By Andrea K. Walker and Yvonne Wenger, The Baltimore Sun
9:36 PM EDT, October 11, 2013
Mercy Medical Center is parting ways with a midwife group that has worked out of the hospital for years because of rising malpractice insurance costs.
The decision to close Kathleen Slone CNM & Associates, which plans to stop delivering babies in February, leaves women with fewer birthing choices outside of the traditional doctor.
But Mercy said high-profile medical malpractice cases in recent months have driven up the cost of insurance, and the hospital was looking for ways to alleviate the financial pressure. Two Baltimore cases, while unrelated to Mercy, contributed to a doubling of the hospital's malpractice insurance costs in fiscal year 2013, according to bond rating company Moody's.
In one case in May 2012, Rebecca Fielding and Enso Martinez won a $55 million judgment against Johns Hopkins Hospital after their son was diagnosed with hypoxic ischemic encephalopathy, a disease that causes permanent cognitive delays.
The birth had started at home, overseen by a midwife, but the mother was rushed to Hopkins because of complications. The couple said the hospital was liable because the baby was deprived of oxygen to the brain as the mother awaited a cesarean section there.
The judgment, one of the largest ever in Maryland, was reduced to $28.3 million by a trial court and eventually thrown out and sent back to a lower court by the Maryland Court of Special Appeals. The case is still pending.
In the other case, in 2012, a jury awarded $21 million to a Glen Burnie couple whose son was born prematurely with cerebral palsy at Harbor Hospital in 2002. In the lawsuit, the family claimed the boy, Jaylan Norfleet, became oxygen-deprived while in his mother's womb and that medical providers at the hospital should have performed a cesarean rather than allow a prolonged vaginal birth.
"The worsening litigation environment in Maryland is driving up the costs of obstetrics programs and Mercy, like other Maryland health systems, is being forced to re-evaluate and adjust related services," the hospital said in a statement.
Mercy, which will continue to offer OB/GYN care, would not say specifically why it chose to end its relationship with Kathleen Slone and not other doctors.
Kathleen Slone CNM & Associates is a practice of four midwives who perform water births, natural births and other techniques not used by traditional obstetricians. The practice delivered 236 babies in 2012, all of them at Mercy.
Many of the group's patients expressed anger over Mercy's decision. By late Friday, an online petition that calls on the hospital to rescind its decision had garnered about 200 signatures on Change.org.
Expectant mother Kathy Webb of Catonsville said she came to Slone's practice months into her first pregnancy six years ago after deciding an obstetrician wasn't a good fit for her. Webb, whose second son is due in December, said she is "sad, angry and frustrated" that other women won't have the same opportunity at Mercy.
"It's such a personal thing to go through this process with someone, to bring your child into the world," Webb said Friday. "It's not just about me, it's about taking away choices for women. The medical community is so geared to telling women what to do, and they are taking another option off the table."
The group said on its website that it was saddened about having to close the practice. Midwife Caitlin LeGros said their deliveries are low-risk. She said midwife practices are sometimes viewed as "outliers because we don't practice defensive medicine, using all the efforts you can to prevent complications."
Advocates such as Debbie Pulley, director of public education and advocacy for North American Register of Midwives, defended midwifery, saying the United States is one of few countries that does not use midwives as the primary care provider for pregnant women.
"Midwives spend more time with mothers, educating them, and they have better outcomes," Pulley said. "Midwives are going to look at birth as a natural process."
Midwives offer an alternative to "overuse of interventions and high instances of cesareans," said Mary Lawlor, director of the National Association of Certified Professional Midwives.
"All pregnant women should have access to midwifery care in all settings — homes, birth centers and hospitals," Lawlor said.
The Mercy-based practice will provide full services until February and limited services, including annual exams, until its contract runs out in April, said Bayla Berkowitz, a midwife with the practice.
"I think the main issue right now is that women's choices are being reduced drastically," Berkowitz said. "For women who don't want a hospital birth, it is getting very difficult. Women should be able to choose who they want to attend their births, where they want to give birth and how they want their birth to go."
The women would like to open another practice, but said there could be obstacles in partnering with another hospital, including the high cost of malpractice insurance. Mercy covered the more than $50,000 a year in malpractice insurance costs for each midwife at Kathleen Slone CNM & Associates.
Mercy said it also is concerned about limited choices for women. The hospital said it is helping with the transition of patients at Kathleen Slone to other practices.
"We are deeply concerned about the potential for reduced health care access for Maryland mothers because of the increasingly unsustainable medical liability environment," its statement said.
David Ellin, a Baltimore-based personal injury and malpractice lawyer, said the number of medical malpractice cases in Maryland has remained steady in recent years at about 600 annually, but the size of awards has risen along with health care expenses.
Even given the state's cap on malpractice payouts, Ellin said, the cases are expensive for all parties. He said it's unfortunate that the city is losing the midwife group at Mercy, but the public needs a means to hold health care providers responsible for the birth injuries they cause.
"Generally, it's sad if you're going to lose a good group like the group over at Mercy," Ellin said. "[But] it's hard to say it's anything other than the cost of doing business. Things get more expensive and costs go up; they don't go down. The cost of providing for an infant that has suffered a brain injury is astronomical."
Another major influence on malpractice insurance costs is lower returns on investment, said Donald H. Beskind, a professor at Duke University School of Law and a litigator for more than 30 years. Studies have shown that insurance companies routinely increase liability premiums to compensate for diminished returns.
"The largest driver of insurance premiums is not claims or payouts but interest rates, and interest rates are basically zero," Beskind said. "In my judgment, that is a flawed system."
Tina Johnson, director of professional practice and health policy at the American College of Nurse-Midwives, said the Mercy midwife group drew expectant mothers from as far away as Frederick and Pennsylvania.
While Chase Brexton Health Care provides midwifery services at Sinai Hospital, as does University of Maryland St. Joseph Medical Center in Towson, options in the region are limited, she said.
One place with services comparable to the midwife offerings at Mercy is Special Beginnings Birth and Women's Center in Arnold, which Johnson said is "bursting at the seams" with demand.
Johnson, a certified nurse-midwife, said the college is "distressed" over Mercy's decision to sever ties with the midwife group. She served as director of midwifery services at Maryland General Hospital until administrators eliminated obstetrics as part of the restructuring with the University of Maryland Medical Center.
Johnson said Kathleen Slone CNM & Associates had excellent outcomes for mothers and babies, rarely requiring expensive medical interventions.
She worried that women may seek other options that aren't as safe, such as choosing health care professionals with fewer credentials or driving longer distances to give birth.
"We want more practices like this practice,'" she said. "I would like to see if another hospital will be wise enough to take this practice on."
To find a midwife
The American College of Nurse-Midwives provides an online database of midwifery services by ZIP code at ourmomentoftruth.midwife.org.y ZIP code at ourmomentoftruth.midwife.org.
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