The U.S. maternal death rate is among the highest in the developed world. Eighteen states haven’t studied these deaths and others tend to blame moms.
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.
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, including 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 reports published by the panels. Among the findings:
- Fewer than 20 states that have panels studying mothers’ deaths 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.
State health officials and experts say it’s important to look at broad public health problems such as smoking, obesity and access to care 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 America for pregnant women and new mothers – the state’s 2012 report on maternal deaths emphasized suicide, domestic violence and car crashes.
It dedicated pages of charts and recommendations to those 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?”
The state review panels are not conducting regulatory investigations. They are studying deaths to identify what went wrong, share lessons learned and identify solutions.
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 deal with 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. “I’m so lucky. It’s pretty miraculous that I survived.”
Focusing on other things
Every year, about 20 women die in Missouri during pregnancy or shortly after childbirth.
Hundreds more suffer life-threatening injuries, about half of which research has shown are preventable with better care.
The state has the sixth-highest maternal death rate in the nation. And it’s been getting worse.
In 2011, health department officials used a federal grant to form a panel of 22 health professionals to study why so many women were dying.
The group met every other month to review deaths.
But the panel members were assigned only to review maternal deaths, tabulate causes and determine “contributing factors,” not to look at the quality of the medical care.
The presentation the team delivered in 2015 – its only report, four years in the making – featured charts about the race, age, body-mass index, smoking habits and insurance coverage of mothers who died.
When USA TODAY asked why it did not touch on the medical care women received, state health officials said they wanted to highlight the broader issue of maternal mortality “rather than emphasize any particular area such as issues with medical providers.”
George Hubbell, an obstetrician/gynecologist and longtime member of the panel, cited resources as one reason the panel’s work didn’t focus more on medical care. Before the 2015 report, he said, the all-volunteer panel had the time of half of one state employee to gather information for cases. That’s now 1½ staff members’ time, he said, but the same employees handle infant deaths, too. Hubbell said hospitals are sometimes reticent about giving the state their dead patients’ charts, and there’s no law requiring them to do so.
Randall Williams, an obstetrician and gynecologist who has led Missouri’s health department since 2017, said the panel’s work hasn’t gone far enough. He said an effective death review process must include looking into the quality of the care patients received. He said he wants to revise the state’s process to study all factors, including mistakes by health care providers – something Hubbell said the panel has already started trying to do more of.
This year, the Republican appointee backed a move by a Democrat, state Rep. Sarah Unsicker, who said Missouri’s committee doesn’t pay enough attention to care.
“It kind of blames the victims without looking at what the hospitals can do,” said Unsicker, a mother of two sons. “If we continue with the status quo, that’s not going to be good.”
Despite bipartisan backing, the Missouri House voted her measure down in May.
Several lawmakers said a more aggressive death review panel would meddle too much in how doctors treat patients. State Rep. Mike Moon, a Republican who spent 27 years in marketing for Mercy Hospital in Missouri, said during the debate on the House floor that women smoking, being overweight and not going to the doctor while pregnant put them at risk for complications that could kill them.
At least 130 more women in Missouri have died from pregnancy since 2012. At least 4,000 suffered severe childbirth complications.
Krystle Jackson of St. Peters, Missouri, is one. She barely survived the birth of her only child, Lila.
She said several doctors and hospitals failed to diagnose a damaged artery in her cervix that caused her to bleed profusely two weeks after a C-section in 2017. She suffered severe bleeding seven times, making five ER visits to three hospitals. All the while, she said her concerns were dismissed.
When a doctor finally diagnosed the problem a month after delivery, she needed a hysterectomy, ending her hopes of another child.
“The public looks at some professions and what they do and puts it under a microscope,” said Jackson, who works in probation and parole. “Like with law enforcement, everything is looked at and discussed in detail. Policies are made based on every little thing.”
Doctors should face similar scrutiny, she said, because they “have your life in their hands.”
Some in Congress are pushing legislation that would give states money to improve the maternal death reviews. They’re also trying to make it mandatory for health care workers to report every death and make reviews uniform so they capture care mistakes and share lessons learned with doctors and hospitals.
“The numbers are staggering. This is not the developing world. This is the United States of America,” said U.S. Rep. Jaime Herrera Beutler, R-Wash. “We can’t answer basic questions like why. Why are these numbers going up?”