Smooth Transitions: Enhancing the
Safety of Planned Out-of-Hospital
Birth Transfers
A Quality Improvement Initiative
of the WA State Perinatal Collaborative
Disclosures
The speakers have no conflicts of interest
to disclose
Learning Objectives
At the conclusion of this presentation, participants will be
able to:
 Describe the categories of midwives recognized in WA
State
 Describe the scope of practice of Licensed Midwives in
WA
 Understand the benefits of a quality improvement
program that addresses transfers from planned out-ofhospital births
 Understand how to engage in such a program at their
hospital
The Issues
Out-of-hospital (OOH) birth is chosen by a
small but growing number of families
Physician and hospital services will be needed
Lack of systemic supports for smooth transfer
of care
Context
AWHONN Position Statement on Midwifery:
AWHONN supports a woman’s right to choose and have access
to a full range of providers and settings for pregnancy, birth and
women’s health care.
It is critical that each health care professional recognize and
respect the scope of practice and state and/or provincial
licensure parameters of each collegial health care professional.
Research suggests that lack of teamwork is associated with less
optimal patient outcomes. Effective communication between
all types of health care professionals is essential to provide safe
and effective care of women and newborns and is especially
critical when the patient’s care occurs in more than one care
setting.
The Context
ACOG Statement on Home Birth:
Although the Committee on Obstetric Practice believes that hospitals and
birthing centers are the safest setting for birth, it respects the right of a
woman to make a medically informed decision about delivery. Women
inquiring about planned home birth should be informed of its risks and
benefits based on recent evidence. Specifically, they should be informed
that although the absolute risk may be low, planned home birth is associated
with a twofold to threefold increased risk of neonatal death when compared
with planned hospital birth. Importantly, women should be informed that
the appropriate selection of candidates for home birth; the availability of a
certified nurse–midwife, certified midwife, or physician practicing within an
integrated and regulated health system; ready access to consultation; and
assurance of safe and timely transport to nearby hospitals are critical to
reducing perinatal mortality rates and achieving favorable home birth
outcomes.
Published in 2011; reaffirmed in 2013
The Context
Home Birth Consensus Summit, October 2011
Statement on Collaboration:
We believe that collaboration within an integrated maternity
care system is essential for optimal mother-baby outcomes.
All women and families planning a home or birth center birth
have a right to respectful, safe, and seamless consultation,
referral, transport and transfer of care when necessary. When
ongoing inter-professional dialogue and cooperation occur,
everyone benefits.
The Context
Home Birth Consensus Summit
Collaboration Workgroup
Best Practice Guidelines: Transfer from
Planned Home Birth to Hospital
May 2014
2013 WA Births
Total Births
86,431
Hospitals
84,053
97.2%
1,161
1.3%
Home
1,753
2.0%
Other
65
.07%
Birth Centers
MD/DO
74,994
86.7%
CNM
7,832
9.1%
LM
2,804
3.2%
629
0.7%
Other or unknown
Out-of-Hospital Births in Washington State
 In 2013 3.2% of Washington’s births occurred in an out-ofhospital setting (N=2,914) ; up from 1.9% in 2006
 60% at home
40% in licensed freestanding birth centers
 Washington’s home birth rate is more than twice the national
rate; birth center rate is more than triple the national rate
 Majority (94% of OOH births) attended by Licensed Midwives
(LMs)
 There are currently about 120 LMs in the state and 16 licensed
freestanding birth centers
Midwives in Washington
Lay (unlicensed) midwives
Certified Nurse Midwives (CNMs)
Licensed Midwives (LMs)
• LMs may also hold a national credential
of Certified Professional Midwife (CPM)
Licensed Midwives
 Complete 3 year education from a Washington State approved school, including
attendance at a minimum of 100 births
OR
 Graduate from an equivalent program from another state or country
OR
 Present documentation of completion of “equivalent subject matter...and number of
clinical managements under a (qualified) preceptor.”
AND
 Pass an examination provided to the state by the North American Registry of Midwives
(NARM)
Licensed Midwives
• Regulated and disciplined by the Department
of Health, in accordance with RCW 18.50, with
assistance from a Midwifery Advisory
Committee
• Most LMs work in independent practices,
attending births in homes and licensed
freestanding birth centers
LM Scope of Practice
Washington law (RCW 18.50)
defines the scope of practice for LMs as
providing care during the prenatal, intrapartum,
and postpartum stages
requires the midwife to consult with a physician
whenever there are significant deviations from
normal in either the mother or the infant.
