Many Women Come Close To Death In Childbirth
RENEE MONTAGNE, HOST:
It seems every mother has a tale of discovering she was pregnant. Samantha Blackwell was working her way through a master's degree at Cleveland State, and she'd be the first to say her reaction may not be what you'd expect.
SAMANTHA BLACKWELL: I was 25, in really good health. I'd been an athlete all my life. It was not a planned pregnancy.
MONTAGNE: So when you found out, you were excited, even though not planned?
BLACKWELL: Very far from excited.
MONTAGNE: Samantha soon warmed to the prospect of becoming a mother. She had a loving extended family and a boyfriend who would soon become her husband. One thing that never occurred to her - just days after giving birth to a healthy baby boy, she would be in a medically induced coma, fighting a runaway infection, hovering between life and death.
BLACKWELL: To me, it was like I fell asleep at that hospital and woke up the next day kind of thing. Then it was kind of like, holy crap. I just woke up, and it's months later.
MONTAGNE: For the past year, ProPublica's Nina Martin and I have been investigating why American mothers die in childbirth at a far higher rate than mothers in all other developed countries, three times more than in Britain and Canada. This morning, we're going to look at another disturbing statistic. In America, 70 women reach the brink of death for every woman who dies.
PETER BERNSTEIN: It's referred to as the tip of the iceberg because for every woman who we lose, there are lots of other women who we came very close to losing.
MONTAGNE: New York obstetrician Peter Bernstein helps lead the Council on Patient Safety in Women's Health Care.
BERNSTEIN: An experience that we would hope and expect would be natural, beautiful, uplifting experience becomes one that's terrifying. Women can wind up losing their uterus and therefore becoming infertile. They can wind up with kidney problems. They can have heart attacks. They can have brain damage from all the blood that they've lost. So there can be permanent physical consequences.
MONTAGNE: About her ordeal, Samantha Blackwell doesn't remember much. Ten days after giving birth, she sat up in bed with a terrible pain. By the time she got to the emergency room, her medical records show she was in septic shock.
BLACKWELL: They kind of didn't have answers for anybody. They went back and forth between infection, blood poisoning. They just knew that it was bad to a point of expect the worst. We don't know if she's going to come out of this.
MONTAGNE: When Samantha did emerge from her coma, she learned she'd undergone an emergency hysterectomy, a last-ditch effort to stop the infection that had originated there. When bad things do happen, life-threatening things, infection is among the top five complications. They also include blood clots, pregnancy-induced high blood pressure, heart conditions and hemorrhage.
According to the Centers for Disease Control and Prevention, the rate of these potentially fatal complications is rising faster than the rate of maternal deaths. It doubled between 1993 and 2014. And to get a sense of how women are affected, NPR and ProPublica launched an online call-out. The stories of catastrophic complications poured in, nearly 4,000 in all, among them, Alicia Nichols.
She and her husband had been trying hard to have a baby. At 39, Alicia finally succeeded in getting pregnant through in vitro fertilization. She gave birth last March just after she turned 40.
ALICIA NICHOLS: You like when Daddy picks you up, huh? And Mommy picks you up?
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MONTAGNE: We joined her and baby Diana at their home in Needham, Mass., outside of Boston, in a spacious room now devoted to stuffed animals and toys.
NICHOLS: Be careful. I can't guarantee you might not step on a block.
MONTAGNE: There, Alicia looked back at an easy pregnancy, a story we heard over and over again. In her case, that ended when her 42-hour labor led to an emergency caesarian.
NICHOLS: The healing was uneventful. I actually healed quite nicely.
MONTAGNE: Until about four weeks later, when she felt a gush of blood.
NICHOLS: My first reaction was call 911.
MONTAGNE: In the ER, Alicia remembers the nurses as compassionate but a cool reception from the resident who came over from the obstetrics department, who chalked it up to natural postpartum bleeding.
NICHOLS: And when I had asked about doing some sort of scan or ultrasound, she said, we feel it's not necessary to do that, if we start, she said, messing around in there. But it came across as, if we start doing these tests, it could lead to multiple unnecessary testing. And then, one of the nurses standing there said, I just think they want you home with your baby.
MONTAGNE: Over the next few weeks, both in an office visit and phone calls, her obstetrician assured Alicia that her bleeding every few days was most likely the beginning of her menstrual period, even as Alicia pointed out to her doctor...
NICHOLS: I had no cramping. There was nothing. It was just bright-red blood. And we all know. We're women. I don't want to be graphic, but we know it's different.
MONTAGNE: And that difference became quite clear eight weeks postpartum, when just before dawn, Alicia experienced a much bigger bleed. This time, she called her doctor and insisted on coming into his office that very morning.
