“I told them, and they just kept sewing,” she said.
To stem the bleeding, doctors placed gauze in her vagina — but didn’t follow standard protocol. They didn’t tell her about the gauze. They didn’t leave a piece of it hanging out of the vagina or put a bracelet on her to alert staff of the situation. And they didn’t attach a catheter to let urine pass. Unaware of the gauze, nurses downplayed her complaints. After about five hours of pain, someone realized what happened and attached a catheter.
“It hurt like hell,” said Toliver. “It was careless, but by that point it didn’t really surprise me.”
All three women are African-American. All three live in central Brooklyn. Many mothers from different backgrounds similarly complain about callous treatment during childbirth. But disregard for patient choice and patient safety appears to be more rampant and more deadly in the poorest black neighborhoods in New York City, like where Hines, McKnight and Toliver live. And in those communities, women often have more health problems, and hospitals have a narrower margin for error.
According to one recent study, New York City hospitals that mainly serve African-American expectant mothers have severe complication rates two-and-a-half times higher than those that mainly serve white mothers, even after you factor in patient complexities.
And data obtained from the New York State Health Department show that four of the five large hospitals in the state with the highest rates of severe hemorrhage — an especially important childbirth complication — are in central Brooklyn: SUNY Downstate Medical Center, Kings County Hospital, Brooklyn Hospital Center and Wyckoff Heights Medical Center.
These hospitals -- almost all of which declined to comment on their complication rates -- are set in communities with high rates of diabetes, hypertension, heart disease and asthma, chronic illnesses that increase the risk of potentially fatal childbirth complications.
In New York City, African-American women are 12 times more likely to diebefore, during and after childbirth than white women — a gap almost four times wider than the country as a whole. Overall, the numbers are relatively small — about 700 each year nationally and 30 locally — but per capita they’re higher than any other developed nation.
And for every woman who dies, about 100 come close. Annually, about 60,000 women nation-wide and and about 2,700 in the city face life-threatening childbirth complications such as hemorrhage, blood clots and organ failure.
Nationally, the rate of these increased from 74 to 163 per 10,000 deliveries between 1998 and 2011. In New York City, things are much worse. A recent Health Department report found the local complication rate climbing from 197 to 253 between 2008 and 2012.
And in the largely African-American communities of Brooklyn, the climb is higher still: to 400 per 10,000 in Canarsie, East New York and Bed-Stuy, and all the way to 500 in Brownsville and East Flatbush
Poverty and the health problems that go with it account for only part of these high complication rates. Even when black women have relatively high incomes and education levels, and even when they don’t have underlying conditions, they’re still much more likely to risk death when they deliver babies.
“Black women with a college education have a higher [complication] rate than white women without a high school degree,” said Assistant Commissioner Deborah Kaplan, who oversaw the Health Department study. “We believe a lot of this is a story of structural racism and the impact that the color of your skin has on how you are treated, what access you have and where you live, regardless of your socio-economic status.”
Kaplan and her staff are the first to look at severe childbirth complications at the city level, using a monitoring system developed by the federal Centers for Disease Control and Prevention. Their study examined racial, economic and other associations. To figure out what’s happening specifically in hospitals, Dr. Elizabeth Howell applied the same CDC tool to 40 of them in New York City, analyzing around 354,000 childbirth records over three years.
Howell, a researcher at the Icahn School of Medicine at Mount Sinai, found severe complications in 12 percent of deliveries at the least safe hospital and around 1 percent at the safest. After accounting for the sickness of the patient population each one serves, she still found a six-fold gap — .8 percent at the low end and 5.7 percent at the high end.
“We think of pregnant women — they go in, they have their delivery, and they bounce back,” said Howell. “And not everyone bounces back.”
In her study, Howell numbered and ranked the hospitals — legally, she couldn’t disclose their names or neighborhoods — and divided them into three complication-rate tiers: average, above average and below average (again, adjusting for the health of their core population). She then looked at the races of the women giving birth. Black women were twice as likely to deliver in below-average hospitals as white women. And white women were three times more likely than black women to deliver at above-average hospitals.
Howell estimated this gap in safety jeopardizes the lives of nearly 1,000 black women in New York City each year.
“It’s quite striking,” she said. “A lot of this is preventable: communication failures, delays in diagnosis, mostly what we call ‘system factors’ that seem to be related with these severe events.”
Howell looked for patterns beyond race and couldn’t find any strong association with hospitals’ size, whether they were public or private, or academic or non-academic. In her ongoing research, she’s trying to figure what high-performing hospitals are doing differently from low-performing ones. She hypothesized the answer could be found in ‘hospital culture.’
“Do hospitals use standardized protocols and procedures, checklists, things that we do, so that if a patient has a blood pressure of 160 over 110, what happens?” she said.
Howell said stories like those of Hines, McKnight and Toliver are widespread and help illustrate the disparity in treatment black women receive — even though it’s difficult to quantify the impact of such shoddy treatment. She can’t prove with data that it leads to the higher complication rates she found in certain hospitals, based on diagnostic codes of patient records.
Still, she strongly believes listening more closely to patients and treating them more humanely is crucial to improving childbirth safety overall.
“For patient safety, communication is one of the basic tools we have — whether that be communication for staff members when they’re caring for an acute event or communication with patients,” Howell said.
Dr. Ralph Ruggiero agrees. He is the chairman of Obstetrics and Gynecology at Wyckoff Heights Hospital on the border of Bushwick and Ridgewood in Brooklyn.
“When a patient has a concern, I want my faculty member to really listen to what they’re saying,” he said. “There could be something to it.”
Since taking the helm of his department three years ago, Ruggiero has taken a multi-pronged approach to improving patient safety and reducing complications.
He helped expand the hospital’s satellite clinics to improve prenatal care and women’s health overall; set up a system where a single doctor or midwife took primary responsibility for each patient; demanded doctors and nurses ask patients more questions, listen to their answers and, as much as possible, accommodate their requests; instituted more drills and training; and standardized and enforced protocols and guidelines.
“When we write a policy, we get down to the nitty-gritty,” he said, whether it’s the details on who goes where when a hemorrhaging patient needs a blood transfusion, or what it takes to medically justify an episiotomy.
Ruggiero said he arrived at Wyckoff on a Monday and ran his first emergency hemorrhage drill that Thursday. It didn’t go well.
“We looked like the Keystone Cops,” he said.
Gradually things have improved, and the drills have gotten more advanced. Along the way he’s ruffled some feathers.
When I first got here, we had a lot of good doctors, but they all practiced differently, and they practiced based on their experience” not based on the latest research, Ruggiero said. “There was some pushback, but now much of the staff has changed.”
When he arrived, the obstetric staff had one woman and a dozen men, and no one was bi-lingual. Now there are 10 women and three men, and almost all are bilingual. And he’s added four midwives.
Ruggiero said the reforms have shown progress: pre-natal visits are up, unnecessary interventions are down — especially episiotomies and C-sections for first-time mothers — and complications have declined significantly.
In the past three years, the annual count of severe lacerations has gone from 27 to 11; severe hemorrhages, from 16 to 6; unplanned ICU admissions, from 15 to 6; blood clots, from 16 to 2; and unaddressed severe hypertension, from 8 to 0.
“It’s all these different approaches working together,” Ruggiero said. “We’re working all the time to make labor and delivery safer, but I think the real work is outside the four hospital walls. We need to get out into the community, get to all the people who are getting erratic care -- or no care -- and get them to come into our clinics to see us sooner.”