My Sister’s Story: A Call for Accountability, Visibility, and Prevention in Maternal Healthcare
January 20, 2023, was meant to be one the happiest days of my life as I became an aunt for the first time, but it turned into the saddest. My sister and best friend, Brooke Shandloff Fernandez, died in New Orleans at the age of 37, just hours after giving birth, due to the extreme negligence of the medical providers in charge of her care. Two years later, the hole in my heart remains, and with Maternal Health Awareness Day approaching, I want to share her story and encourage others to take proactive steps to protect themselves.
Brooke was a loving wife, daughter, sister, aunt, and friend, and a well-known figure in her New Orleans community through her work as Senior On-Premise Manager at FIJI Water, JUSTIN, and Landmark Wines. A graduate of Tulane University, she was passionate about living life to its fullest and excited to become a mother for the first time, looking forward to the close relationship she hoped to have with her daughter, just as we have with our mother.
Brooke was also incredibly health-conscious and knowledgeable about her well-being and that of her unborn child. She often shared parenting tips with me and loved finding new ideas for her own future as a mother. She trusted her OB-GYN and took every reasonable measure to prepare for her delivery, but despite her efforts and the hospital’s reassurances, the failures in care before, during, and after her labor ultimately led to her death.
The Events Leading to Brooke’s Death:
Brooke had a healthy pregnancy and chose a hospital with a Level III NICU for her delivery. A few days after her due date, she consulted with her doctor and decided to get induced. However, things took a turn when complications arose after a prolonged 36-hour induction with Pitocin, causing the baby distress and requiring an emergency C-section.
Tragically, during the delivery, labor complications and the negligent acts and inaction of Brooke’s medical providers led to severe postpartum hemorrhaging. Brooke died within hours of her baby’s birth. The cause of death was initially represented to us by the doctors as Amniotic Fluid Embolism (AFE), but our family made the tough decision to obtain an independent autopsy given what my mother and brother-in-law witnessed during the birth process. The independent autopsy revealed that negligence and a series of medical errors were the causes of Brooke’s death. These included issues with prolonged Pitocin administration causing uterine atony and inadequate care from multiple healthcare providers, including physicians, nurses, and anesthesiologists. These errors are confirmed by Brooke’s medical records and a Statement of Deficiencies prepared by Louisiana’s Department of Health and Human Services.
What My Family and I Wish To Accomplish:
We couldn’t save my sister, but we want to try our very best to prevent this from happening to others. We have created the Brooke Shandloff Fernandez Memorial Foundation to raise awareness about the maternal health and maternal mortality crisis in the United States. Our mission is to advocate for systemic change and support those who are tirelessly fighting for improved maternal health outcomes.
1. Accountability for Providers: Two years after Brooke’s preventable death, it remains unclear whether any changes have been made at the hospital to prevent similar tragedies, or if their trajectory has changed. Accountability for the errors made during her delivery is essential, and corrective actions must be taken to avoid future incidents.
2. Call for Change in Louisiana: We have been working with the Louisiana Department of Health’s Perinatal Quality Collaborative (LaPQC) and Pregnancy Associated Mortality Review (PAMR) to assess the causes of Brooke’s death and to help create new pathways to prevention, health, and equity.
3. Raise Awareness of the Maternal Mortality Crisis: Brooke’s case is part of the larger maternal mortality crisis in the U.S. and, specifically, in Louisiana, which ranks 35 out of 40 states with available data for maternal deaths. According to the March of Dimes 2024 Report Card, Louisiana has an extremely high maternal mortality rate, with 37.3 deaths per 100,000 births. This issue requires immediate attention, including the adoption of supportive midwifery policies and improved maternal care, including reimbursable doula care.
4. Address Systemic Issues in Maternal Healthcare: The U.S. is facing a maternal health crisis, driven by several factors, including provider shortages, lack of access to insurance, chronic conditions, underuse of evidence-based practices, racial and socioeconomic disparities, and insufficient postpartum care. Brooke’s story highlights many of these systemic failures, including inadequate and fragmented care.
5. Education and Empowerment for Expecting Parents: Expectant parents must be equipped with the information they need to make informed decisions about their healthcare. It is essential that you research hospitals and OB-GYNs the best you can, ask critical questions, and advocate for yourselves during delivery.
How You Can Help Yourself If Expecting:
Expectant parents can take proactive steps to avoid similar situations:
- Advocate for access to credentialed doulas, midwives, and comprehensive care during labor and postpartum.
- Research hospitals’ maternal mortality rates and ensure they are below the national median.
- Ensure that healthcare providers are equipped to handle complications, with necessary protocols in place.
Ask questions during hospital and OB-GYN interviews such as the following:
- What do you do to reduce birth trauma for your patients?
- Do you have access to the Jada device in your operating room?
- Are staff meetings or huddles implemented with all providers of the care team to assess and review each patient and their risk factors?
- Is everyone (hospital staff and providers) made aware of the protocols in place that address the main preventable causes of complications and death during pregnancy and childbirth?
- Is there an equipped Postpartum Hemorrhage Cart always present at time of delivery, in addition to a crash cart?
- Does your hospital have access to an extracorporeal membrane oxygenation (ECMO) machine (this is not essential but your only chance of survival in certain rare instances)
- How often do you have emergency drills with the hospital staff?
- How do you keep up-to-date on the latest evidence?
- Who is the decision maker or has the final say in the delivery room? What is the level of attending supervision, if at a teaching hospital? Confirm that the Attending Physician is scrubbed in.
- What is “informed consent” and is it important to you? If so, why?
- What are your hospital’s doctor-to-patient and labor staff-to-patient ratios in OB?
- At this hospital, am I able to use a Doula and/or Midwife for additional support? Based on what you know of this hospital, do you recommend it?
We urge the public to support local organizations such as Birthmark Doula Collective and March for Moms. In addition, March of Dimes, 4Kira4Moms, and Every Mother Counts are fighting for policy changes such as the approval of the Momnibus Act to address maternal health issues in our country. To learn more about Maternal Health Awareness Day, visit their website HERE.
About The Author
Heather is a proud mom of two daughters, ages 10 and 7, and deeply values her family connections. She is especially proud of her brother-in-law, DJ, for raising her beautiful and amazing niece. Inspired by her personal journey, Heather created @GemsFromBrooke on Instagram in honor of Brooke. Through this platform, she aims to raise awareness, share experiences, and advocate for maternal mortality and health. Heather is passionate about using her voice to support and empower others while promoting important conversations around maternal well-being and the challenges many women face before, during, and after pregnancy.