Deaf and pregnant: Live sign language interpreter or video conference for childbirth?

[Donna Maheady]

Imagine being pregnant, deaf, afraid and soon to be delivering your second child. Your first child experienced problems and remained hospitalized for almost 3 weeks.

In a controversial lawsuit, a pregnant woman, who is deaf, wants a live sign language interpreter for the delivery of her child rather than a video conferencing machine, also called a video relay system or video remote interpreting (VRI) the Florida hospital plans to use.

Video conferencing equipment and videophones can be used for direct communication between deaf and hard of hearing people and with their hearing family and friends who know American Sign Language (ASL). They can also be used by deaf and hard of hearing people who do not know ASL, but who benefit from access to visual communication cues, including speech reading (National Association of the Deaf).

The Department of Justice's revised final regulations implementing the Americans with Disabilities Act (title II and III) state "entities are required to give primary consideration to the choice of aid or service requested by the person who has a communication disability. The state or local government must honor the person's choice, unless it can demonstrate that another equally effective means of communication is available, or that the use of the means chosen would result in a fundamental alteration or in an undue burden" (U.S. Department of Justice).

To the disappointment of the woman, it will most likely be a sign language interpreter on a computer screen - instead of a real person by her bedside - who will serve as the sign language interpreter through the birth of her child.

"In a case that may be a first in the nation, U.S. Magistrate James Hopkins issued a report, finding that the woman did not prove that a video conferencing system violates her rights under the Americans With Disabilities Act" (Palm Beach Post).

The woman shared concerns that a machine won't be able to touch her to get her attention when she is screaming or has her eyes closed while in pain. "The VRIs do not work all the time...It's really serious. What if there was something life-threatening that happened during the delivery?" (Hyman, 2015).

In another interview, she stated "A translator stationed at a remote location, being beamed in via video-conferencing technology - is not sufficient..."When I'm giving birth I can't see everything that's going on with a monitor - I have to change position, close my eyes. There are technical problems. That's not effective communication."(Greenfield, 2015)

The hospital's "portable VRI machine is a laptop computer which can fit in small places where an in-person interpreter might not be able to fit". The woman "explains that an in-person interpreter is preferable because during her first childbirth, her interpreter was able to crouch down and kneel on the floor" (Palm Beach Post).

The woman also said "this is not effective communication for a woman giving birth and ultimately a violation of the American Disabilities Act. No one can sit there in labor and just watch a fixed screen.. "You can't do that. It's much better to have a live interpreter that's mobile and can move around. It's a lot more comfortable. They can lean over. They can get in a different spot." (Hyman, 2015)

According to the letter of the law, an in-room translator is not required. The Americans with Disabilities Act (ADA) says hospitals must provide an effective means of communication, but does not specifically state what constitutes "effective".

What are your thoughts about this case? Is this the spirit of the law?

Any deaf nurses who have used sign language interpreters or video conferencing during childbirth?

Can any L&D nurses shed light? How effective are video conferencing/interpreting relay systems?

Any nurses who are sign language interpreters?

Sharing experiences and insight helps us all to grow in our understanding.

References

Greenfield, B. (2015). Why a Deaf Woman Is Suing the Hospital Where She Plans to Give Birth. Accessed on July 16, 1015

Hyman, A. (2015) Hearing-impaired pregnant woman sues Bethesda Hospital, wants interpreter. Accessed on July 16, 2015

Musgrave, J. (2015) Deaf Boynton woman may not get live interpreter during childbirth. Accessed on July 15

National Association of the Deaf. Video Relay Service. Accessed July 15, 2015 Page not found | National Association of the Deaf.

U.S. Department of Justice, Civil Rights Division, Disability Rights SectionAccessed on July 16, 2015 Revised ADA Requirements: Effective Communication

[JustBeachyNurse, LPN]

I agree with this. As I posted previously, I use my husband and teenage kids to clarify things for me all the time. In addition, I know many of the ASL Interpreters who work in my area (and so do practically all Deaf adults, BTW, as the Deaf community is a pretty small world). There are a few Terps who I would certainly not choose to work with and others that I really enjoy, but I know that if I show up in an ER at 2:00 in the morning, I'm going to get whoever is available, if I get a live person at all.

