A Valley couple is speaking out about changes they believe are needed in regulating midwife care to keep mothers and babies safe after the death of their newborn son.
Carson and Dan Neisess were expecting their child, Winston, in June 2023. Then, complications during delivery arose at a local birthing center. Their joy turned to grief when their son died four days later.
"The version of Dan and I that we were before this happened doesn't exist anymore," Carson said.
"I think it's uncomfortable for other people to talk to us about it, or, you know, they don't want us to be upset," Dan said.
"There isn't a day that goes by that we don't - I don't think about him," Carson said.
They are among five families to file lawsuits in the last year against Willow Midwife Center for Birth and Wellness in Mesa. Each family alleges midwife negligence during labor and delivery. So far, Carson and Dan are the only ones to settle their case.
Carson, a first-time mom with a low-risk pregnancy, wanted a natural birth at Willow Midwife Center. However, when her labor dragged on, she became concerned.
"I said, ‘I think I want to be transferred,’" Carson said. But according to the couple, their requests were dismissed.
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"They would reassure us, like everything is normal. This is all going according to plan," Dan said.
When Winston was being delivered, they said they realized the umbilical cord was wrapped twice around his neck. According to their lawsuit, Winston was born limp and pale.
Emergency responders rushed the baby to the hospital, but oxygen deprivation had caused severe brain damage, according to the couple’s lawsuit.
"We didn't really get to hear his voice ever," Dan said.
"After losing our son, that should have been the last time that that happened there," Carson said.
Winston's case wasn't the first or the last, according to a Mesa police report and other records obtained by ABC15.
A hospital staffer commented to police that Winston's case was a “Willow special," explaining the birth center had a reputation for "suspicious patient care and business practices," according to the police report. The officer documented a firefighter interview where he said a "Willow call" meant that a newborn was going to be “in very bad shape.”
Willow settled the couple's lawsuit without admitting fault.
"Doesn't necessarily feel like justice, but you know, that helped pay down a lot of the medical expenses that we had incurred," Dan said.
The Arizona Department of Health Services, which regulates medical facilities, cited Willow in February for failure to ensure fetal heart tones were assessed and documented per policy during Winston’s birth. The ADHS Statement of Deficiency noted that the “deficient practice” can delay identification of fetal distress, “leading to potential complications like oxygen deprivation to the baby, which could result in brain damage or other neurological issues.”
In response to the citation, Willow made a corrective action plan involving retraining midwives on accurate fetal heart tone timing, documentation standards, and escalation procedures if deviations occur. The center also planned to regularly audit patient charts to ensure the training was followed.
Willow Midwife Center remains an active, licensed health care facility.
"I think from the beginning, I've felt very much like I need to protect future families," Carson said.
The Neisess family says there should also be new laws and regulations for midwives and birth centers, including continuous fetal heart rate monitoring.
"Continuous monitoring is a big one,” Carson said. “I do believe that if Winston had been monitored correctly, there's a chance that he would be here today with us."
Continuous electronic fetal heart monitoring is a common practice at many hospitals during labor and delivery. By monitoring the baby’s heart rate, the provider can identify concerns, including drops in oxygen levels, and take steps to protect the baby, according to the Cleveland Clinic. However, some studies have found that routine electronic monitoring increases the rates of unnecessary cesarean sections.
Carson is also calling for clearer-cut policies or regulations on transferring a laboring mom to the hospital.
"I don't think that there should be any wiggle room in whether or not you're transferring a patient," Carson said.
Carson and Dan say these conversations may be uncomfortable, but necessary. They want to help protect other families from experiencing grief like theirs.
"There are probably cases where things are done differently by the midwife, and Winston is still not here with us,” Dan said. “But we would have liked to have lived in a world where every possible opportunity to try and keep him alive was all taken."
ABC15 emailed Willow Midwife Center with a series of questions raised by the Neisess family, other lawsuits, police reports, and regulatory inspections.
Willow’s spokeswoman said they have no further comments for us on their staff or patients. She noted HIPAA requirements and general patient privacy concerns.
When ABC15 reported on another family's concerns about Willow’s practices in January, the company issued this general statement about patient safety:
“Hundreds of families a year choose to birth with Willow. For patients who are healthy and low-risk, it is an excellent and safe choice. As part of rigorous accreditation demands, the birth center shares its data and outcomes and participates in national quality assurance protocols.
Nevertheless, even in a setting like Willow, transfers are sometimes necessary. According to the 2020 Neonatal Resuscitation American Heart Association Guidelines, 10% of all newborns require some breathing intervention; only 1% require extensive resuscitative measures at delivery.
It is difficult, if not impossible to predict which healthy, low-risk pregnancies will require resuscitation. For this reason, each Willow birthing suite carries the same resuscitation equipment found in the hospital. Despite all these efforts, it is simply a reality that some infants born at Willow will need to be transferred to the hospital for more extensive breathing intervention.
In 2023, Willow is proud to have assisted in 283 births. Less than 1% (far below the national average) required transfer to a hospital for medical needs.”
