Crowded County Hospitals Suffer Crisis in Obstetrics

For thousands of expectant mothers in Los Angeles, technicolor visions of their sons’ and daughters’ glorious entrance into the world can be quickly shattered upon their arrival in Ward 5L, the labor and delivery section at Women’s Hospital.

On any given night in the sparsely decorated county facility, poor women with high-risk pregnancies, many of them Mexican immigrants, can be found lying flat on steel gurneys in a busy hallway, staring at a pale wall with only a pillow, a light blanket and the steady beep of a fetal monitor to keep them company.

They are not being ignored by the staff of exhausted physicians. They are being prioritized, assigned a risk value, and checked to see whether their labor should be stopped or induced. Then they are either sent home or moved as quickly and safely as possible through the delivery process to open up a bed for the other women in labor, now lining up in a group of hallway chairs.

It is the cold, hard fact of life on the busiest labor ward in the United States. Last year, the hospital, part of Los Angeles County-USC Medical Center, delivered more babies than any other facility in the country, one out of every 200 infants born in the United States. But it is a fact the staff at Women’s Hospital and other county medical centers are desperately trying to change.

All county hospitals are faced with the same crisis in obstetrics. The labor and delivery wards at county facilities during the past year were so overcrowded that the conditions at the facilities at times became increasingly unsafe, according to obstetricians and county hospital administrators. And they have a growing number of lawsuits to back them up.

At one point in December, staff doctors at Women’s Hospital threatened to make public a videotape that included dramatic scenes of more than a dozen women in labor crowded in hallways. They told Robert Gates, director of the county’s Department of Health Services, that they would release the tape unless steps were taken to reduce the level of “battlefront obstetrics” being practiced at the hospital.

“On a good night, it’s like controlled chaos,” said Dr. Siri Kjos, assistant professor at USC Medical School’s Obstetrics and Gynecology Department, which supervises and teaches the medical students who staff the delivery ward at Women’s Hospital. “But on bad nights, it just seems hopeless. No matter what we do, we are just not able to give the best care possible because there’s just too many babies.

“The private hospitals in the area send us their sickest patients, and many of these ladies have never had prenatal care. So we really deliver the brunt of the most ill patients who are pregnant in Los Angeles County.”

During one particularly heavy night in January, 1989, a single resident physician was left to supervise 42 women on the ward, nearly all of them in labor. The resident was left alone because the other residents and staff physicians were performing two emergency Cesarean sections.

Under less stressful conditions, the resident might have noticed the abnormal fetal monitor readings on one of the women in labor. The abnormal reading went unnoticed for 10 minutes, a critical oversight that resulted in a serious brain injury to the infant. It also resulted in a $500,000 malpractice settlement paid by the county.

A similar injury occurred to another infant a few weeks later because of the overload.

“What’s amazing is that it hasn’t happened more often,” said Dr. Thomas Kirschbaum, head of labor and delivery at Women’s Hospital. “It’s a case where it’s one potentially dreadful thing happening after another. There are just periods when we don’t have control over our delivery room because of the overload.”

The number of malpractice claims stemming from obstetric care at county hospitals rose significantly last year, with more than 71 lawsuits filed, compared to 52 the previous year. The county has paid more than $2.6 million in malpractice claims during the past two years, and that figure is expected to rise dramatically as the remaining cases inch closer to settlement.

The problem is not a new one for Los Angeles or other county facilities in large metropolitan areas across the county. But in the past year, Los Angeles County’s condition shifted from serious to critical.

During fiscal year 1988-89, nearly 38,000 babies were delivered at county hospitals, far outpacing the maximum capacity of 35,000. For this fiscal year, county officials predict that 41,000 infants will be born, although the first six months were on a pace to reach 45,000.

Ward 5L is equipped to handle about 45 births daily, with a maximum of about 15,000 each year. But Women’s Hospital has not delivered fewer than 16,000 babies since 1982, and during two of the years, it topped 18,000. During peak months in September and October, the daily birth rate may hover around 65 for weeks at a time. When Kjos was a fourth-year resident several years ago, she once assisted in the delivery of 84 infants during one 24-hour period.

