Making Home Birth Safer in the United States Through Strategic Collaboration: The Legacy Health System Experience

Research from Canada 1, 2, the United Kingdom 3, 4, the Netherlands 5, and other countries 6 supports the safety and cost-effectiveness 7, 8 of planned home birth with qualified midwives, when the birth takes place within an integrated maternity care system. However, in the United States, home birth midwives are seldom allowed to integrate their practice into the larger maternity care system. Many home birth midwives seeking to build relationships with obstetricians and/or hospitals are rebuffed and/or treated with hostility, and many are unable to secure reliable obstetric and hospital services for patients that need to be transferred to higher levels of care. The lack of effective relationships for the smooth transfer of patients needing specialized care has the potential to negatively affect patient outcomes. I have been a practicing obstetrician/gynecologist in Portland, Oregon, since 1974. During my time in private practice, my relationship to the home birthing community was much like that of ships passing in the night. I was always too busy and sleep-deprived to notice much of what was going on, except that I was aware of some hostility between my fellow physicians or hospital staff, and the home birth midwife community. There were also some publically exaggerated conflicts between them, but that was really about as much as I knew about it. However, about 10 years ago, I took on the position of Medical Director of Women's and Surgical Services for the five hospitals of the Legacy Health System in Portland. With this move, I suddenly found myself as the owner of that particular conflict, much to my surprise. I realized that one of the missions of our hospital group is to be of service to the community. In our community, there was a high rate of out-of-hospital births—about 5 percent of births. I realized that if I were to live up to my commitment to this community, I would somehow have to address the issue of home births. This realization was not related to my personal feelings about out-of-hospital birth—whether I preferred to oppose or promote it. It was more that this is the community we live in and it is my job to support this community. To improve patient care for pregnant women, I would need to improve systems of care and to address the hostility. I was helped in this by a couple of phone calls: one from a very eloquent certified nurse-midwife at the Oregon Health and Sciences University. She had tried to transfer a patient to one of our hospitals during labor and received so much flak, criticism, and expletives over the phone, and so much overt hostility, that she wound up not pursuing the transfer, which would have been a very important transfer. It occurred to me that that was a real system failure. Here was a patient that needed our help. The patient was actually a physician and her husband was a physician. When I learned more about this story and learned what was going on, and how massive this failure was, it was really quite embarrassing. The second thing that happened was that I had a call from one of the community providers who had transferred a newborn into our neonatal intensive care unit after an unexpected adverse neonatal outcome. The midwife was unsure as to the etiology, but she knew that we did case reviews and wondered if she could come to the case review. I thought “Wow, that sounds good.” Of course, without consulting Risk Management, I just said “Sure, come on in.” Three midwives from the midwifery group attended the case review. They had wonderful records, and described the patient's history, the management of the labor and everything, and then wondered what our impressions were. This started a very productive conversation. The five hospitals that I am responsible for include two tertiary care hospitals. Our largest hospital is a very high-end tertiary hospital, and also a teaching hospital. In developing ways to support a Maternal/Fetal Medicine program, I came up with the idea of starting an obstetric hospitalist program, partly as a means for providing the 24/7 in-house faculty coverage required to support our residency program. After putting this program in place, I was now in charge of an entire team, including Hospitalists, the Maternal/Fetal Medicine program, and the employed nurse-midwife program in the hospital. Thus, I was now in a good position to carry on constructive dialog about how we wanted to improve our services. One of the big problems with trying to reach out to the community to improve relationships and hopefully improve care was that, while we could deal with policies, what we really were going to be dealing with was a major culture clash. How to navigate the culture clash and improve relationships was, I felt, the biggest challenge. At that time, our nurse-midwives, by medical staff by-laws, were not allowed to accept intrapartum transfers. Such transfers had to go to a board-certified obstetrician. It was simply a hospital rule. It seemed like if we were going to improve the relationships with the community, the first thing we had to do was change the hospital by-laws. Step one, I thought, was to make the hospital-based midwives the primary recipients of home and birth center transfers. I thought it would be much more acceptable to both the community midwives and to their clients if they could transfer to another midwife who had hospital privileges, rather than transfer to an obstetrician whom most of them did not know, did not trust, and probably feared reprisal from. Under the system we had set up, the required physician consultant for the midwifery service was now one of the four hospitalist obstetricians. After further discussion, these obstetricians agreed that if the nurse-midwife team could accept community transfers, they would provide the obstetric backup for them. This is what really turned the corner for us. We had, before that time, very few transfers to any of our hospitals—just a couple each year. The typical scenario would be that something had gone dreadfully wrong and the community midwives, after exploring their options and receiving nothing but hostile responses from the various hospitals, would finally have the patient transported to the hospital by ambulance. Then they would leave the patient in the emergency room to the care of whoever was on emergency call. We called these “train wrecks,” because whatever medical problems the patient had before arriving at the hospital were compounded by a lack of preparation and communication, until things were actually brought under control. After we created this system for midwife transfer, suddenly the community midwives felt freer to talk to our midwives and prepare these patients for transfer. The hospitalists were very supportive of this, and a lot of the barriers began to crumble pretty quickly. At first, we had a couple of transfers a month. After a few months, our lead midwife and I and sometimes one of the hospitalists went to the practice sites of particular community midwives and we would ask “What did we do well? What did we do poorly? How are we going to do it better the next time?” and so forth. There was a steep learning curve for everyone as to how to do this right. However, over time we were able to build trust and relationships to the point that we wound up seeing more transfers into our program—about two per week. We also began getting very positive feedback from patients who were transferred, who said “We had no idea hospital care could be friendly” and so forth. As far as outcomes of the program, 86 patients were transferred into our midwifery database in 2013. Of these, 41 went on to have cesarean births and 45 had vaginal deliveries. Outcomes were good—there was not a single bad outcome in the group that was not already predetermined by something that no one had control over. As a result of the success of this program, we have expanded it to the other four hospitals in our hospital system. Through the present time (September 2015), our transfer rate system-wide remains at approximately 12–15 per month and our cesarean delivery rate remains just under 50 percent. We continue to meet on a fairly regular basis with the community midwives, meaning that our lead midwife along with myself or one of the OB Hospitalists will travel to one of the midwifery sites to which other midwives have been invited for the meeting and discuss any issues with our program. Our most recent such meeting was early August 2015, and there were no significant concerns raised. Based on continued good outcomes and this kind of feedback, we feel that our program has been successful in meeting our mission of service to the community. Of course, much of the success depends on the willingness of the community midwives to prepare their patients for possible transfer and help allay fears surrounding transfer, which they can do with more confidence in the face of an established program. In summary, the factors which we feel are important include educating the medical staff (it helps to have a focused subgroup to start with such as obstetrician hospitalists), creating a mechanism for transfer directly to another midwife on staff, keeping the referring midwife on the care team as a patient support person after transfer, offering and participating in constructive case review when indicated, and facilitating regular meetings between our hospital team and the community midwives to seek ways to optimize the transfer process. These and other tips for success are described in the recently developed Best Practice Guidelines for Transfer from Home to Hospital 9, developed by delegates of the national Home Birth Summits: http://www.homebirthsummit.org/. We are hopeful that our experience in Portland can help inform change and improve patient safety in other parts of the country. Note: Some of the information in this commentary was first presented at the 2014 Home Birth Summit; see: http://www.homebirthsummit.org/dr-duncan-neilson/.

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