To Keep Women From Dying In Childbirth, Look To California
When Cayti Kane delivered a baby boy via cesarean section last year, her team of doctors was prepared.
Kane had been diagnosed with placenta accreta, a condition that increased the likelihood of a dangerous hemorrhage during delivery. When that happened, she had an emergency hysterectomy. Kane and her son went home healthy.
Complicated, high-risk deliveries in the United States often end tragically. An American woman is three times as likely to die from childbirth as a woman in Canada, and six times as likely as a woman in Scandinavia. It's a story NPR and ProPublica have heard repeatedly over the last year while investigating the startling rate of maternal death in America.
But despite her risk factors, Kane had something going for her that made her delivery less likely to go wrong: She lived – and gave birth – in California.
The state is leading the charge to reverse the nationwide trend: Since 2006, California has cut its rate of women dying in childbirth by more than half. And it's a state whose impact could make a big difference: One in eight infants born in the United States is born there.
It wasn't always that way.
Debra Bingham, a nurse then working toward a doctorate in public health, was in a meeting with state public health officials in 2006, when a startling statistic was unveiled: The rate of California women dying from childbirth had recently doubled.
"It was unexpected and disturbing, very disturbing," recalls Bingham, now the executive director of the Institute for Perinatal Quality Improvement. "We needed to understand and really dig into why."
Soon Bingham was tasked with bringing together key players to dig in: nurses, doctors, midwives, hospital administrators and other officials. Together, they launched a massive, statewide effort to keep as many mothers as possible alive – and to understand why so many were dying in the first place. To understand that, you've got to go back more than sixty years.
An 'Apparently Irreducible' Death Rate
In 1950, the Journal of the American Medical Association, a beacon of medical research, made a dramatic claim: The battle to stop women from dying in childbirth had finally been won.
"The Journal takes pride in announcing that for the first time in history the maternal mortality rate for a large nation – the United States of America – has been pushed slightly below the apparently irreducible minimum of one maternal death per 1,000 live births," an editorial proclaimed in an issue that year.
Only a few other nations, it continued, could reach such stellar numbers: Sweden, Norway, Denmark, the Netherlands and New Zealand. In subsequent years, the rate of maternal death in the U.S., thought to be irreducible, fell even further.
But then it stopped.
"There was this premature declaration of victory," says obstetrician William Callaghan, chief of the Maternal and Infant Health Branch in the Division of Reproductive Health at the Centers for Disease Control and Prevention.
Callaghan says that after the medical community declared that victory, there was a shift in focus.
"Into the late '60s and really through the '70s, the technology of being able to care for the fetus became huge," Callaghan says. "People became really enchanted with the ability to do ultrasound, and then high-resolution ultrasound, to do invasive procedures, to stick needles in the amniotic cavity, and everything did revolve around the baby."
As the focus turned from mothers to babies, the trend lines for both diverged. Infant mortality is now at a "historic low," while the maternal mortality rate has continued to rise in recent years.
Of the 700 to 900 maternal deaths each year in America, the CDC Foundation estimates that 60 percent are preventable.
That's because, as NPR and ProPublica have reported, the American medical system still prioritizes infant survival over maternal care. It approaches childbirth with the assumption that most women who give birth will be fine.
'Practice It And Practice It'
For the minority of women who won't be fine, there needs to be a plan in place, says Debra Bingham. She, along with obstetrician Elliott Main and others, sought to create one.
They helped found the California Maternal Quality Care Collaborative in 2006, where Main says a newly formed maternal mortality review committee was able to access details – for the first time – on how every mother had died over the previous five years.
"It became very clear that there were cases in which, if care had been performed differently there would have been a high likelihood of better outcomes," says Main, who is the medical director of the collaborative and a clinical professor of Obstetrics and Gynecology at Stanford University.
In particular, the committee found two well-known complications offered the best chance for survival if treated properly: hemorrhage and the pregnancy-induced high blood pressure called preeclampsia.
Main estimated that the vast majority of the deaths from those two complications could have been prevented through early recognition, teamwork and a list of well-rehearsed treatments.
"The analogy would be if you had a cardiac arrest and everyone had their own way of doing CPR," Main says. "We've made big advances in emergency care by having some basic standardized approaches to emergencies. That's what we're bringing to maternity care now."
