Bellevue Hospital Could be Another Weak Link in the City’s Maternal Mortality Crisis.

By: Sarah Karpati

Jose Perez stands tall in his newly adopted uniform, if for no other reason than to honor the person whose name it bears. In all capital letters the back of his black jacket reads, “Woodhull Medical Center Murdered Christine Fields.”

“I only chose to have that [text] because no one ever sat me down and said, ‘This is what happened.’” Perez said. “All they did was give me heartaches.”

Fields, 30, a Black woman, died at NYC Health + Hospitals Woodhull in Brooklyn after an emergency C-section, becoming yet another casualty in the country’s Black maternal mortality crisis.  

Fields’ death in 2023 brought a spotlight to Woodhull’s labor and delivery department. 

But a Columbia News Service (CNS) investigation found another city-run hospital, NYC Health + Hospitals Bellevue, is also failing to uphold quality of care to their patients and failing to address weaknesses to avoid future incidents. 

Bellevue is the only city hospital equipped to provide the highest level of care to mothers and infants, making it an essential part of maternity care offered by the New York City hospital system. 

But according to the New York City Department of Health, multiple incidents of substandard patient care led to adverse outcomes for both mother and child at Bellevue.

In New York City, Black women are six times more likely to die due to pregnancy-related conditions than their White counterparts, double the national rate. 

Since 2010, the city’s DOH has been tracking an increasing trend of deaths of pregnant or recently pregnant women.

According to the Maternal Mortality Committee within the DOH, 75% of pregnancy-related deaths between 2016 and 2020 were preventable, 5% fewer than the national rate. 

It identified a lack of clinical skill, quality of care, continuity of care, and care coordination as the top factors that led to preventable deaths.

But in an audit published this year by the Office of the State Comptroller, the same committee’s efforts have not resulted in effective changes to the rate of maternal mortality in New York City. 

Most maternal deaths occur in the twelve months postpartum, or after a woman has given birth. On June 14, 2023, New York Medicaid and Child Health Plus (CHPlus) extended the duration of postpartum health coverage from 60 days to a full year following pregnancy.

While health officials hope this will reduce maternal mortality in the state, according to the Comptroller's analysis, “We found DOH needs to do more to ensure that maternal mortality and morbidity rates decline.”

After the death of his first wife in 2018, Perez, was left a single parent of two sons. 

Fields, also a single parent, had seen Perez around the neighborhood and made an effort to offer him her condolences and a hug. 

“I brushed Christine off because I really wasn't looking for a relationship.” Perez explained. “ I wasn't looking for nobody to love on, nothing, because I was going through a lot.”

Perez eventually began to regularly babysit Fields’ one-year old son Liam. 

“I started bringing him over to my older children and they fell in love with him,” said Perez. “And Christine just ended up falling in love with me because of the way I was with Liam.” 

Together Fields and Perez had a daughter, Nova, and got engaged in 2021.  

They had planned their wedding for 2023, but when they found out Fields was pregnant, they postponed it to 2024. 

Fields never made it to their wedding day. 

According to the Maternal Mortality Committee 80% of maternal deaths in NYC occurred in a hospital setting. 

CNS reviewed data collected by the city and determined that at least 55% of preventable deaths occurred in a hospital. 

Perez believes his fiance’s death could have been prevented. 

According to a lawsuit filed by Perez against the NYC-run Woodhull, hospital staff “were careless and negligent in the medical care and treatment” that they provided to Fields; resulting in a series of injuries that caused or contributed to “Christine Fields’ wrongful death.”

Fields was also a Medicaid recipient. 

While the hospitals these deaths occurred at are kept confidential by the DOH, according to city data, 72% of pregnancy-associated deaths happened to individuals on Medicaid. 

According to NYC Health + Hospitals own documentation, more than 70 percent of the patient population served by the city-run NYC Health + Hospitals system relies on Medicaid. 

This data suggests that a significant percentage of maternal deaths could be occurring in NYC Health + Hospitals. 

Together, Woodhull and Bellevue have been subject to DOH investigations spanning the years 2018 - 2023.

At Woodhull, DOH investigators found that medical staff in the obstetrics and gynecology department (OBGYN) were not held accountable for the quality of their care which at least once directly caused the death of a patient.

Furthermore, according to the investigator, “Incidents and adverse events related to the administration of anesthesia in the Obstetrics and Gynecology Department were not reported, tracked, analyzed and plans of correction implemented to ensure patient safety and improve health outcomes.” 

All hospitals are required by the state to have and enforce a Quality Assurance and Performance Improvement (QAPI) program to analyze and prevent adverse outcomes. Although a QAPI program exists at Woodhull, according to the investigator, it was not enforced. 

