A ProPublica analysis shows that women who deliver at hospitals that disproportionately serve black mothers are at a higher risk of harm.
By Annie Waldman
NEW YORK — When Dacheca Fleurimond decided to give birth at SUNY Downstate Medical Center earlier this year, her sister tried to talk her out of it.
Her sister had recently delivered at a better-rated hospital in Brooklyn’s gentrified Park Slope neighborhood and urged Fleurimond, a 33-year-old home health aide, to do the same.
But Fleurimond had given birth to all five of her other children at the state-run SUNY Downstate and never had a bad experience. She and her family had lived steps away from the hospital in East Flatbush when they emigrated from Haiti years ago. She knew the nurses at SUNY Downstate, she told her sister. She felt comfortable there.
She didn’t know then how much rode on her decision, or how fraught with risk her delivery would turn out to be.
It’s been long-established that black women like Fleurimond fare worse in pregnancy and childbirth, dying at a rate more than triple that of white mothers. And while part of the disparity can be attributed to factors like poverty and inadequate access to health care, there is growing evidence that points to the quality of care at hospitals where a disproportionate number of black women deliver, which are often in neighborhoods disadvantaged by segregation.
Researchers have found that women who deliver at these so-called “black-serving” hospitals are more likely to have serious complications — from infections to birth-related embolisms to emergency hysterectomies — than mothers who deliver at institutions that serve fewer black women.
Still, it’s difficult to tell from studies alone how this pattern plays out in real life. The hospitals are never named. The women behind the numbers are faceless, the specific ways their hospitals may have failed them unknown.
ProPublica did its own analysis, using two years of hospital inpatient discharge data from New York, Illinois and Florida to look in-depth at how well different facilities treat women who experience one particular problem — hemorrhages — while giving birth.
We, too, found the same broad pattern identified in previous studies — that women who hemorrhage at disproportionately black-serving hospitals are far more likely to wind up with severe complications, from hysterectomies, which are more directly related to hemorrhage, to pulmonary embolisms, which can be indirectly related. When we looked at data for only the most healthy women, and for white women at black-serving hospitals, the pattern persisted.
Beyond this bird’s-eye view, our analysis allowed us to identify individual hospitals with higher complication rates, to look at what kinds of protocols they have and to examine what went wrong in specific cases.
We found, for example, that SUNY Downstate, where 90 percent of the women who give birth are black, has one of the highest complication rates for hemorrhage across all three states. On average, 34 percent of women who hemorrhage while giving birth at New York hospitals experience significant complications. At SUNY Downstate, it’s 62 percent.
SUNY Downstate officials defended the hospital’s handling of obstetric hemorrhages, saying it has extensive protocols for responding to them and gets exemplary results despite handling deliveries involving mothers with higher-than-average numbers of health problems like diabetes, obesity and high blood pressure. They would not comment on Fleurimond’s case, citing patient privacy.
Fleurimond was admitted to Downstate on Aug. 9.
Pregnant with twins, her doctor noticed she was in preterm labor at her 34-week checkup and prepped her for an unplanned cesarean section. When they cut into her womb to deliver the babies, Fleurimond’s uterus didn’t fully contract as it should have. She began to bleed. By the time the doctors controlled the hemorrhage, she had lost more than a liter of blood, requiring two transfusions.
At first, it seemed she’d be fine. She awoke the following morning thinking the worst was over, eager to see her new sons.
She wouldn’t survive the day.
Every year in the United States, between 700 and 900 women die from causes related to pregnancy and childbirth. For every woman that dies, dozens more experience severe complications, which affect more than 50,000 women annually.
The U.S. rate of maternal mortality is substantially higher than those of other affluent nations and has risen over the past decade. Outcomes for black women have led the way, intensifying efforts by medical experts and academics to understand what’s driving the racial disparity.
A complicating factor in understanding how hospital care figures in is that hospitals take on different proportions of tough cases — patients who have less access to consistent, quality prenatal care or have chronic health issues, like diabetes or heart disease, that make pregnancy and childbirth riskier.
Some prominent researchers are using a methodology for analyzing birth outcomes that attempts to even the playing field.
The California Maternal Quality Care Collaborative, which studiesmaternal deaths and develops techniques to prevent them, looks at how well hospitals respond to obstetric hemorrhage, typically defined as losing more than 500 milliliters of blood during a vaginal birth or a liter of blood during a cesarean section. Why hemorrhages? Because women of all races experience them at roughly the same rates and their likelihood is less affected by factors like race or economic status, said CMQCC medical director Dr. Elliott Main.
CMQCC evaluates hospitals by calculating what percent of women who hemorrhage during birth wind up with major complications. Researchers count both the complications more directly related to hemorrhages, like hysterectomies and blood transfusions, and those that could be indirectly related, including embolisms, blood clots, heart attacks, kidney failure, respiratory distress, aneurysms, brain bleeds, sepsis and shock. Ultimately, this approach measures how often doctors prevent complications when a hemorrhage occurs, and when looked at over time, can show if a hospital has been able to improve.
ProPublica used the metric to analyze inpatient hospital discharge data collected by New York, Illinois and Florida for 2014 and 2015, examining all obstetric cases that were coded as involving hemorrhages — about 67,000 cases in all.
We also put each hospital into a category based on the concentration of black mothers who gave birth there, defining facilities as low, medium or high black-serving. We crafted our analysis so that it reflected the racial distribution of mothers delivering in each state. In New York, if black mothers represented roughly a third or more of the deliveries at a hospital, we considered the hospital high black-serving. In Florida, we considered a hospital high black-serving if about 40 percent of the mothers were black. In Illinois, we considered a hospital high black-serving if at least half of its mothers were black.
In New York, we defined a hospital as low black-serving if less than eight percent of the women delivering there were black. In Illinois, the cutoff was 14 percent. In Florida, it was 18 percent.
Across the three states, about one in 10 hospitals in our analysis was high black-serving — in some cases, extremely high. Ninety-nine percent of the mothers who gave birth at Jackson Park Hospital and Medical Center in Chicago were black.
While a handful of low black-serving hospitals had high complication rates, our analysis found that, on average, outcomes at hospitals that served a high number of black patients were far worse.
In New York, on average, high black-serving hospitals had complication rates 21 percent higher than low black-serving hospitals. In Illinois and Florida, high black-serving hospitals had complication rates 11 percent higher.
When we limited our patient pool to only mothers of average birthing age — between 25 and 32 — who did not have any chronic conditions like heart disease or diabetes, the pattern remained largely the same. This bolstered the notion that differences in care, along with patient characteristics, affected outcomes.
Deeper analysis of the data for each state underlined this finding. At low black-serving hospitals in New York, just under a third of the women who hemorrhaged had complications. At high black-serving hospitals, that rate climbed to about half.
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