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USA;Hospitals blame moms when childbirth goes wrong. Secret data suggest it’s not that simple.

March 2019 Yahoo news;

How childbirth cost one mother her hands and legs

Shantel Smith developed an infection after a stillbirth at Touro Infirmary in New Orleans in 2011. In an ongoing lawsuit, Smith alleges that delayed diagnosis and treatment resulted in devastating amputations of her legs and hands.

Hospitals blame moms when childbirth goes wrong. Secret data suggest it’s not that simple.

Alison Young and John Kelly and Christopher Schnaars

USA TODAY

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, including one that was extremely painful and another for a rare condition. 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.

Explore USA TODAY’s database of childbirth complication rates here.

With national childbirth harm numbers soaring – 700 women dying every year, 50,000 more 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.”

At some hospitals, more women are harmed

Hospitals across the nation record details of every patient’s treatment in computerized billing records, and most report it to their states. Researchers use that data to study hospital care and trends. But an individual hospital’s rate based on that data is not usually public.

USA TODAY was able to collect the data 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 federal Centers for Disease Control and Prevention – the same one used for years by academics, big insurance companies, hospitals and others to track and study women harmed from childbirth. Touro participates in two programs that calculate rates this way, one run by Blue Cross Blue Shield, another by the state of Louisiana.

Find childbirth complication rates at nearly 1,000 hospitals across the U.S.

How often do women’s deliveries turn deadly? USA TODAY calculated rates of life-threatening complications in 13 states where we obtained data. Used by hospitals, insurance companies and researchers, these rates are often kept secret from patients. Until now.

than 1.5 percent. But at a small group – about one out of eight hospitals studied – 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. While many deal with patients who show up at the hospital with challenging medical conditions, the outliers defy categorization, serving every imaginable mix of patients.

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 life-threatening deliveries more often.

Compare the outcomes for white women, and the same hospitals jump out. White mothers at the outlier hospitals were three times as likely to experience potentially fatal complications. The complication rates also were higher for mothers with health insurance.

Safety advocates said that without public access to data, it has been too easy for hospitals to excuse poor outcomes by blaming mothers’ health problems.

“It’s a valid point, but it’s not a point that hospitals can use to simply not do better,” said Elizabeth Dawes Gay, a founding co-director of the Black Mamas Matter Alliance, which advocates for racial justice in women’s health. “They also have to be willing to change, to look at their practices, their policies, their providers and ask: Where are we failing women?”

Hospitals vary widely in how many maternity patients they serve each year. Some in USA TODAY’s analysis handle 1,000 or more deliveries annually; others deliver only about 100.

The billing records USA TODAY obtained also do not detail every medical problem a patient had before giving birth, making it impossible to gauge how many risky cases a hospital faced or whether doctors and nurses could have prevented problems. For instance, there’s no way to tell whether a woman was obese, which can be a risk factor.

Looking more deeply at New Orleans shows the kinds of 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 who went to other hospitals.

Compare the births of poor mothers at Touro with 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.

The pattern held true with patients coming from individual ZIP codes.

ZIP code 70119 is just blocks northwest of the French Quarter, but it’s a world apart. It is one of Louisiana’s poorest areas.

About half of the 1,800 women from the area who gave birth from 2014 to 2017 went to Touro, where more than 4 percent of them experienced severe complications. The complication rate for women in the same ZIP code who went to the other hospitals: 1.3 percent, less than one-third.

Those same differences played out in almost every ZIP code across New Orleans.

Hospital records offer answers, and more questions

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 struck 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. Hospital records document prenatal care, prenatal vitamins and no history of high blood pressure. They say she was obese, however, weighing more than 200 pounds while pregnant, at just over 5 feet tall.

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 baby boy would eventually be fine. But West would not.

During her stay at Touro, West developed a complex set of symptoms. Along with the seizure, odd blood test results and problems with her kidneys 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. The panel otherwise concluded that there was nothing to indicate the hospital and other staff “deviated from the standard of care.

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 “may be the most important predictor” of a coming stroke in pregnant women and new moms that “if not treated expeditiously can result in maternal death.”

For three hours, nurses recorded those blood pressure spikes in West’s chart. Then, according to medical records obtained by plaintiffs’ attorneys as part of the family’s lawsuit, over the course of nearly another hour a nurse began calling and paging one doctor after another to find someone to help. 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 learning internal medicine skills through one of Touro’s training programs. Even when told the latest reading was 175/94, the resident didn’t react as if West’s blood pressure was 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.

Trainee doctors repeatedly cited in deadly deliveries

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 OB/GYN residency programs, and 22 of them have accreditation histories that include warnings, probation or both. University hospitals tend to be major medical centers and often are OB/GYN training sites.

