Moms, not hospitals, too often get blame
Secret data on deaths, injuries suggest it’s not that simple
NEW ORLEANS – As she lay in her hospital bed a week after giving birth, Felicia West’s body started sending out warning signals.
Her blood pressure spiked. She complained of a splitting headache.
For three hours as she headed toward a stroke, medical records show no one at Touro Infirmary called a doctor to respond to danger signs for any new mother. They gave her painkillers and an ice pack – and they made her wait.
Then, after a series of handoffs, a doctor in training finally was tapped to deal with West’s blood pressure. The doctor was in no hurry.
“OK, well it will be a while before I can see her because I have a lot of people before her,” she responded at 6:45 p.m., the hospital’s nursing notes show. Before dawn, West was dead.
For years, hospitals have blamed rising maternal deaths and injuries on problems beyond their control. Almost universally they’ve pointed to poverty and pre-existing medical conditions as the driving factors in making America the most dangerous place in the developed world to give birth.
That narrative shifts the focus away from examining how doctors and nurses perform in maternity units. When West’s family sued, Touro denied that its medical care had anything to do with what happened to her.
But a USA TODAY investigation shows that West’s death – along with several other deaths and close calls at Touro – cannot be explained by demographics alone. The data, medical records and lawsuits suggest a complicated mix of misdiagnoses, delayed care and a failure to follow safety measures.
West didn’t get the rapid intervention for dangerous blood pressure called for in national treatment guidelines. Another woman nearly bled to death after an emergency C-section performed by doctors in training. A mother showing signs of infection instead was given tests by trainee doctors that their supervisors later testified were of questionable merit. She wound up with gangrene and amputations of her legs and hands.
These kinds of life-threatening childbirth complications are happening at Touro more often than at most hospitals. It is one of 120 hospitals where mothers suffer severe complications at far higher rates, USA TODAY found by examining billing records from 7 million births in 13 states.
Women at these outlier hospitals were more than twice as likely to have had blood transfusions, hysterectomies, seizures, heart attacks, strokes or other indicators that their deliveries turned deadly.
With national childbirth harm numbers soaring – 700 women dying every year and 50,000 injured – a focus on hospitals with the highest rates could provide a road map to improvement. Studies have found half of mothers’ deaths and severe injuries could be prevented or reduced with better medical care.
One of the nation’s leading childbirth safety experts called hospitals’ rates of severe childbirth complications – the numbers USA TODAY produced for this report – “a window into the opportunity for improving maternal care.”
“We all think we’re giving great care and we are treating everybody equally,” said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative. “The data doesn’t support that.”
Hospitals, Main said, too often respond defensively instead of using the data to evaluate their care practices.
In a statement to USA TODAY, Touro said it serves a “medically vulnerable” patient population and called the analysis of hospital data “unsound.” As a result, the hospital said, it would not answer questions about it.
“Lifestyle diseases, the high cost of healthcare, delaying or non-compliance with medical treatment, limited care coordination, poor health, high rates of poverty and high rates of morbidity are all realities of our State and community,” it said.
Childbirth safety advocates called the hospital’s response troubling, particularly because a majority of women who deliver at Touro are black. Nationally, black mothers are dying from childbirth at three to four times the rate of white mothers; they suffer severe complications twice as often.
“We find the responses the hospitals have are full of these dog whistles that are anti-black and anti-woman,” said Monifa Bandele, senior vice president of MomsRising, a national organization working on maternal justice issues. “This statement is a perfect example of how black women feel entering this hospital: You’re poor, you’re uneducated, you’re fat.”
Wide gaps in hospital care
USA TODAY was able to collect computerized hospital billing records from 13 states and use it to scour nearly half of the deliveries nationwide over the past four years for indicators of severe childbirth complications.
The analysis tallied complications at 1,027 hospitals using a formula developed by the Centers for Disease Control and Prevention – the same one used privately for years by academics, big insurance companies, hospitals and others to track and study women harmed from childbirth.
USA TODAY’s analysis marks the first time rates for hundreds of hospitals are available to the public.
Childbirth complication rates at most of the hospitals were less than 1.5 percent. But at a small group of hospitals – about one out of eight – women experienced potentially deadly deliveries at least twice as often as at the typical hospital.
