Federal investigators looking into the treatment of Black pregnant patients at Cedars-Sinai Health System have found evidence that federal laws against discrimination may not have been followed, according to a “letter of concern.”
“Our investigation has uncovered evidence that Cedars-Sinai may have engaged in a pattern of inaction and/or neglect concerning the health risks associated with Black maternity patients,” the U.S. Department of Health and Human Services Office for Civil Rights said in its Nov. 12 letter to Cedars-Sinai officials.
The federal agency said its review, which began more than two years ago, hadn’t reached any “final determinations” about whether Cedars-Sinai violated federal statutes against discrimination.
However, its letter said its investigation to date “raises concerns that a lower standard of care is provided to Black patients compared to their white counterparts — especially leading up to and during obstetric hemorrhage.”
The Office for Civil Rights urged Cedars-Sinai to take several steps to ensure it was complying with federal law. Doing so, it said, “would allow us to suspend our investigation and work towards voluntary resolution of this matter.”
In a statement, Cedars-Sinai said that “we respectfully disagree with the department’s assertions but pledge to continue working to improve maternal health equity.” It thanked the federal department for its work and said the health system shared its concerns about racial inequities in maternal care nationally.
The health system said it had started instituting measures to improve health outcomes for Black mothers well before the initiation of the federal review, including introducing implicit bias training for obstetrician-gynecologists and nurses, creating new roles focused on “equity for patients and inclusion among our work force,” and distributing more than $2.2 million in grants to local nonprofits working to improve Black maternal health.
Cedars-Sinai also emphasized that “the recent department letter contains preliminary findings with no final conclusions or decisions.”
An HHS spokesperson confirmed that, saying that the letter is “only a preliminary document that does not contain any formal findings of noncompliance” and that Cedars-Sinai had cooperated throughout the investigation.
“We look forward to their continued cooperation and work towards reaching a voluntary resolution soon to improve upon health disparities and maternal health outcomes — a goal shared by Cedars-Sinai and HHS,” the agency spokesperson said.
In its letter, the Office for Civil Rights said its investigation suggested that Cedars-Sinai had deviated from its own standards on hemorrhage care with respect to Kira Johnson and other Black patients.
Johnson died at Cedars-Sinai Medical Center in Los Angeles after a caesarean section eight years ago, spurring a public uproar and lawsuits by her husband against Cedars-Sinai and several physicians, which were ultimately settled. Her death was the result of hemorrhagic shock due to blood loss, according to the letter.
The federal office said it had scrutinized medical records, testimony and interviews that “showcase how severely delayed Kira Johnson’s diagnosis and care was.” Cedars-Sinai medical staff had failed to follow up on imaging and lab orders and delayed taking Johnson back to the operating room until nearly 10 hours had passed since her C-section, the letter said.
The Office for Civil Rights added that in an interview with the office, a doctor who had attended her, Arjang Naim, “espoused stereotypical, non-scientific opinions about Black women,” including that Black patients respond differently to hemorrhaging than white patients and “don’t complain as much about pain.”
Dr. Naim “purported to attribute to his opinions to the medical literature,” but was unable to provide any citations when prompted, the letter said. The Office for Civil Rights said its review also found that Naim had failed to provide appropriate care for at least four other Cedars-Sinai maternity patients while he had privileges there.
Naim didn’t immediately respond to a request for comment Tuesday. The physician went on probation, which he completed two years ago, after being accused by the Medical Board of California of “gross negligence” in his treatment of several obstetric patients.
Black women in California have suffered a maternal mortality rate more than three times that of white women in the state. Health researchers have faulted numerous factors for that disparity, including inequities in healthcare, chronic conditions and structural racism.
In its letter to Cedars-Sinai, the federal office said that it examined records of 38 patients who had suffered postpartum hemorrhaging. In 14 of those cases, the treatment concerned investigators as “potentially deviating from protocols” partly because of race, the letter said.
In one instance when a Black woman suffered postpartum hemorrhaging, “management of her bleeding appeared severely delayed” and out of step with Cedars-Sinai guidelines, the letter said. In contrast, a white woman with similar signs of hemorrhage “appears to have received care in line with the guidelines.”
Federal investigators also said they had been reviewing other alleged incidents of racial discrimination reported by patients, including a Black patient who alleged she was denied an epidural injection or medication for pain, although they did not issue findings on those allegations. Data from Cedars-Sinai show that on average, Black patients reported higher levels of postpartum pain compared with their white counterparts, the letter said.
The federal agency also stressed that Black women consistently had higher rates of caesarean sections than other Cedars-Sinai patients and lower rates of a successful vaginal delivery after a previous caesarean. C-sections can save lives in some circumstances but also have a higher risk of hemorrhage, the office said.
Its said its review suggested that doctors for Johnson “steered her towards a non-medically indicated repeat C-section without fully disclosing the benefits and risks.” Doing so “may suggest motivations of racial bias or false notions that Black women are poor candidates” for vaginal birth after a C-section, the office said.
Cedars-Sinai had acknowledged the need to improve Black maternal health and put additional policies in place after Johnson died, the letter said. Despite those efforts, “there is evidence that the problems continue,” the civil rights office concluded.
It urged the health system to take additional steps, including creating an online tool for patients to report incidents of suspected bias. The office also called for the health system to provide the federal agency with its written policies and protocols for any “early maternal warning systems” designed to prevent maternal deaths, among other recommended actions.
Taking such steps could lead to a “voluntary resolution of this matter rather than further, protracted investigation with possible enforcement,” the civil rights office said in its letter.
Nick Rowley, an attorney representing the Johnson family, said the federal agency had outlined “steps in the right direction,” but amid “this epidemic of Black women dying in healthcare, dying in labor and delivery, baby steps aren’t going to stop this from happening.”
“We need radical change if we’re going to save lives and keep Black mothers from dying,” Rowley said.