Every year, thousands of women suffer life-altering injuries or die during childbirth because hospitals and medical workers skip safety practices known to head off disaster, a USA TODAY investigation has found.
Doctors and nurses should be weighing bloody pads to track blood loss so they recognize the danger sooner. They should be giving medication within an hour of spotting dangerously high blood pressure to fend off strokes.
These are not complicated procedures requiring expensive technology. They are among basic tasks that experts have recommended for years because they can save mothers’ lives.
Yet hospitals, doctors and nurses across the country continue to ignore them, USA TODAY found.
As a result, women are left to bleed until their organs shut down. Their high blood pressure goes untreated until they suffer strokes. They die of preventable blood clots and untreated infections. Survivors can be left paralyzed or unable to have more children.
The vast majority of women in America give birth without incident. But each year, more than 50,000 are severely injured. About 700 mothers die. The best estimates say that half of these deaths could be prevented and half the injuries reduced or eliminated with better care.
Instead, the U.S. continues to watch other countries improve as it falls behind. Today, this is the most dangerous place in the developed world to give birth.
Identifying every hospital that doesn’t provide recommended care is next to impossible. There is no national tracking system for childbirth complications. Mothers tell harrowing tales of survival, but they often have no idea whether their doctors and nurses did something wrong.
USA TODAY obtained more than a half-million pages of internal hospital quality records and examined the cases of more than 150 women whose deliveries went terribly wrong. Reporters contacted 75 birthing hospitals to track whether they follow recommended procedures.
Together, these documents and interviews reveal a stunning lack of attention to safety recommendations and widespread failure to protect new mothers.
At dozens of hospitals in New York, Pennsylvania and the Carolinas – where USA TODAY obtained records through federally funded quality programs – fewer than half of maternity patients were promptly treated for dangerous blood pressure that put them at risk of stroke. At some of those hospitals, less than 15 percent of mothers in peril got recommended treatments, the records show.
Many hospitals across the country conceded in interviews with USA TODAY that they were not taking safety steps such as quantifying women’s blood loss or tracking whether moms with dangerously high blood pressure got proper medication in time.
The lack of attention happens at hospitals big and small, from tiny community delivery units to major birthing centers that tout state-of-the art technology and training. It also happens in doctors' offices when they miss or fail to act on signs of serious complications during pregnancy and after delivery.
In Ohio, Ali Lowry bled internally after giving birth in 2013, but medical staff didn’t recognize and act on the warning signs for hours, according to records in a lawsuit that she has since settled. By the time she was airlifted to another hospital for lifesaving surgery, her delivery hospital had nearly run out of blood and Ali’s heart had stopped.
In Texas, Beatriz Garcia nearly bled to death when doctors and nurses were slow to help her after not quantifying her blood loss, she alleged in federal and state lawsuits. Garcia’s heart stopped. She needed a hysterectomy. She’s now awaiting a kidney transplant.
And in South Carolina, one of the state’s top hospitals sent YoLanda Mention home with her newborn despite her dangerously high blood pressure. When she returned to the emergency room with even higher blood pressure and an excruciating headache, the staff made her sit for hours in the waiting room, according to a lawsuit filed by her husband. She had a stroke while waiting, and later died.
Today, YoLanda’s husband, Marco, is raising their three daughters alone in rural Nesmith. He balances work as a school bus driver with all the demands of raising kids on his own – cooking the meals, cleaning and getting three girls to schools and day care.
He spends his evenings leading his church choir and reminding his girls about a mother who the youngest knows as a picture in a curio cabinet.
“The girls, they ask when she's coming home and I don't know what to tell them,” Mention said, wiping tears. “It seems like a nightmare and I just need to wake up.”
It doesn’t have to be this way.
Countries around the world have reduced maternal deaths and injuries by aggressively monitoring care and learning from mistakes. The result has been two decades of steady or reduced maternal harms in the rest of the developed world – as U.S. rates climbed.
One exception in the U.S.: California, where safety experts and hospitals worked together to implement practices that are now endorsed by leading medical societies as the gold standard of care. Statewide, California’s maternal death rate has fallen by half, while deaths rose across most of the country.
