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 in the past 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 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 60 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 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."
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.
About 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.
The 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's 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 had 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 would 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 50 years ago. Today, 1 in 3 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, 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, but 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 1 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.
RENEE MONTAGNE, HOST:
And for more than a year now, we've been bringing you stories about a disturbing national trend. For an American mother, giving birth can be fatal. She is three times more likely to die than a woman in Britain or Canada. This morning's story, wrapping up our NPR-ProPublica series Lost Mothers, offers some good news - how one state, California, bucked that trend beginning in 2006 when public health officials there realized they had a big problem on their hands. Debra Bingham is a registered nurse. She was working on her doctorate in public health when she was invited to a meeting where officials unveiled a startling statistic. The rate of California women dying in childbirth had recently doubled.
DEBRA BINGHAM: Oh, it was unexpected and disturbing - very disturbing.
MONTAGNE: What it did, though, was shock the state into action.
BINGHAM: We needed to understand and really dig into why.
MONTAGNE: Soon, Debra Bingham was tasked with bringing together major players - nurses, doctors, midwives, hospital administrators. They would go on to launch a massive, statewide effort to keep as many mothers as possible alive. A co-founder of California's Maternal Quality Care Collaborative was Elliot Main, a professor of obstetrics and gynecology at Stanford. He says they were able to access, for the first time, details on how every mother had died over the previous five years.
ELLIOT MAIN: We began reviewing cases. And 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.
MONTAGNE: They discovered that two well-known complications stood out, offering the best opportunity for saving mothers - hemorrhage and the pregnancy-induced high blood pressure called pre-eclampsia. Dr. Main estimated that the vast majority of deaths from those two complications could be prevented not with a magic pill or new high tech equipment but with early recognition, teamwork and a list of well-rehearsed treatments. It would be the equivalent of instituting a Code Blue for, say, obstetric hemorrhages.
MAIN: The analogy would be if you had a cardiac arrest, and everybody had their own way of doing CPR. We've made big advances in emergency care by having some basic standardized approaches to emergencies. And that's what we're bringing to maternity care now.
MONTAGNE: And that's what brought me to Pomona Valley Hospital Medical Center. What it's been doing as a member of the collaborative illustrates how California has been able to cut its rate of maternal deaths to a third of the national average. It's about an hour east of Los Angeles and is one of the top birthing centers in the state. Seven thousand babies are born here each year. Obstetrician Maria Helen Rodriguez is the medical director of maternal fetal medicine and happy to show me around.
MARIA HELEN RODRIGUEZ: Today, we're going to take a look at some of the measures that we have taken here at Pomona Valley Hospital to improve the outcomes of women in terms of our approach to obstetrical hemorrhage. Of course, every single woman is at risk for hemorrhage if they're going to deliver.
MONTAGNE: That idea that all mothers are vulnerable is a new kind of thinking here. The longstanding belief among medical professionals and mothers is that when giving birth, everything will be OK. And it mostly is. But being prepared for the worst is key to saving mothers.
RODRIGUEZ: You know, I always look at how - you know, with race cars, how they have the pit stop. And you have those 10 or 12 people come together to perform about 90 or 100 tasks. And they have to do it under 12 seconds. And they practice it and practice it and practice it. So that is the very same thing that we do with all of our emergencies, actually.
MONTAGNE: One early innovation in California - toolkits - a kind of how-to for tackling a potentially fatal complication. That includes lists, medications, equipment. When it comes to obstetric hemorrhage, that includes an actual cart patterned after the crash cart used for cardiac arrest.
JO DUTTON: All right, so this is the hemorrhage cart we came up with. Like I said...
MONTAGNE: Jo Dutton is the clinical nurse supervisor at Pomona Valley Hospital. She proudly wheels over the cart she designed.
DUTTON: And, of course, I picked red because it's obvious - hemorrhage. And it really stands out.
MONTAGNE: There are five drawers, the top one containing the all-important checklist.
DUTTON: Then we have something in here called a Bakri balloon. And this is a balloon that you can put into the uterus. And it puts pressure on the vessels in the uterus to stop it bleeding, like putting pressure on a wound.
