Karen Lynn Moats had been waiting a lifetime for this moment. It was late afternoon July 8 when she reached out to cradle her newborn son.
"Now we've got our family," Karen said to her husband, Todd, as they gazed at their 7-pound, 2-ounce infant and his head of dark hair. They named him Joshua Thomas.
Two-and-a-half days later, Todd Moats stood in the nursery at Hagerstown's Washington County Hospital, holding Joshua and praying as an emergency medical team rushed past in the hall.
His 25-year-old wife was in cardiac arrest.
Karen Moats died from complications of pregnancy and childbirth, joining a surprising and persistent number of women who lose their lives in becoming mothers.
Despite the widespread but false impression that women don't die in childbirth anymore, at least 30 women in Maryland lost their lives this way during the past three years, including 11 in 1995. Nationwide, at least 320 women died of complications from childbirth in 1992, the latest year for which national figures are available.
The rates tell the story: In 1940, the rate of maternal deaths was 364 per 100,000 births nationwide. Since then, the rate has plummeted a remarkable 98 percent. But in recent years, progress has halted, with the rate hovering at about eight per 100,000 births.
"In 1995, I think one or two deaths is almost intolerable, especially with the technology we have today," said Dr. Clarice Green, a medical epidemiologist in reproductive health at the U.S. Centers for Disease Control and Prevention in Atlanta. "We need to really crack down and find out what's going on. Why are infection and hemorrhage still major causes of death?"
In some ways, the advances of the past half-century have fostered a complacency that pregnancy is routine rather than potentially dangerous. But it is a precarious time in which any weakness in the mother's body is exposed. Her cardiac output surges, blood volume increases by about a quarter and blood vessels expand to accommodate the new life. For some women, the strain is too much.
Some experts say care of new mothers in the first few days after the baby is delivered -- at the time they are most vulnerable to blood loss -- has become lax.
"We don't have a continuum of care. As soon as the baby is born, we think it's all done, and we let go of the meticulous monitoring of the mother," said Dr. Dyanne Affonso, dean of the Nursing School at Emory University in Atlanta.
The revolution shaking the country's health care system -- including the overhaul of nursing staffs and shorter stays for new mothers -- also poses threats.
Meanwhile, cases of maternal death are vastly underreported. Death rates two to six times higher than shown in vital statistics reports have been found by various researchers cited in a 1992 CDC review. The gap makes it difficult to track causes, detect trends and train physicians in ways that might save lives.
"There's no national effort to systematically look at these events and say what's happening, and why are they happening, and the societal impact is substantial," said Dr. Jeffrey King, chairman of an American College of Obstetricians and Gynecologists group on maternal mortality. "These are frequently young women who have many years ahead of them, and that is lost."
Maryland victims include:
* Teresa Asid-Oechsler, 33, who died a year ago after suffering complications during the birth of her son, Ryan Alexander. It was the first pregnancy for the Sykesville woman, an engineer at Westinghouse Electric Corp.
* A 35-year-old Baltimore woman, who died Jan. 1, 1995, at the moment her daughter was born. The woman, whose family asked that she not be identified, was in the late stages of her second pregnancy when she began to experience symptoms from an irregular heartbeat, and later developed pre-eclampsia, a pregnancy complication that in rare cases leads to death. Doctors could not stabilize her blood pressure or pulse. Said her husband: "When we went to the hospital, we went there thinking, 'We'll be home soon with the baby.' "
* Susan Moy, a 22-year-old Edgewater woman who died a week after giving birth to her son, Richard III, at Anne Arundel Medical Center in 1986. The family's attorneys charged that two Annapolis obstetricians failed to recognize and treat pre-eclampsia. By the time she was transferred to Johns Hopkins Hospital, she was brain-dead. Her husband has had to live with the words of a Hopkins physician: "If we had her earlier, we could have saved her." A jury in 1992 awarded her husband, Richard S. Moy II, and their son $3.5 million, which the court in 1993 reduced to $1.5 million.
The families are left to care for the infants and to attempt explanations they don't have themselves. At the funerals of several Maryland women, including Karen Moats, hundreds of incredulous mourners asked how the young mothers could have died at the happiest moments of their lives.
"Someone's going to tell me why, in 1995, a young, otherwise healthy 25-year-old girl dies having a baby," said Mrs. Moats' mother, Barbara Oyster.
Ultimately, the family decided to have her body exhumed and autopsied -- and even endured a second graveside service -- to get the answer. In the fall, the state's chief medical examiner changed the official cause of Mrs. Moats' death from heart disease linked to pregnancy to cardiac arrhythmia brought on by blood loss. Her family has filed a malpractice suit, charging that her physician and the Hagerstown hospital neglected her and then lied about what killed her.
