Changes in US maternal mortality; the crisis is not what you think

Medical monitors

On Sunday and Monday I attended a Harvard Medical School annual review of obstetrics. One of the sessions that I was most eager to attend was the session on maternal mortality, and it did not disappoint. The most intriguing aspect was that the crisis in maternal mortality is almost exactly the opposite of what natural childbirth activists claim. Simply put, the crisis is not the over use of technology, but rather a mismatch between the number of pregnant women with pre-existing complex medical problems and the dearth of specialists and specialty units with the appropriate expertise to care for them.

The threshhold question, of course, is whether US maternal mortality is increasing. I’ve written about that many times over the years, and the speaker pointed out that it is probably not increasing; the apparent increase that we have seen (from 10.4-14.5/100,000 between 1990-2006) almost certainly reflects the ongoing efforts to appropriately classify deaths that occur in the wake of pregnancy. In other words, the rate of maternal death is not rising, the accuracy of our statistics is rising.

Be that as it may, maternal mortality is certainly not falling, and maternal morbidity (complications that do not result in death) is rising. Most importantly, the profile of maternal mortality is changing, as illustrated by the following graph from the paper Pregnancy-Related Mortality in the United States, 1998 to 2005 (the markings were added by the speaker).

Pregnancy related mortality small

Note that the traditional killers of pregnant women (hemorrhage, pre-eclampsia/eclampsia, blood clots) are being supplanted by new killers including pre-existing heart disease, cardiomyopathy of pregnancy (a weakening of the heart muscle) and other complex medical conditions. Indeed, while the death rate from traditional causes of maternal mortality has been steadily falling, the death rate from unusual causes has been steadily rising.

This almost certainly is a reflection of the increasing age and increasing obesity of pregnant women. So while complications from vaginal birth and C-section (infection, bleeding and blood clots) are still important causes of death, they are being supplanted by pre-existing medical conditions. We can and should work to decrease traditional causes of maternal death. For example, treating women with short courses of blood thinners around the time of surgery could drive down the rate of blood clots much further. However, the real crisis in maternal mortality is that we have not responded effectively to the increasing medical needs of pregnant women.

The speaker compared our response to maternal mortality with our response to perinatal mortality and raised an issue so obvious that I’m embarrassed that I hadn’t thought of it before. The dramatic decrease in perinatal mortality over the past 50 years reflects the creation of a specialty devoted to critically ill newborns (neonatology), specialty units for the care of critically ill newborns (neonatal intensive care units, NICUs), a rating systen for hospital nurseries (levels I, II, and III) to facilitate triage and transport of critically ill newborns to hospitals that have the experts and equipment to to treat them.

We have done nothing similar to address the increase in critically ill mothers. Although the number of pregnant women requiring intensive care is increasing, there are very few obstetric intensivists, very few obstetric intensive care units, and no rating system to facilitate transfer of critically ill mothers to hospitals that have the experts and equipment to treat them.

This image graphically represents the difference in our approach to preventing maternal mortality vs. preventing perinatal mortality.

Protocols for maternal health small

In contrast to a wide variety of protocols defining best care practices for high risk perinatal complications, there are virtually none for high risk maternal complications.

The bottom line is that the solution to any crisis in maternal mortality is NOT indiscriminately decreasing interventions, since obstetric interventions are not the proximate cause of most cases of maternal mortality. It is imperative that we INCREASE our ability to identify critically ill pregnant women, transfer them to specialty obstetric units that have the personnel and equipment to manage their complex medical problems so we can apply MORE interventions to those complex medical problems, and identify best practices for managing complex medical conditions in pregnancy.

We may not have a crisis in maternal mortality yet, but if we fail to take these steps, we almost certainly will.

  • pburg

    Many of these risks are directly related to the increase of cesareans
    “Potential risks of cesarean delivery on maternal request included greater complications in subsequent pregnancies, such as uterine rupture, placenta previa, placenta accreta, bladder and bowel injuries, and the need for hysterectomy. A Canadian study of primiparous women with singleton pregnancies showed an increased risk of postpartum cardiac arrest, wound hematoma, hysterectomy, major puerperal infection, anesthetic complications, venous thromboembolism, and hemorrhage that required hysterectomy in patients who had a planned primary cesarean delivery” – ACOG

  • Mathi Bear

    My first thought is that there really needs to be more awareness about the causes of certain maternal complications. The campaigns against smoking and drinking have gone quite well I think. Unfortunately those are easy compared to the much-more-sensitive topics of age and weight. Morbidly obese 40 year old pregnant women used to be very rare…now not so much. I know a few people who waited to their 40s to start having kids (several) and didn’t think anything of it. Out of 7 friends who have had kids in the last few years, 2 were not severely overweight or obese. Untreated heart disease, poorly managed diabetes. I am kind of amazed maternal outcomes are as good as they are.