Those 120 hospitals come in all types, sizes and locations – from New York City to the hills of Kentucky to the California desert.
There are reasons some hospitals might have higher rates. Poor women often have less consistent access to prenatal care. Black mothers are more likely than white mothers to have hypertension, blood disorders and other conditions that complicate pregnancies. A couple dozen of the hospitals are specialty centers that care for women with extreme underlying health problems.
But the list also includes community hospitals in cities, suburbs and small towns where many routine births typically occur.
What’s more, at the 120 hospitals with the highest severe complication rates, it wasn’t only poor women or black women who experienced lifethreatening deliveries more often. Compare the outcomes for white women, and the same hospitals jump out.
Looking more deeply at New Orleans shows the differences among hospitals the analysis exposed. Seven hospitals deliver all the city’s babies. Of them, Touro’s maternity patients were far more likely to face serious complications.
Touro’s rate was 2.8 percent, or about 360 of more than 13,000 women who delivered there from 2014 to 2017. The next highest rates in the city were Ochsner Baptist Medical Center (1.9 percent) and Tulane Lakeside Hospital (1.5 percent) – two other hospitals that also take on risky births.
No matter how USA TODAY sliced the data, moms delivering at Touro experienced worse outcomes than women in similar situations in other hospitals.
Compare the births of poor mothers at Touro to poor mothers at other area hospitals – Touro’s moms had more complications. Compare black mothers. White Mothers. Mothers with private insurance. Touro’s patients fared worse.
‘Something’s wrong with her’
A short walk from the historic St. Charles Streetcar Line, Touro Infirmary has been a cornerstone of health care in New Orleans for more than 165 years. It has long marketed itself as the place “Where babies come from.”
When Felicia West fell in her bathroom at home and hit her six-month-pregnant belly on the tub, she headed to Touro to get checked out. West’s pregnancy had been healthy, said her sister and roommate, Renata McClendon. Not even morning sickness.
Shortly after arriving at Touro in October 2012, West had a seizure – her first ever, McClendon said – and went into respiratory arrest. When doctors became concerned West’s placenta had detached, they delivered her baby by emergency C-section. The boy would eventually be fine. But West would not.
While at Touro, West developed a complex set of symptoms that led a doctor to diagnose a rare blood disorder.
He was wrong, a misdiagnosis and improper treatment course that later would be the only care failure cited by a state medical review panel.
After West was still hospitalized a week after birth and being treated for that diagnosis, records show, her blood pressure shot up to dangerously high levels: 177/67, 171/90, 174/103.
Nearly a year earlier, the American College of Obstetricians and Gynecologists had warned doctors that pressures above 160 need fast treatment and “may be the most important predictor” of a coming stroke in pregnant women and new moms.
For three hours, nurses recorded blood pressure spikes in West’s chart. Then, according to medical records obtained as part of the family’s lawsuit, over the course of nearly another hour, a nurse began calling and paging one doctor after another. Some were off duty, others on-call for them.
The nurse ran through five doctors before she found someone who would address West’s blood pressure: a doctor in one of Touro’s training programs. Even when told the latest reading was 175/94, the resident didn’t react as if it were an emergency.
That evening, McClendon got call on her cellphone from her sister’s hospital room. “I kept saying, ‘Hello, hello,’ ” McClendon said. West didn’t say a word. A nurse took the phone. “What’s wrong with her?” McClendon asked. She recalls the nurse saying: “‘She’s being kind of stubborn, she doesn’t want to talk on the phone.’ ”
McClendon knew better. She hopped in her car. By the time she arrived at the hospital, her 21-year-old sister seemed in a daze.
“It was almost like she was having an
out-of-body experience,” McClendon said. “She would look at us, turn away, look at us, turn away.”
McClendon rushed to the nursing station. “Something’s wrong with her. Something’s wrong with her.”
That was the last time McClendon would see her sister alive.
A spotlight on trainee doctors
Over the years, the OB-GYN training program at Touro has drawn concern from a national accreditation group that oversees medical education. Four recent lawsuits accused trainee doctors at Touro of failing to order the right tests, being slow to recognize emerging complications and making surgical or medication mistakes.