At Pomona Valley Hospital Medical Center, a member of the collaborative, doctors and nurses are doing just that.
An hour east of Los Angeles, the hospital is one of the state's largest birthing centers, delivering more than 7,000 babies a year.
Maria Hellen Rodriguez, the medical director of maternal-fetal medicine at the hospital, recently led a training drill for nurses and doctors on how to improve outcomes for women who hemorrhage during or after giving birth. Using a medical mannequin, a team practices a simulated hemorrhage.
"Every single woman is at risk for hemorrhage if they are going to deliver," Rodriguez explains.
That idea – that every woman is at risk – is a new thought in the world of obstetrics. Preparing for the worst case scenario, Rodriguez says, is key to saving mothers.
"You need to make sure that you can work [it] into your muscle memory. So it happens every time you take care of a patient," Rodriguez says.
That starts with one early innovation of the California collaborative: toolkits that contain everything needed to tackle an emergency complication, from checklists to equipment to medications.
For an obstetrical hemorrhage, that toolkit is a cart – not unlike a crash cart used for cardiac arrest. Red, with five drawers on wheels, the hemorrhage cart is filled with every kind of equipment a team of doctors and nurses may need in an emergency: things like a checklist, an IV line, oxygen masks, a special speculum, and a Bakri balloon, which, when inserted into the uterus, puts pressure on blood vessels.
And, for measuring blood that is lost: sponges and pads. Traditionally – and in many hospitals still – nurses and doctors estimate the amount of blood lost by sight.
The team working in Rodriguez' drill gathers the sponges and pads collecting blood and weighs them on a scale. They know how much these items weigh when dry. Once they subtract the dry weight, they can more accurately gauge how much blood has been lost.
The lesson, delivered over and over again, is that each team member – doctor or nurse – has the power to change the outcome.
An 'Extremely Good Decision'
Even though she'd had five previous c-sections, Cayti Kane had never heard of placenta accreta before she was diagnosed.
She also didn't know that each repeat c-section increased the chance that she'd develop the condition. In placenta accreta, scar tissue on the uterus from previous surgeries can allow a placenta from a new pregnancy to grow through the uterine wall, which can lead to hemorrhage.
The disorder used to be exceedingly rare in the U.S. In the 1950s, it appeared in one in every 30,000 births. Today, placenta accreta appears in one in every 500 births. Its rise has coincided with the rise in c-sections, the rate of which is six times what it was fifty years ago. Today, one in three babies is born via c-section.
A woman having her sixth c-section – like Kane – has a much higher chance of developing placenta accreta.
"If I had known that this was a possibility, there's no way I would have ever done this," Kane says. "There's no way I would have put my life at risk and risk my children losing their mom."
It was by chance that Kane ended up at Pomona Valley Hospital Medical Center. She lives in Apple Valley, Calif., in the high desert and more than an hour's drive away.
At 30 weeks pregnant, she went into pre-term labor and when she arrived at her local hospital, her regular doctor was out of town. In what Kane calls an "extremely good decision," the on-call doctor transferred her to Pomona Valley, because of the risks associated with her five previous c-sections.
Pomona Valley was prepared for her delivery. But just as important, the small, rural hospital where Kane delivered previously – also a member of the statewide collaborative – was quick to identify a problem it was not prepared for and send her to one that was.
At Pomona Valley, Dr. Rodriguez immediately diagnosed Kane with placenta accreta. Two weeks later, Kane delivered a healthy boy via c-section. When, as expected, she hemorrhaged, she was surrounded by a team able to handle it.
From 2006 to 2013, the maternal death rate in California fell 55 percent. These protocols – the checklists, carts, drills and teamwork – have not only saved women from dying, they have also dramatically reduced the rate of women who nearly died.
A study in The American Journal of Obstetrics and Gynecology found hospitals that signed up to implement the toolkits lowered the rate of severe maternal morbidity due to hemorrhage by nearly 21 percent. In hospitals not participating, that rate dropped by just over one percent.
As of June 2018, 88 percent of California's birthing hospitals have joined, accounting for 95 percent of all the births in the state.
NPR's Meg Anderson and Barbara Van Woerkom and ProPublica's Nina Martin contributed to this report. Copyright 2018 NPR. To see more, visit https://www.npr.org/.