  • AmyP

    An old friend of mine is a 30-something Type 1 diabetic living in Russia. She would desperately like to have a baby, but it would probably kill her–she has quite enough trouble staying healthy as it is.

    I suppose that’s more a case for advances in diabetes treatment, though.

  • Sue

    Hmmm….some thoughts.

    Is the concept that ”pregnancy is not a disease” (which is true) actually now getting in the way, as more and more women are able to enter pregnancy older and sicker?

    The concept that HBMWs still cling to is that pregnancy and childbirth are reliable physiological processes occurring to healthy women who are ”designed to give birth”.

    The principle of obstetrics and modern midwifery is that this physiological process can, and does, go catastrophically wrong – mostly in mechanical ways, but sometimes physiologically (PIH, thrmboembolic events etc).

    Perhaps were are now in an era where the internal medicine side aspect of obstetrics is becoming more and more important, as older and sicker women are able to become pregnant and complete a gestation. This requires either more internal medicine training for obstetricians and nurse-midwives, or greater collaboration between the obstetrics profession and internal medicine, or both.

    Either way, the knowledge and experience of the lay MW is even more woefully inadequate in the face of greater medical issues.

    • Haelmoon

      Pregnancy may not be a disease, but it is an altered physiological state, plus there are diseases specific to pregnancy. I tell patients pregnancy is like a nine-month stress test. It will highlight your life long risk hypertension, diabetes and other conditions. Pregnancy is not a normal state no matter that the NCB crowd wants to think.

      • rh1985

        Yeah, I don’t understand why anyone wants to take the chance of not having medical care available. I had pre-e as a 28 year old with no preexisting major health issues (just allergies/sinuses) and absolutely no risk factors. Luckily I got it at 39 weeks and so the baby was delivered immediately with no lasting effects on either of us.

        • Karma Kidney Stone

          I know what you mean. I was a healthy 24 year old with no health issues at all, and I ended up with a baby with IUGR and severe Oligo (fluid at 4) and had an emergency induction at 36 weeks with a small sickly little baby. If I’d opted for a midwife and homebirth, my baby’s death would have been written up on this site.

          Also, by comparison, later I had another 36 weeker induced. He was a few days earlier gestation, and weighed a pound and a half more and was clearly a healthy, vigorous little guy. It really cemented to me, seeing how healthy he was, compared to my IUGR baby, what an emergency that was.

          • Young CC Prof

            My scheduled c-section with my IUGR baby apparently happened about a day before it would have been an emergency, although no one realized this until they dissected the placenta. He was healthy, just little, and his placenta was near death. Man, were we lucky.

    • Adelaide GP

      There is the specialty Obstetric medicine/ Physicians, present at most major public hospitals, looking after patients with gestational diabetes, pregnancy induced hypertension, etc. I recall their service was inundated though with ridiculous wait times. For example a recent shared care patient of mine developed gestational diabetes and there was a 6 week wait, which almost took her to delivery time! I had to get on the phone to try to push it forward. Think we need more Obstetric physicians, definitely expand the service, more trainees etc.

      • KarenJJ

        South Australia seems a bit thin on the ground for specialists. I’ve been frustrated over the years trying to help a family with a rare disease diagnosis get seen by an immunologist at a big public hospital. It’s sort of worked, but even still there are a lot of ongoing issues of access to medication and second opinions appear to be impossible..,.

        • Adelaide GP

          Immunology/allergy wait times are very long! Unless the patient has had anaphylaxis you can expect 1 to 2 years of waiting for paediatric allergy in the public system. Demand very much outstripping supply. It’s a specialty that needs expansion for sure.

  • Deena Chamlee

    Before I became a nurse midwife , oh lets say 30 years ago, my first nursing job was at Grady Memorial Hospital in Atlanta. Green, happy, eager to learn high risk obstetrics in an obstetrical ICU. MAN those were the days. TTP , peritoneal dialysis, eclampsia, DKA comatose clients, abdominal pregnancies at 32 weeks gestation, on and on. It formed a basis for my ability to assess clients appropriately today as a midwife. Yes pregnancy is certainly not benign.

    • http://www.antigonos.blogspot.com/ Antigonos CNM

      THIS is central to the CPM/homebirth/NCB problem: unless you have experience of how catastrophic birth has the potential to be, you simply assume it is always benign. The few deliveries done, hopefully with low risk women, compared to the level of experience gained by those working in hospitals, combined with the lack of educational grounding in the specialty, means it it is very easy to believe that pregnancy and birth are “always” a simple matter; a case of “normal physiology”.

      • Deena Chamlee

        An so true. But their narcissitic belief in their ability to attend high risl clients, in a higher risk setting with high school educations leaving a wake of destruction and death without remorse is classic sociopathic in nature. The emotional manipulation of innocent womens reality that they are trained tp attend sich births is an immeasurable public health risk.

