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Health News Florida

Report: Out-Of-Hospital Births Put Mothers, Babies At Risk

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Courtesy Mike Lang/Sarasota Herald-Tribune
Riva Majewski lost her daughter, Vayden, during an attempted home birth in Sarasota in March 2016.

According to a new Sarasota Herald-Tribune and Gatehouse Media report, it's more dangerous to deliver a baby in the United States than anywhere else in the developed world -- and the risk for mothers is climbing.

Health News Florida's Daylina Miller recently talked with GateHouse Media National Data Projects Editor Emily Le Coz about the investigation, Failure to Deliver, which looks at the safety of out-of-hospital births in Florida and across the country.

Daylina Miller: So tell me a little bit about this investigation.

Emily Le Coz: “We found that it's actually more dangerous to deliver babies outside of the hospital than inside the hospital. And that is despite claims that are often made by midwives that it is just as safe.

One of the reasons that we found this discrepancy is that typically with low risk pregnancies and uncomplicated deliveries, the risks would be perhaps more comparable. But one of the things that we've discovered is that there is no uniformity in regulations or best standards of practice for out-of-hospital midwives throughout the United States.

So while, in general, out-of-hospital midwives are supposed to handle these low-risk pregnancies and uncomplicated deliveries, because many states lack any regulations, midwives are free to take on as much risk as they want, which is unlike midwives in other countries who practice out-of-hospital  deliveries and are restrained by those best practices and guidelines and regulations here.”

Why is there not as much regulation for these out-of-hospital births and how does Florida compare to other states?

"Florida actually has pretty good laws on the books in terms of out-of-hospital  midwifery. We are one of about 32 states that do recognize non-nurse midwives as being a profession. They are licensed, they are regulated, they are required to report statistics to the state which then come out in an annual report and the state actually passed a law [in 2018] that requires even more reporting for adverse incidents that happen in out-of-hospital births to help them better track the numbers and track the statistics.

So Florida is doing pretty good, but there are several other states that either outright ban the practice of non-nurse midwifery and restrict it to only certified nurse midwives. And then there are a dozen states that just have no regulation whatsoever. So I, for example, could move to Nevada and hang a shingle and practice as a midwife and deliver babies. And I wouldn’t be breaking the law in doing so. And so the issue really comes down to it's a state-by-state basis whether or not they decide to regulate midwives and license midwives and provide oversight and have parameters in which these midwives can practice.

For example, in Florida, midwives cannot allow a woman to go beyond 41 weeks gestation without a physician consultation or transferring them to a physician. Whereas, for example again, in Nevada because there's no oversight or regulation a midwife can allow a woman to carry a baby to 43 weeks. And statistically babies who are gestated beyond 41 weeks have a higher risk of dying in utero due to a host of issues. One of the big ones is placenta degradation so your placenta isn't as viable after a certain point of time and so your baby could suffer a lack of blood and oxygen.

So there's all these things that really should be in place to ensure that women choosing an out-of-hospital  birth with a midwife are cared for using best practices and guidelines and that's just not happening in many places throughout the country.”

You interviewed a lot of women for this story, but your team also had some personal connections. Can you talk about that and how you balanced it with your reporting?

“One of the reasons that we decided to pursue the investigation was my colleague Josh Salman and I were talking one day and his wife's best friend had lost a baby in an out-of-hospital  birth here in Sarasota. And I said, you know, that's obviously tragic. I know a couple of people who also had adverse outcomes from out-of-hospital  births. My best friend here in Sarasota ended up hemorrhaging after delivering her baby at home and was rushed to the hospital and lost quite a bit of blood and thought she was going to die. So it was not a good situation for her and then my sister in law also had a situation in which her baby had fluid in the lungs and had to be rushed to the hospital, too.

Obviously, we're very cognizant of those situations. And that was the motivation for us looking into this. But at the same time I’ve always personally been kind of a fan of midwifery and home birth and had contemplated having a home birth for my first child 12 years ago, but I was living in a smallish town in Mississippi and there were no midwives at the time and so I ended up having a hospital delivery which went fine. But I certainly understand the motivation for women to want to have this experience and avoid having the hospital, the fluorescent lights, the doctors and nurses and potential interventions. So I kind of see both perspectives.

And I felt very comfortable putting aside my own personal opinions and personal experiences and just looking at the data, looking at the research, looking at the overwhelming number of people we interviewed who were saying the same thing whether it was in Florida or Oregon or Alabama. The stories were consistent throughout the United States of these specific things being a problem.”

What kind of records did your team scour to report this series?

“Well, we looked at CDC statistics. So the CDC is sort of the central repository of birth certificate information collected throughout the United States. And the birth certificate information that they have is far more robust than what you would get if you requested your birth certificate from the Department of Health. So there are dozens and dozens of questions and data points that they collect that you can have access to in their flattened files and some of which is accessible through this sort of user friendly portal on the CDC website.

But we looked at that data and we analyzed women who had births either at home or in a freestanding birth center attended by a midwife, versus women who had births in a hospital attended by either a physician or a certified nurse midwife working within the hospital. And we looked at only full-term babies who had at least 37 weeks gestation, 2,500 grams, no congenital or chromosomal anomalies who, you know, those types of issues would have made them maybe more susceptible to an adverse outcome in the first place. 

