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00000171-95d3-d2cb-a5f3-9fff6d610000Would-be home birth moms -- and the midwives who care for them -- say Oregon health officials are unfairly limiting birth options for many women who get their insurance coverage through the Oregon Health Plan.JPR's Jennifer Margulis spoke with doctors, licensed midwives, mothers-to-be and others to get the story of a state agency that's making it harder for low-income women to give birth anywhere but a hospital.

Denied: Home Birth Put Out Of Reach For Many Low-Income Moms

Jennifer Margulis/JPR
Ivy, 18 months old, was born in a cabin in Talent, Oregon with the help of state-licensed midwives. Her mother had insurance through the Oregon Health Plan, but the application for insurance coverage of her out of hospital birth was denied.

Oregon has one of the highest rates of home birth in the United States. These births are usually attended by state-licensed midwives. But some pregnant women and the midwives who care for them say that a state agency is unfairly --and maybe illegally-- denying low-income women access to home birth. 

Ivy is 18 months old. She has wispy brown hair and dark eyes. She loves to stuff her baby animals in their soft pea pod. Her mother, Jade Bounce, who’s 26, says she had an easy, uneventful pregnancy.

“I’m young and healthy,” Bounce says. “No risk factors at all. I had blood work done once in the beginning of my pregnancy and it was just perfect.”

Bounce says home birth was a natural choice: her boyfriend was born at home, as was her younger sister.

Bounce’s health insurance comes from the Oregon Health Plan, which provides coverage to low-income Oregonians. Women on OHP can choose to give birth in the hospital or have an out-of-hospital birth—meaning at home or at an independent birth center. As long as pregnant women meet certain criteria, OHP pays for out-of-hospital birth.

And here’s a statistic that might surprise you: nearly half of pregnant women in Oregon are on OHP.

Hermine Hayes-Klein is a Portland lawyer and founder of Human Rights in Childbirth, a global non-profit. She says Oregon is one of the states with the most secure access to out-of-hospital birth.

“Oregon midwives worked for many years with the legislature to become legal, to make sure that women could have secure, above board, legitimate access to out-of-hospital birth and to midwifery care,” she says.

A woman who wants her out-of-hospital birth covered by OHP must apply for what’s called an “Open Card,” essentially an authorization for insurance reimbursement. The problem, Hayes-Klein believes, is that the Oregon Health Authority is denying women access to out of hospital birth for unfair reasons.

“Certain choices are perfectly legal for women to choose and for midwives to support but OHP is arbitrarily refusing to cover those choices anymore.”

That was Jade Bounce’s experience.

“They didn’t give me a medical reason for denying the open card,” she says. “It seems that they pretty much just didn’t want to cover home birth.”

The Oregon Health Authority, which oversees the Oregon Health Plan, refused repeated interview requests. But in a written response, the Oregon Health Authority estimates they denied Open Cards to 250 of the 1,000 Oregon women who applied in 2015, “due to inadequate documentation or assessed risk.”

Jenn Head is with the Oregon Midwifery Council and an Ashland midwife.

“I’ve been hearing from midwives all across our region and all across the state that they’ve been having healthy women denied and pended over and over again for non-medical reasons,” she says.

“Pended” means the applications are put on hold. But when a woman’s pregnant, the clock is ticking.

“This is a very frustrating situation for me and for all the midwives and for our clients.”

JPR reviewed a number of these denial letters. One states that because the applicant previously delivered a breech baby at home without a midwife or doctor present, and the baby was large, she was not eligible for home birth. Yet no obstetrical guideline or Oregon rule indicates that a previous unassisted breech birth would make a subsequent midwife-assisted birth unsafe.

Another mom was denied for “the convenience of the provider of treatment.”

Augustine Colebrook, a veteran midwife who owns Trillium Waterbirth Center in Grants Pass, says these kinds of letters are typical.

“Some letters were just ambiguous saying, ‘high risk,’ ‘not eligible for home birth,’ not appropriate for midwifery care, without any correlating reasons,” she says. “So it does seem completely random. It does seem very biased against midwifery care.” 

Colebrook says a third of her clients on OHP were refused coverage for out of hospital birth. She finds these denials baffling.

“I mean, if you read through all the denials we’ve gotten, one might surmise that nobody is safe for an out-of-hospital birth.”

Though Jade Bounce was denied insurance to cover her home birth, she didn’t have her baby in the hospital. Bounce gave birth to Ivy in a cabin in Talent, up a winding dirt road, with the help of a midwife. It cost $3,000.

“I paid out of pocket,” Bounce says. “I had to. And I’m lucky that my midwives were so nice.”

Her labor lasted only 13 hours but, she says, it took her and her boyfriend six months to pay for the birth.

Jennifer Margulis, Ph.D., is a regular contributor to the Jefferson Journal and also produces radio features for JPR. She's a former senior fellow at the Schuster Institute for Investigative Journalism at Brandeis University. Her writing has appeared in the New York Times, the Washington Post, and on the cover of Smithsonian magazine.