If if she had a support person with her who was a certified Interpreter, I would really wonder if there was some other reason for wanting another specific Terp there. I don't know anything about this woman's specific situation, and I don't have any ties to Deaf communities outside of my home state, but there's something really strange about this situation, and I suspect that more details will emerge. They always do.

Good insight. My few encounters with the deaf community working in ED was a strong support system with many knowing the local resources available. Non-certified translators but fluent in ASL & hearing would often be willing to come and help with basic communication but not medical interpretation until a qualified translator was available. I thought it was local but apparently not...

[elkpark]

Is there a lesson in this for us?

Yes, get out of nursing and into a less litigious line of work. :)

[DawnElaine]

The term 'effective communication' is defined by the perspective of hearing people. The hospital did NOT ask the deaf patient what HER effective communication would be. Clearly, a live interpreter during a childbirth is HER gateway to effective communication. Sadly, the hospital decided the best mean of communication FOR her. The hospital did not work with the patient ensuring that she would be having a full communication accessibility. In other words, HER best mean of communication was denied because the hospital believed VRI was the best and effective communication FOR the patient. Using VRI should not be used at ALL medical situations. What does 'accommodation' really mean to the medical staff? The patient's or the hospital's? In this case, the hospital should have accommodated to the patient's best interest - HER best interest was to have a live interpreter during a childbirth. The hospital dismissed the patient. The hospital treated the patient like a piece of tool at an assembly factory....just passin' through. This MUST stop.

[deaf258]

I wrote a long reply explaining VRI vs Live interpreters, qualifications, suggestions, etc. But I got timed out of this site so my response was lost. I realized I may be fighting an uphill battle if nurses are adamant on being Audist. For now, I'll keep it simple and share the link from ADA.

What is effective communication? Revised ADA Requirements: Effective Communication

[JustBeachyNurse, LPN]

What if the patient insists on a female interpreter, as this one did, but no qualified female ASL interpreter is available? (Which reportedly happened here) What if the interpreter cannot understand the patient and there is difficulty obtaining a qualified replacement? (As happened here)

Is it reasonable to insist on an in person interpreter 24/7? This is not considered reasonable for other scenarios including those who English is not the primary language. I could consider 12-16hrs for a bedside interpreter realistic and reasonable. This complaint also wanted an interpreter for family members not just the patient.

In my opinion I don't see anything wrong if a patient comes in emergently as labor is not always planned and using a video translator until a qualified interpreter could respond to the hospital, or like is done in other patient care scenarios use a friend or family member (this case patient brought a female friend who happens to be a hearing, qualified ASL interpreter) for basic communication in the interim.

It shouldn't be disputed that the video interpreter system failed at least part of the time as evidenced by tech support needing to physically come to the room. Clearly this was not a reasonable accommodation for effective communication but technically not determined until after patient arrived in labor. I've read mixed results on the stability and reliability for video interpretation depending on network resources and physical facility capabilities. Clearly risk management grossly overestimated the stability of video interpretation in this facility.

The judge determined that the ADA was not violated for effective communication based on the hospitals' initial care plan. The key is reasonable accommodation.

Is it reasonable to demand an in person interpreter 24/7? (Not reasonable according to published guidelines)

Is it reasonable to demand a second or third interpreter for family/friends? (Not usually a reasonable request)

Was the hospital reasonable in limiting the in person interpreter to 4 hours? (Rather ridiculous expectation on the part of risk management in my opinion)

Was it reasonable for the patient to demand female only interpreters when only male interpreters were available at the time? (Unrealistic, one can request just like one can request a female or male physician but sometimes one is not available)

Was the hospital reasonable in delaying calling for an in person interpreter once the VRI failed several times? (And this will likely be their downfall even if they claim her friend, a hearing qualified interpreter, was at bedside. The hospital failed to correct the situation in a timely manner)

[JustBeachyNurse, LPN]

The term 'effective communication' is defined by the perspective of hearing people. The hospital did NOT ask the deaf patient what HER effective communication would be. Clearly, a live interpreter during a childbirth is HER gateway to effective communication. Sadly, the hospital decided the best mean of communication FOR her. The hospital did not work with the patient ensuring that she would be having a full communication accessibility. In other words, HER best mean of communication was denied because the hospital believed VRI was the best and effective communication FOR the patient. Using VRI should not be used at ALL medical situations. What does 'accommodation' really mean to the medical staff? The patient's or the hospital's? In this case, the hospital should have accommodated to the patient's best interest - HER best interest was to have a live interpreter during a childbirth. The hospital dismissed the patient. The hospital treated the patient like a piece of tool at an assembly factory....just passin' through. This MUST stop.