MONTAGNE: In another drawer, oxygen masks, which can act as an important visual cue for the nurses.
DUTTON: Every room has oxygen masks at the head of the bed. But I put them in here so people would open the drawer and go, oh. Have we given her oxygen?
MONTAGNE: Other drawers contain a kit to start an IV line, a special speculum and more. In a real emergency, this hemorrhage cart is rushed down the hall to a patient's room. On this day, Jo Dutton has brought it to a simulated emergency, where nurses and doctors play different roles.
RODRIGUEZ: OK. This is Mrs. Sims - Jane Sims.
MONTAGNE: The patient in the bed, Jane Sims, is an anatomically correct mannequin. The scenario begins with a shift change and nurses exchanging vital information.
UNIDENTIFIED PERSON #1: She's post-vaginal delivery about an hour ago. She was induced because of her elevated blood pressures.
MONTAGNE: Minutes later, the patient complains that she's nauseated and dizzy. And the nurses discover she's bleeding. Jo shouts into the hallway.
DUTTON: Hello? Can I get some help in here? I've got a postpartum hemorrhage.
MONTAGNE: And quickly, a team with diverse specialties descends on the room.
RODRIGUEZ: Do you have a second line, Jo?
DUTTON: No, could - Maxine, will you start a second line for me? OK. I'm going to get the check list.
RODRIGUEZ: I have the second line, Jo.
MONTAGNE: To illustrate just one important low-tech innovation, traditionally, and still in most hospitals, nurses and doctors eyeball the amount of blood a woman is losing. That estimate can easily be wrong. This team uses something far more accurate. The medical pads and sponges that have been collecting blood are gathered and weighed on a scale. The nurses know exactly how much the dry pads weigh, so they subtract the dry weight in order to gauge how much blood has been lost.
DUTTON: We need to weigh these pads, please. Is the scale here? Yes, it is. Could you weigh that for me, please, Edna?
MONTAGNE: This drill is not the end of it. When the simulation is over, there's a de-brief.
RODRIGUEZ: OK, so now we're going to go about things that are going to help us in the scenario that you need to make sure that you kind of work into your muscle memory, so it happens every time you take care of a patient.
MONTAGNE: Dr. Rodriguez begins a rapid Q&A.
RODRIGUEZ: We want to avoid open-air commands. What do we mean by that?
DUTTON: So you didn't tell me to do it, so I think Nancy's going to do it, so Nancy thinks I'm going to do it. And then neither of us do it.
RODRIGUEZ: So it's important to state the name of the nurse that you want to do a specific task.
MONTAGNE: One thing that really stands out in this drill and de-brief is that nurses are on the frontline of these obstetric emergencies. And part of the state's initiative is about empowering nurses like Jo Dutton.
DUTTON: Years ago, there was more of a pyramid type of style where the doctor was at the top. And the nurses sometimes would feel intimidated or wouldn't want to speak out if they thought something. And we had occasion where we had some bad outcomes. And then afterwards, they kicked themselves because people said, well, I thought it was so-and-so. But I didn't say it.
MONTAGNE: The message delivered again and again is that each team member has the potential to change the outcome. It's a concept that Pat Croskerry has spent a lifetime studying. He's an emergency room physician who, from his perch teaching critical thinking at Dalhousie University in Nova Scotia, has published dozens of papers on how doctors think. Some years ago, he coined the term zebra retreat.
PAT CROSKERRY: In medicine, there is that statement when you hear hoof beats, think of horses, not zebras, right? So common things are common. But now and again, uncommon things come along. And it really is a zebra. So what tends to happen sometimes is that physicians back away from the zebra because they don't want to be accused of thinking of esoteric things and losing the big picture.
MONTAGNE: Dr. Croskerry remembers well when he experienced that kind of resistance. It was in the middle of the night in the ER. A woman came in who had given birth a couple of weeks earlier. Her symptoms were vague. She complained of aching from head to toe. The nurses settled quickly on a not-too-far-fetched diagnosis - postpartum depression. But Dr. Croskerry noticed one very unusual symptom.
CROSKERRY: Gradual loss of reflexes as you go from the feet up the body.