        The statement regarding licensure by Cheyney and Moray “licensure is not gping to create more safety”. This is them being brutally/braggarts in regards to no morals, no ethics amd no conscious. And you know what? It doesn’t majority of deaths are by licensed cpms.

        It will come to an end someday and we will be free to grow and become healthy. Because right now American Midwifery is crazy messed up abusively dysfunctional.

        • http://www.antigonos.blogspot.com/ Antigonos CNM

          I know that you and I agree on many things. IMO, there has to be a special department for the oversight and standards of education and licensing, as well as acceptable protocols and mandatory keeping of accurate records and statistics for ALL midwives as part of the DHSS, or we will continue to see midwives moving from state to state and eluding the authorities. And whatever regulations come into practice, they must be enforced, and the laws have teeth — or the US will continue to have a “Wild West” approach to birth. Rogue midwives must be removed from practice, period.

          • Deena Chamlee

            Yes YES YES. I hate to use terminology such as anti social because it doesnt make one any less or inot important. However labeling behaviors assist with naming what I have experienced.

            I deeply feel with all that has occurred in the hombirth movement in America that, and this is sad to say, it cant be fixed. Too many ethical violations by MANA and NACPM. And we must not place their needs above our own. The dysfunction has held us back.
            It is just so

            A national board of midwifery that regulates, standardizes, and advocates is needed. I also think it should not be within the ACNM structure. Thus keeping boundaries very clean. I would also hope for an appointed by merit ethical noard that oversees ethical teachings and breaches. Again not within the ACNM structure. And client’s are the central theme for rendering care. Informed choice informed consent where the client chooses site of birth with shared descision making.
            .
            CNMS and CMS LICENSED in all states rendering care across all three sites as the client desires. This can be a reality if we put our needs above others

            We cannot and should not attempt any further attempts at changing anyone but us. It is all we have the ability to change.

  • Andrea
    • Amy Tuteur, MD

      Awesome!

      • KarenJJ

        They’ve raised $1.7million since 2002!?!?!

  • Elaine

    OT, but MDC is now only allowing “members who post regularly as supporters and advocates of homebirth” to question homebirth. http://www.mothering.com/community/t/1398327/moderator-for-this-forum

    Sigh.

    • Renee

      That site is horrible, and partially liable for so many deaths.

    • yugaya

      Lol.
      “Posts made purely for the purpose of debate and criticism of homebirth are not appropriate.Topics of concern, including discussion of the risks and instances wherein homebirth might not be a good choice for a particular pregnancy or presentation may be examined and discussed critically by members who post to this forum regularly as supporters and advocates of homebirth.”

      Mothering . com when it comes to risks of homebirth has the same level of objectivity that you would find on a death penalty advocacy forum which allows the topic of miscarriage of justice in “discussion of the risks and instances wherein death penalty might not be a good choice for a particular crime or case”, with further restriction that it may be examined and discussed critically only by “members who post to this forum regularly as supporters and advocates of death penalty.”

      If you got ‘educated’ on homebirth on mothering . com I guess you are as safe as walking through a mine field blindfolded.

      • LMS1953

        In similar fashion, the New York Times will no longer accept letters to editor that deny global warming or climate change ……. all the propaganda that is fit to print.

        • theNormalDistribution

          wat

        • http://gamesgirlsgods.blogspot.com/ Feminerd

          Well, that’s because that one is a settled question. They don’t print people’s letters who defend Charles Murray’s theories on the genetic superiority of white people or who insist the world is flat, either.

          You can still make posts about it on the blogs and stuff. They just won’t print those letters to the editor.

          • LMS1953

            Is it not a “settled question” that breech birth NOT be attempted at home? Yet here is the New York Times/Pravda glorifying it and Saint Ina Mae:

            http://www.nytimes.com/2011/08/09/health/09birth.html?_r=0

            Any day now, I anticipate NYT to issue a policy that it will not accept letters to the editor critical of home birth. Just you wait and see.

          • http://gamesgirlsgods.blogspot.com/ Feminerd

            I highly doubt you will see that policy. You may see one saying praise of homebirth will not be allowed, though, given that all evidence points to it being very dangerous.

        • Certified Hamster Midwife

          Peer-reviewed obstetrics journals won’t accept my letters asserting that babies are delivered by stork, either. What’s with that?

          • LMS1953

            In case you haven’t noticed, the New York Times/Pravda has a very liberal agenda. There are more people that believe the earth is flat than people who believe Benghazi was caused by a YouTube video that insulted the Prophet Mohammed, peace be unto him. Yet the New York Times/Pravda published that as truth – which is the equivalent of your stork analogy. What’s with that?

