What states aren’t doing to save new moms’ lives
Many reviews haven’t even scrutinized medical care provided
If you were going to try to stop mothers from dying in childbirth, you might try what most states in America have done: Assign a panel of experts to review what’s going wrong, and offer ideas to fix it. But that hasn’t worked.
Death rates among pregnant women and new mothers have gotten worse, even as wealthy countries elsewhere improved. Today, the U.S. is the most dangerous place in the developed world to deliver a baby.
Turns out, well-meaning states across the country have been doing it wrong.
At least 30 states have avoided scrutinizing medical care provided to mothers who died – or they haven’t been studying deaths at all, a USA TODAY investigation has found.
Instead, many state committees emphasized lifestyle choices and societal ills in their reports on maternal deaths. They weighed in on women smoking too much or getting too fat or on their failure to seek prenatal medical care.
Virginia published entire reports about cancer,
opioid abuse and motor vehicle crashes among moms who died. Minnesota’s team recommended more education for pregnant women on seat belt use and guns in the home. Michigan’s team urged landlords to make sure pregnant women’s homes have smoke detectors.
In July, a USA TODAY investigation revealed that thousands of women in the U.S. suffer life-changing injuries or die during childbirth because hospitals, doctors and nurses ignore basic best practices known to head off disaster.
Experts say half of those women’s lives could be saved if doctors and nurses took simple steps such as measuring blood loss during and after delivery and giving timely treatment for high blood pressure.
Yet state panels across the country have focused a fraction of their attention on the quality of care hospitals provide or on advocating for improvements, USA TODAY found.
USA TODAY examined every state to see how they review maternal deaths and read more than 100 of the panels’ published reports. Among the findings:
Fewer than 20 state panels identify medical care flaws such as delayed diagnoses, inadequate treatments or the failures of hospitals to follow basic safety measures. Most reports just list stats or emphasize problems other than quality of medical care.
Among 10 states with the highest death rates, just four panels reported on flaws in medical care.
More than a third of states haven’t been studying deaths at all. At least 1,165 pregnant women and new mothers died from 2011 to 2016 in the 18 states that had no review panels. Some have created panels since, but the federal government does not review maternal deaths.
‘You’ve got to go there’
State health officials say it’s important to look at broad public health problems such as smoking and obesity because they contribute to mothers’ deaths.
“Yes, it’s clinical factors. But it is also the person’s access to care and the social determinants of health,” said physician Pooja Mehta, interim chief medical officer for the Louisiana Department of Health. She said that includes the person’s access to care and the conditions in which people are born, grow and live.
In Louisiana – the deadliest state in the U.S. to give birth – the state’s 2012 report on those deaths emphasized suicide, domestic violence and car crashes.
It dedicated pages of charts and recommendations to such issues. Near the end of the report, the panel spent two paragraphs encouraging doctors and hospitals to follow basic maternal care procedures known to protect women.
The state panel did not issue another report for six years. This month, that report was the first in which Louisiana focused largely on medical care given to its mothers.
Cindy Pearson, executive director of the National Women’s Health Network, a Washington consumer advocacy group, said it’s “shocking” that every state’s maternal death review team doesn’t squarely confront medical care.
“You’ve got to go there,” Pearson said. “Don’t tell me what was wrong
with the women. Don’t give me a list of whether they smoked or how much they weighed. Someone was taking care of the women. What did those people do?”
Melissa Metzler of Doylestown, Pennsylvania, said lessons from past tragedies could have prevented her from nearly dying when she gave birth to twins in 2012. She hopes Pennsylvania’s new maternal death review panel will teach doctors how to better recognize and react to deadly conditions like hers.
Metzler said doctors dismissed her pain and sent her home when she went to a hospital thinking she was in labor. When she went to her doctor’s office the next day, her kidneys and liver were failing. She was on the verge of death.
“There are so many things that could be prevented if people take a closer look at what happened before,” she said.
Dying in darkness
While more than 1,000 women died this decade in states that did not study women’s deaths at all, countless more died unnoticed because even states with review panels miss hundreds of deaths.
The panels assigned to look into deaths say they miss out on many cases because reporting mothers’ deaths is often voluntary or because medical records are inaccurate or incomplete.
Kentucky’s review panel never had a chance to examine Jessica Butler’s case. The Louisville woman’s death was never discovered by the state panel. No one is sure why.
A host of problems, including death certificate inaccuracies and doctors forgetting to note their patients were recently pregnant, keep cases hidden, said Stanley Gall, chairman of the state panel.
Butler, 27, had told a nurse her pain was “worse than childbirth,” but she was sent home without seeing a doctor, the family alleges in a lawsuit.
The next morning, Nate Butler found his pregnant wife vomiting and crawling across their kitchen floor. He rushed her back to the hospital. Doctors discovered a spreading kidney infection, just like she experienced in a prior pregnancy.
Witnesses disagreed about her care. An expert testifying for the family said the hospital should have admitted Jessica immediately and started IV antibiotics. A defense expert said her urine test and abdominal pain suggested a common urinary tract infection.
Baptist hospital denied liability and settled the lawsuit for an undisclosed amount, but it would not discuss details. The obstetrician’s lawyer defended his client’s care, but a jury found he and the hospital at fault and awarded a $7.4 million verdict to the family.
The infection spread to Jessica’s blood, and her heart stopped during surgery. The baby girl inside her died. Jessica lingered on life support for three days before Nate let her go.
He had to tell his toddler son Max, “Mommy’s not coming back home.”
Then he walked out of the hospital a single dad.
Full coverage can be found online at maternal.usatoday.com.