The Last Person You’d Expect to Die in Childbirth

The death of a neonatal nurse in the hospital where she worked illustrates a profound disparity: The healthcare system focuses on babies but often ignores their mothers.

This article by Nina Martin, ProPublica, and Renee Montagne, NPR, originally appeared on ProPublica on May 12, 2017.

As a neonatal intensive care nurse, Lauren Bloomstein had been taking care of other people’s babies for years. Finally, at 33, she was expecting one of her own. The prospect of becoming a mother made her giddy, her husband Larry recalled recently — “the happiest and most alive I’d ever seen her.” When Lauren was 13, her own mother had died of a massive heart attack. Lauren had lived with her older brother for a while, then with a neighbor in Hazlet, New Jersey, who was like a surrogate mom, but in important ways she’d grown up mostly alone. The chance to create her own family, to be the mother she didn’t have, touched a place deep inside her. “All she wanted to do was be loved,” said Frankie Hedges, who took Lauren in as a teenager and thought of her as her daughter. “I think everybody loved her, but nobody loved her the way she wanted to be loved.”

Other than some nausea in her first trimester, the pregnancy went smoothly. Lauren was “tired in the beginning, achy in the end,” said Jackie Ennis, her best friend since high school, who talked to her at least once a day. “She gained what she’s supposed to. She looked great, she felt good, she worked as much as she could” — at least three 12-hour shifts a week until late into her ninth month. Larry, a doctor, helped monitor her blood pressure at home, and all was normal.

On her days off she got organized, picking out strollers and car seats, stocking up on diapers and onesies. After one last pre-baby vacation to the Caribbean, she and Larry went hunting for their forever home, settling on a brick colonial with black shutters and a big yard in Moorestown, not far from his new job as an orthopedic trauma surgeon in Camden. Lauren wanted the baby’s gender to be a surprise, so when she set up the nursery she left the walls unpainted — she figured she’d have plenty of time to choose colors later. Despite all she knew about what could go wrong, she seemed untroubled by the normal expectant-mom anxieties. Her only real worry was going into labor prematurely. “You have to stay in there at least until 32 weeks,” she would tell her belly. “I see how the babies do before 32. Just don’t come out too soon.”

When she reached 39 weeks and six days — Friday, Sept. 30, 2011 — Larry and Lauren drove to Monmouth Medical Center in Long Branch, the hospital where the two of them had met in 2004 and where she’d spent virtually her entire career. If anyone would watch out for her and her baby, Lauren figured, it would be the doctors and nurses she worked with on a daily basis. She was especially fond of her obstetrician-gynecologist, who had trained as a resident at Monmouth at the same time as Larry. Lauren wasn’t having contractions, but she and the OB-GYN agreed to schedule an induction of labor — he was on call that weekend and would be sure to handle the delivery himself.

Inductions often go slowly, and Lauren’s labor stretched well into the next day. Ennis talked to her on the phone several times: “She said she was feeling okay, she was just really uncomfortable.” At one point, Lauren was overcome by a sudden, sharp pain in her back near her kidneys or liver, but the nurses bumped up her epidural and the stabbing stopped.

Inductions have been associated with higher cesarean-section rates, but Lauren progressed well enough to deliver vaginally. On Saturday, Oct. 1, at 6:49 p.m., 23 hours after she checked into the hospital, Hailey Anne Bloomstein was born, weighing 5 pounds, 12 ounces. Larry and Lauren’s family had been camped out in the waiting room; now they swarmed into the delivery area to ooh and aah, marveling at how Lauren seemed to glow.

Larry floated around on his own cloud of euphoria, phone camera in hand. In one 35-second video, Lauren holds their daughter on her chest, stroking her cheek with a practiced touch. Hailey is bundled in hospital-issued pastels and flannel, unusually alert for a newborn; she studies her mother’s face as if trying to make sense of a mystery that will never be solved. The delivery room staff bustles in the background in the low-key way of people who believe everything has gone exactly as it’s supposed to.

Then Lauren looks directly at the camera, her eyes brimming.

Twenty hours later, she was dead.

In the U.S., unlike some other developed countries, maternal deaths are treated as a private tragedy rather than as a public health catastrophe. A death in childbirth may be mourned on Facebook or memorialized on GoFundMe, but it is rarely reported in the news. Most obituaries, Lauren’s included, don’t mention how a mother died.

