What states do not do to save the lives of new mothers

IIf you tried to prevent mothers from dying in childbirth, you could try what most American states did: assign a panel of experts to look at what was wrong and suggest ideas for remedying it.

But that did not work.

Mortality rates among pregnant women and new mothers have worsened, even though rich countries have improved elsewhere. Today, the United States is the most dangerous place in the developed world to give birth.

It turns out that well-intentioned states across the country are mistaken.

At least 30 states have avoided examining the medical care provided to deceased mothers, or they are not investigating deaths at all, according to a survey conducted by USA TODAY.

Instead, many state committees have focused on lifestyle choices and societal issues in their reporting of maternal deaths. They emphasized that women smoke too much or become too fat or their inability to seek prenatal care.

Virginia has published comprehensive reports on cancer, opioid abuse and road accidents among deceased mothers. The Minnesota team recommended that pregnant women be better informed about the use of seatbelts and firearms at home. The Michigan team urged homeowners to ensure that pregnant women's homes have smoke detectors.

In July, a US TODAY survey found that thousands of women in the United States suffer injuries or die during childbirth as hospitals, doctors and nurses ignore known best practices to avoid disasters.

Experts say that half of these women's lives could be saved if doctors and nurses took simple steps, including measuring blood loss during and after delivery, and timely treatment for cancer. hypertension.

Yet state panels across the country have focused some of their attention on the quality of care provided by hospitals or on promoting improvements, USA TODAY found.

USA TODAY has reviewed each state to see how they examine maternal deaths and read more than 100 panel reports. Among the results:

• About 20 states with maternal death review panels identify gaps in medical care, such as delayed diagnoses, inadequate treatment, or failure of hospitals to follow basic security measures. Most reports simply list statistics or focus on issues other than the quality of medical care.
• Of the 10 states with the highest mortality rates, only four panels reported gaps in medical care.
• More than a third of states do not study deaths at all. At least 1,165 pregnant women and new mothers died from 2011 to 2016 in the 18 states that did not have any review committees. Some have created panels since, but the federal government does not review maternal deaths.

Public health officials and experts believe it is important to look at major public health issues such as smoking, obesity and access to care because they contribute to the death of mothers.

"Yes, it's clinical factors. But it's also the person's access to care and the social determinants of health, "said physician Pooja Mehta, Acting Chief Medical Officer of the Louisiana Department of Health. She said this includes the person's access to care and the conditions under which people are born, grow and live.

In Louisiana, America's deadliest state for pregnant women and new mothers, state report on maternal deaths in 2012 focused on suicide, domestic violence and car accidents .

He has devoted pages of graphics and recommendations to these questions. Toward the end of the report, the panel passed two paragraphs encouraging doctors and hospitals to follow the basic maternal care procedures known to protect women.

The state group has not released any other reports for six years. This month's report was the first in which Louisiana focused heavily on the medical care provided to its mothers.

Cindy Pearson, Executive Director of the National Women's Health Network, a Washington-based consumer advocacy group, said, "The maternal mortality assessment team in each state was not really confronted with medical care.

"You have to go," said Pearson. "Do not tell me what was wrong with women. Do not give me a list of smoke or weight. Someone took care of women. What did these people do?

State examination commissions do not conduct regulatory investigations. They study deaths to identify what went wrong, share lessons learned and identify solutions.

Melissa Metzler of Doylestown, Pennsylvania, said that lessons from past tragedies could have prevented her from dying when she gave birth to twins in 2012. She hopes the new examination committee maternal deaths in Pennsylvania will teach doctors.

Metzler said the doctors rejected her pain and sent her home when she went to the hospital, thinking that she was giving birth. When she went to see her doctor the next day, her kidneys and liver were failing. She was on the verge of death.

"There are so many things that could be avoided if people take a closer look at what happened before," she said. "I'm so lucky, it's a miracle I've survived.

Focus on other things

Each year, about twenty women die in Missouri during pregnancy or shortly after childbirth.

Hundreds more have life-threatening injuries, nearly half of which have been prevented by better care.

The state has the sixth highest maternal mortality rate in the country. And it gets worse.

In 2011, Ministry of Health officials used a federal grant to train a group of 22 health professionals to investigate why so many women would die.