Except for anemia that was easily controlled through vitamins, Mrs. Moats had always been healthy. Her case shows that even when a pregnant woman takes care to do everything right, she still faces a risk of dying.
A bubbly young woman
It was an ending that no one could have imagined for Karen Moats.
The Oysters' youngest child grew up in Hagerstown in a familiar world of piano and ballet lessons, 4-H projects -- one involving 13 Labrador puppies -- and three siblings. The bubbly teen-ager met her future husband at a high school dance. It was near the end of the evening, and they danced every dance together after that.
Although they split up when she pursued a business degree and he went into the Army, Todd called her from the Persian Gulf war to tell her he loved her.
They married in 1991.
She won awards for her work as manager of women's clothing stores and organized her life with the same care and detail. Having children, buying a house and maybe someday running her own boutique were her dreams.
When she had difficulty becoming pregnant, her first dream seemed almost out of reach. She bought pregnancy tests in double packs and lavished attention on her nieces.
"She wanted a baby so bad she didn't know what to do," her mother said.
Karen finally got the news she yearned for in the fall of 1994, and revealed she was expecting in a poem she gave her parents Thanksgiving Day.
In the first months of her pregnancy, she woke up sick in the mornings. But in the evenings, when she felt better, she was "joyous," her husband said. She read books about babies, picked out names and cross-stitched teddy bears turning cartwheels to hang over the crib.
Along the way, she kept track of her health in a pregnancy planner, from cravings for bacon and ice cream to when she started to show. "Getting excited!" she wrote. In anticipation, she pushed an empty stroller in her parents' front yard. Some days, she lay in bed, playing a lullaby tape, rubbing her stomach and talking to her developing child.
But as the months passed, family and friends noticed she became pale and weak. Her worried mother began to accompany her to routine appointments with the obstetrician, Dr. Louis V. Gabaldoni of Hagerstown.
Dr. Gabaldoni has refused to discuss Karen Moats' treatment. His attorney, Richard Stuhr of Baltimore, said, "I don't want to try this case in the press."
In late May, Dr. Gabaldoni told Mrs. Moats she had toxemia, another term for pre-eclampsia. One in 10 women pregnant for the first time will develop this poorly understood syndrome. Common yet dangerous, pre-eclampsia is often unpredictable in its onset and progression, and doctors don't know what causes it.
In pre-eclampsia, the kidneys often are damaged, causing them to filter the blood improperly. Proteins that should be retained by the body instead are expelled in the urine, a sign the woman may have the condition. Other hallmarks are high blood pressure and swollen face and hands. Physicians try to treat the symptoms, but eventually, the only way to cure the mother is to deliver the baby.
A small proportion of the women who start with pre-eclampsia ultimately die from complications.
At Karen's baby shower the first Sunday in June, about seven weeks before she was due, guests could tell she felt miserable, although she tried to hide it. She was placed on strict bed rest that week. In accordance with nationally accepted guidelines, Dr. Gabaldoni told her to check her blood pressure several times a day, and he gave her blood and urine tests weekly.
Unable to shop for her husband's 26th birthday, Karen made him a card on their computer. "Thank you for taking such good care of me the last few weeks," Karen wrote. "Our little baby will make all of this worth while. I guess you'll be getting a birthday gift out of me anyway!"
During her darker moments, though, she feared the worst. In June, she called a close friend.
"She was crying," recalled Nicki Weedon. "She said, 'I'm going through all this, I'm sitting here looking at all the baby stuff,' and she was scared. She was scared she was going to die."
In late June, she was hospitalized overnight to monitor her blood pressure. On July 6, during a regular doctor's exam, her high blood pressure, blurry vision and swelling persuaded Dr. Gabaldoni to send her to Washington County Hospital to induce the birth.
Just before she left home, she replayed the video of her sonogram a last time. It made her feel that everything would be all right.
A stressful phenomenon
Pregnancy is a serious condition that causes major changes to a woman's body.
"It's one of the most physiologically stressful phenomenons you can go through," said Dr. Evan Mortimer, the state's assistant medical director of maternal health and family planning.
After delivery, it's considered normal for the mother to lose as much as a liter of blood, Dr. Mortimer said. That can amount to nearly 20 percent of the average adult's total. Sometimes, internal or external bleeding can be difficult to stop and leads to death. In other cases, clots form in compressed blood vessels in the pelvic area and migrate -- fatally -- to a lung. Fatalities also stem from cardiomyopathy (a heart muscle disorder), complications from pregnancy-induced hypertension, or difficulties with anesthesia.
Worldwide, about 585,000 women die in childbirth every year, thousands more than previously estimated, according to a report released last week by the World Health Organization. In some parts of the world -- Sierra Leone in Africa, for example -- one woman in every seven dies of pregnancy-related complications, mainly from lack of health care.