          • Trixie

            Oh, here we go again….

          • LMS1953

            What side of the home birth debate do you think the NYT would come down on? Could you please reference an article from the NYT that condemned the use of CPMs as we do here?

          • expat

            They did write a somewhat romantic profile of Ina May.

          • Trixie

            That has nothing to do with whether global warming is real, which is what you seem to want to make it about.

          • Certified Hamster Midwife

            They would come down on whatever side the average Park Slope primagravida in her mid-forties with a $5,000 stroller waiting in her hallway is on. So pro-homebirth.

          • LMS1953

            Check out this bullshit puff piece on home birth that was highly critical of the 2011 ACOG article …meta-analysis…confounding factors..blah, blah, blah that showed it to be (what we now KNOW was underestimated) three times riskier than hospital birth. WE now KNOW it to be at least 450% higher, and the risk of a 5 minute APGAR less than or equal to 4 to be TWELVE times higher.

            http://www.nytimes.com/2011/08/09/health/09birth.html?_r=0

          • Trixie

            And I do agree that that article was bullshit, FTR.

          • LMS1953

            Or this hagiography of Saint Ina Mae glorifying such things as home breech birth.

            http://www.nytimes.com/2011/08/09/health/09birth.html?_r=0

          • Certified Hamster Midwife

            Isn’t Pravda a pro-Putin paper now? You need to update your slurs.

    • rh1985

      Oh ffs… that is ridiculous.

    • no longer drinking the koolaid

      Well, i’m responsible for the ” group think” comment. This is disappointing as we have had some really good discussions of late.

    • http://kumquatwriter.wordpress.com/ Kumquatwriter

      Only those with no questions may question us!

      • Young CC Prof

        An excellent example of a catch-22. Only by proving that you consider home birth safe do you earn the right to say it may not be safe.

        • KarenJJ

          So much for being “educated” if you can only hear and discuss one side of the story.

    • Sue

      All the more reason for Dr Amy’s blog to have a voice.

      Oh, and speaking of another organisation that only allows ”debate” between fans, you may be interested to hear about progress against the Australian-based anti-vax group, the FORMER Australian Vaccination Network.

      1. The organisation was forced by the state Dept of Fair Trading (essentially the consumer safety regulator) to change its name because it was judged to be misleading to the public. After a long delay, they have changed it to the Australian Vaccination-skeptics Network (hyphen and lower case ”skeptics” so they could keep the acronym, US spelling of sceptics because someone else registered the Oz spelling!).

      2. The organisation has been forced to relinquish their ”charity” status for fund-raising.

      3. They are again under investigation by the state Health Care Complaints Commission (its governing legislation having been updated so that it could include organisations without direct patient care in its remit. A complaint no longer has to link to harm to an individual patient).
      and
      4. They claim that their FB page is now ”owned” by someone off-shore (under a sock name), thinking that this dissociates the FB page from the regulatory structure that covers the incorporated organisation. Ms Dorey still posts under the “AVN” banner, so, somehow, I don’t think this clever trick will work.

      Great progress overall….on-line activism works!

    • Trixie

      Is this because of Amazed? She was doing some good work over there.

      • Amazed

        No, it was another poster here. I wouldn’t have the patience to explain things that are just self-explanatory to me. Maybe I am privileged and overindulged but there are certain things that I think are just self-evident and hell, I am not explaining them to women who behave like children – no, no, no, you’re mean and I don’t want to hear it, and I have my own research to prove it.

        It reminds me of the time I watched my mother tutoring her students. I am not teacher material.

        I am not a MDC material either.

        • Trixie

          I’m sorry, I meant Appalled. Two past-tense verbs starting with an A!

  • LMS1953

    So, we are talking about maybe 600 maternal deaths per year out of 4 million deliveries. Typically there are about 10 near misses per death. That is a hard asymptote to chase and the money spent (for high cost intensivist intervention) will soon meet diminishing returns. Let’s say the home birth rate attains 3%. That would be 120,000 moms and babies at significant risk of morbidity that would relatively dwarf the aforementioned 6,000.

  • Trixie

    Thanks for writing about this topic, Dr. Amy. There’s a non-accredited “birth place” run by a quacky doula near me, and she keeps holding alarmist meetings about the “crisis in maternal mortality”…the solution to which, conveniently, is more births at her quacky birth center and essential oils, etc.

    • LibrarianSarah

      When ncbers do this can we call it “playing the dead mommy card?”

      Please?

      • Young CC Prof

        Especially since (according to MANA’s own numbers) a vaginal birth at home is 4-5 times more likely to end in PPH than a vaginal birth in the hospital? (Usually not fatal in either case, but sometimes results in an emergency transfer, as per Ruth Iorio.)

