Kristin Marlowe was seven months pregnant and admitted for a small placental tear at Mercy Hospital in Springfield, Mo., when she began to complain of a headache. An hour later, she stopped breathing. Strong, healthy and only 20 years old — she died of a stroke.
Her son, Trennon, was delivered by emergency C-section and survived.
“We knew we were going to spend our life together,” said her husband, Nick Marlowe, 22, still reeling from her death last August. “I can tell you right now, if it wasn’t for my kid, I wouldn’t be here.”
The hospital staff is also struggling for answers. Doctors are unsure how a young woman with no risks or obvious signs quickly took such a tragic turn. “How did this happen?” said obstetrics director Dr. David Redfern. “Why did this happen?’
The maternal death rate in the U.S. is creeping upward — to more than double what it was 25 years ago. Systems identifying deaths have improved, so how much the increase can be attributed to risk is uncertain. But experts agree maternal deaths are no longer declining, are underestimated, largely preventable and disproportionately affect certain groups.
“We have not seen a decrease in maternal mortality, and that is worrisome,” said Dr. George Saade, director of maternal-fetal medicine at University of Texas Medical Branch. He said black women were three to four times more likely than white women to die from pregnancy. “These two things are very concerning, particularly in a developed country like the U.S.”
The 20th century saw a dramatic decrease in pregnancy-related deaths, largely because of improvements in sterile techniques — reaching the lowest point in 1987 at 7.2 deaths per 100,000 live births. The most recent figures available show the rate hovers around 15 deaths per 100,000 births — placing the U.S. near the bottom among developed nations.
More coverage of childbirth
The rate of severe complications during and after delivery have also doubled in the last decade, according to a 2012 federal study. Near-misses, where a woman nearly dies, increased by 27 percent.
That means each year in the U.S., about 700 women die of pregnancy-related complications and 52,000 experience emergencies such as acute renal failure, shock, respiratory distress, aneurysms and heart surgery. An additional 34,000 barely avoid death.
The nation’s largest health care accrediting organization, the Joint Commission, warned hospitals three years ago about maternal deaths. Hospitals have since worked to identify risks and respond to emergencies. But experts say more needs to done to improve education, research and guidelines for care — much like the efforts that have improved outcomes for premature babies.
Researchers call it putting the “M” back in maternal-fetal medicine.
Redfern said reviewing Kristin Marlowe’s case alone provided little insight. Cases need to be compared across the state and nation.
“How many pregnant women come in the hospital and complain of a headache? That number is sky high. And how many have a stroke that ends their life? That number is very small,” Redfern said. “What information can we gain from this to prevent this from happening? That is the bottom line. We need to do what is necessary to keep this from happening again.”
After she complained of a headache, Kristin was given a narcotic for the pain. Over the next hour, Nick Marlowe said, she complained of numbness starting in her toes, spreading up her legs and to her neck. She struggled to swallow.
“I kept asking, ‘Why is she going numb? Why does her head still hurt?’ ” he said.
Numbness can be caused by the narcotic she was given, Redfern said. She was not bleeding. Her blood pressure was normal. The persistent headache was a concern, though, and a doctor had just ordered a CT scan when she suddenly turned blue, and her heart stopped.
Marlowe watched his wife slip away as they rushed her to the operating room. “I freaked out, and dropped to my knees and started screaming and praying,” he said.
Doctors are unsure what caused her stroke. Typically, a clot breaks off from somewhere in the body and blocks a main blood vessel to the brain. But in her case, the scattered brain injuries did not fit the pattern of a clot, Redfern said.
She was so sweet, Nick Marlowe said. A polite Southern girl, she was in church every Sunday. “She was the best thing that ever happened to me,” he said.
When he looks at Trennon, he sees Kristin’s deep blue eyes. “I think about having to tell him what happened,” Marlowe said. “How am I going to do it? When am I going to do it? Someday he’s going say, ‘Why does everyone at school have a mommy? Where is my mommy?’ ”
RISK FACTORS CAN PILE UP
As someone with Type 1 diabetes, Nicole McLeroy got thorough counseling about the risks of getting pregnant. Her disease could worsen, disabling her with nerve damage or kidney failure. She could have a stillbirth or a baby with a birth defect.
“They told me all the risks that could be involved,” said McLeroy, 33, of Belleville. “It really scared me.”
So when she got pregnant with her baby, now 4 months old, she traveled across the river to the Barnes-Jewish Hospital high-risk clinic for her prenatal care. “I knew I had to really stay on my A-game through nine months,” McLeroy said.
Studies show that maternal deaths and severe complications can largely be prevented with changes in health behaviors and quality of care. Doctors say pregnancy has become increasingly risky for several reasons: the prevalence of obesity, Type 2 diabetes, hypertension and cardiovascular disease; more older women having children; advancements in fertility treatments resulting in twin births; and the high rate of C-sections.
