realized there’s a lot of momentum here, it’s going to pass, and if we don’t really come to the table and truly negotiate, it’s going to pass the way it is, and if we want to try to get some changes, we’re going to have to actually sit down and talk.
Because the opposition’s version of negotiation prior to that point was to present their demands or their wishlist and expect us to put it in the bill. There was no give and take. It wasn’t true negotiation. But in that final year, 2019, we did have some true give and take, and there were many hours spent of just myself as the consumer representative, one of our CPMs representing the professionals, and then the OB who had become in the leadership of our state ACOG. We spent many hours sitting down over coffee, Panera, and just going line by line through the bill and discussing why we felt that it needed to be a certain way. He would give his input of why he felt it shouldn’t be that way.
Even though he may not always agree, he was willing to hear particularly what the midwife said about why it was important to have things the way they were, why it was important to have access to VBAC. The midwife was able to speak using medical terminology and professional language in a way that I as a consumer didn’t have that knowledge. I think he was really able to see her as an educated professional who knew what she was talking about when they were able to talk one-on-one about very specific examples of what you might do in this scenario with the client if this happened, and we were able to talk about CPMs are not permitted to attend VBACs. People are still going to have VBACs outside of the hospital. They’ll just do it either on their own or they will do it with someone who may not have the skill set to be attending that VBAC. It will still happen, you’re just going to make it less safe.
Rebecca Dekker: It wasn’t part of the reason for that, because VBAC is so difficult to come by in Kentucky hospitals, right? Most of our hospitals have bans on VBACs.
Mary Kathryn DeLodder: There’s not a lot of VBACs supportive providers in hospitals in Kentucky, and he is an obstetrician, he knew that and acknowledge that. That was helpful. But he acknowledged that and knew that that was a problem. Even though he didn’t condone someone choosing to have a VBAC at home, his final take on it was, if you choose to do this, even though I don’t recommend it, we want you to at least be informed of your choice, know the pros and the cons of your choice, the risks and the benefits, and still have this. We were able to come up with some language that said a client who wants to have a VBAC or some other things, breech in twins, some few other scenarios, if you want to do this at home, there was a form.
An informed refusal form is what we called it, so that the midwife is required to recommend that you see a obstetrician for a consultation, but the client is not obligated to have that consultation. You can decline that, and then if you wish to and continue on having your VABC at home, assuming that you’re still a good candidate for the VBAC, which the midwife will of course ensure that you are a good candidate. That was an example of something that we created that was unique. I don’t know of another state that has come up with a solution like that. But it allowed the midwives to still practice to their scope of their training, and it gave some comfort level to the medical community that there would still be appropriate consultation.
Rebecca Dekker: Okay. What do you think were some of the most influential factors in the coalition favor as you came upon 2019 and the momentum was in your favor? What were some of the things that you feel like you had on your side?
Mary Kathryn DeLodder: The biggest advantage that we had all along was our grassroots support, that we had families from all across the state who really cared about this and were dedicated and just kept coming back year after year. Whether it be coming to the Capitol in person or whether it was just sending emails, making phone calls to their legislators, but really having constituents reach out to their individual legislators and say, “This is important to me, and this is why.” That was the most powerful thing we had, because ultimately, the legislators care about what the people in their districts think, the people who can vote for them at the end of the day. When more and more legislators heard from their own constituents in different parts of the state, that was powerful.
When we would have committee hearings or we would have our lobby day, this was all pre-COVID, we brought our families to the Capitol. People brought their children, they brought their spouses, their parents and grandparents. We had all sorts of folks come to lobby with us. People would be walking in the hallways of the Capitol with their babies in their baby carriers, strapped to them. People knew who we were because we always had kids and babies with us, and so that was helpful just because it-
Rebecca Dekker: It also made you very sympathetic and attractive in a way because I remember how many legislators would stop anybody carrying a baby and be like, “Let’s take a picture.” Then they wanted it to be posted on Twitter with them tagged with the baby. The babies were definitely a positive part of the coalition.
Mary Kathryn DeLodder: Yeah. I started off this whole process of being involved in this with one child. He wasn’t yet crawling at that time. When we finished and our bill was signed, I had my fourth baby with me. She’s in the photos. I definitely had a lot of times of having my own baby with me or being pregnant.
Rebecca Dekker: You were pregnant in a lot of hearings and meetings, or had a brand new baby with you.
