Neonatal Mortality Part 1: "Babies Die in Hospitals Too!"

(This will be a two part post, the latter specifically focused on the populations served and what data says about the outcomes, as stratified by birth attendant for both hospital and out-of-hospital birth.)


Midwife (to a mother whose baby didn't survive out-of-hospital birth):  "I'm sorry your baby didn't make it.  Babies die in hospitals too.  You know, some babies just aren't meant to live.  You could always try again.  Come have another baby with us someday.  We did everything we could, there just wasn't anything we could have done differently."   

Yes, babies do die in hospitals, but there's a little more to it than the statement implies.  Sometimes everything possible was done to save a baby's life, and other times errors are made, regardless of place of birth.  The difference is that in one environment (hospitals) there are protocols, review processes, oversight, regulation, insurance, and the opportunity for accountability...and in the other (out-of-hospital birth) there is not.  The purpose of oversight, review processes, insurance, and regulation becomes abundantly clear.  I'd like to look more deeply at the context and implication of the statement, "Babies die in hospitals too," to gain a more complete perspective.

Let's focus first, on how hospitals are accredited and what precisely happens when a baby dies from complications at birth in a hospital setting.

Our focus is Sparrow Hospital in Lansing, MI, because that is the hospital we know best.  Sparrow is accredited by the Joint Commission, an organization that has accredited hospitals for more than 60 years and today it accredits approximately 4,168 hospitals nationwide. Approximately 82 percent of the nation's hospitals are currently accredited by The Joint Commission.  Listed on a document entitled, Facts about Hospital Accreditation, are statements explaining why hospitals seek Joint Commission accreditation.  Here are just a few:

• Helps organize and strengthen patient safety efforts.
• Improves risk management and risk reduction.
• May reduce liability insurance costs.
• Provides education on good practices to improve business operations.
• Provides professional advice and counsel, enhancing staff education.
• Provides a customized, intensive review.
• Provides a framework for organizational structure and management.
• May fulfill regulatory requirements in select states.

Sparrow also applies for and has achieved many other notable recognitions that can be found at http://www.sparrow.org/recognitions.  Not mentioned there, but relevant to our discussion specifically related to obstetrics, is the MHA Keystone OB study.

     
     "MHA Keystone: OB focuses on eliminating preventable harm to mothers giving birth  
      and their newborn babies in Michigan hospitals. The collaborative integrates    
      evidence-based clinical and science-of-safety interventions that, together, support a 
      culture of safety to prevent harmful outcomes. Strategies are incorporated to prevent
      fetal and maternal harm due to complications of labor induction and management of the 
      second stage of labor. The collaborative aims to reduce the number of birth injuries from 
      the current estimate of three injuries for every 1,000 births in the United States, and  
      aligns with Gov. Rick Snyder’s “dashboard” priority to reduce infant mortality."

Sparrow was one of the 8 hospitals chosen to participate in the MHA Keystone OB pilot study in 2008, and then continued in the large prospective trial that started in 2010 and is ongoing.  When asked about this initiative, the chief obstetrician at Sparrow, Dr. Molly Guerin says, "Data is starting to come in and looks excellent.  The commitment to avoiding preventable harm is job number one at Sparrow.  We are not perfect but we strive for perfection at all times."  I then asked Dr. Guerin a series of follow up questions.  Here is our dialogue: 

Me: What happens when a baby does die in a hospital? 

Dr. Guerin: "At Sparrow Hospital, specific review processes and protocols are in place for any death, including babies.  Nationwide the Joint Commission on Accreditations of Hospitals mandates reporting of and investigation of "sentinel events", which are events that result in harm or risk of harm to hospitalized patients, including moms and babies. (See their website http://www.jointcommission.org/sentinel_event.aspx)

When we have a sentinel event we do a Root Cause Analysis, which is a specific framework for identifying systems and individual causes of these harms, and make appropriate changes if issues are identified.  Sparrow is fully JACOH accredited, is randomly inspected, and has passed all inspections in full." 

Me: Does Sparrow Hospital report doctors whom they suspect have acted negligently?

Dr. Guerin: "We have taken action against individual physicians in the 22 years I have been here, and those physicians are no longer on our staff. Because these issues are part of Peer Review they are confidential. Certain changes in status of hospital privileges are reported to the State of Michigan and also to the National Practitioner Data Bank." 

Me: Dr. Guerin, am I right in pointing out that what you have stated are the steps Sparrow takes upon themselves to report questionable circumstances?  What can the patients do in terms of reporting questionable care?  

Dr. Guerin:  "Patients can report complaints to the Risk Management Department directly at Sparrow.  These complaints are taken very seriously.  The can also report adverse care, and negligence to Licensing and Regulatory Affairs to request a state investigation.  Patients can  file a lawsuit if they feel negligent circumstances have occurred that have not been resolved by other means."  

Conversely, let's briefly look at what happens when a baby dies in home birth or at a freestanding birth center.  You could report you concerns to NARM, but their process for "complaints" is a peer review, essentially group therapy for when you have had a bad outcome among your colleagues.  Nothing gets submitted to NARM from those peer reviews and none of the "recommendations" are required changes in practice.  I've heard it described as, "Fight Club with all the oaths of silence."  When MANA and NARM were approached about how many midwives in MI have had disciplinary action taken or credentials revoked, they would not disclose the information.  In fact, they couldn't even tell us how many CPMs were certified and working in MI.  I guess it's true that midwives do police midwives, just not very safely, effectively, transparently, or responsibly.  

Some wonder if doctors & nurses are held accountable at all?  While I recognize this isn't a perfect system, doctors and licensed midwives are more likely to be held accountable than unlicensed midwives with NO system of accountability and NO insurance.  There is good reason for oversight and dangerous consequences without it.  For disciplinary actions taking place over the past 7 years against licensed individuals in MI, visit this link: 

Disciplinary Action Reports (Licensing & Regulatory Affairs for the State of MI)

Negligence is negligence no matter where it happens, in a home or hospital.  The point is that there must be mechanisms in place to hold responsible parties accountable, to consistently review & improve practices taking place.  Babies do die in hospitals, true, but at least there is an immediate system of review, mandated reporting of outcomes, and malpractice insurance as a means of recourse.  In addition, hospitals are licensed facilities, full of licensed professionals, both of which have oversight and opportunity for reporting negligent circumstances. 

A freestanding birth center has no such oversight, as they are not a licensed facility.  A CPM or DEM?  No such regulation exists in MI.  They are not licensed or insured, and they are not mandated to report outcomes.  When a baby dies at a freestanding birth center or at home, it's as if it never happened and there's not a damn thing you can do about it.  There isn't any opportunity for recourse in any way.  While no system is perfect, something is better than nothing.   

                      
10 cm blog ~ "Babies Die in Hospitals Too"