“All of those things put together are causing what seemingly was a downward-going problem to tick back up,” said Dr. Michael Nelson, vice chairman of obstetrics at Washington University School of Medicine. “Even though the absolute risk of having a mortality from one complication is very low, many women have multiple conditions.”
The leading causes of pregnancy-related deaths are changing. When the Centers for Disease Control and Prevention began in 1987 taking a closer look at maternal deaths, hemorrhage was blamed for more than one in four. Now it’s diseases of the heart and blood vessels.
Deaths from stroke are also on the rise. A recent CDC study shows pregnancy-related strokes increased by 50 percent in 2006-2007, compared with 1994-1996.
Experts are calling for more research on how chronic conditions are best managed during pregnancy and how to identify and respond to complications.
“Pregnancy has a lot of symptoms that go along with it which are normal,” said Dr. William Callaghan, director of the CDC’s maternal and infant health branch. “But how do we discriminate the normal shortness of breath from the shortness of breath that comes with an impending blood clot or impending heart attack?”
Researchers and high-risk pregnancy specialists say an important step is stratifying maternity care, parallel to what has been adopted in the care of high-risk newborns. Higher-level hospitals would have the specialists and infrastructure needed to take care of complex cases, help institute guidelines to improve care, and consult with lower-level hospitals. The approach allows for comparisons of outcomes and a more efficient use of resources.
“You have hospitals building these high-level NICUs to get these preemies, but they don’t spend the same resources on the maternal side,” Saade said.
Saade and his team published a commentary last fall in the Obstetrics & Gynecology journal calling for stratification, arguing that hospitals often transfer a woman only because they are unable to provide care for her baby.
“Most of the time no one is asking, ‘Can that other hospital care for the mother?’ That’s why we wrote this commentary. To me it was shocking and amazing,” Saade said. “We say, ‘We are going to send you here because they can take care of the baby.’ But almost half the time, the baby is premature or early because the mother is sick. Often, the mother needs as much attention as the baby or even more.”
McLeroy’s pregnancy was closely watched. She started with an electrocardiogram to test the strength of her heart. She worked with a nutritionist. Her kidney function, insulin resistance and the size of her baby were routinely tested. Her weekly prenatal appointments became semiweekly as she neared her due date.
Her delivery required the same attention. Her blood pressure increased during labor, requiring a risky medication to control it and prevent seizures. She needed a C-section. After the operation, her blood sugar shot up, placing her in danger of organ failure or even coma. She stayed six days in the hospital.
High-risk specialists say counseling women about risks before getting pregnant, much like the warnings McLeroy received, is also key in improving outcomes — especially because half of pregnancies are unplanned.
“We aren’t doing well enough, there’s no question about that,” Nelson said. “We aren’t educating and giving our population preconception counseling and conditioning for optimal pregnancy outcomes.”
TRAINING, PREVENTION ARE KEY
Lucy Richards gave birth about an hour ago. Her labor was induced and she had a large baby, both risk factors for hemorrhage — massive bleeding accounting for about 12 percent of maternal deaths.
Lucy is a high-tech simulator. The lifelike mannequin can deliver a baby with an umbilical cord and placenta. She bleeds, has vital signs and takes needles. She is controlled and given a voice by operators in a nearby room, filming how trainees care for her.
A group of students at the Goldfarb School of Nursing at Barnes-Jewish College noticed her sheets soaked in blood. They inserted a catheter, gave her oxygen and constantly massaged her uterus to help it contract — while also dealing with family members and her questions and fears. The team gave Lucy the wrong dose of a medication.
“This is good practice,” said assistant professor Katherine Hufker, “so we can make mistakes in practice and not in real life.”
Using emergency simulations is one of many things St. Louis-area hospital officials say they are doing to better care for a riskier population of pregnant women.
Other efforts include in-depth reviews of cases; improving communication; educating staff about risk factors and signs of trouble; and instituting strict rules on labor inductions.
Patients must wear compression socks during C-sections to help prevent blood clots. Each room has “hemorrhage carts” with all the necessary supplies at the ready.
“Is risk acutely higher? Yes. And is our attention to safety higher? Absolutely,” said Mercy’s vice president of women’s services, Dr. Marc Gunter.
A year ago, Mercy Hospital St. Louis hired round-the-clock laborists — obstetricians who only deliver babies. They work with the nurses, private physicians and medical residents, and participate in twice-daily safety rounds. “It adds another level of safety,” said the chair of obstetrics, Dr. Octavio Chirino.
Barnes-Jewish Hospital launched last November the region’s first maternal-fetal transport service that staffs the helicopter or ambulance with obstetric and pediatric nurses.