But in the United States, maternal death is rare. In Maryland, experts say women have a much higher chance of being killed in a car crash.
"It's just like a traffic accident is a big deal and horrible and devastating thing. It's not something that you can predict terribly well," said Dr. David Nagey, director of maternal-fetal medicine at the University of Maryland Medical Center. "You could obey all the laws and still get clobbered. The same is true for this."
But some pregnant women face a higher risk of dying. "For certain groups, it's a major problem," said the CDC's Dr. Green. "If you just look at the overall rate, we're masking the picture."
Women with no prenatal care, particularly poor teen-agers, have a risk nearly six times higher than women who receive adequate care. Public health experts fear that risk may increase with cuts in federal and state health programs. African-American women as a group, older women and those with underlying chronic disease, such as lupus or diabetes, also face a higher risk of dying.
Karen's diagnosis of pre-eclampsia meant she confronted the possibility of such complications as kidney damage and internal bleeding, but her husband said he was assured repeatedly that her symptoms were in the "normal range."
Joshua was delivered healthy, although three weeks early. But within two hours of the birth that Saturday, nurses began to write on Karen's chart about her pallor and complaints of dizziness. For the new mother, the next two days were a jumble of sickness, exhaustion and a few brief chances to breast-feed Joshua. She was too weak to hold him, so her husband laid him in the bed beside her.
By Monday afternoon, visiting friends were shocked. "She looked so sad and so scared," Ms. Weedon said. "She tried to talk and she couldn't."
A nurse sat beside Karen, telling her the problems would resolve themselves now that the baby was born, but her mother had a feeling something was wrong.
When Barbara Oyster brushed her daughter's hair, Karen uncharacteristically did not insist she could do it herself. When she bent close to her daughter, Mrs. Oyster heard a rattle with each breath. Nurses detected the crackling sound, too, and added it to the chart.
That evening, after Mrs. Oyster kissed Karen on the forehead, she stopped at the nurses' station to say her daughter seemed too sick. But the nurses were busy, and Mrs. Oyster left. Twice on her way home she turned back, only to reassure herself that her daughter was in a hospital.
That night, her daughter's condition worsened. She had to sit up to catch a good breath.
"It was like she was starting to drift away," said her mother-in-law, Patricia Moats, who visited that evening.
What Karen's relatives and their attorney, Marvin Ellin of Baltimore, now believe -- and the autopsy confirmed -- is that the new mother was bleeding to death.
The pre-eclampsia had corrected itself, but laboratory records show that the volume of blood and level of oxygen-carrying hemoglobin declined steadily to levels far below normal.
Her only blood transfusion, Monday night, was too late to save her, the autopsy report indicates.
According to notes made by Dr. Gabaldoni, he talked to Karen three times -- at delivery and twice later -- about the possibility of a blood transfusion, but she was scared and, his notes say, she refused each time. Her husband acknowledged that his wife was reluctant but said no one made it clear that a transfusion was essential until Monday night, when a nurse told them. Part of the problem, he said, is that although he was with his wife almost around the clock, he never saw Dr. Gabaldoni check on her after the birth -- until after her cardiac arrest.
As Monday night turned into Tuesday morning, Karen's breathing became so labored that her husband propped her up in bed, sitting back-to-back with her. Anxious, he called one of her friends, telling her Karen's skin wasn't turning pink when he pushed on it.
"I'm a first-time father, I don't know what they're supposed to do," he said.
By about 4:45 a.m., Karen seemed to be nodding off. She whispered to him, " 'You know I love you with all my heart. You and Joshua, you are my whole world,' " Todd recalled.
" I said, 'I love you, too.' "
Then she sank forward. A nurse said, "Come on, Mr. Moats, you have to go." Karen stopped breathing moments later, records show.
The hospital's attorney, E. Dale Adkins, said that she was surrounded by nurses when her heart stopped, and that an emergency team immediately did all it could to resuscitate her.
The circumstances of that effort figure in the Moatses' malpractice suit, which contends that the respirator tube was mistakenly put into her esophagus, depriving her brain of oxygen for several minutes. When the tube was placed into her trachea, the suit contends, it was done with such force that it punctured her lung. The hospital's attorney disputes those assertions.
Dr. Gabaldoni, who arrived at 5:05 a.m., after many telephone calls back and forth with nurses, decided to have his patient flown to University of Maryland Medical Center in Baltimore.
Todd feared his wife was already dead. He tenderly pulled her wedding ring from her swollen finger, and removed her cross necklace. The day before, she had made sure the cross showed in the only family photo taken of her, Todd and Joshua.
In his written summary of the case, Dr. Gabaldoni said he believed Karen Moats had developed a rare heart problem and, after consulting with other physicians, he decided she needed treatment in a specialized setting. It was that diagnosis, postpartum cardiomyopathy, that would go on her death certificate.