        • VeritasLiberat

          Some mothers just aren’t meant to live…

    • The Computer Ate My Nym

      Which cause of maternal mortality does she think can be treated with essential oils?

      • The Bofa on the Sofa

        Which cause of maternal mortality does she think can be treated with essential oils?

        The hospital caused ones of course.

        (you actually think she has the first clue about why mothers die?)

      • auntbea

        My friend’s child dropped a chair on his foot today. She thought it might be broken. She rubbed some oil on it. All better!

        • yugaya

          Are we talking rubbing some oil on a broken foot or a broken chair? Should hail similar results though. :)

        • Elizabeth A

          Does the oil in this story have the same function as the ice pack that cures my children’s bumps and bruises instantaneously? Or is she making a claim for it besides, “trivial, momentary injury successfully cured by parent’s attention”?

          (BTW, observational studies in my house reveal that most abdominal pain stems, not from the usual suspects like sugar or gluten, but from subtraction and handwriting practice.)

          • Melissa

            That reminds me of how I used to do lamaze breathing when I’d have a tummy ache as a child. I’d seen my Mom practicing when she was preparing to have my brother (who ended up a c-section anyway) when I was 4. She said that breathing like that would help her not feel her tummy hurt during labor. So, of course, I figured it would do the same for my tummy aches. (Although in hindsight those tummy aches were most likely abdominal migraines, and so breathing probably helped them as well as anything else would have)

          • Amy M

            When my boys were 2 or 3, one got a stomach virus, but he must have heard us say “stomach bug.” The following conversation ensued between the brothers:
            Healthy:Why your stomach hurt? Did you eat too much food?
            Sick: No.
            Healthy: Did you eat a bug?
            Sick: Yes.
            Healthy: What kind of bug?
            Sick: A beetle. They don’t bite or sting.

        • AmyP

          Love you guys.

          I was recently with a sweet lady who offered me some sort of scented balm when I was asking around for Neosporin for a scrape.

          This really happens.

          Sometimes I wonder how we got the vote.

      • Trixie

        I think I’d have to go to the seminar to find out. Something about Johnson and Johnson formaldehyde probably.

    • Karen in SC

      Link to this post on their Facebook page :)

      • Trixie

        I’d love to, but she blocked me from posting anymore. She linked to something about Lisa Barrett and how “there’s so much more to her” and then I got a little stabby and linked back with the 47 days between twins story, and that was the end of me on her page.

    • Melissa

      That is especially scary since the causes of maternal mortality are not better treated in an NCB setting. If the increase was because of people dying from fatal infections they picked up in the hospital, then I could see an argument that a birth center setting would be better. But what exactly will they do about heart failure?

      • Trixie

        Trust their instincts?

      • Young CC Prof

        You know, to hear some NCBers talk, they seem to think women ARE still dying of childbed fever in significant numbers, or maybe MRSA, which apparently permeates the entire hospital like a cloud.

  • Captain Obvious

    Hemorrhage, VTE, AFE, infection, anesthesia, and maybe stroke may be slightly more common with cesarean than NSVD. So how can you control for maternal factors to determine if cesarean is killing more women?

    • http://Www.awaitingjuno.blogspot.com/ Mrs. W

      First you’d have to seperate out the planned cesareans from the emergent ones. And then you’d have to conclude that the emergent cesareans are the result of planned vaginal deliveries. Then you’d have to see what actually kills women: PVD or PCD – I have a strong suspicion that the cesarean has been wrongly accused of doing something that it really can’t be blamed for.

      • The Computer Ate My Nym

        But a planned c-section might be planned for maternal risk. So I’m not sure it’s a fair comparison group. It might be weighted against PCD.

  • The Bofa on the Sofa

    Here’s an alternate look at the top graph. Instead of breaking it down by percentage of deaths, I have it broken down by the absolute mortality rate, using 10.5/100K for the 87-90 data and 14.5 for the 98-05 data, and for the 91-97 I just used 12.5. Close enough all the way around.

    You want to know why the mortality rate jumped from 10.5 to 14.5? It’s pretty clear from the chart – the big differences are columns 6, 8, 9 and 10, which are all about medical conditions. I think that’s consistent with Dr Amy’s assessment that it is a change in attribution – now, women who die from a cardio-related problem are included in the maternal mortality.

    Notice that the net change in those things that AREN’T medical conditions have a net drop of .5/100K, the bulk of which is death due to hemmorhage (column 1). The others are essentially unchanged.

    • expat

      So if a good portion is an increase in attribution or increase of cardiac problems, that leaves hemorrhage as the main thing which is changing due to an actual change in practice. The cesarean rate has increased over the same period and there is some evidence that planned cesarean has a lower rate of hemorrhage compared to planned vaginal birth (http://www.uptodate.com/contents/cesarean-delivery-on-maternal-request/abstract/23 ). Anathema to the NCB scaremongering that cesareans are driving an increase in mortality, there is data that implies the opposite! ((Speculations of a non expert))

  • FormerPhysicist

    How long after childbirth are the numbers tracked and considered pregnancy-related? I know women who developed heart problems, or chronic hypertension and I think that’s eventually just considered part of life.

