Q&A with Nathanael Johnson: Why more California mothers are dying in childbirth

Nathanael Johnson, a Bay Area radio reporter and freelance writer, has made a nice career examining the many ways Americans go overboard – from the food that we eat to the health treatments that we seek. He has written about the Orwellian world of pork farming and the radical raw milk movement for Harper's magazine. He has written about the surge in "functional beverages" for New York magazine. And he has written numerous features, including an insightful piece on excessive medical treatments, for his day job at KALW News.

In February, the Center for Investigative Reporting's California Watch published an investigation by Johnson that made the entire state - and large news outlets such as ABC World News with Diane Sawyer - sit up and take notice.

The mortality rate of California women who die from causes directly related to pregnancy has nearly tripled in the past decade, prompting doctors to worry about the dangers of obesity in expectant mothers and about medical complications of cesarean sections. For the past seven months, the state Department of Public Health declined to release a report outlining the trend.

This investigation had all the makings of a blockbuster. Innocent victims. Shocking trends. And the specter of government malfeasance. But it also had something else lacking in most investigations of this scope: a measured tone. Johnson made sure to underscore how few women actually die every year and, by contrast, how many healthy babies go home with healthy mothers.

I reached him at his home office. The interview has been edited for space and clarity. The first part is below. The second part will run next Friday.

Q: How did you get started on this project?

A: I'm working on a book right now, and my research for the book led to this little tidbit about maternal mortality. I pitched it to a few magazines, and a lot of them said, "No thanks." It's really hard to sell editors on medical stuff because it's so easy to BS your way through the stats. They've had that happen to them before, and they're wary.

Q: What's the book about?

A: The book is about nature versus technology and our extremism in this culture. We either just rely on technology to solve all our problems or people get disenchanted and want to go back to living in the woods. I'm talking about my very all natural family and lovingly making fun of my upbringing, starting with a home birth and seeing where there were some nuggets of truth in my parents' ideology and where it was just wrongheaded. I'm trying to find a more sane way of approaching these questions, especially with medicine. The biggest problem with the health care debate right now is that people are not approaching the subject in a sane way.

Q: And how did this tidbit end up coming your way?

A: It's not a huge secret. It's just that nobody had poked around in this particular area before. The state of California had put together a report about it, but it hasn't been published yet. They had published some of the findings, and those are what I saw in about February of 2009. So I started to call the researchers. They told me about this finding that had not been published that showed that maternal mortality had more than doubled in California in the past decade. The California Department of Health had actually put that figure on a graph and posted it in the nethermost bowels of the internet, but nobody saw it because, even though it was public information, it was not part of any sort of big push.

Q: What was the first public records request that you made?

A: I didn't really make any official public records requests. I asked if I could see the report back in June of 2009. I didn't request the report officially because it wouldn't have been covered under the CPRA. And the state was actually being really cooperative in the beginning. When you're dealing with state public relations people they can be very nice. They said, "You'll be the first to know when we actually release the report." Then six months passed.

Q: What other records were you denied?

A: I asked for any emails or memos on the report to see if anyone had sent something from the governor's staff saying let's hold onto this. And there was nothing that I came across like that. We also were having a really hard time finding people to come forward and talk about this. So we asked for the death certificates from 2007 and ended up paying the state to filter out just the pregnancy-related death certificates.

Q: What did that turn up?

A: They sent me a spreadsheet of 106 deaths that were pregnancy-related and 95 that were maternal mortality. The higher number includes people like Nancy Barnes, who had a C-section, and they nicked her bowel while they were doing it. She survived for nine months and then when her colostomy bag was removed, it caused all this scarring and obstructed her bowel and killed her. She is not counted in the 95. But her case is pregnancy-related.

Q: Let me ask a potentially simple-minded question. Why didn't you just go through the data yourself and decide what was a maternal mortality case and what wasn't?

A: I did look at the raw data for 2007 to find names, and it became clear quickly what a disadvantage a reporter would be at if he or she took that raw data and tried to duplicate those findings. The raw death certificate information is just kind of a mess. The death certificate might say "hemorrhage" and then be marked "pregnancy-related." That's it. You have no idea what that means, what caused the hemorrhage.

Q: Did you get any autopsies on any of these women?

A: No. I didn't drill down that deep.