The group meets every two months to review deaths.

But the panel members were assigned solely to the examination of maternal deaths, the tabulation of causes and the determination of "contributing factors", and not to the quality of medical care.

The presentation presented by the team in 2015 – its only report, four years after its inception – featured graphics on race, age, body mass index, smoking habits and the insurance coverage of the deceased mothers.

When USA TODAY asked why the medical care received by women had not been taken into account, health officials said they wanted to focus on the issue of maternal mortality.

George Hubbell, an obstetrician / gynecologist and a long-time panel member, cited resources as one of the reasons why the panel's work did not focus on medical care. Before the 2015 report, he said, the all-volunteer panel had time to find half of a state employee to gather information on cases. It's now 1½ working hours, he said, but the same employees are also dealing with infant mortality. Hubbell said hospitals are sometimes reluctant to give the state their records of deceased patients, and there is no law requiring them to do so.

Randall Williams, an obstetrician and gynecologist who has headed the Missouri Department of Health since 2017, said the panel's work had not gone far enough. He said that an effective death review process must include examining the quality of care received by patients. He said he wanted to review the state process to study all the factors, including the mistakes made by health care providers – which Hubbell said the panel had already started to do more.

This year, the Republican candidate supported a decision by a Democratic representative, state representative Sarah Unsicker, who said the Missouri committee was not paying enough attention to care.

"It blames the victims without looking at what hospitals can do," said Unsicker, a mother of two sons. "If we continue with the status quo, it will not be good."

Despite its bipartisan support, the House of Missouri voted against its measure in May.

Several lawmakers have stated that a more aggressive death review committee would meddle too much with the way doctors treat patients. State Rep. Mike Moon, a Republican who has spent 27 years in marketing for Mercy Hospital in Missouri, said during the debate in the House that women who smoke, are overweight and do not go to the doctor. kill them.

At least 130 other women in Missouri have died of pregnancy since 2012. At least 4,000 have suffered serious complications during childbirth.

Krystle Jackson of St. Peters, Missouri, is one of them. She barely survived the birth of her only child, Lila.

She said several doctors and hospitals had failed to diagnose a damaged artery in her cervix, which caused her to bleed two weeks after a cesarean section in 2017. She suffered seven bleeds severe in three hospitals. All the while, she said that her concerns had been rejected.

A doctor finally diagnosed the problem a month after giving birth and needed a hysterectomy, thus ending his hopes for another child.

"The public looks at certain professions and what they do and puts them under the microscope," said Jackson, who works on probation and parole. "As with law enforcement, everything is examined and discussed in detail. Policies are based on every little thing. "

Doctors have to face a similar exam, she said, because they "have your life in their hands".

Some members of Congress put in place legislation that would provide states with the financial means to improve the examination of maternal deaths. They are also trying to get health care workers to report each death and make uniform examinations so that they can capture the errors of care and share lessons learned with doctors and hospitals.

"The numbers are staggering. This is not the developing world. These are the United States of America, "said US representative Jaime Herrera Beutler, R-Wash. "We can not answer basic questions like why. Why are these numbers increasing?

Proven assessments to save lives

Done right, maternal death reviews save lives.

In the United Kingdom, a team of 10 or more experts examines maternal deaths to determine what did not work in each case. The team has access to medical records and examines each stage of the mother's care.

The panel alerts doctors, nurses and hospitals to problems. The solutions are integrated into the courses taught in the faculties of medicine.

The United Kingdom has been studying this issue for more than six decades. Between 2000 and 2015, maternal deaths were reduced by almost a third, with the maternal mortality rate in America increasing by about half.

Marian Knight, a professor at Oxford University who runs the UK program, said it was crucial to be honest about what kills mothers.

"We are doing this to help women," said Knight. "We owe it to the families who stayed behind to learn about the deaths of women."

It is recognized in the United States and around the world that what happened after the worst event is one of the most important ways to improve medical care.

These exams are commonly used to learn from all kinds of other mistakes made in hospitals.

Deadly deliveries: Hospitals know how to protect mothers. They just do not do it.

In their own words: The women tell their story of survival: "I am one of 50,000 people."

A family story: "Mom went to heaven"

Go further: How hospitals miss new moms, in graphics

In the United States, California is one of the few states that scrutinizes maternal deaths so closely, weighs on specific clinical failures, and advocates for changes in care.