At Missouri Baptist Medical Center, pregnant women experiencing risky complications stay in intensive care adjacent to labor and delivery, should conditions rapidly worsen, said obstetrics chief Dr. David Weinstein.
St. Mary’s Health Center has a no-weight-gain program for obese patients, with a nutritionist and diabetes educator. “Through an aggressive approach, we can keep weight gain down and reduce C-sections and improve neonatal outcomes,” said maternal-fetal medicine director Dr. Gilad Gross.
Yet, hospitals can do more to rein in “rogue doctors” who are not following the latest safety evidence, said Dr. George Macones, obstetrics chairman at Barnes-Jewish. Examples include not offering flu shots, administering antibiotics too late during C-sections and improperly giving medications to women who suspect they are having preterm contractions.
“I’m going to lay major responsibility on hospitals to educate physicians on guidelines and protocols …,” Macones said. “Hospitals are somewhat reluctant to do that because they are afraid of making doctors angry.”
What hospitals can also do, many say, is promote spontaneous, vaginal births — the safest for mothers and babies. One procedure or drug increases the risk for another, often causing a cascade of interventions that ends with a C-section.
The surgery carries risk as well as increasing the chances for having an ectopic pregnancy or life-threatening problems with the placenta in later pregnancies. In the U.S., the C-section rate has skyrocketed to 33 percent of all births. The World Health Organization says it should be closer to 15 percent.
“We don’t want to turn a natural thing into a high-risk condition for a low-risk population,” Nelson said.
St. Mary’s officials say they are considering using nurse midwives, advanced nurses trained to promote natural birth. Their low-tech approach has been shown to reduce C-section rates and improve other health outcomes. Mercy St. Louis is also considering opening an adjacent birth center staffed by midwives.
At the nursing college, the students also responded to another simulation — a normal birth. “They need to know what that looks like too,” said instructor Gale Bunt.
SHARING DATA BUILDS ON SUCCESS
Recordia Kennedy chose to spend her baby’s first birthday with cake and balloons in a Barnes-Jewish Hospital meeting room. The party guests were doctors and nurses.
“This is the best present I could’ve thought of, to have everyone here who saved my life,” said Kennedy, 42, of St. Louis. “You guys worked a miracle.”
During labor, Kennedy suffered one of the least understood and catastrophic complications of pregnancy: an amniotic fluid embolism. Most women don’t survive. Most who do have brain damage.
She survived because the chief of obstetric anesthesiology happened to take an interest in the rare complication. Dr. Barbara Leighton pored through stacks of animal studies and came up with a potential life-saving cocktail of drugs. And the cocktail worked.
Kennedy’s survival shows a need to understand the causes and treatments of potentially catastrophic maternal conditions.
Kennedy was nearing the end of her labor when she complained of chest pain. Within seconds, her heart stopped.
Amniotic fluid had entered her bloodstream, producing a rapid, allergic-like reaction that causes the heart and lungs to fail. Her baby was delivered by forceps. For nearly 45 minutes, nurses and doctors worked to revive Kennedy.
Nurse Dan Parmeley remembered the list of drugs to try in case of an embolism, which Leighton had posted in the operating rooms. Within seconds of getting the drugs, Kennedy’s pulse returned. “These are four generally safe drugs, but they are not what you usually give in a cardiac arrest,” Leighton said. “You would just think, ‘Wow, that’s a weird combination of drugs.’ It’s not in any protocols.”
Leighton plans to present the case later this month at the annual meeting of anesthesia professionals and hopes to get her research published, but that can take months.
The key to improving safety and quickly sharing findings such as Leighton’s, experts say, are statewide maternal mortality review committees made up of key players in prenatal, childbirth and postpartum care.
Ideally, committees would regularly review deaths to gain insight on warning signs, prevention and treatments. Addressing severe complications and near-misses would also help identify gaps in care.
Callaghan at the CDC calls state mortality review committees the “Rolls-Royce” in collecting accurate data. Changes could be implemented statewide.
Missouri created its Pregnancy Associated Mortality Review Committee two years ago to determine the number of pregnancy-related deaths over the past 10 years.
The Illinois Maternal Morality Review Committee has been cited as an example for other states to follow. The committee was formed in 2000 to review deaths in-depth. By 2007, the committee determined hemorrhage was the leading cause, prompting a state requirement that every doctor and nurse working in hospital obstetrics complete a hemorrhage education program.
Many states, however, lack the resources for such efforts. Federal legislation proposed two years ago to beef up state maternal mortality committees stalled.
But Callaghan says the alarm has sounded. “Nationally, there is a bigger effort around improving care than there ever has been before” by government, doctors groups and researchers, he said.
Before Kennedy opened birthday gifts from the staff, she asked a question that silenced the room. She wanted to know more about what happened to her and whether it had happened before.
Someone somberly answered that it had happened before. Although not often. And not with the same results.