Midwives and Liability: Results of the 2018 National Midwives and Liability Survey.

INTRODUCTION: This is the third national survey about the incidence of midwifery involvement in malpractice litigation, case outcome, methods of coping, and the influence of fear of liability or actual litigation on midwifery practice and professional liability insurance. Incidence of disciplinary action was also included. METHODS: A link to a web-based survey was sent to all American College of Nurse-Midwives members with an active email address in January 2018. Students and associate members were excluded from analysis. Logistic regression was used to identify predictors of involvement in lawsuit. RESULTS: Of 6199 email links sent, 880 midwives responded (14%). One-third of participants (n = 280, 32%) have been named in at least one lawsuit after a median of 7 years in practice. Claims most often involved intrapartum hospital-based care and resulted from fetal heart rate interpretation. The most common outcome of a case was settlement prior to court or arbitration (n = 117, 42%). Significant predictors of litigation included older age of the midwife and region of practice (increased in Northeastern states, decreased in Midwestern states). Midwives' most common source of emotional support was their attorney. Only 6% (n = 53) of participants experienced disciplinary action against their state license. Half of the actions by a state governing board were unrelated to a lawsuit. DISCUSSION: Midwives may experience litigation the longer they are in practice, but there has not been a significant change in the incidence since the previous survey in 2009. More resources and education are needed for midwives to provide adequate peer support to colleagues following adverse events or when named in a lawsuit. Continued education is also needed for midwives regarding types of professional liability insurance, affordability, and how policy terms and limits influence clinical practice.

Examination of the Pharmacology of Oxytocin and Clinical Guidelines for Use in Labor.

The use of exogenous oxytocin to induce or augment labor has increased in recent years. This literature-informed review examines the action of this medication and the potential associated complications, with an evaluation of current professional practice guidelines. A brief history of the use of exogenous oxytocin for labor induction or augmentation is presented. In addition, risk management strategies for the prevention of oxytocin-related adverse outcomes and subsequent litigation are identified.

Closed Claims Analysis of Medical Malpractice Lawsuits Involving Midwives: Lessons Learned Regarding Safe Practices and the Avoidance of Litigation.

INTRODUCTION: The risk of litigation remains of concern to midwives, their practice partners, employers, and malpractice insurance providers. Closed claims analysis is a method of examining risk patterns and behaviors in lawsuits, including those involving health care practices. The purpose of this investigation was to evaluate claims brought against midwives, with the intent of developing strategies to decrease the incidence of litigation. METHODS: Data were collected in joint meetings with members of the American College of Nurse-Midwives (ACNM); the American Association of Birth Centers; the American International Group (AIG), a major malpractice insurer for certified nurse-midwives/certified midwives (CNMs/CMs); and Contemporary Insurance Services, an independent insurance agency that has worked with AIG to facilitate the writing of malpractice insurance policies for CNMs/CMs. The purpose of the meetings was to review 162 litigation cases that involved midwives insured by AIG and had been closed between the years 2002 and 2011. Follow-up analyses of data and reporting of results were performed by the authors, who are members of the Professional Liability Section of the ACNM Division of Standards and Practice. RESULTS: Findings reflected 7 major categories of liability risk ranging from the most prevalent (ie, fetal/newborn complications or death) to the least prevalent (ie, attending a vaginal birth after cesarean). Data also were examined regarding the highest amounts incurred in court decisions or pretrial settlements because they were related to types of adverse outcomes that occurred. DISCUSSION: Recommendations for improving clinical practice and avoiding litigation based on findings from the closed claims analysis include, but are not limited to, the need for thorough and accurate documentation in practice, appropriate and timely consultation and collaboration, and the presence of practitioners whose clinical skills match the level of care assessed to be necessary for each woman for whom care is offered.

'The Best Health Care Delivery System in the World'? Women's health and maternity/newborn care trends in Philadelphia, PA, United States-1997-2011: a case report.

Despite being ranked number one globally in terms of health care cost per capita, the United States (US) has ranked as low as 37th in the world in terms of health care system performance. This poor performance for one of the most developed nations in the world has been reflected in the underachieved attempts of the multiple US health care systems at improving maternal and newborn health, according to the goals set in 2000 by the United Nations with Millennium Development Goals (MDG's) 5: Improve Maternal Health, and 4: Reduce Child Mortality. This paper will examine the progress, or lack thereof, over a period of 15 years of the fifth largest urban area in the US - Philadelphia, Pennsylvania - in its delivery of health care to pregnant women and their newborns. Using data collected from national, state, and city health agencies, trends concerning pregnancy care will be presented and compared to the target goals of MDG-5 and MDG-4, as well as Healthy People 2020, a US government-based initiative to improve health care of all Americans. Findings will demonstrate that urban areas such as Philadelphia are on a path of not reaching goals that have been set by the United Nations and the US government, and by some indicators are moving away in a negative direction from these goals.

