It's hard to imagine that in a state with as many hospitals as New Jersey has, how can we be one of the worst states for maternal deaths. How does this happen? Costa Rica has better outcomes than New Jersey does. Our NJ mothers are dying at the rate of 37 per 100,000 live births, putting our state between the countries of Georgia and Uzbekistan both having 37 maternal deaths per 100,000 live births and Mexico at 38 deaths per 100,000 live births. The national U.S. average is 20 deaths per 100,000 live births. The highest number of deaths is occurring in African American women who are 5 times more likely to die from complications of childbirth. The disparity between white infant deaths and black infant deaths is concerning. While the death rate has slightly improved, 1 in 1,000 white babies dies while black infant deaths is 9.7 in 1,000 live births.
So why is this happening? How do we improve the health of our moms and save lives?
One of the biggest barriers has been lack of access. As an emergency room nurse in Newark, NJ I witnessed first hand the provider desert that exists in areas of lower socioeconomic areas. Women who found out they were pregnant in the ER would be scheduled for the hospital clinic, which could take up to three months. By the time the patients got into the clinic they could be in their third trimester. Clearly this delay in care can have serious impacts on both the health of the mother and fetus.
Risk factors related to maternal complications associated with maternal death include: obesity, lack of early prenatal care, high blood pressure, diabetes, smoking and drug use.
As New Jersey's maternal death rate was on the rise so was the opiate crisis. Many of the risk factors mentioned above are avoidable or manageable, meaning that deaths are avoidable.
State, county and local agencies need to take a hard look at this crisis. Avoidable maternal complications often result in premature births which can result in long term complications for the baby if it survives. In the U.S. 1 in 10 babies is born premature, before 37 weeks., roughly 10% of all babies born in New Jersey are born prematurely. Nationally preterm births cost $26 billion dollars, 50% of preterm births were insured by state funded Medicaid. Not only is the cost of preterm birth and issue, but loss of household income is directly associated with premature birth, as is the increased cost of education for the child.
While every premature birth, fetal death and maternal death may not be avoided, it is clear that there is relationship between avoidable risk factors and poor outcomes. Access to care and early prenatal care is found to positively impact this crisis.
In addition to the care for the mothers, it is also important to ensure that nurses and providers are adequately trained on recognizing and treating maternal complications. Many postpartum nurses spent time teaching new moms about how to care for their baby, but little if any time was spent on warning signs for the mother's own health. In my own experience in the ICU I have care for moms who were transferred to the ICU that were very sick, yet knew very little about what was happening to them and the course of treatment. In my ICU it is policy that any nurse caring for a maternal fetal patient, meaning a mom who is pregnant or recently delivered, who is admitted with and infection such as sepsis, preeclampsia or heart failure, must have completed specific training. I have been in my ICU for almost 3 years and the class has never been offered to me, yet I have cared for these women. Thankfully there are podcasts and online education that allows me to learn about these serious complications. We are failing the women of New Jersey.
For more information read the propublica article The Last Person You'd Expect to Die
Nursing Home Fines Reduced- If the Government Is Protecting the Millionaires, Who Protects the Patients?
In June 2017 the Trump administration rolled back an Obama era law that lifted a rule which forced nursing home patients and their caregivers to forego their right to file a motion in court and bound them to arbitration for legal claims. The significance of this 2017 law means that even in a situation where a patient in the care of a nursing home has claims of neglect after injures or illness, the representing party of the patient can no longer file a motion for their day in court, without going though arbitration. Arbitrations are confidential proceedings that are not public record and often require any agreement to remain confidential and secret.
In 2016 Frank McMahon admitted his sister to a Care One facility. When he was filling out the admitting forms he signed a form, that he later learned was an agreement that in the event that legal recourse was sought on behalf of the patient, it could only be through arbitration. His sister's care while she was in Care One was less than ideal. She contacted infections and developed bedsores. As a result he decided to sue Care One. A New Jersey court ruled in his favor to allow a trial date to be scheduled regardless of the forced arbitration agreement.
Unfortunately the new law of the land which was implemented in June 2017, will force patients and families into arbitration which will decrease transparency and allow these facilities to continue to operate understaffed and providing unsafe and inhumane living environments for millions of our nations most vulnerable patients.
If forced arbitration wasn't enough, the Trump administration gave further relief to nursing home owners by drastically reducing fines. Instead of being held responsible and fined for the number of days the facility was in violation, there would be a one day $20,965 cap. This means that in the event that a facility did not provide adequate care based on evidence for 30 days they can only be fined for one day.
In 2014 Care One was sued by another patient's family for the neglect of their elderly mother who suffered from Alzheimer's. Her family had originally filed a motion for the plaintiff, their mother, calling her Jane Doe. Care One's attorneys filed motions to have the original motion dismissed because it was not done under the patient's given name. The family felt that lack of staff was a contributing issue for the neglect that their mother was subjected to, but since there are virtually no staffing laws the lawsuit had little traction. As a result a legislative bill to standardize the number of aids in these facilities was introduced by Assemblyman Joseph Lagana in 2015 and was then sponsored by the New Jersey Senate in 2016. This bill A4636 or Senate Bill S2878, was approved in the Assembly and Senate by the Democrat majority, but every Republican voted against the bill. Regardless of successfully passing the bill in the Senate, Governor Christie vetoed it.
The common link in these unfortunate experiences is lack of staff. Unfortunately our elderly and at risk populations will continue to be neglected unless the state's lawmakers finally make safe staffing a law. Reach out to your legislative representatives and tell them you want safe staffing in New Jersey facilities. To locate your Senate and Assembly representatives click here. Call, email, write or tweet them often.
(links to original articles or news footage)
NY Times: Trump Administrative Eases Nursing Home Fines in Victory for Industry
Brother of Care One Nursing Home Patients Sues for Neglect
New Jersey Nursing Home Patient Dies From Bedsores
Care One Sued For Neglect Nursing NJ Nursing Home Bill Introduced
There will inevitable be a time in your career where you are shocked. I know that I have certainly had several moments where I'm pretty sure in my unconsciousness yet conscious state, my jaw dropped in utter disbelief of what I was hearing or seeing. As a trauma nurse you see it all. Objects in places they shouldn't be, extremities displaced and the Jerry Springer like ER Family Reunion. Any of these could be shocking, but I can honestly say the most shocking incident of my career had nothing to do with a patient's illness or injury. This shock came from a the mouth of a supervisor.
As nurse we must have compassion in order to do our work and our healing effectively. We cannot be hardened and cold, or at least we shouldn't be.
She said what?
I was getting ready to leave after a night shift in the ICU. I had two patients, which was our normal staffing level. One patient was older and was not going to be leaving the ICU. Her condition was terminal. We were waiting for the family to make the decision to terminally extubate her. The other patient was young and was having a difficult time dealing with the unfortunate results of pressor medication, necrosis to the fee and hands.
As I was getting ready to punch out, my direct supervisor came to me and wanted to know why I was punching out at 8:10 in the morning instead of 7:45. Instead of asking about my night, or the break I didn't have a chance to take, she said "You had two patients, one of which was brain dead. How much care did you really have to do?"
Those words even a year later resinate with me today. I know I never want to be that person. I pray I never lose my ability to be compassionate.