Maternal Mortalities are Often Caused by Systems Problems
Joseph Goldstein, a reporter for the New York Times, wrote a story about Christine Fields. She was a 30-year-old woman who died at Woodhull Hospital in Brooklyn, New York, a few hours after her emergency C-section for “fetal distress.” According to state investigators, the death was caused by a “doctor’s mistake.” Joseph Goldstein added that this death of Christine Fields occurred not long after the death of a 26-year-old first time mother who died during a botched epidural and intubation in the same hospital.
Apparently, in the earlier death, the woman stopped breathing during her epidural and the anesthesiologist intubated her esophagus rather than her windpipe. Rather than delivering oxygen to her lungs, the apparatus deprived her of what air she might have been getting. Certainly there is doctor error here, but is it just doctor error?
From what I can gather by reading Joseph Goldstein’s New York Times article, investigators with the New York State Department of Health (NYSDH) fail to understand the full nature of the problems. Furthermore, they are unable to discern the most practical and safest solution.
Since the investigators are a legal state body, they are required to make decisions which conform to the state laws. These law choices are similar to having to choose a diagnosis from an electronic medical record which offers a variety of diagnoses that don’t really cover the situation at hand.
With the information available in Joseph Goldstein’s article, it is hard to determine if the NYSDH investigators understood the many ramifications of the information they were getting. The investigators labeled the problem with these maternal deaths as a lack of communication, a violation of communication rules. What isn’t reported by the state investigators is that this violation is a symptom of much larger systems problems. The investigators found no written evidence in Christine Fields’ medical records to indicate any problems. This doesn’t mean there was no verbal communication about the case, but this information is missing from the record. In reality, the current healthcare love affair with electronic medical records means many busy caretakers can either write about the problem or actually take care of the problem.
The NYSDH investigators’ goal was to dig up someone they could blame and punish. This narrows their vision drastically, causing them to not only miss layers of real problems, but also to miss the opportunity to repair the real, underlying problems, which allows the same problems to arise again and again at a later date.
It is easy to blame doctors, but one doctor is usually unable to fix the bigger picture problem, the systems problem. This requires attention from the hospital administration. When systems problems are left unaddressed, the results of these problems such as the maternal deaths reported by Joseph Goldstein tend to recur.
Who is responsible for these deaths? In the earlier maternal mortality referred to by Joseph Goldstein in his article, the anesthesia department was responsible. With Christine Fields, the obstetrics department was responsible. But these deaths are also the responsibility of the chief of staff, the person responsible for both of the anesthesia and the obstetrics departments. In addition, the hospital Chief Executive Officer (CEO) should be held accountable for leaving the systems problems unaddressed. The hospital board is also accountable for the systems problems because the hospital board employs the CEO. In addition, the state is responsible for holding the local hospital boards accountable, although we rarely see this.
The hospital did fire the doctor who lacerated Christine Fields’ uterine artery. Granted, the uterine artery should not have been lacerated by the surgeon, but the bigger problem was sending the patient out of the operating room without repairing the laceration. Surgeons doing C-sections should never end their surgeries and send the patient out of the operating room before the bleeding is under control.
There are layers and layers of failed responsibilities in the care of these two patients. What the state should bear in mind is how to repair all the elements which caused the problem, not single out a single player for punishment.
As an obstetrician who has been-there done-that for 45 years, this entire situation begs the first question, was the C-section really indicated? That is an important issue for appropriately reviewing this case and placing it into some kind of context. Was there really fetal distress indicating the need for an emergency C-section? We know that the use of a fetal monitor results in an increase in C-sections for presumed “fetal distress.” Does this apply to this baby? What were the APGARS? How was the labor? All of this information should be available to the NYSDH. Was it?
There are many layers of responsibility in these two maternal deaths, layers which did not work very well. Certainly, the obstetrics department should make sure that all of the doctors can do a reasonable C-section and that they have reasonable judgment.
According to the NYSDH, the lack of communication between the surgical team and the doctor doing the surgery and the doctor who was supposedly taking care of the patient post operatively is the one legal or punishable problem they can site. This leaves unaddressed the many communication problems on many levels from the top down. The doctor who has done the surgery ought to be the doctor who stays with the patient postoperatively and must be certain that the patient is doing well. This isn’t a communications problem. It’s a systems problem. The hospital communication procedures need to be clearly outlined and enforced to ensure the safety of the patient.
Fragmentation of care associated with disconnected team members does not serve the public well because shared responsibility is confusing and not direct. For the best patient outcomes, physicians need to own their care and feel personally responsible for the good outcome and ultimate welfare of their patients. I’ve written before about how the kind of communication problems such as Dismissiveness leads to the death of babies. In Centers of Excellence , the government has funded hospitals to collect data, but does this really save the lives of women?
Maternal mortality is the canary in the coal mine. According to the Center for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), for every death, there are 30 to 50 near deaths or cases of physical harm to patients. And if you want to drill down on this a little bit more, for every severe maternal morbidity, there are unknown dozens of lesser injuries which never make it into a patient chart.
So, the solution to this problem lies not in firing one doctor or finding one federal or state mandate that satisfies the definition of a legal violation. The solution is to fix the systems problems from top down and that needs to begin immediately.
In Joseph Goldstein’s article, if top down problem-solving had been implemented at the time of the mother’s death in 2020, there would likely have been no subsequent maternal mortality. Problem solving is exactly where we must be. Blaming doesn’t help because the wheels of quality assurance appear to move, but they often go nowhere.