Using a mannequin to simulate dangerous scenarios, a team at Pomona Valley
Hospital Medical Center learns standard treatments for obstetric emergencies
Bethany Mollenkof for NPR
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 ProPublicahave 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.
Pomona Valley Hospital Medical Center, a member of the California Maternal
Quality Care Collaborative, is one of the state's largest birthing
centers, delivering over 7,000 babies a year.
Bethany Mollenkof for NPR
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.
"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
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
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 Foundationestimates 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.
Pomona Valley Hospital Medical Center staff run through a hemorrhage drill
with a mannequin.
Credit: Bethany Mollenkof for NPR
"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.
Maria Hellen Rodriguez runs drills at Pomona Valley Hospital Medical Center
to simulate real obstetric emergencies, so standard approaches become
"muscle memory" to hospital staff, she says.
Bethany Mollenkof for NPR
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.
Hospital staff at Pomona Valley Hospital Medical Center review video footage
of an emergency drill performed on a medical mannequin.
Bethany Mollenkof for NPR
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.
Hospital staff at Pomona Valley Hospital Medical Center practice strategies
that can improve outcomes for women who hemorrhage during or after giving birth.
Bethany Mollenkof for NPR
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."
Cayti Kane was diagnosed with placenta accreta, a dangerous complication.
But Pomona Valley Hospital Medical Center was prepared and two weeks later,
Kane delivered a healthy boy via C-section.
Courtesy of Pomona Valley Hospital Medical Center
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
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.
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.