Lauren’s passing was more public than most, eliciting an outpouring of grief. Hundreds of people attended her wake and funeral — doctors and nurses from the hospital, friends from around the country, families Lauren had taken care of. Vaclavik was there, utterly devastated, Larry’s family said. The head of Monmouth’s OB-GYN department paid his respects and, according to Larry, promised in a private conversation at the wake to conduct a full investigation.

In the days after Lauren’s death, Larry couldn’t dwell on the implications of what had happened. He had to find a burial plot, choose a casket, write a eulogy. He was too shattered to return to the Mooresville house, so he took Hailey to his parents’ place, a one-bedroom apartment they were renting while they renovated their home, and slept with the baby in the living room for the first month.

After the funeral, he turned all his attention to his daughter. He knew nothing about newborns, always imagining Lauren would teach him — “What could be better than having your own NICU nurse to take care of your baby?” he had thought. He relied on his mother and sister and Lauren’s friends to guide him. He took time off from his job at Cooper, figuring three months would be enough. But as his return date approached, he knew he wasn’t ready. “I don’t think I can see a patient that’s on a ventilator right now,” he realized. “Or even just a hospital bed.” He didn’t want to leave Hailey. So he quit.

He sold the house, though he couldn’t bring himself to attend the closing — “I couldn’t stand handing those keys over to someone else.” He took Hailey a couple of times to stay with his sister and her family in Texas, where he didn’t have to answer the constant questions. But traveling with his baby daughter was painful in its own way. People didn’t know what to make of him. “It’s strange for people to see a father alone.” Wherever he went, he felt disconnected from almost everything around him. “You’re walking around this world and all these people are around you, and they’re going on with their lives and I just felt very, very isolated and very alone with that.”

Back in New Jersey, Larry found a job closer to his parents’ place, performed one operation and tried to quit. His new employers, though, persuaded him to stay. To avoid reliving the funeral, he returned to Texas for the first anniversary of Hailey’s birth and Lauren’s death in late September 2012. In one of his suitcases, he packed a giant cupcake mold Lauren had bought when they first married — she thought it would make a perfect first-birthday cake for the kids she yearned for. He baked the cake himself — chocolate, Lauren’s favorite, covered with sprinkles.

Other people in Lauren’s and Larry’s circle had been asking questions about her care since the night she died. “That was the first thing I literally said when I walked [into the hospital] — I said, ‘How did this happen?’” Jackie Ennis recalled. In the next week or two, she probed Larry again: “‘Did they do everything they could for her?’ He said, ‘No, there were warning signs for hours before.’” Ennis was too upset to dig any deeper.

As Larry’s numbness wore off, his orthopedist friends began pushing him as well. Larry was hesitant; despite the missteps he had witnessed, part of him wanted to believe that Lauren’s death had been unavoidable. “And my friends were like, ‘We can’t accept that. … With our technology, every single time a woman dies [in childbirth], it’s a medical error.’”

Lauren’s death, Larry finally admitted to himself, could not be dismissed as either inevitable or a fluke. He had seen how Lauren’s OB-GYN and nurses had failed to recognize a textbook case of one of the most common complications of pregnancy — not once, but repeatedly over two days. To Larry, the fact that someone with Lauren’s advantages could die so needlessly was symptomatic of a bigger problem. By some measures, New Jersey had one of the highest maternal mortality rates in the U.S. He wanted authorities to get to the root of it — to push the people and institutions that were at fault to change.

That’s the approach in the United Kingdom, where maternal deaths are regarded as systems failures. A national committee of experts scrutinizes every death of a woman from pregnancy or childbirth complications, collecting medical records and assessments from caregivers, conducting rigorous analyses of the data and publishing reports that help set policy for hospitals throughout the country. Coroners also sometimes hold public inquests, forcing hospitals and their staffs to answer for their mistakes. The U.K. process is largely responsible for the stunning reduction in preeclampsia deaths in Britain, the committee noted its 2016 report — “a clear success story” that it hoped to repeat “across other medical and mental health causes of maternal death.”