The latest California review, released this spring, looked at more than 1,000 maternal deaths and highlighted medical failures and potential solutions using case vignettes based on real women.

The California exams stimulated action. Four years ago, California released checklists and easy-to-follow training programs that could help doctors and nurses save women suffering from dangerous high blood pressure. The state had done the same thing for another great killer of moms: bleeding.

Its maternal mortality rate is now one quarter of that of the nation.

What prevents states from doing more

In the United States, every state has the power to do what California does.

However, elected officials and health services have neither recruited nor funded birth panels to complete such comprehensive reviews.

Rhode Island is one of seven states that remain without a review committee. (The others are Arkansas, Idaho, Montana, Nevada, South Dakota and Wyoming.) Three more, plus the District of Columbia, have just adopted measures to create panels this year. Ana Novais, executive director of health in Rhode Island, said a global grant from the Federation for Children's and Children's Health gives states leeway to decide how to use the money. Rhode Island has chosen other priorities, such as chronic diseases that affect all individuals.

Novais said that state officials "feel comfortable" with hospitals that review their own maternal deaths.

Other states spend a tiny portion of their budget on preventing maternal mortality. Health officials in Louisiana estimated that they were spending $ 750,000 of their $ 14 billion budget to prevent maternal mortality.

In addition to limited resources, there may be other reasons why review boards avoid looking at providers.

Panels from three states are partially or totally controlled by private medical associations and lobby groups that represent the interests of physicians or hospitals. In all states, panels are provided with doctors, nurses and hospital officials – the people involved in the care that would be examined.

Kevin Kavanagh, a physician who heads the nation's non-profit watchdog, Health Watch USA, laments that his state's Kentucky panel is headed by a private medical association and not by the health ministry. This is a conflict of interest, he said, because the profession itself carries out its policing duties and may not want to recommend changes that may affect physicians. Dr. Stanley Gall, long-time chairman of the Kentucky panel, said his group considered the facts of each case unprejudiced.

Abby Koch, research specialist at the Center for Research on Women and Gender at the University of Illinois, who helped examine the deaths of mothers in her state, said that the fact that elected officials and state regulators sign of bias too.

More than 1,000 local and state panels examine the deaths of children or children in America, and some have been doing so for decades.

"It's not difficult to mobilize the political will to look at child mortality," Koch said.

"In one way or another, it's a little less universal to look at mothers too. It's a political reality: as soon as women become pregnant, they become vessels for the baby, rather than people who have value on their own. "

To die in the dark

While more than 1,000 women have died this decade in states that did not study female deaths at all – countless others have gone unnoticed as even states with review committees are missing hundreds of deaths.

Death expert groups report that they often lack information because reporting of maternal deaths is often voluntary or because medical records are inaccurate or incomplete.

The Kentucky Review Panel never had the opportunity to review Jessica Butler's case. The death of Louisville's wife and baby was never discovered by the state panel. Nobody knows why.

A series of problems, including inaccurate death certificates, computer problems and doctors failing to note that their patients were recently pregnant, prevented cases from being reported, said Gall, chair of the state panel.

Butler, 27, had told a nurse that the pain was "worse than a delivery", but she was sent home without seeing a doctor, according to the family.

The next morning, Nate Butler found his pregnant wife throwing up and crawling on the kitchen floor. He brought her back to the hospital. Doctors have discovered widespread kidney infection – an infection like the one she experienced in a previous pregnancy.

The witnesses were not in agreement on his care. An expert who testified for the family said that the hospital should have admitted Jessica immediately and started taking intravenous antibiotics. A defense expert said that his urine test and abdominal pain suggested a common urinary tract infection.

The Baptist Hospital denied any responsibility and settled the dispute for an undisclosed amount, but it did not discuss the details. The obstetrician's lawyer defended his client's care, but a jury ruled that the doctor and the hospital were at fault and awarded the family a $ 7.4 million verdict.

The infection spread to Jessica's blood and her heart stopped during the surgery. The little girl in her is dead. Jessica is delayed for three days before Nate lets her go.

The young father had to tell his son Max, "Mom do not go home."

Then he left the hospital one dad.