Spotlight on David C. Lagrew Jr., MD

There is perhaps nothing more tragic in healthcare than a mother dying from childbirth. Advances in medical technology and practices during the past century had reduced maternal mortality in the U.S. to less than 0.01% by the 1990s. Unfortunately, and surprisingly, these rates are on the rise again, though thankfully still far from the levels seen in the first half of the 20th century.

Serving Earlier in his career, during a fellowship at Long Beach Memorial Hospital, he was part of a care team that witnessed the post-partum death of a mother from a massive hemorrhage caused by a placenta percreta, brought on by multiple scars from previous C-sections. The experience left a lasting impression on the young doctor.

“Any maternal death is traumatic on anybody. Obviously, for the mother’s family and loved ones, it’s the biggest deal. But for the treatment team, it’s a real personal thing. You go through a lot of reflection on ‘what could I, or we, have done differently?’”

The incident helped motivate his career-long search for ways to prevent future negative outcomes for mothers and their babies. During the next 25 years at Saddleback, Dr. Lagrew worked on bringing down C-section rates and improving emergency response to crash C-sections, maternal hemorrhaging, hypertension, and other potentially fatal delivery complications. In 2006, he was asked to join the newly formed state-funded California Maternal Quality Care Collaborative (CMQCC), whose mission is to end preventable morbidity, mortality, and racial disparities in maternal care throughout the state.

For the first time, Dr. Lagrew was exposed to maternal mortality on a large scale. CMQCC was launched as a response to California’s rising maternal mortality rate, which by 2005 had risen back to levels not seen since the 1970s and 80s. All the work he had been doing throughout his career to improve maternal health and safety was being wiped out, statistically speaking.

One of Dr. Lagrew’s initial tasks with CMQCC was to work on a toolkit to address maternal post-partum hemorrhage. He also co-chaired a taskforce to create a toolkit for reducing first-time cesareans, a primary risk factor for maternal hemorrhaging in subsequent deliveries.

Since no one knew for certain why C-section rates continued to climb, his work with CMQCC centered on getting at the root causes. Among the new factors, more patients now are older—the number of women over 35 and 40 having babies has increased remarkably. Also, more patients are heavier due to the obesity epidemic. And an unprecedented number of women have had a prior cesarean. Uterus rupturing, blood clots, infections, and the need for transfusion all go up in mothers whose first delivery was by cesarean when compared to rates for mothers who have already had a vaginal delivery—the safest type of delivery. Hence, the current focus of his work with CMQCC is devising and implementing a long-term strategy to reduce the rate of first-time C-sections.

“Bottom line is if we can bring the C-section rate back to lower levels, there won’t be as many placenta accretas and blood clots. And of all the risk factors for maternal mortality, it’s the one we can modify. It can be done safely, but it’s not an easy task.”

In fact, a study Dr. Lagrew conducted at Saddleback in the early 90s showed that the C-section rate can be cut in half in a private hospital setting and result in a greatly reduced number of complications for mothers and their babies.

According to Dr. Lagrew, the present challenge is that mothers are focusing on what’s the risk right now to themselves and their baby and aren’t looking the cumulative risk. With the rates of placenta accreta and post-partum hysterectomy almost doubling, along with increases in maternal mortality, it’s essential that doctors continue to address this issue with mothers to be.

The good news is, through focusing on risk factors in California, the CMQCC has seen maternal mortality rates drop in the state, according to 2014 data, to what they were in the mid-90s from the increase seen in the mid-2000s. The rate is currently back to 7–9 per 100,000 births. However, the overall mortality rate nationally has increased to 20 per 100,000. And given that California makes up one in five deliveries in the U.S., the mortality rates in other states are increasing that much more.

“Most of the time the baby lives. So now you have a child that will not only never see their mother, but their own birth will be tied to that loss. That’s why the impact of the Patient Safety Movement’s work is just so critical for us.”

Being part of the PSMF also enables Dr. Lagrew to take his work and lessons learned in California to the national and international level while continuing to learn from others in the field.

“This isn’t the sort of thing you declare a victory on and go home. This is an ongoing process. We are always trying to figure out how we can be a little safer. Our foremost goal is quicker, easier, and safer deliveries.”

Looking to the future, Dr. Lagrew is concerned with how to train the next generation of people who are going to make medicine safer and more effective.