Despite widespread recognition that the California safety measures save lives, hospitals elsewhere have been slow to use them.
“Our medicine is run by cowboys today, where everyone is riding the range doing whatever they’re wanting to do,” said Dr. Steven Clark, a leading childbirth safety expert and a professor at Baylor College of Medicine. While there are hospitals that follow best safety practices, change is happening slowly, he said. “It’s a failure at all levels, at national organization levels and at the local hospital leadership levels as well.”
In part, that’s because regulators and oversight groups that could require hospitals to do more have not, USA TODAY found.
The lack of action by the Centers for Medicare and Medicaid Services to protect mothers stands in sharp contrast to its more aggressive approach to trying to improve care for elderly Medicare patients.
As a condition of getting Medicare payments, the federal agency requires hospitals to disclose information such as complication rates for hip and knee surgeries and whether heart attack patients got prompt care. All of that information is posted online.
That same agency helps pay for about half of the nation’s nearly 4 million births each year via Medicaid, and it could set similar rules about childbirth complications.
So far, it has not.
The Joint Commission, a private accreditation group that sets safety standards for thousands of hospitals, makes hospitals track cesarean section rates.
But the commission has no requirements that hospitals report how often their health care providers fail to follow national guidelines for protecting moms against leading childbirth dangers. Officials said the group is still studying the safety practices, some of which have been known for at least eight years.
“For us to make it a requirement for every organization to follow something, there has to be clear national consensus that this is the standard of care,” said Dr. David Baker, executive vice president of the commission's Division of Health Care Quality Evaluation.
Baker said the safety practices to protect moms from hemorrhages are “promising.” But he said there are questions about whether the protocols calling for fast treatment of dangerous blood pressure are appropriate for the commission to require at the hospital level. “I suspect within the next two months, there will be a decision on whether to go forward,” he said.
The American Hospital Association, the influential trade association representing nearly 5,000 hospitals and health networks, has in recent years held closed-door training sessions aimed at getting maternity hospitals to improve care.
In a series of webinars, AHA first warned anyone not invited to disconnect.
Then, trainers for the association went on to bluntly discuss how wide-ranging care failures at birthing hospitals are causing needless deaths and injuries.
“What we know about those deaths is that most of them were absolutely preventable,” a trainer for the association told maternity staffs during a 2015 webinar. “They were from causes that we could have done something about. We could have prevented it if we had recognized the emergency early on.”
During another closed session in 2016, a hospital association trainer said studies show that as many as 93 percent of women who bled to death during childbirth could have been saved if hospital staff had been aware of how much blood the woman lost.
The trainer said 60 percent of studied deaths from preeclampsia, a severe blood pressure disorder in pregnancy, also were preventable “because we failed to control the blood pressure or to recognize other emergencies that were happening.”
“We’re not talking about a Third World country, we’re talking about us, here,” the trainer said. “This shouldn’t be happening here.”
The hospital association declined to grant an interview and wouldn't answer questions about the toll of preventable harms at its member hospitals or how many of those hospitals follow best practices. In a statement, the group said U.S. hospitals are "committed to continuously working to keep all patients safe."
There is a growing recognition by hospitals that they need to adopt standardized care practices to save mothers' lives. In the past year, the number of maternity hospitals participating in a voluntary childbirth safety improvement program endorsed by leading medical societies has more than doubled.
The 985 hospitals currently enrolled in the AIM Program to reduce harms to mothers represent about 40 percent of the nation’s birthing hospitals and they are in various stages of implementing care reforms, organizers say.
For more than a decade, the experts who guide medical practices in the U.S. have been pushing doctors and hospitals to change how they treat pregnant women.
At least as far back as 2010, researchers in California began promoting “tool kits” of childbirth safety practices to reduce deaths and injuries.
These kits, built upon years of published research, were made up of policies, procedures and checklists that, pursued together, appeared to save mothers’ lives.
Around the same time, the American College of Obstetricians and Gynecologists was lending its influence to address one of the leading childbirth killers: high blood pressure.