Mary Kathryn DeLodder: Yeah. I remember one time having a committee hearing and I think my baby was two weeks old and sitting in the back of the room, still in that newborn nursing phase where you’re still getting the hang of it with that particular baby and trying to figure out if there was a convenient place where I can go nurse. When my babies were a little bit older, I was more confident in nursing wherever. But with that little tiny newborn, trying to find a place, and there weren’t really lactation rooms and there aren’t changing tables in the bathrooms at the Capitol. Things like that. It’s not necessarily a family friendly place. I remember when I was going to testify, I was worried about, well, if she starts crying and needs to nurse or something.
My midwife happened to be there, and I was like, “Will you sit right behind me, and if she starts to make any noise, I’m going to hand her to you,” and she did. My midwife didn’t always support me during birth, but she was right there and ended up bouncing my baby in the back of the hearing room for me, and just so many memories like that of being there. When our bill finally passed, I’ve got a picture of our governor at the time, and he’s holding two babies as he’s sitting there signing it, and one of them was my infant at the time. Yeah. Someday I’ll be able to show my children these pictures of you were there with me when I was doing this at the Capitol.
Rebecca Dekker: Yeah. Tell us about that day that it passed. Was there any drama or did it unfold pretty smoothly? Did it pass through the House first and then the Senate?
Mary Kathryn DeLodder: It passed in the Senate first, which nothing is ever a given. But it had passed the Senate the prior year…
Rebecca Dekker: That’s right. Okay.
Mary Kathryn DeLodder: We had a little confidence that it would pass. But then that was the … Because it didn’t have time to go through the House the first year it passed the Senate, we felt like we had so much more work to do in the House. We had focused so much of our effort in the Senate. We had lots of meetings and-
Rebecca Dekker: There’s lots of educating because a lot of the House members didn’t really understand the bill or home birth or anything.
Mary Kathryn DeLodder: In Kentucky, there’s a lot more members in the House in the Senate. You just had a greater volume of people to educate. There was a lot of back and forth of which committee is it going to get assigned to and trying to advocate for which committee we thought was the best, and it ended up … It was able to be assigned to the committee that we thought was going to be the most hospitable. It passed through the committee fairly easily, and I think a lot of that had to do because we had those negotiations with the OB from ACOG and he had given it his seal of approval, and because ACOG was giving it their seal of approval via this OB who had worked with us, therefore, the Medical Association was giving it their seal of approval.
Rebecca Dekker: Did they officially approve it or did they stay neutral?
Mary Kathryn DeLodder: They became neutral, which-
Rebecca Dekker: Okay, which was a win?
Mary Kathryn DeLodder: Yes. Which is much better than them being opposed, and the legislators knew that too. They were never going to say, “We wholeheartedly endorse this bill,” but they were neutral. They were no longer opposed, which is an important distinction with legislation I have learned. Our bill, everything was going great, it was in the House, we made it through committee, and ACOG had asked for some particular language around liability protection for physicians in the event of a transfer. I’m not an attorney. It looks fine to me. I’m like, “If that’s what the OBs want, if it makes them more comfortable with the bill, it…
Rebecca Dekker: They just don’t want to be sued if something goes wrong in a home birth, and they transfer to the hospital. The OBs wanted protection.
Mary Kathryn DeLodder: Yes, or at least they wanted the-
Rebecca Dekker: The feeling?
Mary Kathryn DeLodder: … perception of protection.
Rebecca Dekker: Perception of protection.
Mary Kathryn DeLodder: They had some language that I believe came maybe from ACOG national, someone that had drafted this language. We agreed to put this language in the bill. No one had really made any comments about the language or having any issue with it. But when our bill was poised to be heard by the full House, the Kentucky Justice Association, which is the trial attorneys association of the state, expressed that they had major problems with this liability language, and we’re like…
Rebecca Dekker: All the sudden … The attorneys have been silent all these years, they’ve never cared once.
Mary Kathryn DeLodder: This whole new thing erupted, and there was a particular legislator in the House who was an attorney, and he also thought it was a problem and he was a member of leadership. So he was in influential position. He stepped in and said, “I’m going to work on this,” and it suddenly was out of our hands. It became an issue between the trial attorneys and the obstetricians, and we had to sit back and wait for them to negotiate it out, and we were on the sidelines of watching our own bill and it was terrifying. Are they going to come to an agreement? Are they going to do it quickly enough for our bill to pass? Our lobbyist was trying to monitor the process and talk to the other lobbyists for these other groups, and they ended up coming to some language that they …
I don’t think the medical community was really thrilled with it, but I think they were maybe forced to accept it. There was still liability language in there that just said this bill does not create any new liability, and that reinforced that if there were trades for a doctor, it’s still liable for their own mistakes. I think that the way that the language was originally worded would have almost made it seem like if it was a transfer situation. Even if a provider at the hospital did something wrong after you got to the hospital, that would be fully their mistake. It was almost saying that they got a free pass just because it’s a transfer situation.