NICHOLS: And I got on the elevator. And the minute the elevator door opened, that's when I began to hemorrhage.
MONTAGNE: She managed to get the 10 feet down the hall to her doctor's door.
NICHOLS: I remember I had really tight sweatpants on that day. Thank God. It kind of helps keep everything in. I think the nurse was a little shocked. She was oh, honey, didn't I tell you to bring a different pair of pants with you? I said no. This is serious. You need to get the doctor. And she said, he's in with somebody else. I said, get him out here.
MONTAGNE: And at the sight of her, her doctor quickly called an ambulance and alerted the hospital that she would soon be on her way.
NICHOLS: I remember putting my hand down. And when I lifted up my hand, it was just - my whole left hand and my wedding - I remember seeing my wedding ring, just blood. Just my hand - my left hand was soaked with blood. It was just, the wall, on me. It was just everywhere.
MONTAGNE: According to Alicia's medical records, she lost nearly half the blood in her body. As a last resort, as with Samantha, doctors performed an emergency hysterectomy. In an addendum to her records, 24 hours later, her obstetrician stuck with his original theory about her bleeding. Quote, "patient came to office with onset of first period that seemed heavier than average," and he added, "suddenly hemorrhaged." In fact, a pathologist's report found an entirely different cause for the bleeding.
Enlarged blood vessels in the lining of her uterus, which had sent nutrition and oxygen to her growing baby, failed to return to their pre-pregnancy size and instead bled into Alicia's uterus. Though rare, it could've been detected earlier with a scan and treated before it became a life-threatening hemorrhage.
Alicia's case highlights how complications can get out of control. Dr. Elliott Main, a national leader in maternal health reform, says because most mothers will do fine on their own, obstetricians and nurses strongly tend towards expecting the best and not the worst.
ELLIOTT MAIN: That sets up the opportunity for what we call the twin demons of denial and delay - denial that it's actually something serious, and that leading to delay before you get the care that's going to make the difference.
MONTAGNE: And though these life-threatening complications are not common in the U.S., they add up to 50,000 mothers each year, according to the CDC. The patient safety group the Alliance for Innovation on Maternal Health did a more in-depth study of hospitals in several states and came up with a higher number, about 80,000 women a year. Bringing those numbers down would not only spare thousands of women from nearly dying, but it would also bring down the cost of health care, points out Dr. Barbara Levy. She oversees health policy at the American College of Obstetricians and Gynecologists.
BARBARA LEVY: Severe morbidity is expensive. ICU care is expensive. Transfusions are expensive. Dialysis is expensive. And we can actually save money by putting processes in place that reduce risk.
MONTAGNE: Samantha Blackwell's long hospital stay, rehab and home care soared to nearly $540,000, covered mostly by her mother's insurance, except for a helicopter ambulance that carried her to a bigger hospital.
BLACKWELL: I'm still actually fighting the life flight bill. The insurance covered all the medical attention I got while on the life flight, but the actual flight was over $30,000 for a 15-minute flight that, technically, I was not conscious to make the decision to send me on. I mean, I wouldn't put a price on my life. I'm glad that they flew me. But $30,000 dollars is - that's another car.
MONTAGNE: Alicia Nichols measures her costs by what it would take to have another baby via a surrogate, around $80,000. No single study has tallied the total cost of America's high rate of severe complications, but there are clues that it runs into the billions. A report in the American Journal of Obstetrics and Gynecology found the cost of caring for mothers suffering from pre-eclampsia - that's pregnancy-induced high blood pressure - is more than a billion dollars each year.
The federal Agency for Healthcare Research and Quality has put a dollar figure on the thousands of hysterectomies related to childbirth complications - $95,000 each. And then, of course, there is the human cost.
NICHOLS: I have a lot of anger. I do. I know that my obstetrician feels terrible that things went this way, but it just makes me so angry, you know, because I know I'm not the only one. There's so many women out there.
MONTAGNE: And Alicia Nichols' troubles did not end with one massive hemorrhage. Days later, she was feeling dizzy. Even her family tried to reassure that nothing was wrong. But this time, she sought help immediately. A CT scan revealed blood clots in her lungs, a pulmonary embolism that could have killed her. She's now being treated for post-traumatic stress disorder, PTSD. And Alicia is among hundreds of women we heard from who describe their trauma as hard to shake.
NICHOLS: It's funny. I remember speaking with a critical care pulmonologist. And I was sort of having a pity party and just devastated. And I said, I'm just so unlucky. And he said, no, you should go buy a lottery ticket because you shouldn't be alive right now.
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MONTAGNE: There are positive changes being made. And in our NPR-ProPublica series, I'll be looking into how California has managed to dramatically lower the numbers of mothers dying and nearly dying from giving birth.
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