    • Sullivan ThePoop

      I develop mild chronic hypertension that they recently discovered is autoimmune. Though luckily, since it is unresponsive to all treatments except a biologic, I also have a genetic predisposition to high circulating HDL levels, so it has not had any long term health consequences that they have seen so far. Though recently they have been throwing around the idea of putting some kind of stent in an artery in my thigh which is a relatively new procedure that has shown some success for resistant kinds of high blood pressure.

    • http://whatifsandfears.blogspot.com/2012/12/the-business-of-being-misled.html Doula Dani

      “For reporting purposes, a pregnancy-related death is defined as the death of a woman while pregnant or within 1 year of pregnancy termination—regardless of the duration or site of the pregnancy—from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”

      http://www.cdc.gov/reproductiv

      I have a question regarding this…. any experts here know if other countries report maternal mortality the same way we do? Are there differences?

      (Something is either going on with my computer, browser or my disqus account. Every time I comment, it shows up for a bit, then when I refresh the page, my comment disappears…. so apologies, this is the 4th time to leave this comment. Hopefully it sticks this time (switched to Explorer this time instead of Chrome).)

      • http://whatifsandfears.blogspot.com/2012/12/the-business-of-being-misled.html Doula Dani

        Must have been Chrome. My comment stuck this time after I refreshed.

      • araikwao

        Within 1yr is also the WHO definition

        • http://whatifsandfears.blogspot.com/2012/12/the-business-of-being-misled.html Doula Dani

          Thanks! Perinatal mortality definition varies by country so didn’t know if maternal mortality might also.

      • Dr Kitty

        The UK counts murder and suicides in the maternal mortality data, as pregnancy was often an aggravating factor.

        Most murders of pregnant women and new mothers are by current or former partners. Pregnancy often marks the start of intimate partner violence, or an escalation of already occurring domestic abuse.

        Perinatal mood disorders are important causes of maternal suicide.

  • no longer drinking the koolaid

    If you want to know what care should look like for high risk pregnancies and the pre-existing conditions, the California Maternal Quality Care task force has put together some excellent materials for providers. Rather than sidestepping and wishful thinking management (AKA denial), all providers need to have a really high index of suspicion with the first little thing that seems out of normal, like a slightly elevated BP even w/o any pre-e symptoms. If you are interested, here is the link to there home page.
    https://www.cmqcc.org/

  • Young CC Prof

    Interesting point overall. I saw a very nice regular OB through my whole pregnancy, and the perinatologist of the day (whichever one was on duty) from weeks 32-37, after we were diagnosed with IUGR. And I kind of noticed what you’re saying here. When I went to the regular OB, we talked about the baby AND about how I was doing. The perinatologists didn’t seem to be interested in me at all, just the baby. (I did get the “watching for preeclampsia” talk from their nurse, though.)

    • ngozi

      Even though I only have only gone to a regular OB, I still mostly felt like I was a box with a baby in it…

      • http://thefresstyler.blogspot.com/ Hannah

        I felt like that at the height of my morning sickness . I really like my OB, and she was quick to put me on Zofran the moment I was unable to keep down water, but when I called her week after week begging for something to do more than stop vomiting as I could still barely eat or drink with the nausea, retching and vertigo (Zofran seems to stop the vomiting but not the urge to vomit) that came with my sickness and I was basically told to deal with it. At that time, I truly felt like I was just an incubator.

        • Jessica S.

          I’m beginning to feel that way with my iron deficiency. I’m 22 weeks along and have been low from the beginning. I’m now taking iron three times a day (not including the iron in my prenatal vitamin), dealing with the unwanted side effects no matter how much water and fiber I try to ingest, and I still feel awful ALL the TIME. I’ve almost given up hope that it will get better before she’s born, b/c from what I’ve read, it takes awhile for the iron supplements to work. It also exacerbates my ADHD, which is already taking a hot from decrease in medication. I have a 3.5 year old at home with me all day and I feel bad that I can’t do more with him. Sorry for the rant, I just totally understand that feeling of “why can’t anyone help me?!”. Although, I’d take my situation any day over what you had to endure. I hate throwing up and the constant nausea is the worst. :(

          • Haelmoon

            I who recommend iron infusions if oral is not tolerated. Not all obstetricians are feto-centric. Some of us care about the mom and baby and take care of both.

          • Dr Kitty

            Yum, lovely liquorice Venofer.
            I love the way iron infusions smell. Not so much it’s ability to stain my skin and clothing.