Rebecca Dekker: What they didn’t want was liability from what the midwife did. But legally, you can’t be liable for what somebody else you don’t have control over does.
Mary Kathryn DeLodder: There’s also a concern because the bill doesn’t require the licensed midwife to carry malpractice insurance professional liability insurance, and that was a misconception we ran up against a lot, is that a lot of legislators assumed that legally doctors and other providers are legally required to carry malpractice insurance and they are not. There is no law in Kentucky that says that they must carry that. They carry it for other reasons. They carry it because they feel that it’s the right thing to do to protect themselves professionally. They do it because to be contracted with insurance companies or to be contracted with Medicaid, they have to carry professional liability insurance. If they work for a large medical system, they usually know the medical system may provide no pay for the malpractice insurance.
Doctors carry it for other reasons, but it’s not because they are legally in Kentucky required to carry it. We made that point that why should we legally require the midwives to do this when we don’t require it of any other medical profession? Some of the midwives will choose to carry it and maybe some won’t, but part of the law says that they must disclose to their clients whether or not they carry it so the person knows at the outset. It ended up that they worked out the language, and I think that maybe the medical community really wasn’t totally on board with it, but they had already been neutral on it and the train was just out of the station at that point. It had enough momentum. Our House has 100 members, and it passed overwhelmingly with only one no vote.
Rebecca Dekker: Wow.
Mary Kathryn DeLodder: Many of us were there that day…
Rebecca Dekker: Were you sitting up in the balcony?
Mary Kathryn DeLodder: We were sitting in the gallery, again pre-COVID. We were allowed to be there in person and watch the floor discussion, and then they have a electronic board that shows up with red and green to show the boats and it just started lighting up green, all these names except for one. When it passed, we weren’t really expecting this. But the House members started applause, and so-
Rebecca Dekker: Didn’t they stand up and turn to you all?
Mary Kathryn DeLodder: Many of them were definitely looking at us. They knew we-
Rebecca Dekker: They were looking at you. Yeah.
Mary Kathryn DeLodder: They knew that this had been a long road, and so they applauded. It was just this unexpected moment. When they started applauding, we just started hooping and hollering and cheering, which was probably not the typical appropriate thing to do in the House chambers. But it was okay for that day. So much happiness and high emotions. We made our way downstairs and the legislators who had supported us came out in the hallways to shake hands and hug and take pictures and congratulations. It was just a great day. Even with all that and all that excitement, there was still a lot of work to be done after that because it still took at least another year of work to create the regulations and to actually get licenses issued. This was about July of 2020 before the midwives were actually able to get their licenses, which was actually pretty quick compared to how long it takes some states to do that process.
Rebecca Dekker: You weren’t able to just say, “All right, we’re done here.” You had to stay involved, the coalition had to keep paying its lobbyists. The work didn’t end after the bill passed.
Mary Kathryn DeLodder: No, the work did not end. The work just took on a whole new approach and a whole new process to learn of how the regulations work. A CPM Advisory Council was formed. In Kentucky, the way our legislation worked out was that it is under the Board of Nursing. I know some folks will cringe to hear that, but it has worked well so far in Kentucky, and that’s how it had to happen in Kentucky with the way things played out. It was not going to be financially possible for us to have our own board because of how few midwives there would be projected. That we could not financially support a board and we could not have gotten a bill passed that was going to create something that was going to operate in the negative.
It had to live under a different board, and for Kentucky, it ended up being the Board of Nursing, and so far that has worked out really well even though it could have gone a lot of different directions. We had to start working with the Board of Nursing with their leadership, and they were very great to work with. People were nominated to be on the CPM Advisory Council. We had folks that we had encouraged to submit their name to be a part of this. We had CPMs, we had nurse midwives, Obs, neonatologist, members of the general public, and we had been working to solicit the right people to put their names forth. We wanted people who wanted to do that work. We didn’t want them to have to go pick an OB who really didn’t want to be there. That wouldn’t be helpful.