Professional issues related to obstacles to midwifery practice in the Americas: a pilot survey.

BACKGROUND/OBJECTIVES: the WHO (2011) estimates that 350,000 newly trained midwives are needed internationally to meet Goal 5-- Improve Maternal Health--of the 8 Millennium Development Goals established by the United Nations in 2000. Recognizing the challenges in accomplishing this goal, it is also imperative to retain trained midwives in the profession. Little to date has been investigated regarding the factors that lead to experienced midwives leaving the profession prematurely, particularly in low resource countries. DESIGN: in an effort to initiate identification of barriers that limit midwives' ability to continue in practice, a pilot study was conducted with a convenience sample of 58 midwife attendees, representing 12 countries, at the International Confederation of Midwives - Americas Triennial Regional Meeting in 2010. A survey was distributed to midwife respondents to explore potential influences on work retention, including: encounters of adverse outcomes in practice; empowerment to make change in the work setting; and migration. FINDINGS: sixty per cent of respondents reported encountering a maternal or newborn death or injury, and 10% had considered leaving the profession. Over 50% of the midwives listed three potential results that could occur after experiencing an adverse outcome in practice. These included: (a) an investigation by a governmental agency; (b) complaints about the midwife via available media; and (c) involvement in a lawsuit. The consequence most frequently cited for not enacting evidence-based changes in the workplace was resistance from obstetrical colleagues. CONCLUSIONS: while there are limitations to gathering data from attendees at a professional meeting, this is the first known international survey of midwives regarding factors that may contribute to their leaving the profession at a time when there is an increasing global awareness of the need for a skilled birth attendant at every birth.

Midwives and liability: results from the 2009 nationwide survey of certified nurse-midwives and certified midwives in the United States.

INTRODUCTION: In partnership with the American College of Nurse-Midwives (ACNM), the authors conducted a survey of ACNM members to examine the incidence of lawsuit involvement, the outcomes of the litigation in which they were involved, and coping mechanisms among midwives who had been involved in a lawsuit. METHODS: In the spring of 2009, a nationwide Web-based survey was completed by ACNM members. In addition to using chi-square tests and nonparametric testing in data analysis, a logistic regression model was used to evaluate predictors of lawsuit involvement. RESULTS: Among 1340 midwives responding to the survey, 32% had been named in a lawsuit at least once. The median number of years in practice when the event leading to lawsuit occurred was 6. The majority of midwifery lawsuits involved hospital births and were settled prior to going to court. Three variables were statistically significant for involvement with litigation: the midwife's age, the number of births attended, and the ACNM region of practice in the United States. DISCUSSION: Lawsuits among midwives were significantly related to exposure to births over time. Practice patterns and job security were not greatly affected by the experience of a lawsuit. Future cyclic surveys are needed to track the frequency of litigation and the outcomes that lead to lawsuits and to better define the relationships between midwifery practice and medical malpractice litigation.

Criticisms of chlorination: social determinants of drinking water beliefs and practices among the Tz'utujil Maya.

OBJECTIVE: To explore social determinants of drinking water beliefs and practices among the Tz'utujil Maya of Santiago Atitlán, Guatemala, through analysis of demographics, socioeconomic status, memory of historical events, sensory experience, and water attitudes. METHODS: Parallel mixed (qualitative and quantitative) methods, including participant observation, in-depth interviews based on a purposive sample, and 201 semi-structured interviews based on a regional quota sample, were used to collect data from March 2007 to August 2008. Data analysis included the use of grounded theory methodology and Pearson's chi-square test for independence. RESULTS: Qualitative results based on grounded theory highlighted how memory of the Guatemalan Civil War and Hurricane Stan, attitudes about Lake Atitlán water, and the taste and smell of chlorine influenced Tz'utujil Maya drinking water beliefs. Quantitative survey results revealed that differences in ethnicity, literacy, years of schooling, distrust of the water supply during the Civil War and Hurricane Stan, and current beliefs about Lake Atitlán and tap water quality were associated with significantly different water self-treatment practices. CONCLUSIONS: In accordance with social determinants of health paradigms, demographic, socioeconomic, social, cultural, political, and historical factors continue to be significant determinants of water-related health. Public health water interventions must address inequalities related to these underlying factors in order to achieve maximum effectiveness.