LM Scope of Practice
Legend Drugs and Devices
LMs do not have prescriptive authority but are authorized to obtain
and administer:
 Prophylactic ophthalmic medication
 Postpartum uterotonics
 Vitamin K
 Rho immune globulin
 Local anesthetic
 IV fluids
 MMR, Hepatitis vaccine & HBIG
 IV Antibiotics for GBS prophylaxis
Legend Drugs and Devices
In addition, the Midwifery Advisory Committee has
established protocols for use of:
 Epinephrine for use in allergic reactions
 Magnesium Sulfate in cases of preeclampsia
 Terbutaline for non-reassuring FHR
ALL PENDING TRANSPORT
LMs may also “administer such other drugs or
medications as prescribed by a physician”
LM Practice in WA
• LMs are trained in both neonatal resuscitation
and CPR and required to renew every 2 years
• LMs carry oxygen to births and are trained in
the use of laryngeal mask airways and pulse
oximeters
LM Practice in Washington
 LMs contract with a variety of health insurance plans,
including Medicaid
 Liability insurance
 89 of the 120 LMs in Washington have liability
coverage through a state-mandated Joint
Underwriting Association (JUA); malpractice
insurance is also now available through an out-ofstate company
 All 16 of the licensed freestanding birth centers in
the state have liability coverage, all but one through
the JUA
Professional Association
Midwives’ Association of Washington
State (MAWS)
www.washingtonmidwives.org
Professional Association
 MAWS establishes standards of practice, provides
continuing education, advocacy, and legislative
support
 There are currently 116 professional MAWS
members,100 LMs and 16 CNMs
 MAWS maintains a Quality Management Program
(QMP) with state-protected, confidential peer review
and incident review; all professional MAWS members
are required to participate in the QMP
QMP Incident Review
Midwives are required to self-report sentinel
events within 14 days
Anyone may submit a report (patient, family
members, other healthcare providers).
Review includes recommendations and may
include report to the Department of Health,
pursuant to state law
Intrapartum Hospital
Transfers
 Intrapartum transfer rates range from 10.9% – 20% (about 580
transfers/year from OOH births in Washington)
 Intrapartum transfer rate for primips=22.9%; rate for multips= 7.5%
 96.5% are non-urgent
 55.9% of IP transfers for prolonged labor, exhaustion, or maternal
request for pain relief; 56.1% receive epidurals; 22% receive
oxytocin augmentation
 53.2% deliver vaginally; overall c-section rate = 5.2%
Sources: Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America
Statistics Project, 2004 to 2009. Melissa Cheyney PhD, CPM, LDM, Marit Bovbjerg PhD, MS, Courtney Everson MA, Wendy
Gordon MPH, CPM, LM, Darcy Hannibal PhD and Saraswathi Vedam CNM, MSN, RM. Journal of Midwifery. January 2014. Jane
Hutcheson, Group Health, and Thomas Benedetti, MD, Personal communications.
Intrapartum Hospital
Transfers
 1.5% mothers were transferred immediately
postpartum, primarily for hemorrhage and retained
placenta
 0.9% newborns were transferred after birth,
primarily for respiratory problems
Source: Outcomes of Care for 16,924 Planned Home Births in the United
States: The Midwives Alliance of North America Statistics Project, 2004 to
2009. Melissa Cheyney PhD, CPM, LDM, Marit Bovbjerg PhD, MS,
Courtney Everson MA, Wendy Gordon MPH, CPM, LM, Darcy Hannibal
PhD and Saraswathi Vedam CNM, MSN, RM. Journal of Midwifery.
January 2014.
Historically, intrapartum hospital transfers have
not always gone well…
Both “sides” have a role in
ensuring efficient transfers
of care
Intrapartum Hospital
Transfers
Obstacles reported by hospital-based
providers:
Belief that home birth is unsafe
Burden of assuming care of unknown
patient with elevated risk
Working with “difficult” patients or
“difficult” midwives
Intrapartum Hospital
Transfers
Obstacles reported by midwives:
Lack of awareness among hospitalbased providers of OOH research
supporting safety
Defense of co-negotiated assessment
of risk
Feeling judged by the “exception
rather than rule”
Model Practices for the Midwife
In the prenatal period, the midwife provides
information to the woman about hospital
care and procedures that may be necessary
and documents that a plan has been
developed with the woman for hospital
transfer should the need arise.
The midwife assesses the status of the
woman, fetus, and newborn throughout the
maternity care cycle to determine if a
transfer will be necessary.
Model practices
for the midwife
The midwife notifies the receiving provider or
hospital of the incoming transfer, reason for
transfer, brief relevant clinical history,
planned mode of transport, and expected
time of arrival.
The midwife continues to provide routine or
urgent care en route in coordination with any
emergency services personnel and addresses
the psychosocial needs of the woman during
the change of birth setting.
Model Practices for the Midwife
Upon arrival at the hospital, the midwife
provides a verbal report, including details on
current health status and need for urgent
care. The midwife also provides a legible
copy of relevant prenatal and labor medical
records.