The U.S. has no comparable federal effort. Instead, maternal mortality reviews are left up to states. As of this spring, 26 states (and one city, Philadelphia) had a well-established process in place; another five states had committees that were less than a year old. In almost every case, resources are tight, the reviews take years and the findings get little attention. A bipartisan bill in Congress, the Preventing Maternal Deaths Act of 2017, would authorize funding for states to establish review panels or improve their processes.

New Jersey’s review team, the second-oldest in the U.S., includes OB-GYNs, nurses, mental health specialists, medical examiners, even a nutritionist. Using vital records and other reports, they identify every woman in New Jersey who died within a year of pregnancy or childbirth, from any cause, then review medical and other records to determine whether the death was “pregnancy-related” or not. Every few years, the committee publishes a report, focusing on things like the race and age of the mothers who died, the causes of death, and other demographic and health data. In the past, the findings have been used to promote policies to reduce postpartum depression.

But the New Jersey committee doesn’t interview the relatives of the deceased, nor does it assess whether a death was preventable. Moreover, like every other state that conducts such reviews, New Jersey “de-identifies” the records — strips them of any information that might point to an individual hospital or a particular woman. Otherwise, the medical community and lawmakers would refuse to go along. The goal is to “improve care for patients in general,” said Joseph Apuzzio, a professor of obstetrics and gynecology at Rutgers-New Jersey Medical School who heads the committee. This requires a process that is “nonjudgmental” and “not punitive,” he said. “That’s the best way to get a free discussion of all of the health care providers who are in the room.”

Yet the result of de-identification, as Larry soon realized, is that the review is of little use in assigning responsibility for individual deaths, or evaluating whether some hospitals, doctors or nurses are more prone to error than others. To Larry, this seemed like a critical oversight — or perhaps, willful denial. In a preventable death or other medical error, he said, sometimes the who and the where are as important as the why. “Unless someone points the finger specifically,” he said, “I think the actual cause [of the problem] is lost.”

Someone eventually steered Larry toward the New Jersey Department of Health’s licensing and inspection division, which oversees hospital and nursing home safety. He filed a complaint against Monmouth Medical Center in 2012.

The DOH examined Lauren’s records, interviewed her caregivers and scrutinized Monmouth’s policies and practices. In December 2012 it issued a report that backed up everything Larry had seen firsthand. “There is no record in the medical record that the Registered Nurse notified [the ob/gyn] of the elevated blood pressures of patient prior to delivery,” investigators found. And: “There is no evidence in the medical record of further evaluation and surveillance of patient from [the ob/gyn] prior to delivery.” And: “There was no evidence in the medical record that the elevated blood pressures were addressed by [the ob/gyn] until after the Code Stroke was called.”

The report faulted the hospital. “The facility is not in compliance” with New Jersey hospital licensing standards, it concluded. “The facility failed to ensure that recommended obstetrics guidelines are adhered to by staff.”

To address these criticisms, Monmouth Medical Center had implemented a plan of correction, also contained in the report. The plan called for a mandatory educational program for all labor and delivery nurses about preeclampsia and HELLP syndrome; staff training in Advance Life Support Obstetrics and Critical Care Obstetrics; and more training on the use of evidence-based methods to assess patients and improve communications between caregivers.

Some of the changes were strikingly basic: “Staff nurses were educated regarding the necessity of reviewing, when available, or obtaining the patients [sic] prenatal records. Education identified that they must make a comparison of the prenatal blood pressure against the initial admission blood pressure.” And: “Repeat vital signs will be obtained every 4 hours at a minimum.”

An important part of the plan of correction involved Vaclavik, though neither he nor the nurses were identified by name. The head of Monmouth’s OB-GYN department provided “professional remediation for the identified physician,” the Department of Health report said. In addition, there was “monitoring of 100% of records for physician of record per month x 3 months.” The monitoring focused on “compliance of timely physician intervention for elevated blood pressures/pain assessment and management.”

The department chairman, Robert Graebe, found Vaclavik’s charts to be 100 percent compliant, Vaclavik said in the deposition. Graebe was asked in a March 2017 deposition if Vaclavik was in good standing at the hospital at the time of Lauren’s treatment. “Was and is,” Graebe replied.

In a separate note, the Department of Health told Larry that it forwarded his complaint to the Board of Medical Examiners and the New Jersey Board of Nursing. Neither agency has taken disciplinary action, according to their websites.