That process started and then there were meetings, very frequent meetings of that group to really go through the regulations to get the more nuts and bolts of how do you apply for a license and how much is it going to cost, and what are the real practice standards? There’s even regulations about what would be required if someone wanted to open a future CPM school in Kentucky. I didn’t ever dream that we would be getting to that level of detail, but we did. That took a while, and then there is a…
Rebecca Dekker: Then the process was open in July of 2020, and now we’re in the summer of 2021. How many CPMs have gotten their license? I know you’ve been tracking it.
Mary Kathryn DeLodder: We have 24, currently. My highest projection was always that 20 would be the absolute ceiling based on the CPMs who actually reside in Kentucky and the ones from border states who serve Kentucky. When we hit that number in less than six months, 20, and then kept going higher, I was just amazed. There have been additional CPMs from border states who have chosen to get licensed who may not have served Kentucky before. But now that they can do it and feel that they are not going to be in any sort of legal gray area or any legal jeopardy to practice in Kentucky, they are more willing to come into Kentucky and serve. We have had a real explosion of interest in students.
Rebecca Dekker: I was going to say we have so many people who are starting midwifery school this year, including our own Chante Perryman at Team EBB who was part of this whole legislative process and went to all the lobby days and was super involved, and they’re all starting midwifery school this year, all these new folks. It’s very exciting.
Mary Kathryn DeLodder: Yeah, Chante was definitely a part of the process. Like me, she was there many times with a baby or pregnant…
Rebecca Dekker: I know.
Mary Kathryn DeLodder: …with legislators. But it was a tough decision in the past for students to pursue this career knowing that it was-
Rebecca Dekker: It’s expensive to go through the schooling, and then there’s no guarantee you can practice legally.
Mary Kathryn DeLodder: Right.
Rebecca Dekker: Yeah.
Mary Kathryn DeLodder: For profession that is basically operating underground, that’s a tough decision to make for your career. Now it is not underground, they can be licensed and fully recognized as a part of our health care system in Kentucky. The adage of if you build it, they will come and it’s proven true that we’ve seen such an explosion of interest from students who are starting the process.
Rebecca Dekker: Yeah. Yeah, I want to thank you, Mary Kathryn, and all the other members of the Kentucky Birth Coalition, which was truly a coalition and that include all different kinds of professionals and families, just regular people from all over the state who made phone calls, who drove to the Capitol, who wrote letters, who met with their legislators, who were involved in fundraising. That was a huge thing. Everybody had to be involved in several times a year to raise the funds for the lobbyists. Thank you so much for all of your work. What are the next steps? Because it seems to me you did not decide to retire from this advocacy role. Even after the regulations were passed, you made an announcement. We have a very wonderful active Facebook group of the Kentucky Birth Coalition, and you told us what we’re going to work on. What is it?
Mary Kathryn DeLodder: Well, there are still things that we’re working on regarding CPMs, for example, trying now to get CPMs as eligible to be Medicaid providers in Kentucky, and that’s a whole nother process, and just continuing to monitor things with the Board of Nursing, different issues might come up. There’s still this active monitoring.
Rebecca Dekker: Yeah, I didn’t realize it would be such a barrier to get the state to have Medicaid reimburse CPMs. But that has become a problem that you’re working on.
Mary Kathryn DeLodder: Yeah. We’re working on that. But our main focus now has turned to birth centers. We have zero freestanding birth centers in Kentucky, because we have a bureaucratic red tape process known as the certificate of need, where to open a medical facility, you have to prove that there’s a need for it, and people who disagree, competitors, can argue against that. In Kentucky, that has proven to be a barrier when individual entrepreneurs such as a nurse midwife wants to open a birth center in Kentucky. We have seen, in recent years, the hospitals come out in force and oppose that and say, “We provide the same service, there is no need,” and essentially the last person who tried was outspent through the legal appeals process.
She tapped into her retirement fund savings, and finally gave up and didn’t continue to take it through the court system because she couldn’t. She was outspent and that has stuck in lots of minds of others who would like to open the freestanding birth center. We are working … You could have a birth center in Kentucky if you could get through that barrier.
Rebecca Dekker: Process. But the hospitals are almost guaranteed to oppose you, and they have very deep pockets-
Mary Kathryn DeLodder: Yes.
Rebecca Dekker: … to keep appealing and prohibiting you.