Bellevue, like Woodhull, has also been cited by the DOH for not implementing the necessary changes to improve patient outcomes. 

According to their investigation, on January 21, 2022, an unnamed pregnant woman arrived at Bellevue at 6:46 am with abdominal pain. She had fallen on her stomach and noticed her fetus’s activity had slowed down. 

Investigators confirmed that at 7:10 am the fetal heart rate (FHR) was documented as 155 beats per minute (bpm), within the normal range of 110 to 160 bpm. 

Five minutes later, the fetal heart rate dropped to 100 bpm. 

“A rate below 110 bpm for an extended period of time is cause for serious concern,” said Dr. Christina Flores, an OBGYN at NYU-Langone. “When this happens, babies should be delivered within 10 minutes.”

While this drop was recorded by Bellevue’s monitor, its staff did not catch it for more than 25 minutes. Even then, nursing staff did not escalate the issue, per Bellevue’s policy, as they claimed that all available doctors had been called away to the emergency room for a separate delivery. 

At 9:30 am, two and a half hours after the patient arrived, a doctor was finally notified and performed an emergency C-section. 

The baby boy was breach, or upside down. His skin was blue, and his umbilical cord was wrapped around his neck and body. 

The baby died.

The DOH report concluded that the Bellevue Labor and Delivery unit’s care “...resulted in serious adverse outcomes” and “places all patients in the Labor and Delivery unit at risk for serious adverse outcomes.” 

Four months after the stillbirth of the unnamed woman’s baby and in response to the DOH’s statement of deficiencies, the hospital outlined two steps they would consider taking. 

The first was to update its staffing structure on Friday mornings to create better coverage for patient care. The hospital also pledged to assess management of abdominal trauma in pregnant women if an autopsy identified issues.

During the same DOH follow-up visit, the Associate Director of Clinical Standard at New York Health + Hospitals acknowledged that they do not “do a formal review of patient incidents” and that there was no system in place to count the number of incidents or occurrences, and there were too many incidents for them to count. 

Seven months after the unnamed woman’s case, the state found that the hospital showed no evidence that any corrective actions were taken. 

It placed Bellevue Hospital under a “Immediate Jeopardy (IJ)” designation, meaning the hospital was actively placing patients at risk for serious injury, serious harm, serious impairment or death. 

Only then did Bellevue compile a comprehensive list of corrections that had been implemented.  

Still, nine months after the initial incident the DOH returned and found that in ¾ of the medical records they reviewed, patients were not assessed by an obstetrician within 30 minutes of their arrival, something the hospital had pledged to do three months earlier.

Bellevue has also shown a lack of quality of care in 2018. Micaela Balbuenas, 38, a Hispanic mother of three and born in Mexico, is currently suing Bellevue after delivering her son stillborn on July 31st, 2018. 

According to a review of Balbuenas’ medical records, the hospital staff regularly failed to adhere to New York State rules and regulations to ensure she was provided translation services. 

Bellevue knew as early as 2016 that Balbuenas did not speak English. 

Regardless, the hospital's staff regularly spoke to Balbuenas in English rather than her documented language of Spanish. 

During several hospitalizations, she was supposed to receive treatment and education about her diabetes - which can directly cause stillbirth - in her native language. 

Instead, Balbuenas was labeled “medicine and diet non-compliant” after she failed to show any improvement in her blood glucose levels while under Bellevue’s care. 

According to the Maternal Mortality Committee patterns of discrimination can be identified by auditing descriptions in clinical records for language such as “non-compliant.” 

Only at 27 weeks pregnant did a provider document that Balbuenas was illiterate. 

“Of note, at time of discharge nutrition and medication counseling it became clear that patient cannot read and is illiterate.” a provider emphasized using asterisks in Balbuenas’ records.

Paradoxically, prior providers had written that she “learns best by reading.”

When Bellevue finally recognized Balbuenas’ limitations and adjusted their treatment style, Balbuenas’ blood sugar levels showed a steady improvement in her overall health. But due to the delays in her proper care she remained at risk of stillbirth.

On July 31st, 2018, days away from her scheduled C-section, Balbeunas arrived at Bellevue complaining of decreased fetal movement. 

Upon examination, no fetal heart rate was found. Balbuenas was induced later that night, delivering her son, dead.

The lawsuit is still ongoing. 

Bellevue and NYC Health + Hospitals deny all accusations in the lawsuit. NYC Health + Hospitals did not respond to a CNS request to comment. 

Perez vividly remembers the day he lost Fields. 

 On November 12, 2023, Fields went into labor and hurried to Woodhull for her delivery. 

At about 11 p.m., hospital staff rushed into the room. “They said the baby’s heart rate had dropped,” Perez said. Fields was rushed into the operating room for an emergency C-section. 