Q: So how did you end up trying to contact these women's families?

A: I tried to contact everybody, basically. The state said it was not allowed to release the names of their parents or their husbands. They did give me the first initial of husband's name. And so that gave me a clue. And they gave me the address where the woman lived, the date of birth and date of death. I just started trying to find phone numbers for those addresses. Probably 80% of the people had moved between 2007 and now. I got the impression that when a young woman dies in a family, it sort of breaks everything apart. People just want to get away. I also sent a bunch of letters. Not one person responded to the letters. A few people I got in touch with on the phone said, "I really don't want to talk about this." Of the rest, there was just dead air. Every single person I found was through the activist community. People who decided that they wanted to fight for fewer medical errors.

Q: You didn't find any through lawsuits?

A: Some of these people had filed lawsuits, but that was kind of a secondary thing. When we were looking at the entire state of California, it was prohibitive to go through and look at all the county courthouses for lawsuits.

Q: But couldn't you use Merlin and Nexis and other services to find those?

A: I looked through Nexis, and California Watch has a database. But it's not a common thing, so there are not many lawsuits. Also, a lot of them will settle out of court or during mediation before they get to court. If the child dies, then there's a real incentive to go through the legal system because you can get damages for all the years that child would have lived, but it's much harder to push the case for a young woman who dies. The baby could have ended up being the next Bill Gates, but not mom.

Q: You mention that you spoke with investigators who wrote the report. How did you persuade them to talk with you and to use their names?

A: I was surprised how easy it was to get them to talk. They wanted this information out there because they had put a lot of work into it. One detail that's not included in the story is that the state told me it is still making revisions on this report, and yet the researchers said they haven't been asked to make any revisions in the last six months.

Q: Revisions being made without the researchers? That sounds ominous.

A: I have spent a lot of time thinking about this and a lot of time talking to all the different people involved. I don't think it's someone reaching down and saying, "California has six crises right now and we can't afford a seventh." I think it's just that California has a really big budget problem that is forcing state workers to take furlough days, and that has made the process achingly slow. This report is probably sitting on someone's desk, ripening until it reaches the correct vintage.

Q: Maternal mortality is not very high on the radar in the US because there are so few deaths. How did you decide where to go for outside expertise?

A: There are a select group of people who are really working hard on this issue. I just spent enough time working on this topic that I managed to talk to nearly all of them. The American College of Obstetricians and Gynecologists has a special group devoted to this. There are various advocacy groups who are interested in this. And doctors in general are really interested in this. If a woman dies in your hospital in your care, that can shatter your career. It also can completely change the mood of the place. Even if it's not your patient it goes from being a really happy place where all these babies are coming into the world to casting this pall over the entire labor and delivery department.

Q: Did you find out how the Joint Commission was able to make the statement that "maternal mortality rates may be increasing in the U.S."?

A: The statement they made on it was very cautious. I took the strongest thing that they said. When the Joint Commission talks everyone pays attention, so I knew that would be important for the story. Their numbers are just what hospitals report to them. I think that their number was 85 for the entire US. But obviously that's far too low if we have 95 in California in just one year.

Q: It could be a huge underestimate, and yet they still think it's something to make note of.

A: Exactly. Because they had numbers from earlier years that were underestimates as well. Suddenly the numbers, right or wrong, are creeping up.

Q: So the Joint Commission was helpful. That's not the typical health reporter's experience.

A: I didn't get a lot of help from them because they weren't really focusing on this to the same degree as ACOG or other groups. The National Quality Forum, for example, had come out with a whole new perinatal package, which is interesting to look at. Some of these low-tech, high-touch theories are incorporated into that.

Q: Speaking of low-tech, high-touch, when did you start zeroing in on C-sections as a possible culprit for the rise in maternal mortality?

A: Very early. My first question was, "Why is this happening?" Everybody told me, "We don't know, but the one thing we can tell you is that there has been one big quantifiable change in practice in the last 10 years." And that was the change in C-sections. But C-sections are not the only factor and may not even be the largest factor. But it was obvious and was an area where we could make an improvement. We know how to do this. The obesity thing is probably an issue as well. But that gets to fundamental lifestyle choices and changing our society.

Related Posts:

Q&A with Nathanael Johnson, Part 2: The side effects of too much health care