What if the facility agreed but when she went into labor obtaining a qualified interpreter took a little time? What if the only interpreter available was male and it would be 8 hours for a qualified female interpreter?

Granted not this scenario, but while it may be reasonable to plan for an in person interpreter babies don't follow the rules and may come at any time not wait for a qualified interpreter. Then what?

I'm curious as I've had parents that don't speak extensive English have to wait confused and lost as their medically complex critically ill child is trying to die, but a qualified medical interpreter cannot be secured for 30-60 minutes or longer depending on the language. I've seen the fear and frustration not knowing what is going on, and they can hear the tone of voice that a hearing impaired person likely cannot.

This scenario was definitely handled poorly by risk management regardless of the judge agreed. I can understand the mothers frustration postpartum about what she felt could have been.

[Donna Maheady]

These situations are very complicated to say the least. Thanks for sharing.

[deaf258]

I would also like to point out one cold, hard fact: the VRI industry is not regulated by any federal agency. Would you go see doctors or be operated by surgeons who are not regulated? Let that sink in for a bit.

[elkpark]

I would also like to point out one cold, hard fact: the VRI industry is not regulated by any federal agency. Would you go see doctors or be operated by surgeons who are not regulated? Let that sink in for a bit.

And what federal agency regulates "live" sign language interpreters?

[JustBeachyNurse, LPN]

I would also like to point out one cold, hard fact: the VRI industry is not regulated by any federal agency. Let that sink in for a bit.

What do you mean? A lot of technology used for accommodations (not just that for deaf/hearing impaired) is not regulated. Assistive communication devices are not all regulated by federal agencies. (However I can bet the devices used for VRI like many ACC devices are under FCC regulation which is not the same as standardization for reliability or functionality. Cell phones, radios, remote controls are all under FCC regulations). Unlike durable medical equipment such as hearing aids, wheelchairs, and insulin pumps which are regulated and registered per FDA.

Nursing and the medical profession isn't regulated by any federal agency either, all are under state domain.

It's my understanding the one part of VRI that is to be standardized is the use of credentialed translators providing the service. The technology component is dependent on other resources such as device used (laptop, dedicated device), other software running in the background or concurrently, wifi or cabled connectivity, strength of the internet signal whether cabled/wired or wifi, operating system of the device even lighting in the room and quality of the microphone and speakers affect technology. Some is controllable, some is not.

I think this case demonstrates the unreliability when a facility makes presumptions about technology and it's stability. Many healthcare professionals may never have heard of VRI and now know a little more.

I don't think it's unreasonable to request an in person qualified translator. I think it's unreasonable to expect the facility to keep one on call in case of early or emerging labor. I think it's unreasonable to demand a specific translator or only one gender, unless the patient wants to pay the in call fees to have the specific translator on standby. I don't think it'a unreasonable to prefer a specific gender but have flexibility if your request cannot be fulfilled as there isn't a female translator immediately available. Just like if you wanted Dr. Susan Jones to deliver your baby but the infant comes early and only Dr. Mike Smith is on call and available. Life happens.

[JustBeachyNurse, LPN]

And what federal agency regulates "live" sign language interpreters?

None. JCAHO has recommendations for medical translators that are voluntarily complied with.

Nurses and physicians aren't regulated by a federal agency either.

[JustBeachyNurse, LPN]

Clearly in this scenario risk managements stubborn decision did not work. VRI failed most of the time for this patient. There are times when VRI is appropriate and effective, clearly this was not one of them and caused additional frustration and distress for a laboring mother.

Many things, items, services and products are not regulated by federal agencies but that does not define good or bad, appropriate or ineffective. It's a red herring argument.

ASL is not regulated by a federal agency so by your logic should the deaf community stop using ASL to communicate and just bag their heads and hands?