MONTAGNE: He thought he'd spotted a true zebra.
CROSKERRY: This was something called Guillain-Barre Syndrome.
MONTAGNE: That's a rare disorder where one's immune system attacks the nerves.
CROSKERRY: And I had never seen it in my life. But, you know, this odd finding did actually fit the diagnosis. So I made a consult to the neurology department and said, I've got a woman here that I'm very worried about. I think she might have Guillain-Barré Syndrome. As soon as I said that, I could hear the person's eyes rolling from the other end of the phone. You know, here's a guy calling me at midnight with a diagnosis of Guillain-Barre Syndrome in a woman who's probably got a postpartum depression. Eventually, reluctantly, they agreed to accept the patient in transfer.
MONTAGNE: Dr. Croskerry turned out to be right, of course.
CROSKERRY: If we'd sent her home, she would have died.
MONTAGNE: One reason California has been so successful is that obstetrics departments across the state are on the alert for zebras, like placenta accreta.
CAYTI KANE: I didn't know what placenta accreta was. I had never even heard of it until I was diagnosed here.
MONTAGNE: When Cayti Kane arrived at Pomona Valley Hospital, she was pregnant with her sixth baby after having to deliver five babies by cesarean section. Yet through all of those pregnancies, she did not know she was at great risk for developing this dangerous complication, placenta accreta. Every C-section makes that more likely because the scar tissue that builds up on the uterus after each surgery can allow a placenta from a new pregnancy to grow through that scar tissue and attach to other organs. That can lead to an out-of-control hemorrhage. Placenta accreta used to be exceedingly rare in the US. In the 1950s, it appeared in one in every 30,000 births. Today, the rate of C-sections is six times what it was 50 years ago. Now 1 in every 3 births is cesarean. And placenta accreta - it now shows up in every 500 births.
KANE: If I had known that this was a possibility, there's no way I would have ever done this.
MONTAGNE: You wouldn't have gotten pregnant again?
KANE: No. No, not a chance - not knowing that I could have lost my life and risked my children losing their mom.
MONTAGNE: Cayti Kane did not expect to deliver at Pomona Valley Hospital. She lives more than an hour away in the high desert of rural Apple Valley. But in her 30th week, she started having contractions.
KANE: I went into preterm labor, so I went to that hospital that I delivered all my other babies at. And my OB was actually out of town, so the on-call OB did not want to touch me because of my five previous C-sections, so they had me transported down here to Pomona.
MONTAGNE: So someone made a really good decision?
KANE: Yes, extremely good decision.
MONTAGNE: And this illustrates one of the positives of the California Collaborative. Smaller hospitals, like the one in Apple Valley, also have clinicians trained and on the alert for trouble. And if they can't handle it themselves, they're ready to send the mother to a hospital that can. At Pomona Valley Hospital, Dr. Rodriguez immediately diagnosed placenta accreta. Two weeks later, Cayti Kane did hemorrhage during her cesarean surgery. But she was surrounded by a team of specialists that included a gynecological oncologist because accreta can spread like a cancer. Cayti Kane named her healthy baby boy Iokua, Hawaiian for God delivers. And looking back, she's still puzzled but has an idea of why, given the high odds of a fatal complication, her own obstetrician cleared her to have a sixth cesarean.
KANE: I mean, he's a high-risk OB, so I know he knows about this. I think he is just such a confident person, such a confident doctor that he was convinced it wouldn't happen.
MONTAGNE: Which brings us back to the philosophy that underpins California's initiative. Tragedy can happen to any mother. And this collaborative is not only saving women from dying. It has also proved that it can bring down the rate of women who nearly die. A study in the American Journal of Obstetrics and Gynecology found hospitals that signed up to implement the toolkits - those lists and carts and drills and teams we just saw in action in Pomona - lowered the rate of severe, life-threatening complications due to hemorrhage by nearly 21 percent. In hospitals that did not participate, the rate dropped by just over 1 percent. As of this summer, nearly all of California's birthing hospitals have joined the Maternal Quality Care Collaborative. They now account for 95 percent of the babies born in that state.
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