Criticisms of chlorination: social determinants of drinking water beliefs and practices among the Tz'utujil Maya / Críticas a la cloración: factores sociales determinantes de las creencias y prácticas con respecto al agua potable de la población Maya Tz'utujil

OBJECTIVE: To explore social determinants of drinking water beliefs and practices among the Tz'utujil Maya of Santiago Atitlán, Guatemala, through analysis of demographics, socioeconomic status, memory of historical events, sensory experience, and water attitudes. METHODS: Parallel mixed (qualitative and quantitative) methods, including participant observation, in-depth interviews based on a purposive sample, and 201 semi-structured interviews based on a regional quota sample, were used to collect data from March 2007 to August 2008. Data analysis included the use of grounded theory methodology and Pearson's chi-square test for independence. RESULTS: Qualitative results based on grounded theory highlighted how memory of the Guatemalan Civil War and Hurricane Stan, attitudes about Lake Atitlán water, and the taste and smell of chlorine influenced Tz'utujil Maya drinking water beliefs. Quantitative survey results revealed that differences in ethnicity, literacy, years of schooling, distrust of the water supply during the Civil War and Hurricane Stan, and current beliefs about Lake Atitlán and tap water quality were associated with significantly different water self-treatment practices. CONCLUSIONS: In accordance with social determinants of health paradigms, demographic, socioeconomic, social, cultural, political, and historical factors continue to be significant determinants of water-related health. Public health water interventions must address inequalities related to these underlying factors in order to achieve maximum effectiveness.

OBJETIVO: Explorar los factores sociales determinantes de las creencias y prácticas con respecto al agua potable de la población maya tz'utujil, que habita en Santiago Atitlán (Guatemala), mediante el análisis de la información demográfica, la situación socioeconómica, la memoria de hechos históricos, la experiencia sensorial y las actitudes con respecto al agua. MÉTODOS: De marzo del 2007 a agosto del 2008, se recopilaron datos por medio de métodos paralelos mixtos (tanto cualitativos como cuantitativos), como la observación de participantes, entrevistas en profundidad basadas en un muestreo intencionado y 201 entrevistas semiestructuradas basadas en un muestreo por cuota regional. En el análisis de los datos se usó el método de la teoría fundamentada o muestreo teórico y la prueba de la chi al cuadrado de Pearson para la independencia. RESULTADOS: Los resultados cualitativos basados en la teoría fundamentada pusieron de relieve que los recuerdos de la guerra civil guatemalteca y del huracán Stan, las actitudes acerca del agua del Lago Atitlán, y el gusto y el olor del cloro influían las creencias de los tz'utujiles con respecto al agua potable. Los resultados cuantitativos de la encuesta indicaron que las diferencias a raíz del grupo étnico, el alfabetismo, los años de escolaridad, la desconfianza del abastecimiento de agua durante la guerra civil y el huracán Stan, y las creencias actuales acerca de la calidad del agua del Lago Atitlán y del agua de grifo estaban asociadas con prácticas de autotratamiento del agua sumamente diferentes. CONCLUSIONES: En consonancia con el paradigma de los factores sociales determinantes de la salud, los factores demográficos, socioeconómicos, sociales, culturales, políticos e históricos siguen siendo determinantes significativos de la salud en relación con el agua. Para que puedan lograr la mayor eficacia posible, las intervenciones de salud pública con respecto al agua deben abordar las desigualdades relacionadas con estos factores fundamentales.

The pain that binds us: midwives' experiences of loss and adverse outcomes around the world.

Although much has been written about helping women and their families cope with loss related to childbearing, little exists in the literature to guide and support the midwives who witness these losses. We conducted qualitative interviews globally with 22 midwives from nations located on six different continents to begin exploring common themes of experiences and coping methods of midwives involved in adverse perinatal outcomes. The concept of critical incident stress (CIS) is presented as a framework for understanding practitioner reactions that occur after adverse outcomes. Implications for practice, education, and continued research are addressed.

The role of litigation in midwifery practice in the United States: results from a nationwide survey of certified nurse-midwives/certified midwives.

Professional liability litigation is playing an increasing role in the practice of women's health care in this country. Although the impact of litigation on obstetricians' practices has been widely documented, data on the effect of litigation on midwifery practice are scant. The authors conducted a nationwide Web-based survey of American College of Nurse-Midwives (ACNM) members about the experience of being involved in litigation. The survey was completed by 600 midwives (17.5% response rate). Of those midwives completing the survey, 152 (25.3%) had been named in a lawsuit at least once during their midwifery careers. The litigation cases had been resolved for 114 (75%) of these respondents at the time of the survey. Forty-one (36%) reported being dropped from the case, even though the litigation continued without their involvement. Another 54 individuals (47.4%) were involved in cases that were settled before going to court, and an additional 10 cases (8.8%) were dropped without a settlement. Of the nine lawsuits (7.9%) that went to court, four favored the plaintiff (3.5%) and five (4.4%) favored the defendant. Future surveys are needed to better define the relationship between the practices of midwives and medical malpractice litigation.