Medical teams in hospitals caused nearly 158,000 avoidable injuries to new moms and their babies during childbirth in 2006, according to a new federal report that should be an eye opener for any health provider.
Not only do these tragic mishaps cause disability and anguish for patients, they add costly legal bills and extra days of expensive care that will never be fully reimbursed.
"Delivery of newborns (is) the most common reason for hospitalization," noted the Agency for Healthcare Research and Quality's report, which encourages providers to scrutinize their practices to better understand the reasons for such complications.
"Identifying which types of patient safety problems exist for different sub-groups of patients is an important first step in developing interventions to reduce disparities and achieve high quality of care for all patients," the report added.
The report was based on data submitted for 15 million discharges by 1,900 hospitals in 25 states, including the largest, California, Texas, New York, and Florida.
Against this backdrop of worrisome statistics, the report actually contained some good news.
Between 2000 and 2006, the rate of potentially avoidable injuries to women while giving birth vaginally without the use of instruments such as forceps declined 30%. For mothers whose babies were delivered vaginally with the use of instruments, injuries declined 21.3%. For mothers having a cesarean delivery, injuries declined 16.7%.
The report, however, doesn't explain what factors might have dropped the rates of injuries and study author Roxanne Andrews of AHRQ says it's an area for future study.
"It is possible that medical knowledge and practice has improved," she speculates. However, she quickly cautions a new study suggests improvements may not extend to the most serious maternal complications, which may have increased since 1998.
The report detailed the actual rates of injury, which were higher when instruments were used. For example, trauma to the mother during vaginal delivery occurred 160.5 times per 1,000 discharges when instruments were used, but only 36.2 times when instruments were not used. Obstetric trauma to mothers undergoing cesarean delivery occurred 3.9 times per 1,000 discharges. Injuries to the mother were most commonly perineum tears, which are usually preventable, the report said.
For the newborn, traumatic injury during childbirth occurred 1.6 times per 1,000 discharges. Injuries included broken collarbones, infections, and head injuries, many of which are very serious and sometimes debilitating and fatal.
The rest of the report was discouraging for the wide array of care disparities it disclosed for patients in wealthy versus poor communities, source of hospital payment, age, area of residence, race, and sex of the mom and infant. In many cases, the results were a surprise and counterintuitive.
For example, women giving birth who lived in the highest income communities suffered 44% more obstetric injuries during vaginal delivery than those from the poorest communities. And black and Hispanic mothers experienced fewer child-birth related injuries than whites. Asian-American and Pacific Islander mothers had the highest rate of injuries.
Mothers covered by Medicaid were far less likely to be injured while giving birth, 127 injuries per 1,000 deliveries, than women who had private health insurance, who incurred 185 injuries.
But injury rates for babies covered by Medicaid were higher than for those with private insurance, (1.7 compared to 1.5) the report said.
Injuries to babies also varied widely by geographic region, with those born in rural areas and the Northeast having 2 injuries per 1,000 deliveries versus those born in the West, 1.4, and those born in large metropolitan areas, 1.5.
White babies were injured more often (1.9 babies per 1,000) than babies in other racial groups (1.4 to 1.5 per 1,000 births.)
Hospital officials also couldn't explain some of the report's statistics. At Sharp Mary Birch Hospital for Women in San Diego, the hospital that delivers more babies than any other in California, 8,698 infants last year, Mary Henrikson, senior vice president and CEO, offered a few guesses.
For starters, rates of injury might be worse in hospitals "where you don't have 24/7 obstetrician coverage" in case complications arise. "Or maybe you have a physician using forceps who has never really gotten the technique," she says.
Henrikson says a hospital should own the responsibility for tracking down its own statistics so it can compare the facility with other hospitals and discover any potential problems.
"You've got to know the issues and know what you need to do to fix them," Henrikson says. "You need to know what's expected for your population, and if those numbers don't look right, start pulling those cases and look for trends, either with individual practitioners or with certain types of technology," she says.
"You may have started using a new type of vacuum extractor and the rates (of injuries) go up. If that's the only variable introduced in the situation, you may have to relook at what you buy to use," she adds.
An attorney who has won big money awards against hospitals in birth litigation also weighed in on the issue. Brian McKeen, former co-chair of the birth trauma litigation group for the American Association of Justice, was asked what he would do to lower obstetrical complications if he were a hospital CEO.
First and foremost, he says, he'd limit or stop allowing "young inexperienced doctors, some of them still in training" to be left alone when delivering a baby. "They don't always appreciate manifestations of fetal distress on the monitor and they don't always know that things are going awry," he says.
"In community hospitals, there's a pattern I see over and over again. The attending physician seems to think their role is to come in and catch the baby, and allow the nurses to oversee the management of labor and delivery," he adds.
Nurses also should be better educated, he says.
Most of all, however, is what he calls a failure of hospitals to perform appropriate introspective analysis of a case that went bad. "They should take these failures as a teaching opportunity to explain to the staff how they should be avoided."
Another issue that has brought lawsuits is what he describes as a failure of hospital staff to follow or even have appropriate chains of command when a patient's labor becomes troublesome. This could include "a chain of command that's regarded as hypothetical gobbledegook that's not really practiced in the real world. To the extent staff knows that there is one, they don't have a good understanding of when to invoke it or what steps are in the chain," he says.
Years ago, hospitals allowed physicians to rush to cesarean sections, sometimes for their own scheduling convenience. These days, he says doctors seem to want to avoid cesarean sections even when they're indicated, in part, because of a perception that they're associated with increased cost for the hospital and because now many hospitals are advertising their low c-section rates as a marketing tool, he adds.
"Have we gone too far the other way? Yes," McKeen says.