By John Kelly and Alison Young, USA TODAY. March 7, 2019 | Updated 11:43 a.m. ET June 28, 2019
Shantel Smith developed an infection after a stillbirth at Touro Infirmary in New Orleans in 2011. In an ongoing lawsuit, Smith alleges that delayed diagnosis and treatment resulted in devastating amputations of her legs and hands. Jarrad Henderson, USA TODAY
People facing hip and knee replacement can go online and find out how often those surgeries go awry at hospitals across the country.
They can look up a hospital’s death rates for stroke and heart attack patients, too, or how many of its patients get infections.
Yet, in the United States – the most dangerous country in the developed world to give birth – maternity hospitals’ childbirth complication rates are a well-guarded secret.
Many hospitals know them. So do many state health agencies, insurance companies and researchers. But they fear the complication rates are too complex for regular folks to understand.
There are certainly questions about the data. Some hospitals are more likely to treat patients with health problems, so childbirth complication rates are difficult to compare. Some of the best-equipped hospitals in the country may have higher complication rates because mothers who are very sick get referred there.
Because of that, hospitals and others in the health care industry have argued against releasing complication rates, saying they are unfair and could lead women to make bad choices.
One of the nation’s top childbirth safety experts, however, said looking at the rates presents an opportunity for health providers to evaluate the care they’re giving to women and to find ways to improve.
“You’re going to get a lot of defensiveness in response to probing questions,” said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative. “But the value of a story or a series like this is it truly is making people stop and think about their reflexive responses.”
That’s why USA TODAY is publishing severe complication rates for hundreds of maternity hospitals in 13 states where its journalists obtained records documenting patients’ care. USA TODAY sought the data in all 50 states, but many refused to provide it or imposed restrictions rendering the data useless.
The data reveal wide variations from hospital to hospital. The exclusive analysis of 7 million anonymized patient records found women suffered life-threatening complications at rates at least double the median at about one in eight U.S. hospitals that delivered babies from 2014 to 2017.
Where the number comes from
More than a decade ago, the U.S. Centers for Disease Control and Prevention created a method for calculating how often women giving birth endure severe complications using diagnosis and procedure codes that hospitals record in patient billing records.
The resulting “severe maternal morbidity rate” is like a composite score of things that can go wrong at the hospital before, during or after delivery – heart attacks, strokes, blood transfusions, hysterectomies and other emergencies that can permanently harm or even kill a new mother.
The CDC developed the rate to study trends at state and national levels. It’s now widely used privately to evaluate outcomes at individual hospitals. Patient safety groups, state health departments, insurers and hospitals regularly use them to measure hospitals’ progress in reducing preventable deaths and injuries.
The rate is not a definitive count of how many women suffered serious complications, but instead an indicator or estimate.
For example, the CDC method uses blood transfusions as an indicator that a woman may have hemorrhaged. But it’s impossible from billing data to know whether the woman received one unit or many units of blood.
Some experts say that could inflate the rate. Others note that transfusions are counted for all hospitals and a blood transfusion is not part of a routine childbirth.
Also, some hospitals have higher rates because they are specialty facilities where doctors send the riskiest cases. Some serve more poor mothers, who often get less consistent prenatal care. Others serve larger numbers of black mothers, who tend to have higher rates of certain health problems, such as hypertension, that can lead to serious complications.
“Put simply, comparing hospitals with differing case mix profiles is equivalent to comparing apples, oranges, and lemons,” physicians at Dallas’ Parkland Hospital wrote to USA TODAY in response to questions about that hospital’s childbirth complication rate, which is about four times the median.
Parkland noted it serves complex cases and a disproportionate share of poor mothers. USA TODAY’s analysis found many hospitals with similar challenges but lower complication rates.
High blood pressure took one mom’s life. Excessive bleeding left another with a hysterectomy. Would long-known safety practices have saved both? Walbert Castillo, USA TODAY
There’s no consensus among experts about how to adjust the data to factor in all of the variables unique to childbirth.
In some studies using experimental risk adjustment, many hospitals with higher rates of complications still stood out. USA TODAY found the same: after removing some kinds of risky cases, almost all of the same hospitals had the highest rates.
Making the complication rates more public
In recent years, Blue Cross Blue Shield noticed the “majority of hospitals were not even aware of SMM rates,” the company told USA TODAY.
The insurer began sharing complication rates with hospitals it designates as excelling in other areas of maternity care to “encourage them to assess and improve their rates.”
The insurance group said the number is an important one that hospitals should be aware of, evaluate and strive to improve.
Researchers said the complication rates are not appropriate for head-to-head comparisons of one hospital against another. Some state programs use the measure to help hospitals compare themselves against groups of patients or hospitals. Academics and government agencies use the rates to compare hospitals in studies.
That’s what USA TODAY has done: calculated hospitals’ complication rates and then compared them against the median among hospitals in the 13 states that released data. Reporters then scrutinized hospitals with complication rates at least twice the median.
Childbirth safety experts caution that a hospital with a lower rate isn’t necessarily safer. The hospital might just serve many more healthy women at lower risk of complications. A smaller hospital with a lower complication rate, because it does not regularly treat high-risk cases, may be less prepared for an emergency.
The rates are a starting point for scrutinizing a hospital’s maternity care.
“It’s important we treat providers fairly, but it’s also important we hold them accountable,” said Carol Sakala, who leads maternity care programs for the National Partnership for Women & Families, a Washington, D.C.-based nonprofit that advocates for women’s health care. “The act of collecting and reporting – especially public reporting – of results can make a difference in accountability and quality of care.”
The federal Centers for Medicare and Medicaid Services and the Joint Commission have the power to collect and report numbers that could inform mothers and their loved ones about individual hospitals. So far, neither has done so.
For moms, the Joint Commission, a private group that accredits hospitals, makes hospitals track only C-section rates, but rates for individual hospitals aren’t public. CMS tracks nothing related to injuries to mothers.
USA TODAY reported last summer that the Joint Commission was studying whether to create any new rules to protect moms. Spokeswoman Maureen Lyons said the group met this week to review draft standards for hemorrhage and high blood pressure – two of the leading preventable causes of mothers’ deaths. Lyons did not release details and said it could take three to four months before the standards are finalized, she said.
Contributing: Christopher Schnaars and Sean Ross