          • Durango

            InFed is the devil (for the nurse) though, as it comes in 100mg/2ml vials and doses are usually a gram or two (so 10 to 20 vials to draw up) and it has a tendency to spray.

          • Jessica S.

            Thanks! I have to remind myself I have access to a great Maternal Fetal Medicine depart at the Univ of WA; I’m not being seen by one of the OBs, tho, but instead, it’s my regular family practitioner at one of the UW clinics (who is wonderful, really) so I need to remember to be more vocal about it.

          • Bombshellrisa

            And they can read your chart (since it’s all part of the same system when you go to one UW clinic) and really help you, not give you herbs and tell you to eat kale. I hope you can get some treatments that help.

          • Bombshellrisa

            Jessica-I know you are with UW but Swedish has a bloodless surgery program and they do some kind of iron infusion for anemic pregnant women. Not sure if UW can do that same type of treatment but worth looking into.

          • Jessica S.

            Thanks for the info! If things don’t look better by the next draw (in a few weeks) I’ll ask my doctor what other alternatives there are to oral supplements.

          • http://www.antigonos.blogspot.com/ Antigonos CNM

            iron transfusions are regarded somewhat warily as one of the side effects can be premature contractions. however, sometimes there just isn’t any alternative, and when there are’t any side effects the results are astonishing and nearly immediate.

          • http://thefresstyler.blogspot.com/ Hannah

            Oh, you poor thing. I really do sympathise, especially with the ahem, side effects of iron supplements. I gave up on prenatals at 15 weeks after my spina bifida results came back perfect and I was able to eat a lot of fruit and vegetable (while taking Zofran, I have had two Zofran-free days since 6 weeks, one of them being today and I may yet ‘break’).

            My iron has held despite my meat aversions so far but my doctor said if it dropped a lot after 27 weeks we would look into transfusions because all supplements seem to make me puke. Maybe see if your OB can look into them.

            Feel better x

          • Young CC Prof

            I gave up on prenatals after one pill. The belly pain started almost as soon as I swallowed it and lasted five days, following the darned thing all the way down. I took separate folic acid and D, and that was it. My iron got a little low by the end, (like 11) but not seriously low, and it came right back up afterward. Baby’s iron was plenty high.

            Iron supplements in pregnancy are usually a good idea, but if you just cannot find a way to live with them, they aren’t always necessary.

          • Mishimoo

            I ended up choosing my own supplements too, which I ran past my GP and CNMs, and were checked by the Ob/Gyn.

            According to the drug database for Aussie doctors, as of late 2012, so it may have changed; Omega 3 and 6 had not been cleared for use in pregnant women even though it was in all of the prenatal tablets. My GP showed me the entry + warning, and said that it was up to me if I wanted to take them or not, but he wouldn’t feel comfortable recommending them due to lack of information.

          • AmyP

            This is going to sound really crunchy, but have you considered eating a lot more salads (particularly spinach based ones)?

            I had gestational diabetes with my last pregnancy in the last trimester and ate baby spinach based ones religiously. A very interesting side effect of the change in diet is that I never, ever had any issues with constipation. I had lots of other discomfort, but no constipation at all–and that had definitely not been the case with previous pregnancies.

            If I were you, I’d see if I could the doctor to approve a more diet-based approach for a couple of weeks. You could even ask for a blood draw to see if it’s working.

            A steak salad with spinach might be just the thing. Panera’s used to do a steak and blue cheese salad with lettuce, but spinach would be even better.

            Good luck!

          • Jessica S.

            Thanks for the tip! Some sort of steak spinach salad doesn’t sound terrible. I’m not a huge fan of spinach leaves, but maybe I need to try a better preparation!

          • anion

            Have you tried spanakopita? I’m not a big spinach fan, either, but I love it. And I pretty much lived on it for most of my second pregnancy. (That’s not an exaggeration; frozen spanakopita appetizers and frozen Friday’s potato skins appetizers were the only things that sounded appealing and I was able to stomach for the first four or five months of morning sickness, and they were still more appealing than anything else for the rest of it.) It was a textbook pregnancy, and I had boundless energy, looked great, felt great, and gained exactly 35 pounds. (And come to think of it, I had none of the constipation issues I had with my first pregnancy.)

            Now I make my own spanakopita, which is way easier than it seems. Spinach, garlic, lots of feta cheese, a couple of eggs…good stuff. You can find recipes online, or I’ll happily give you mine, if you like. The phyllo pastry is a little tricky but again, much easier than I’d expected.

    • Haelmoon

      It is one of the reasons I prefer the term MFM to perinatologist. I specialize in maternal AND fetal health, not one or the other. In the system where I work, nearly half my case load it due to maternal illness, and I manage the mom and reassure her the baby is fine. There is some overlap of course in which there are maternal, fetal, placenta and cervical complications are mixed together.