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.

As Nedopak was taken to a side table to meet their newborn daughter, the doctors whispering near his wife “looked panicky,” he said. A woman was talking to someone on the phone.

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.

No OB/GYN faculty member was present when Jenny Nedopak’s delivery turned dangerous in 2015, the lawsuit and the Nedopak’s attorney allege. Trainees didn’t call their professors for help until 20 minutes after the baby was delivered and Jenny was hemorrhaging.

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 lawsuit 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 and Nathan Nedopak said that before her delivery went bad, they hadn’t given much thought to residents being involved in her care. They just assumed experienced physicians would be there, too.

Jenny Nedopak remembers only the first part of her emergency C-section – needed because her baby’s heart rate had slowed during labor. 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. Bleeding from ruptures can be fatal.  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 Nedopak’s lawsuit says that “extensive uterine damage occurred due to aggressive and inexperienced delivery maneuvers by the residents.” 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.

There is no national requirement that a professor be in the room when OB/GYN residents and fellows treat patients or do surgery. Faculty only must be “immediately available.”

The Accreditation Council for Graduate Medical Education lets programs determine the level of supervision needed based on each trainee’s skills and each patient’s needs. Even then, the group allows supervision to come in many forms, including by other residents and fellows – or professors reachable by phone.

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.

Reasons for the actions are kept confidential by the privately run council. According to the council’s records, warning status “was created to let a program know when the Review Committee is seriously concerned about its performance.” Probationary status reflects a higher level of concern. Both actions are relatively rare across the country.

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 resident supervision was an issue.

Capo sent repeated statements to USA TODAY suggesting that Hurricane Katrina was the reason behind its OB/GYN program’s 2005 probation. Yet a 2008 medical journal article – written by OB/GYN officials at the university – says the residency program was put on probation “before Katrina” for “inadequate clinical experience in training.”

The CEO of Touro’s parent company urged LSU officials to make sure residents didn’t respond to USA TODAY’s queries, according to internal emails obtained through a public record request.

“Residents speaking to the media could have far-reaching ramifications,” wrote Gregory Feirn, CEO of LCMC Health.

LSU spokeswoman Capo also objected to USA TODAY’s continued reporting.

“We told you that the warning had nothing to do with patient care. Period,” she said in an email. “Your emails make it seem that you are planning to link our accreditation status to maternal morbidity and mortality. THERE IS NO LINK. It has no place in your story.”

Hospital explanations don’t hold water

Like Touro, hospitals across the country blame their high complication rates on demographics. A closer look at them indicates that’s not a full explanation.

About 30 miles outside New York City, Westchester Medical Center has a complication rate double its state median and three times the median of all hospitals examined by USA TODAY. Like Touro, it is a primary teaching site for new doctors learning to become obstetricians.

Medical center officials said the rate is entirely driven by maternity patients with underlying medical problems, and they said the residency program has no effect on that.

that.

Healthy mothers 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, also an OB/GYN teaching site, 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. And University’s rate was more than four times higher than one of them, the UT hospital in Galveston.

“You know, they’re probably not true apples to apples,” University chief medical officer Dr. Bryan Alsip said after being 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.

Among the hospitals where most maternity patients are black, just over half had complication rates twice the norm, meaning nearly half had lower rates.

And, among hundreds of hospitals where two-thirds of mothers giving birth were on Medicaid, only one in five had complication rates twice the norm. Almost 100 of those hospitals’ rates were below the median.

In the heart of Baltimore, Mercy Medical Center – the largest birthing hospital in the city, delivering one of every five babies – is surrounded by poverty. Its maternity patients’ race and Medicaid status nearly match Touro Infirmary’s.

Yet, Mercy’s rate of childbirth complications 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. He said very low-risk patients are uncommon at the hospital.

Atlas isn’t sure why Mercy’s complication rate was lower than that of other urban medical centers. 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 that includes eliminating “poverty, the widespread denial of human rights … the continued oppression of women.” That mission, he said, is a core value for the hospital’s administrators, doctors, nurses and other health care providers.

“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.”

Behind the rates, a human toll

As policymakers and health care providers search for solutions to the nation’s maternal health crisis, the human toll is enormous – and growing.

Jenny Nedopak lost the ability to have the four children she had 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 after surgeons discovered her ovaries had turned blue from dead tissue and her abdomen was filled with pus. It means using a girdle to support and cover the enormous 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.”

She still grieves over her baby boy, Jamal, who died before birth, yet has no grave to visit: the hospital disposed of his body without her permission, her lawsuit alleges.

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 healthcare providers were involved in that settlement.

As to 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 medical 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 also 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 for 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.”

 

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