Perez didn’t see Fields again until 2:30 am the next morning. 

After checking on his newborn baby, Perez joined Fields in her recovery room. He was not prepared for the condition she was in. 

“I come to show Christine a picture of the baby and, at this point, Christine doesn't look like she's here no longer,” said Perez, tears in his eyes. “Her lips are gray, really dry, ashy; her tongue is literally like, hanging out the side of her mouth.”

Perez’s first wife had died of cancer in a hospital room just five years earlier. Looking at the condition Fields was in, he recalled what his first wife had looked like moments before she died.

“Just the way she slumped to the side, something hit me differently and I got scared,” said Perez. 

With no nurses in the room, Perez called a nurse to Fields’ bedside.

“She then runs into the room… She didn’t even touch Christine, she just looked at her and then she called a code blue.” 

According to Perez, hospital staff kicked him out of the room. When he returned, “I can see Christine is lifeless already,” said Perez.

Fields was briefly revived, then transferred to the ICU, where she died shortly after due to a hemorrhage, according to Perez.  

Perez’s case against Woodhull is one of five lawsuits CNS has identified against Woodhull’s Labor and Delivery department.

Sandra Fuentes, a 38-year-old Hispanic woman from Nicaragua alleges that in 2018, Woodhull hospital “failed to provide prenatal care, labor and delivery, and treatment of multiple severe birth injuries and developmental delays.” 

According to her complaint, Fuentes was cleared by doctors to deliver vaginally. She alleges doctors failed to account for her history of “shoulder dystocia,” where a baby’s shoulders get stuck during delivery. 

“Every minute that a baby is where the head is out, stuck on the shoulders or not, the baby is really not getting much oxygen…particularly the brain,” according to a consulting expert, Flores. 

According to Fuentes’ lawsuit, the shoulder dystocia caused oxygen to be deprived to her infant, which led to developmental delays and extensive and continued therapy.

Ultimately, Fuentes needed to undergo an emergency C-section. 

While Woodhull is staffed to handle most perinatal cases, some situations necessitate additional care. Due to its special designation babies requiring specialized care are sent to NYC Health + Hospital Bellevue. 

In Fuentes’ case, the infant was transferred to Bellevue to treat it for the lack of oxygen it received during birth. 

The complications Fuentes experienced are categorized by health professionals as a severe maternal morbidity case. 

Severe maternal morbidity is a term used to describe cases that include unexpected outcomes of labor and delivery that result in significant short or long-term health consequences. Simply put: cases that had serious complications that may not have led to the death of both the mother and fetus, but could have; or could in the future. 

While NYC does not publicly record how often morbidity cases like this occur, according to the Centers for Disease Control and Prevention (CDC), severe maternal morbidity is on the rise across the United States.

In response, the CDC developed a comprehensive list of medical conditions that state and city health departments can use to track severe maternal morbidity (SMM) rates in local hospitals.

Without this data, the state DOH has no reason to investigate hospitals until after a hospital reports a death, or when a patient submits a complaint to the DOH directly.

According to an audit authored by the New York State Comptroller this year, if the DOH collects and creates a system to analyze severe maternal morbidity data, conditions like an increased number of stillbirth cases could be caught early.

DOH investigators would have the data to evaluate which hospitals require their interventions and where to allocate extra support or training before a mother dies rather than waiting for a maternal death.

The audit continues to say “DOH does not collect severe morbidity data and has no analytic strategy to evaluate it, thus limiting its ability to effectuate change.”

Now raising three children on his own, Perez honors Fields by lobbying for the passage of the Grieving Families Act in New York State.

Due to a 150-year-old wrongful death statute in New York State, families of the deceased cannot recover damages for emotional suffering they allege was caused by negligent parties. 

According to the bill’s sponsor New York State Senator Brad Hoylman-Sigal it would serve to “permit the families of wrongful death victims to recover compensation for their emotional anguish.”

As it stands, families can only receive “pecuniary compensation” or compensation for strictly financial losses that can be quantified. 

“It is ironic and contrary to public policy that currently a wrongdoer may take advantage of the law that makes it cheaper to kill someone than to seriously injure them,” Senator Hoylman-Sigal said in a statement.        

On December 21st, 2024, for the third year in a row, Governor Hochul vetoed the bill citing the potential for “higher costs to patients and consumers, as well as other unintended consequences.” 

Disappointed, Perez has not given up on getting the Grieving Families Act passed and remains an outspoken activist regarding maternal mortality. 

“I never thought I was going to be standing in front of the news,” said Perez. “I always shied away from that.”“But I'm going to keep fighting for justice and I'm going to keep continuing to do what I do.”