Of the 120 high-complication hospitals identified by USA TODAY’s analysis, at least 56 are training sites for OBGYN residency programs.
In 2015, Nathan Nedopak suited up to go into the operating room, thinking he was going to be with his wife, Jenny, for her emergency C-section. Instead, he encountered a shocking scene: their baby already delivered, his wife unconscious – and a lot of blood.
All three of the doctors in the operating room were trainees in Touro’s medical education program, run by the Louisiana State University Health Sciences Center, according to the family’s lawsuit. Two were residents, newly graduated from medical school and still learning to be obstetricians. The third had recently completed her residency but was a fellow, not yet board-certified as an obstetrician.
Trainees didn’t call their professors for help until 20 minutes after the baby was delivered and Jenny was hemorrhaging, the Nedopaks’ lawsuit alleges.
In addition to Nedopak, Shantel Smith – after a stillbirth at Touro in 2011 – nearly died from a pelvic infection, unrecognized so long by a team of mostly trainee doctors that she developed sepsis and gangrene, her suit says. Doctors had to amputate her right hand, most of the fingers on her left hand and both of her legs below her knees.
Nicole Phillips stopped breathing the day after she gave birth in 2014 and spent 19 months in a coma before dying. Her family has accused Touro, nurses and doctors – several of them also trainees – of giving her too much pain medication after her C-section and failing to quickly address signs that she was having problems breathing, according to a lawsuit filed last year.
Jessiffi Francois died from blood clots in her lungs in 2014 after a trainee doctor failed to send her home with clot-reducing drugs after delivery, her family says in a lawsuit filed in December. Francois had a family history of blood clots. She had been on such medications during her pregnancy and while hospitalized after the delivery, records say.
Jenny Nedopak remembers only the first part of her emergency Csection – needed because her baby’s heart rate had slowed. The trainee doctors started to deliver the baby’s head, but they couldn’t get it out. “There was a lot of yanking. The whole table was rocking,” she said. Then the anesthesiologist put her under.
After delivery, the OB-GYN fellow discovered Jenny Nedopak’s uterus had ruptured, court records say. Only then, the family’s lawsuit alleges, did the trainee doctors call their LSU professors to help perform a hysterectomy to stop the bleeding.
Jenny Nedopak lost massive amounts of blood and needed another lifesaving surgery several hours later.
The doctors, as well as Touro and LSU officials had no comment.
In court records, Touro and other health care providers have generally denied the malpractice allegations in lawsuits filed over the care received by Nedopak, Smith and Phillips. The suit over Francois’ death is so recent that Touro and other defendants haven’t yet filed responses with the court.
Accreditation records show the LSU OB-GYN training program that uses Touro as its primary teaching site has drawn concern from the council. It was placed on “warning” status from February 2018 until last month and probationary status from 2005 to 2007.
Asked about the 2018 warning, LSU spokeswoman Leslie Capo said only that it “had nothing to do with patient care” and was addressed. She wouldn’t say whether supervision was an issue.
Explanations don’t add up
Like Touro, hospitals across the country blame their high complication rates on demographics. A closer look indicates that’s not a full explanation.
Thirty miles outside New York City, Westchester Medical Center has a complication rate double its state median.
Medical center officials said the rate is entirely driven by maternity patients with underlying medical problems.
Healthy moms rarely deliver at the center, said communications director Andrew LaGuardia. “Here, all are considered high-risk.”
Westchester is among 17 maternity hospitals designated by New York to take on more complex cases. Fourteen had lower complication rates than Westchester.
In Texas, officials at University Hospital in San Antonio explained its complication rate of 6.9 percent – more than four times the median – by saying its patients are uniquely complex.
University Hospital said it could be fairly compared only to a tiny group of specialty hospitals in Texas. Asked to identify peers, officials named three – University of Texas Medical Branch Hospital in Galveston, Ben Taub Hospital in Houston and Parkland Hospital in Dallas.
All three have lower rates, USA TODAY found.
“You know, they’re probably not true apples to apples,” University’s chief medical officer Dr. Bryan Alsip said when shown the numbers.
While many hospitals with the highest rates pointed to patients’ poverty, the USA TODAY analysis identified plenty of hospitals serving high concentrations of poor women or black women with far lower complication rates.
