Nov. 29, 2018 -- Jamie Larson had just been wheeled into a room at Sutter Roseville Medical Center in Roseville, CA, after the birth of her first child when a nurse popped in to tell her, “It’s a boy!”
Larson, a 30-year-old schoolteacher, had a more somber question on her mind.
“Is he alive?”
Larson had just given birth to him in the hospital parking lot. His birth came less than an hour after nurses at the same hospital had assured her that her
back pain was from a
urinary tract infection and sent her home.
Larson’s son was born at 24 weeks and 5 days -- well before the end of a normal 40-week
pregnancy and on the cusp of the age when the most advanced neonatal medicine can keep a premature infant alive.
At the time, a doctor explained to Larson that babies born this early have a 20% to 30% chance of survival, but only if they are delivered under ideal circumstances. Her son was not.
Larson’s case was cited by federal authorities as a violation of the Emergency Medical Treatment and Labor Act, or EMTALA. It was one of at least 72 different violations committed by hospitals over a 27-month period ending in March 2018 involving the care of women who were pregnant or in active labor, according to federal records obtained through the Freedom of Information Act. The cases represent about 8% of the total number of violations investigated by the Centers for
Medicare & Medicaid Services (CMS) over that period.
Lack of Birthing Services
Under federal law, labor is considered a medical emergency. Any hospital that accepts payments from federal programs such as Medicare or Medicaid is required to take care of patients who are in labor when they come to the ER, regardless of their ability to pay for that care. Because virtually all hospitals accept these payments, nearly all are covered by the law.
The law received its name, in part, because of a woman in labor in California who was refused treatment by two private hospitals even though medical tests showed her
baby was in distress. The hospitals mistakenly thought she was uninsured. By the time she arrived at the public hospital, where doctors rushed to perform an emergency C-section, her baby had died.
Despite their special protection for pregnancy under the 1986 law, the records show that pregnant women remain vulnerable to violations, though not for all the same reasons.
Now, instead of not treating patients who don’t have insurance, a practice called patient dumping, some hospitals turn away women in labor because they no longer have dedicated obstetrical units or enough staff who are properly trained to handle pregnancy and labor complications.
A study published in 2017 in the journal Health Affairs found that between
1985 and 2002, 760 U.S. hospitals shuttered their obstetrical units. That trend has continued. The study also found that 9% of rural counties lost their OB services between 2004 and 2014. Counties with more black residents had nearly five times higher odds of losing their OB services than counties with more white residents.
“We know that those closures have continued. If we were to do an update, it would look I think even more dire than it does now,” says study author Carrie Henning-Smith, PhD, assistant professor in the division of health policy and management at the University of Minnesota School of Public Health in Minneapolis.
“Today, fewer than half of all rural counties have an obstetrical unit in a hospital,” Henning-Smith says.
‘We Do Not Deal with Babies’
Federal records show that the erosion of birthing services has created confusion about how to respond when a woman in labor arrives at the ER.
That’s what happened on July 11, 2017, when a man pulled up outside the 98-bed emergency room at Leonard J. Chabert Medical Center in Houma, LA. His wife was 36 weeks pregnant and bleeding. He requested a wheelchair from a nurse in the ER. Instead he was told, “We cannot help you here. We do not deal with babies,” according to a federal investigation report. The incident, captured by a hospital security camera, shows him driving away moments later. The report didn’t include names for privacy reasons and doesn’t document what happened to the couple or their baby.
In an emailed statement, Leonard J. Chabert Medical Center declined to comment on the specifics of this violation, citing patient privacy laws.
“Our physicians, leaders, nurses and employees participate regularly in ongoing education and training to ensure that they live our vision of changing and saving lives each day,” the statement says.
On Dec. 12, 2016, a man approached a nurse in the Deer Lodge Medical Center in Deer Lodge, MT. He told them that his girlfriend was in labor. A federal investigation report says that a nurse at the 16-bed hospital told him they didn’t deliver babies and suggested the couple travel to a hospital in either Anaconda or Butte, 27 or 39 miles away, respectively. The man drove away. His girlfriend was almost fully dilated by the time she reached the next hospital and delivered the baby immediately after arrival.
Tony Pfaff, chief executive officer of Deer Lodge Medical Center, pushed back against that description of events. “It’s not remotely accurate,” he says.
He says the man approached a nurse and a doctor in the ER. The man asked if the hospital delivered babies. They told him that they didn’t, but offered to evaluate his girlfriend. He asked which hospitals in the area did deliver babies. They told him, and he drove away. Pfaff says his staff never saw the woman in labor.
When asked if the hospital had tried to correct the version of events in the investigation report, Pfaff says “No.” “We just decided to take our beating and move on because you can’t win” against the federal government, he says.
In response to the violation, Pfaff says the hospital has given its staff additional EMTALA training. They also created a way to log patients and their representatives who come into the ER but refuse treatment or leave without being seen. Those two actions satisfied CMS, he says. Pfaff says if the same thing happened again today, they’ve instructed their staff to try to be a little more aggressive in trying to see the patient. He says the hospital knows its obligations under the law.
“We’ve delivered babies in our ER before. It’s unusual, but we do it,” he says.
CMS officials say their EMTALA investigations are thorough and include interviews with hospital officials, physicians, and nurses and reviews of medical records. If a violation is found, hospitals must submit a plan of correction, where they can address any objections or issues they have with the federal findings. Hospitals can also appeal any fines levied for violations, CMS says.
Federal investigators cited both Deer Lodge and Leonard J. Chabert Medical Center for failing to do proper medical screening exams for the women, which are required by law
