By Ina May Gaskin, CPM, MA
Originally published by Journal of Perinatal Education, 2005-08-04
When a woman is discharged from a hospital after giving birth and later dies from causes directly related to her birth or the care she got, she may be die in a different hospital or in a different part of the hospital than the maternity ward. This is what happened to Lara Nuerge Schultz, of Perryopolis, Pennsylvania, who died of a pulmonary embolism in an Ohio hospital nearly a month after the cesarean birth of her first child in 2000. It is very possible that her death was not recorded as pregnancy-related, since the death certificate in Ohio did not include a checkbox asking if the deceased person had been pregnant within the year preceding her death. Could her death have been prevented? Almost certainly, it could have been. Lara’s mother-in-law, a nurse, had already noticed that Lara was limping three weeks after her surgery. She examined her, and urged her to go right to an emergency room. Lara didn’t believe anything could be wrong. Both her mother-in-law and husband begged her not to take a long automobile trip with other family members to visit an elderly relative in Indiana. If she had had better patient education and follow-up care after her discharge from the hospital, her problem might have been detected earlier and in a way that she would have taken seriously.
Thirty-six-year-old Virginia Wanjiru Njoroge had boy and girl twins by cesarean at a Kansas City hospital on October 23, 2007. A recent immigrant from Kenya, she was discharged from the hospital and went home to her apartment in a Kansas City suburb. With the babies’ father still in Kenya, she was alone in caring for herself and her babies. Three weeks later a neighbor noticed an unpleasant odor coming from the apartment and notified police. Emergency workers found Virginia’s badly decomposed body on the bed. They reported that they might have missed her babies, had it not been for a weak cry they heard when they accidentally bumped the bed. The babies had somehow moved from the bed until they wedged between the wall and the bed. The girl died later at the hospital, but Virginia’s boy survived and was sent to Kenya to be raised by extended family.
We’ve had clues for years that the United States has problems in the area of reporting on mistakes made in hospitals. In 1999, the National Institutes of Health (NIH) issued a report to the media that approximately 100,000 deaths per year take place in U.S. hospitals because of medical errors. (Charatan, 1999) That’s one third of the population of Iceland per year. The NIH report called for health-care providers to be required to inform state governments of any medical errors leading to serious harm. At that time, only 20 states had such reporting requirements, and just 5 more states have joined the mandatory reporting group in the nine years since, leaving half of the states with no such requirements. (Rosenthal, Riley, & Booth; see below) That report did provide the insight to anyone who read it carefully that mandatory reporting about medical errors has never been carried out on the federal level in the United States. In a survey that followed the NIH report, 60% of patients thought that mandatory reporting of medical errors through a national agency was a good idea, while only 32% of doctors thought so. (Tanne, 2002)
If medical errors are to be prevented in maternity care, one of the essential ingredients of a nation’s care system is a nationally mandated and funded way to accurately collect data on the number of pregnancy-related deaths that occur in any given year. The maternal mortality rate—along with life expectancy and the neonatal mortality rate is one of the vital measures of any health care system—one which must be monitored from year to year. Ideally, of course, the maternal mortality rate should be reduced every year as physicians, midwives, and nurses learn from past mistakes how to make pregnancy and birth safer. Such reduction can only be expected when the past mistakes are noted, analyzed, and appropriate recommendations are fed back to healthcare providers and to the public.
The NIH report sparked a national debate on the reporting of medical errors, but the only legislation stemming so far from the report was a 2005 law which made hospital reporting of errors voluntary. They made a law for this? That’s like looking at your dog sitting in front of you and yelling at him, “Sit!!” Significantly, the debate surrounding the issue of the shocking number of medical errors never touch on a question that should have been asked: how many of the medical errors uncovered by NIH happened in maternity wards?
