Wednesday, May 30, 2012

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  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

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: 

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"


  1. Excellent post! It brings up a painful subject for me, however. With my last birth, I encountered a shoulder dystocia with only my poor, scared husband and a grossly unprofessional and incompetent nurse in attendance. My baby was born a little blue and with only a small bruise where the nurse yanked her out. I reported chest pain several hours later and was immed. given an EKG. The anesthesiologist diagnosed it as bruised intercostal muscles from pushing so hard. When I replayed all the events, I felt that negligent care and unprofessionalism were apparent with both the doctor and the hospital. About a year later I filed a grievance with my insurance against the doctor and hospital. I wanted accountability even though I would never know the outcome. Accountability is SO important,as well as common decency. Both were lacking by many people during my hospital stay. I still hope that in some way it made a difference. I am a strong advocate of women speaking out about adverse experiences because hospitals want their repeat business and that of their friends, family and neighbors!

  2. I think the most important thing here is that all "sentinel events" are reported and investigated, not just deaths. So, when you hear about that homebirth in which "everything was perfect but baby came out a little gray and floppy but pinked up after some rubbing" and other near misses, those would be investigated as well even though "everything turned out fine."

  3. Since my loss happened with an OB, I have a different perspective. The system in this country failed me and continues to fail way too many families. Statements like, “we may not be perfect, but we” ring so hollow when you’re the one who has trusted the system and yet had to bury your baby. The fact is 99% of births in the US occur in a hospital setting and the US has one of the worst perinatal mortality rates in the industrialized world. We shouldn't be comparing bad to bad (one hospital's loss rate in the US to another) and patting ourselves on the back and saying we are doing such a great job. The perinatal loss rate in Findland is 5 per 1000, Sweden is 6 per 1000, the US is 10 per 1000. When you read journal articles about how women give birth in those countries you will see some important differences. For example, in Sweden 90% of births take place in a hospital setting, but 100% of those births are attended by a midwife. Doctors do not assist at a birth except in cases of complication and then the midwife will send for a doctor. At Sparrow, families do not have access to a midwife attended hospital birth. You can have all the "procedures" you want in place but if they are not saving lives then they are meaningless. Please stop deluding yourselves into thinking we are doing a great job in this country. As a parent of a baby who didn't survive a hospital birth I implore you to seriously consider how you can get your loss rates down to 5 or 6 percent. That should be your goal!

    1. Dear Mark,
      Let me say how grateful I am for your comment and how sorry I am for your loss. I understand completely when you talk about how hollow words can be. The more I write about our experiences and learn about those of others, the more I think I should have started a blog/website to advocate for safer maternity practices, period. You're right, the hospital is far from perfect too, and I hope we aren't sending that message. All I can speak about is my own experience, knowing how ridiculous and preventable it was, how there is very limited opportunity for accountability, and how I think things could be improved. I agree that there is much room for improvement in maternity care. We're shifting our focus starting this week and the next several, to look more at collaborative care, meaning nurse midwives functioning in some capacity with obstetricians in our area. The points you made are important ones, and our greater Lansing area NEEDS more options for women and babies. I believe that Ingham county and the state of MI are among the worst when it comes to neonatal mortality rates according to the March of Dimes Peristats website. If you're willing or able, I'd love to talk more with you about your experience and ways you think things could be improved given your experience. We're currently starting a letter writing campaign and committee to gather research, visit other collaborative care models, and push for better options here. Whatever you're willing to share or in any way you'd like to take part, it would help all of us. Thank you for sharing. You can email me through the site or message Sara Snyder on face book to get in touch if it is something that interests you. Our best to you and your loved ones.