“Any time we deliver 60 or more in a day, the only way we can avoid injury is if we’re lucky,” said Kirschbaum. “On a day when you are delivering that many babies, when we may have six to eight women lined up for Cesarean sections, some with internal bleeding, . . . we wind up making decisions on the basis of imperfect information and that has huge significance for the health of the baby.”

And while the situation is more dramatic at Women’s Hospital than other county facilities, the overcrowding problems are mirrored throughout the system. A serious obstetrics overload plagues Harbor-UCLA Medical Center, Martin Luther King Jr./Drew Medical Center in Watts and Olive View Medical Center in the San Fernando Valley.

Last year at Harbor, the obstetric load was nearly double the hospital’s capacity. The facility delivered more than 2,000 infants over its capacity and doctors there began pleading with the county for mercy.

“It’s critical, we’re day to day,” Dr. Charles Brinkman, chief of obstetrics at Harbor-UCLA, said of the situation. “We’re having major problems with our staff. I try and tell them that there is a light at the end of the tunnel. But there isn’t. And it’s not reasonable to expect this to continue.”

There are dozens of reasons for the overload, but a few stand out: the continued influx of hundreds of thousands of immigrants from Mexico and Central America; the withdrawal of private physicians and hospitals from Medi-Cal contracts because of extremely low reimbursement rates; the reluctance of the state to provide Medi-Cal contracts only for obstetric services, and state and county reluctance to provide more obstetrics funding.

The situation grew so grim in 1989 that health chief Gates pleaded in late November with members of the California Medical Assistance Commission, which oversees the state’s Medi-Cal contract program, to change the contract guidelines. Gates said that if something wasn’t done, he might be forced to adopt a plan similar to the controversial “obstetrical diversion” policy initiated by UC Irvine Medical Center last summer in which security guards were used to turn away women in labor.

Gates said last week that the plan is still under consideration by the county, although he continues to oppose it.

Obstetricians at Women’s Hospital grew so frustrated by the county’s inability to address the overload that they decided to take their case to the public and made a videotape during one busy night on the ward. At the same time, county supervisors grew so alarmed that they gave Gates two weeks to come up with a solution to the problem which they said “exposes patients to unsafe care and expands the county’s potential for legal liability.”

“It took almost an act of God for them (the county) to look at our problem,” said Dr. Richard Paul, chairman of the division of Maternal/Fetal Medicine, part of the Obstetrics and Gynecology Department at USC Medical School.

Gates immediately responded and within a few weeks, Ron Hansen, an administrator with the county’s medical contracting division, was promoted to Gates’ special assistant, in charge of handling the county’s obstetric crisis.

“Clearly, the number (of births) has gone up and the unmet needs haven’t changed,” Hansen said. “And no doubt the number will go up each year. But we’re making a huge push to address the problem and I’m optimistic that we can do it.”

So far, the physicians say the efforts are paying off. The number of births for January was down by 500 from the same period last year, but staff doctors say they are not sure if it is because private hospitals are picking up the excess or that there are just fewer babies being born this winter.

Hansen said the county’s short-term goal is to increase the number of private hospitals that contract with the county to deliver overflow births. The county is also trying to entice private physicians and hospitals without Medi-Cal contracts to handle some deliveries and to persuade CMAC to change rules that do not allow hospitals to sign obstetrics-only contracts. Under current guidelines, any hospital signing a Medi-Cal contract must provide a full range of medical services, and cannot contract for just one.

In recent years, physicians have been reluctant to sign Medi-Cal contracts to ease the county’s obstetrics problem because the reimbursement rate for obstetric and pediatric services is so low and it takes so long for the state to pay its bills.