Mary Kathryn DeLodder: We are now using our knowledge and our ground base of support to work on legislation. 2022 will be our third year to work on that, to exempt freestanding birth centers from certificate of need process, so making it easier for someone to open a birth center in Kentucky because our consumers would like to have access to birth centers. We actually changed the name of the organization. It was originally Kentucky Home Birth Coalition, and we changed it to just the Kentucky Birth Coalition because we really want to advocate for birth options, not just home birth, birth center birth. In the future, maybe there’ll be some aspects of hospital birth that we advocate about improving or changing. But certainly opens the opportunities to say we just want to be a consumer voice for birth in Kentucky.
Rebecca Dekker: Yeah. What’s the plan then for 2022? Are you allowed to say?
Mary Kathryn DeLodder: Yeah. We are working with our bill sponsors. We have different bill sponsors for the birth center bills. We are planning. We’re in the drafting process now to get the bills pre-filed for 2022. We’ve just had some meetings with legislators and some other folks to talk about birth centers. Again, it took a list of legislators bringing the other groups to the table. We had a big Zoom meeting last week with different medical groups present to learn about birth centers. And starting the process again of going through all these steps and education.
Rebecca Dekker: Educating everybody.
Mary Kathryn DeLodder: Yes, educating them that birth centers are not going to put hospitals out of business. Yeah, want more education.
Rebecca Dekker: It’s very exciting, though. All that experience you had in advocating for the CPM legislation will only be an advantage as you work through the birth center legislation.
Mary Kathryn DeLodder: Yeah. We are starting from a definitely a different place because we have all this knowledge. I know how the system works, and many of our supporters have learned how the legislative process works by being involved in it themselves. We have a lobbyist who we have a great working relationship with starting. We’ve got so much more of an advantage of just understanding how things work. We’re not starting as complete novices to this one.
Rebecca Dekker: Any words of advice for change makers listening who are working on legislation in their own communities? Now you’re coming up upon 10 years of experience of advocating for birth options at the state level, what words of advice do you have?
Mary Kathryn DeLodder: I think building your support of the consumers is so powerful, and I think one reason that we were able to be successful with Kentucky Birth Coalition, whereas all those groups in the decades prior to us may have had more challenges, is because they were working with having to make telephone calls or using snail mail to bring their consumers together, and…
Rebecca Dekker: We have social media.
Mary Kathryn DeLodder: Social media that we could have a meeting place on Facebook or on Zoom or whatnot, and talk to people from the other side of the state, and get the word out with the push of a button and not have to use a phone tree or use postcards or something. Use those tools to your advantage in build the consumer base because that was such a powerful tool. There is going to be wins and there’s going to be defeats, and you just have to be persistent and know that it’s going to be long haul. I’ve met folks from other states who have been working at legislation for longer than we have. I know somewhat of what they’re going through, and that you just have to keep at it.
Rebecca Dekker: Well, thank you so much, Mary Kathryn, for sharing your story and for educating us on the process. Could you share with us the best or easiest ways to follow the Kentucky Birth Coalition?
Mary Kathryn DeLodder: Yeah. Our website is Kentuckybirth.org, and we are on Facebook as Kentucky Birth Coalition. We’re on Twitter and Instagram. But probably Facebook is … We are the most active on our page, and we also have a closed group for our supporters where I try to share with him more of the insights of what’s going on and what meetings are happening and whatnot. If anybody certainly is in Kentucky and wants to be involved, and if you’re on Facebook, our Facebook group is a great place to be involved. We have auctions twice a year, online auctions, and anybody can support us through that and buy some cool items and help us to continue to pay our lobbyists, our legislative doula.
Rebecca Dekker: Yeah, I was going to say if anybody is interested in helping contribute to the Kentucky Birth Coalition, we’re always looking for help supporters and you can support financially at Kentuckybirth.org as well. Thank you, Mary Kathryn.
Mary Kathryn DeLodder: Thanks, Rebecca.
Rebecca Dekker: Bye.
Mary Kathryn DeLodder: Bye.
Rebecca Dekker: This podcast episode was brought to you by the book, Babies are Not Pizzas: They’re Born, Not Delivered. Babies are Not Pizzas is a memoir that tells the story of how I navigated a broken healthcare system and uncovered how I could still receive evidence based care. In this book, you’ll learn about the history of childbirth and midwifery, the evidence on a variety of birth topics, and how we can prevent preventable trauma in childbirth. Babies are Not Pizzas is available on Amazon as a Kindle, paperback, hardcover and audible book. Get your copy today and make sure to email me after you read it to let me know your thoughts.
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