Birth centers are a popular option for couples who appreciate the collaborative approach and softer, compassionate approach of midwife care.
In routine labor and delivery situations, midwife care can be great. As a medical malpractice attorney representing families across Texas, though, I’ve seen firsthand how midwife-assisted births can have devastating consequences when things go wrong. This comprehensive guide will help you understand the legal framework governing midwifery in Texas, with special attention to morbidity rates and safety requirements.
What are birth centers?
In Texas, birth centers offer an alternative to hospital births, focusing on natural and less invasive birthing experiences. These facilities are more loosely regulated by the Texas Department of State Health Services (DSHS) rather than a specific state board dedicated solely to birth centers. With that said, birth centers must comply with the Texas Health and Safety Code, which requires them to be licensed and adhere to specific standards to ensure safety and quality of care.
To operate legally, a birth center in Texas must pass an initial inspection and then undergo regular inspections to maintain its license. These inspections assess various aspects including emergency preparedness, infection control, equipment maintenance, and staff qualifications. The regulations stipulate that birth centers should have written protocols for transferring patients to hospitals in case of complications, emphasizing the need for close proximity to medical facilities for emergency care. We talk about this in our article how in high risk pregnancies, labor and delivery team shouldn’t wait for a problem before delivering the baby.
Despite these regulations, governmental oversight is less rigorous compared to hospitals, leading to concerns about the adequacy of emergency response capabilities. While midwives often staff these centers, they operate under different licensing and certification than physicians, including obstetricians who deliver babies at hospitals.
Midwife responsibilities
Texas Administrative Code Rule 115.115 requires midwives to evaluate the patient’s condition upon arrival and continuously monitor their progress through labor. This includes assessing vital signs, fetal heart tones, and other labor indicators to ensure the well-being of both mother and baby.
Midwives are barred from certain practices that could escalate complications, such as applying fundal pressure or administering certain drugs during labor.
Under Texas rules, midwives may only assist with normal, spontaneous vaginal deliveries. This inherently means that any complications beyond this scope would necessitate a transfer to a hospital where more advanced medical intervention is available.
Birth centers emergencies
The calm environment of a birth center can become stressful and frantic when there’s a labor and delivery emergency.
Rule 115.115 details specific responsibilities and limitations for midwives, particularly concerning the transfer of patients to a hospital during labor and delivery. Here’s what the rule requires regarding patient transfers:
Immediate Emergency Transfer: The rule lists specific conditions that mandate immediate emergency transfer. These conditions range from prolapsed cord and uncontrolled hemorrhage to abnormal fetal heart rates and presentations not compatible with spontaneous vaginal delivery. If any of these conditions are detected, the midwife must act swiftly to transfer the patient to a hospital, documenting the decision and action taken in the midwifery record. This list is not exhaustive; any condition or symptom that could threaten the life of the mother or fetus also requires a transfer, showing the broad discretion midwives must exercise in emergency situations.
Fetal Heart Rate: In hospital labor and delivery units, patients are typically continuously monitored with electronic fetal monitoring systems. In birth centers, it’s common to do intermittent auscultation (periodically listening for the fetal heart rate). When this method is used, midwives are required to follow the recommendations of the American College of Nurse-Midwives, ensuring that monitoring is conducted in a manner that can reliably indicate when a transfer might be necessary.
The rules are in place to prevent adverse outcomes by ensuring access to higher levels of care when needed. That’s why Texas birth centers must maintain comprehensive transfer agreements with nearby hospitals who can assume care if something goes wrong. These agreements must include:
Written Protocols
- Detailed transfer procedures with receiving hospitals
- Specific criteria for emergency vs. non-emergency transfers
- Chain of command during transfer situations
- Communication protocols between facilities
- Transport arrangements and preferences
Hospital Requirements
- Must have transfer agreements with at least two hospitals
- Primary hospital must be within 30 minutes travel time
- Secondary hospital must be within 45 minutes
- Both hospitals must have 24/7 obstetric services
- Must maintain current contact information for on-call physicians
Waiting Too Long
One of the most frequently cited criticisms of birth centers and midwives is the potential delay in escalating care to a hospital when complications arise during childbirth. This concern centers around the timing and decision-making process for transferring a patient from a low-intervention birth setting to a facility equipped for emergency medical care. Learn how labor and delivery nurses decide which moms need priority evaluation and care.
In labor and delivery emergencies, a baby may require delivery within minutes by C-Section – something that no birth center or midwife is licensed or equipped to do.
Birth centers and midwives often promote a natural birthing experience, focusing on minimal medical intervention, which can be advantageous for low-risk pregnancies. However, critics argue that this philosophy might sometimes lead to a reluctance to recognize or act swiftly on signs of complications. The primary worry is that midwives, adhering to a model of care that emphasizes normalcy, might underestimate or overlook the severity of labor issues, leading to delayed transfers.
Several factors can contribute to this delay:
- Philosophical Approach: Midwives trained to support physiological birth might be predisposed to waiting longer, hoping for a natural resolution, before acknowledging the need for hospital intervention. This approach, while beneficial in many scenarios, can become a liability when rapid medical response is required.
- Lack of Immediate Medical Resources: Unlike hospitals, birth centers might not have immediate access to advanced medical equipment or specialists, meaning that even when the decision to transfer is made, there can be a lag time before the patient is under hospital care, potentially worsening outcomes in emergencies like severe bleeding, fetal distress, or complications with the placenta.
- Training and Experience: The scope of practice for midwives varies, and not all might have the same level of training or experience in recognizing when a situation has escalated beyond their control. This variability can lead to inconsistencies in when and how transfers are initiated.
- Transfer Protocols: Even when protocols exist for transferring patients, the execution can vary. Delays can occur due to logistical issues like the availability of transportation or the nearest hospital’s preparedness to receive a transferring patient.
Studies and litigation have shown that while many transfers are non-emergent, a significant portion are due to complications that could have benefited from earlier intervention. For instance, conditions like prolonged labor, failure to progress, or fetal distress might lead to hospital transfers that, if delayed, could result in poorer outcomes for mother or baby. While not every delay results in harm, the potential for negative consequences has fueled ongoing debates about the safety protocols at birth centers and the decision-making processes of midwives. One of these protocols is no know there are risks to stopping fetal monitoring before delivery.
Understanding the detailed requirements for birth centers and the comparative risks of different birth settings is crucial for both providers and patients. While birth centers can provide safe care for low-risk pregnancies, their limitations in equipment, monitoring, and emergency response capabilities must be carefully weighed against the potential risks.
Getting Legal Help
If you believe birth center or midwife care has led to a serious injury of your baby, such as a brain injury called hypoxic-ischemic encephalopathy (HIE), consult with a qualified medical malpractice attorney who understands this complex are of medicine and law.