“CMAC is at the crux of this problem,” said David Langness, a spokesman for the Hospital Council of Southern California. “If they changed the rules to allow for single-service contracts, I know of at least 22 hospitals in Los Angeles County alone who would sign up tomorrow for OB services.

“The county is so overburdened and under-funded in this area that it’s unlikely that it will ever catch up. But the obstetrics problems will be felt in other areas as well. Because both the public and private hospital system must work together, either they will work out a solution or both will ultimately fail.”

Currently, there are nearly two dozen private hospitals that have contracts to deliver 1,190 babies, and Hansen said the county hopes to double that amount before the peak months in late summer and early fall.

But even a six-month delay for the contract expansion could prove critical to the bursting county facilities. Even if the number of private hospitals providing obstetrical services to the poor increases, they only handle low-risk patients, leaving the sickest women in the county’s hands.

In 1988 alone, doctors at Women’s Hospital handled the deliveries for 885 diabetic patients, by far the largest number in the nation. The patients there, as in most county hospitals, are nearly all indigent and minorities. At Women’s, 85% of the patients are Latina, 70% of them from Mexico and 10% to 15% from Central America, with the remainder almost evenly divided between blacks and whites.

Because of its expertise in handling high-risk patients and a huge volume of deliveries, Women’s Hospital is thought to be one of the best teaching programs and research centers for obstetrics in the country. Dr. Paul did much of the clinical research that led to the development of the modern fetal monitor, now used at nearly every major hospital in the country.

Paul and others insist that the standard of care remains extremely high at Women’s Hospital, and that the facility’s residency program has not suffered because of the overload.

However, at various times, they admit that the excess number of births has resulted in the staff’s “inability to provide adequate supervision and care.”

One night in Ward 5L earlier this month, there was only one third-year resident to monitor 29 women in labor because other house doctors were handling two emergency Cesarean sections in the surgical ward. More than a half-dozen patients were suffering from severe hypertension which can result in seizures. One baby was in breech. Two were more than two weeks late. One 42-year-old woman was waiting to deliver her 13th child.

By 10 p.m., every bed in every room on the ward was filled and there were five women lined up on gurneys in the hallways.

February is traditionally one of the slowest months.

Kirschbaum said the workload has caused him to spend an inordinate amount of time in the past year counseling depressed residents who are troubled by their inability to deal with the huge number of high-risk patients.

“I’m really proud of the work and the care that we provide here, but personally, I find it very disturbing to see these fine young (doctors) subjected to a workload that is excessive by anybody’s standards.”

Kjos said the impact is felt in the type of hands-on patient care available to the residents. The way it is now, she said, residents throughout the county “learn extensively about acute obstetric care but very little about preventive care. They just never have time to intervene and prevent complications.”

The Department of Health Services’ slow response to the obstetric overload has raised skepticism that the county will continue to stay on top of the problem. Gates has assured the physicians that he will, although he said the obstetrical crisis is just one of several in the county’s crumbling health system.

“I get a lot of people involved in problems (throughout the county) saying that they have serious problems,” Gates said. “I don’t have a ranking of problems because there are so many. I have a group of No. 1s that . . . are all real problems that result to one degree or another on a lack of adequate funding.

“The obstetric problem comes and goes. A couple of years ago, when we opened the Olive View Medical Center, things immediately got better. But we didn’t anticipate the sharp increase in the numbers of patients coming into our system.”

Gates said he is now getting a daily status report on the obstetric crisis, adding that the county is very optimistic that it will be able to reduce the overload by increasing the number of delivery contracts with private hospitals.

Kjos, who along with the other obstetricians has praised the county’s recent efforts to come up with short-term solutions to the problem, is much more skeptical about the future. The reason is clear: Future projections call for more than 84,000 deliveries in county hospitals by the year 2000. Given the current state of affairs, she said it’s impossible to imagine a more grim scenario.

“It can’t get any worse than it is; it’s already critical,” she said. “The only alternative is to put up a sign saying, ‘If you enter this building, you may be endangering your health.’ ”