Larry’s copy of the DOH report arrived in the mail. He was gratified by the findings but dismayed that they weren’t publicly posted. That meant hardly anyone would see them.

A few months after the DOH weighed in, he sued Monmouth, Vaclavik and five nurses in Monmouth County Superior Court in Freehold, New Jersey. For a medical malpractice lawsuit to go forward in New Jersey, an expert must certify that it has merit. Larry’s passed muster with an OB-GYN. But beyond the taking of depositions, there’s been little action in the case.

As the maternal death rate has mounted around the U.S., a small cadre of reformers has mobilized. Some of the earliest and most important work has come in California, where more babies are born than in any other state — 500,000 a year, one-eighth of the U.S. total.

Modeled on the U.K. process, the California Maternal Quality Care Collaborative is informed by the experiences of founder Elliott Main, a professor of obstetrics and gynecology at Stanford and the University of California-San Francisco, who for many years ran the OB-GYN department at a San Francisco hospital. “One of my saddest moments as an obstetrician was a woman with severe preeclampsia that we thought we had done everything correct, who still had a major stroke and we could not save her,” he said recently. That loss has weighed on him for 20 years. “When you’ve had a maternal death, you remember it for the rest of your life. All the details.”

Launched a decade ago, CMQCC aims to reduce not only mortality, but also life-threatening complications and racial disparities in obstetric care. It began by analyzing maternal deaths in the state over several years; in almost every case, it discovered, there was “at least some chance to alter the outcome.” The most preventable deaths were from hemorrhage (70 percent) and preeclampsia (60 percent).

Main and his colleagues then began creating a series of “toolkits” to help doctors and nurses improve their handling of emergencies. The first one, targeting obstetric bleeding, recommended things like “hemorrhage carts” for storing medications and supplies, crisis protocols for massive transfusions, and regular training and drills. Instead of the common practice of “eye-balling” blood loss, which often leads to underestimating the seriousness of a hemorrhage and delaying treatment, nurses learned to collect and weigh postpartum blood to get precise measurements. Hospitals that adopted the toolkit saw a 21 percent decrease in near deaths from maternal bleeding in the first year; hospitals that didn’t use the protocol had a 1.2 percent reduction. By 2013, according to Main, maternal deaths in California fell to around 7 per 100,000 births, similar to the numbers in Canada, France and the Netherlands — a dramatic counter to the trends in other parts of the U.S.

“Prevention isn’t a magic pill,” Main said. “It’s actually teamwork [and having] a structured, organized, standardized approach” to care.

CMQCC’s preeclampsia toolkit, launched in 2014, emphasized the kind of practices that might have saved Lauren Bloomstein: careful monitoring of blood pressure and early and aggressive treatment with magnesium sulfate and anti-hypertensive medications. Data on its effectiveness hasn’t been published.

The collaborative’s work has inspired ACOG and advocates in a few states to create their own initiatives. Much of the funding has come from a 10-year, $500 million maternal health initiative by Merck, the pharmaceutical giant. Originally intended to focus on less developed countries, Merck for Mothers decided it couldn’t ignore the growing problem in the U.S. The U.S. maternal mortality rate is “unacceptable,” said Executive Director Mary-Ann Etiebet. Making pregnancy and childbirth safer “will not only save women’s lives but will improve and strengthen our health systems … for all.”

But the really hard work is only beginning. According to the Institute of Medicine, it takes an average of 17 years for a new medical protocol to be widely adopted. Even in California, half of the 250 hospitals that deliver babies still aren’t using the toolkits, said Main, who largely blames inertia.

In New York state, some hospitals have questioned the need for what they call “cookbook medicine,” said Columbia’s Mary D’Alton. Her response: “Variability is the enemy of safety. Rather than have 10 different approaches to obstetric hemorrhage or treatment of hypertension, choose one or two and make it consistent. … When we do things in a standardized way, we have better outcomes.”

One big hurdle: training. Another: money. Smaller providers, in particular, may not see the point. “It’s very hard to get a hospital to provide resources to change something that they don’t see as a problem,” ACOG’s Barbara Levy said. “If they haven’t had a maternal death because they only deliver 500 babies a year, how many years is it going to be before they see a severe problem? It may be 10 years.”