As Karen was wheeled onto the helicopter pad, her husband, joined by her mother, hovered over her. Karen was surrounded by machines. She was swollen and her eyelids were fluttering, apparently from seizures.
Her mother bent to kiss her. "I swear I saw a tear in her eye," Mrs. Oyster said. "I told them Karen doesn't like to fly."
After she was admitted to the medical center, she was considered to be in a coma. For two days, her relatives tried, futilely, to spark awareness. They kept the lights on and played Top 40 music. Her mother made sure to spray on her longtime perfume, a scent Karen might find familiar.
Meanwhile, physicians gave Karen transfusions and stabilized her. She lost the excess fluid and regained color. Her siblings saw the freckles across her nose again. But her brain was beyond saving.
Thursday morning, five days after the birth, her brother Jeff walked into her room and found the music and lights off. Soon, ZTC doctors told the family Karen was brain-dead.
Said her father, Thomas Oyster: "She looked as good as you do when they announced it was time to pull the plug."
No one knows the numbers
Nationally, because of inadequate tracking, experts don't know how many women die the way Karen Moats did -- or why. One study by the CDC found that over six years, in 16 states, the actual number of maternal deaths was 40 percent higher than officially reported.
States and other jurisdictions define and count "maternal deaths" differently. For years, a group of obstetricians and gynecologists has been pushing states to use a standard definition and allow it to analyze the cases, said Dr. King of the obstetrics association, who heads this effort.
"There's loads of reasons why, on a national basis, it makes sense to take a proactive look at this thing, but it generally falls on deaf ears because they are small numbers," said Dr. King, who also is director of maternal/fetal medicine at Wright State University in Dayton, Ohio.
CDC experts recommend state-based monitoring that relies on many sources to identify and classify the deaths. But starting in the 1980s, the number of states with such systems fell dramatically. The reason, experts agree, is fear of legal liability. Any analysis of patient charts could subject the reviewing physicians to testifying against their colleagues.
CDC researchers have begun to collect death certificates from states on a voluntary basis. But even though all 50 states participate, researchers get varying amounts of information, and the numbers still are considered artificially low.
In Maryland, health officials believe many maternal deaths are preventable, and they have tried to get better numbers by searching records at the state medical examiner's office. In the last few years, a committee of the state medical association has also begun to examine some of the cases to look for trends.
But records won't tell all, because doctors sometimes put the wrong cause on death certificates to avoid being sued, contends Dr. Baha Sibai, chief of the division of maternal-fetal medicine at the University of Tennessee. The longtime researcher of pre-eclampsia and other complications added that few autopsies are done to set the record straight.
Learning to cope
As the months have passed, Karen Moats' family is struggling with grief and regret.
Her mother is angry at herself for not making an issue of her daughter's worsening condition that evening at the hospital. Her father wishes he had just scooped her out of bed and driven her in his car to another hospital.
Their youngest child is buried in the plot they bought for themselves. Her gravestone is engraved with, "The Lord is Salvation." That's what Joshua's name means.
Karen's 89-year-old grandmother, who everyone feared wouldn't live to see the baby, now visits the young woman's grave. One of Karen's friends has saved Karen's cheery voice -- chatting about birthing classes -- on an answering machine tape.
Karen's husband is raising Joshua, who has his mother's smile and brown eyes. The child rubs his feet together just like his mother used to. In a blue terry-cloth jumper, he sits contentedly on Mrs. Oyster's lap, and then gurgles and laughs as he recognizes his father coming in the door.
"I miss her terrible," said Todd Moats, looking at Joshua. "She was my soul mate."
At their house, on the calendar his wife marked in thick blue ink, from Nana's picnic June 11, to Sept. 11, the day she expected to return to her job, her husband took over with a black pen: "Josh born" on July 8; "Karen arrested" on July 11; "Karen goes to heaven" on July 13.
In the baby book Karen meant to keep so carefully, he hasn't been able to keep up. He works full time in facilities management at Hagerstown Junior College, and every night picks up the baby from his mother-in-law, who watches the infant weekdays. He did manage to write in what he said when Joshua was born: "Mom worked very hard for you. She is my hero."
And Joshua is what holds his life together. "I don't feel like it's a trade. I just feel like basically, they killed her," said Mr. Moats. "Now, I don't know what I would do if it wasn't for Joshua. I don't know how I would be emotionally. But I have a purpose."
So after bundling his son and gathering up the diaper bag, after his mother-in-law kisses the baby over and over, he tucks Joshua into his car seat.
It is starting to sleet as Mr. Moats drives away over narrow, winding roads, over the hills, past large yards. He is alone in the front seat. In the back, Joshua looks out the rear window, and there isn't a star in the sky.