In the heart of Baltimore, Mercy Medical Center – the largest birthing hospital in the city – is surrounded by poverty. Its maternity patients’ race and Medicaid status nearly match Touro’s.
Yet, Mercy’s rate of childbirth complications rate was far lower than Touro’s: At 1.4 percent, it matched the norm across the nation. Black mothers delivering at Mercy also bucked the national trend among delivery patients. Their severe complications were half the overall rate from USA TODAY’s analysis.
“We too have a similar issue with a lot of patients coming in late to care, or with no prenatal care, and substance use disorders becoming a real problem,” said Dr. Robert Atlas, chairman of Mercy’s OB-GYN department.
Atlas isn’t sure why Mercy’s complication rate was lower. Perhaps it’s because Mercy was an early adopter of many childbirth safety practices, he said, or because it requires the two big OB-GYN doctor groups that deliver there to have an on-call physician in the building 24/7.
He also noted the hospital is run by the Sisters of Mercy, a Catholic religious organization with a social justice mission including to “eliminate poverty, the widespread denial of human rights … the continued oppression of women.” That mission, he said, is a core value.
“Everybody, no matter what your ability is, gets the same level of care,” he said. “That’s so incredibly important as it relates to how the outcomes are looked upon.”
The lives behind the numbers
As policymakers and health care providers search for solutions, the human toll is enormous – and growing.
Jenny Nedopak lost the ability to have the four children she’d always wanted. Nicole Phillips’ and Jessiffi Francois’ daughters and Felicia West’s son will never know their mothers – and, as their families raise those children, they continue to grieve.
For Shantel Smith, survival means raising her four children without legs and fingers. It means coping with hot flashes from an emergency hysterectomy at age 30. It means using a girdle to support and cover the scar that runs across her abdomen. It means the heartbreak of sensing that her children are embarrassed by her appearance.
“You get up every day, you want to look pretty and normal like other women. But you’re always going to look different,” Smith said. “I just try to be there like a normal mother.”
Lawsuits still are pending over the care received by Nedopak and Francois. The suit over Phillips’ care is pending against Touro, but was dismissed against her LSU doctors because they weren’t properly notified of the lawsuit. A confidential financial settlement in the lawsuit over West’s death exhausted Louisiana’s $500,000 malpractice payment cap, according to court records. Because most of the records are sealed, it is unclear which health care providers were involved in that settlement.
As for Smith, she has spent more than six years fighting an uphill battle through Louisiana’s malpractice system seeking financial compensation for her injuries and answers to what went wrong. In 2015, a three-member review panel of Louisiana doctors said Smith’s caregivers recognized her complications “as soon as they were manifest.”
Smith’s suit against Touro, LSU and various doctors still is pending. In court records, they, too, have denied her malpractice allegations.
If any lessons were learned by the experienced and trainee doctors involved in Smith’s care, they weren’t shared with the chief OB-GYN resident on her case. When he was questioned by Smith’s attorney last year, Dr. Barry Hallner testified he had thought for all these years that her sepsis was caused by a ruptured bowel obstruction.
The day Smith was transferred to the ICU and headed into exploratory surgery was Hallner’s last day on a residency rotation at Touro. Now an assistant OB-GYN professor for the same LSU program that trained him, Hallner declined to comment.
In response to USA TODAY’s questions, Hallner and LSU have asked a court in New Orleans to stop Smith and her legal team from sharing any more information with the news media.
Smith moved to Baton Rouge to escape reminders of her old life – one in which she had a good job with medical insurance as an assistant manager at a fast food restaurant and enough money to take her kids to the mall and Chuck E. Cheese’s in her red Mustang.
“It’s really hard, but you just have to be strong,” Smith said. “I wish it never would have happened. And I wish that it never, ever happens to another woman.”
Contributing: Miranda Moore of Treasure Coast Newspapers in Stuart, Florida, David Robinson of The Journal News in Westchester County, New York, Kevin Robinson of the Pensacola NewsJournal, Sean Rossman of USA TODAY, Laura Ungar of the Louisville CourierJournal, and Colleen Wilson and Allison Wrabel of USA TODAY
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