In New Jersey, providers don’t need as much convincing, thanks to a recent project to reduce postpartum blood loss led by the Association of Women’s Health, Obstetric and Neonatal Nurses. A number of hospitals saw improvements; at one, the average length of a hemorrhage-related ICU stay plunged from 8 days to 1.5 days. But only 31 of the state’s 52 birthing hospitals participated in the effort, in part — perhaps — because nurses led it, said Robyn D’Oria, executive director of the Central Jersey Family Health Consortium and a member of the state’s maternal mortality committee. “I remember having a conversation with [someone from] a hospital that I would describe as progressive and she said to me, ‘I cannot get past some of the physicians not wanting to buy into this.’”

So New Jersey hospitals are about to try again, this time adopting mini-toolkits created by the ACOG-led Alliance for Innovation on Maternal Health for hemorrhage and preeclampsia. “We’re at the very beginning” of a rollout that is likely to take at least two years, D’Oria said. Among those helping to create momentum has been Ryan Hansen, the husband of the teacher who died at Monmouth Medical Center a few months before Lauren Bloomstein.

Still, as hospitals begin to revamp, mothers in the state continue to perish. One was Ashley Heaney Butler. A Rutgers University graduate, she lived in Bayville, where she decorated the walls of her house with anchors, reflecting her passion for the ocean. She worked for the state Division of Vocational Rehabilitation Services as a counselor, and served as president of the New Jersey Rehabilitation Association. Her husband Joseph was a firefighter. She gave birth at Monmouth last September to a healthy boy and died a couple of weeks later at the age of 31, never leaving the hospital. It turned out that she had developed an infection late in her pregnancy, possibly related to a prior gastric bypass surgery. She was under the care of several doctors, including Vaclavik.

The death of a new mother is not like any other sudden death. It blasts a hole in the universe. “When you take that one death and what that does, not only to the husband, but to the family and to the community, the impact that it has in the hospital, on the staff, on everybody that’s cared for her, on all the people who knew them, it has ripple effects for generations to come,” Robyn D’Oria said.

Jackie Ennis felt Lauren’s loss as an absence of phone calls. She and Lauren had been closer than many sisters, talking several times a day. Sometimes Lauren called just to say she was really tired and would talk later; she’d even called Ennis from Hawaii on her honeymoon. The night Lauren died, Ennis knew something was wrong because she hadn’t heard from her best friend. “It took me a really long time not to get the phone calls,” she said. “I still have trouble with that.”

During Lauren’s pregnancy, Frankie Hedges had thought of herself as Hailey’s other grandmother. She and Lauren had made a lot of plans. Lauren’s death meant the loss of their shared dreams for an entire extended family. “I just feel she didn’t get what she deserved,” Hedges said.

Vaclavik’s obstetric practice is “larger” than in 2011, and he continues to have admitting privileges at Monmouth and two other hospitals, he said in his deposition. “I will never forget” Lauren’s death, he said. “… I probably suffer some post-traumatic stress from this.”

Hailey is five years old, with Lauren’s brown hair and clear green eyes. She feels her mother’s presence everywhere, thanks to Larry and his new wife Carolyn, whom he married in 2014. They met when she was a surgical tech at one of the hospitals he worked at after Lauren died. Photos and drawings of Lauren occupy the mantle of their home in Holmdel, the bookcase in the dining room and the walls of the upstairs hallway. Larry and Carolyn and their other family members talk about Lauren freely, and even Larry’s younger daughter, 2-year-old Aria, calls her “Mommy Lauren.” On birthdays and holidays, Larry takes the girls to the cemetery. He designed the gravestone — his handprint and Lauren’s reaching away from each other, newborn Hailey’s linking them forever. Larry has done his best to keep Lauren’s extended family together — Ennis and Hedges and their families are included in every important celebration.

Larry still has the video of Lauren and Hailey on his phone. “By far the hardest thing for me to accept is [what happened] from Lauren’s perspective,” he said one recent evening, hitting the play button and seeing her alive once more. “I can’t, I literally can’t accept it. The amount of pain she must have experienced in that exact moment when she finally had this little girl. … I can accept the amount of pain I have been dealt,” he went on, watching Lauren stroke Hailey’s cheek. “But [her pain] is the one thing I just can’t accept. I can’t understand, I can’t fathom it.”