The midwife may continue in a primary role
as appropriate to her scope of practice and
privileges at the hospital. Otherwise the
midwife transfers clinical responsibility to the
hospital provider.
Model practices
for the midwife
The midwife promotes good communication
by ensuring that the woman understands the
hospital provider’s plan of care and the
hospital provider understands the woman’s
need for information regarding care options.
If the woman chooses, the midwife may
remain to provide continuity and support.
Model practices for the
hospital provider and staff
Hospital providers and staff are
sensitive to the psychosocial
needs of the woman that result
from the change of birth
setting.
Hospital providers and staff
communicate directly with the
midwife to obtain clinical
information in addition to the
information provided by the
woman.
Timely access to maternity and
newborn care providers may be
best accomplished by direct
admission to the labor and
delivery or pediatric unit.
Whenever possible, the woman
and her newborn are kept
together during the transfer
and after admission to the
hospital.
Model practices for the
hospital provider and staff
Hospital providers and staff
participate in a shared decisionmaking process with the woman
to create an ongoing plan of care
that incorporates the values,
beliefs, and preferences of the
woman.
If the woman chooses, hospital
personnel will accommodate the
presence of the midwife as well
as the woman’s primary support
person during assessments and
procedures.
The hospital provider and the
midwife coordinate follow up
care for the woman and
newborn, and care may revert
to the midwife upon discharge.
Relevant medical records, such
as a discharge summary, are
sent to the referring midwife.
MD/LM Workgroup
Convened in September 2005 as a
subcommittee of the Department of Health’s
Perinatal Advisory Committee
Charge: To study and improve the process of
transferring women and their babies from a
planned home or birth center location to an
acute-care hospital when a higher level of care
becomes necessary
Smooth Transitions
A Quality Improvement Initiative of
the WA State Perinatal Collaborative
www.waperinatal.org
Smooth Transitions
A voluntary, free, customizable program
to help hospitals
improve the efficiency of planned out-ofhospital birth transports
enhance patient safety
decrease liability
promote greater satisfaction for all
parties involved
Smooth Transitions
GOALS:
 Build greater understanding between OOH
birth midwives and hospital personnel
 Improve interactions between providers
when intrapartum transfers occur
 Increase probability of safe and satisfying
care for mothers and babies
Smooth Transitions
Getting Started
Download the materials from the
website: www.waperinatal.org
Identify a project lead at your facility
Contact the Project Coordinator to
arrange a pre-project interview
Smooth Transitions
Next Steps
Form a Planned OOH Birth Transfer Committee
• Local Licensed Midwives
• Obstetricians, Family Physicians, CNMs
• Emergency Department Physician & Nursing
Leadership
• Obstetrics Nurse Manager
• Obstetrics Charge Nurses
• Hospital Administration Representatives (including
risk management department)
• EMS personnel
Smooth Transitions
Next Steps
Committee develops a transfer process
• Sample on the website
MD/LM Workgroup is working on a survey tool
• Sample on the website
• All perspectives: patient, midwife, OB
provider, labor and delivery nurse
• Ideally would be electronic
• Must be secure, confidential
Smooth Transitions
Follow-up
Planned OOH Birth Transfer Committee
meets 2 – 3 times/year to review
transfers
Share successes and identify areas that
need improvement
Submit an annual summary to the
MD/LM Workgroup
Smooth Transitions
Seven (7) hospitals have had initial presentations:
• University of WA Medical Center, Seattle
• Evergreen Health, Kirkland
• Providence Health and Services, Everett
• PeaceHealth St. Joseph, Bellingham
• Jefferson Healthcare, Port Townsend
• Yakima Valley Memorial Hospital, Yakima
• Kittitas Valley Healthcare, Ellensburg
Three (3) other hospitals have expressed interest in the QI project:
• St. Joseph Medical Center, Tacoma
• Providence St. Peter Hospital, Olympia
• Valley Medical Center, Renton
These 10 hospitals account for over 30% of the births in WA State
A model that works
Legacy Emanuel Hospital in Portland, OR
In 2006, Dr. Duncan Neilson, Chief of Women’s
Health Services, began to implement “wholesale
structural and cultural changes” designed to
make all five hospitals in the Legacy system
“more appealing to women who start delivering
at home and to the midwives who help them—
thus providing a safe and welcoming alternative
when problems arise."
A model that works
OB hospitalist program
Midwife to midwife transfers of
care for clinical situations that are
not high-risk or emergent
Waterbirth
Staff training
A model that works
“We used to have these horrible
[home-birth] disasters show up at the
ER. And we do not see those disasters
now. They have just about gone
away.”
Smooth Transitions
THANK YOU!
Smooth Transitions Project Coordinator: Audrey Levine
nelsaud@comcast.net
(360) 709-0888