So we really try to hone in on just full-term, healthy babies and whether or not they survived within a week or within a month of delivery. And the data that we crunched showed that more babies died after birth when they were delivered at home or in a freestanding birth center with a midwife versus in the hospital. And the research and data analysis that we did was modeled after previous peer-reviewed research done by Dr. Amos Grunebaum and his colleagues that was published in The Journal of Obstetrics and Gynecology. And so we felt pretty comfortable in that methodology and in our outcome, the findings that we had pretty much tracked with what his previous findings were.

And then beyond that, the records that we obtained. So we looked at every single state and we read their state law and all the regulations pertaining to midwifery and out-of-hospital  deliveries. We also requested disciplinary records from every single state going back at least 10 years for every midwife to see what some of the most common infractions were and what type of sanctions were imposed upon midwives, especially midwives who had been involved in a delivery that caused death or catastrophic injury for the baby or midwives who had been involved in numerous, repeated violations to see at what point the state would actually impose really serious sanctions on the midwives.

And what we found was in many cases, states offered midwives numerous opportunities to continue practicing despite sometimes a string of very serious previous adverse outcomes. So that made us question whether or not states were taking seriously the responsibility of protecting women from midwives who might not be doing a really great job. We also read lawsuits as well.”

Where does Florida fall in terms of state discipline if midwives don’t follow the rules?

“So we found that in Florida, certainly they have taken action. But the most frequent type of discipline is requiring a midwife to take more continuing education classes or paying fines or working under the supervision of a different midwife for a period of time. Very rarely has the state actually revoked a license. In fact, only one time in the past 10 years have we seen a license revocation. Although there were a half-dozen other midwives who voluntarily surrendered their license after a state inquiry found that there was probable cause to pursue disciplinary action against them.

But Florida seems to be pretty much in line with other states that have these boards of midwifery and regulate midwives and that the emphasis doesn't seem to be necessarily punitive as much as it is giving them an opportunity to grow and learn from the experience, which you could argue is fantastic. You certainly don't want to strip people of their licenses outright at the first sign of any type of violation. But you do wonder at what point it becomes complicit for the state to allow midwives who repeatedly violated the law to continue to practice and whether they're doing a good job of protecting mothers.

But that said, at least Florida does have regulations in place and the regulations that they do have over midwives seemed to be pretty comprehensive. Florida, I will note, is one of only three states that regulate midwives that require them to carry malpractice insurance, which is fantastic. However, the malpractice insurance that's required in Florida is only $100,000 per incident or $300,000 aggregate. Sounds like a lot but that's compared to the average obstetrician that would carry probably $1 million per incident and $3 million aggregate.

The problem is that it's very costly to file a lawsuit against a midwife. While in many cases it would cost far more than $100,000 not just file the lawsuit, but take the depositions, and pay for the attorneys, and calling witnesses and everything that goes into filing a malpractice claim against a midwife. It’s pretty substantial. So from a lot of families and attorneys who do this type of work we've heard that the $100,000  is not really sufficient and it's not so much just suing the midwife because your child died for example.

But we've spoken to families who their children have suffered lifelong injuries, substantial brain damage. And so suing the midwife is a way for them to get the money necessary to care for this child for the rest of its life. So it's very important. I think after doing my research that midwives all across the country should be required to carry malpractice insurance and to carry enough of it to cover these types of things.

What can Florida do going forward to make sure out-of-hospital births are just as safe, just as regulated as in-hospital births and what can expectant mothers do to protect themselves if they decide to go with a midwife out of the hospital?

“I think an important thing would be for legislators to require out-of-hospital midwives to carry more malpractice insurance than just the $100,000. And I think it's also important that midwives and hospitals collaborate and that's a really difficult thing to do and I know lots of hospitals across the United States are starting in earnest to reach out to out-of-hospital  midwives and work with them to establish better transfer protocols to get things in place in case of an emergency.

It's not just this chaotic scene where doctors are sort of caught off guard at the hospital when these women come in and they don't know their histories. There just needs to be, across the board, far better collaboration between these two camps to make sure that women come first at all costs. Beyond that, I think there needs to be some scrutiny into how the Council of Licensed Midwifery under the Department of Health is holding fellow midwives accountable to make sure that midwives who routinely violate state regulations are given more than just ten extra hours of continuing education.

And then as far as what mothers can do, we do have on our website a list of questions that we recommend mothers ask prospective midwives who they are considering hiring to help them have an out-of-hospital delivery. Our research shows that certified nurse midwives have the best outcomes as opposed to non-nurse midwives.

So certainly I think they ought to be looking at that. They ought to be looking at how close their out-of-hospital birth would be to the nearest hospital. I would find out what that midwive's transfer protocols were, who that midwife consults with as a physician if there is an established partnership beyond just something that's a formality and a piece of paper that says there is. Did they actually visit with the obstetrician on a regular basis? Also, they would want to check whether their midwife has been disciplined before and how that all shook out."

Read the entire series here