  • no longer drinking the koolaid

    In a nutshell: Maternal Special Care Unit. The one at Hutzel Hospital in Detroit has been there for years. The population they serve is probably 99 % AA, with about 98 % using Medicaid for insurance. Inner city Detroit. Probably helps that the hospital is associated with Wayne State and the Perinatology Research Branch of the NIH.

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    The approach seems consistent – it is “all about the baby” and mothers need to have some focus on their health needs as it is a period of significant health vulnerability. I think if we were to focus on maternal health – and the drivers of maternal mortality during pregnancy and the year post-partum there’d be some really meaningful advances made. Currently, we don’t do universal screening for mental health issues during pregnancy and the post-partum period – yet one of the leading causes of death in the year post-partum is suicide. Walker Karraa has started a petition on this: https://petitions.whitehouse.gov/petition/every-mother-every-time-universal-mental-health-screening-every-pregnant-and-postpartum-woman/rG1jLyYj . You are correct to point out the disconnect between what we do for babies and children versus what we do for women who are mothers. Notably – women tend to receive worse treatment then men for cardiovascular health issues.

    • Amy Tuteur, MD

      I’m not sure that is a completely fair assessment. It’s hardly surprising that more attention is paid to perinatal mortality when you consider that 700+ mothers die each year and more than 20,000 babies. The tremendous imbalance in deaths makes perinatal mortality seem like a more urgent problem.

      The other factor is that for the group of women currently getting pregnant, pregnancy is more dangerous than it was before. In addition, it is nearly impossible to convey that information to the public. There are already women who insist that it is sexism to mention that waiting to have children increases the risk of infertility. It would be an incredibly tough sell to create a public education campaign to inform women that by delaying childbirth they are risking their own lives.

      • http://Www.awaitingjuno.blogspot.com/ Mrs. W

        Pregnancy and childbirth are hazardous to women’s health – and that risk is modified by certain factors. That’s science – and withholding that information from women is far more sexist than being upfront about it. Informed choice. I do think there’s a certain sexism in access to health services and barriers to access as well – there’s no movement for lay-urologists after all. There’s no widespread urging of men to forego pain relief for kidney stones.
        I do think there’s some evidence that men should also not delay fatherhood – all be it that has to do more with fetal/child health than the health of the man.

        • Houston Mom

          Men should also be informed that delaying commitment/consent to fatherhood until their partners are staring infertility in the mirror everyday isn’t a great idea either. I met my husband at 23. He refused to get married until I was 31 and worried about my clock. After two years of trying and him refusing testing, I made an appointment with a doctor and found out he had azoospermia from a bout of mumps. First time I heard he had ever had mumps: while he was being wheeled into surgery for his first TESE. He honestly had no suspicion himself. No one had told him sterility was a possibility when he was a kid. We wasted time with a crummy RE. IVF was so expensive and emotionally barbaric. There were a couple of years we didn’t try at all, we were so shell shocked from the disappointments. It was really hardest on my husband, and he really regrets the delays now. We switched REs for one last try and the new doc finally did my first ever hysteroscopy, found a polyp the size of a golf ball with its own blood supply which was removed and presto! finally pregnant at 40. I know that we are more mature now than we were at 23/25 when we met, but I think young us would have been good parents. My husband is a kind, gentle man and he didn’t need to grow into anything to be a good father, and that’s also the reason I waited 8 years for him to marry me.

          • Jessica S.

            *sniff* I got a little teary-eyed reading this! Such a sweet story. :)

      • Guestll

        They also won’t believe you. Tell the average 40 year old woman who is trying to conceive her first what her odds are. She either won’t believe you or believes that for whatever reason, she will beat the odds. Sexism, yes, but also the argument that it’s unfair (I was busy with my career/didn’t meet my husband until I was 37) or simply untrue (my dry cleaner had a baby at 46). It’s already a tough sell, that delaying fertility can have consequences — I agree with you that extending that argument to delaying childbirth is a giant uphill climb.

        • Amazed

          But why does an average 40 year old woman need an OB to tell her that her odds are not that great? This is high school knowledge? I certainly remember reading about that in my biology textbook when I was 14.

          • The Bofa on the Sofa

            My wife was 37 I think when we first ttc. She had been on the pill for 16 years or so. We had no idea as to whether either of us were even fertile, much less whether there would be an issue with age. We expected to have problems with it, even. We didn’t – after one wronky month of a non-pill regulated cycle, she got pregnant the next month around.

            Then when she did get pregnant, we worried about the increased risk of everything due to the fact that she was 37.

            Ditto second time around, when she was 40.

          • Amazed

            I remember asking my grandmother, ‘Why you aren’t the one raising me?” Sometimes, I liked it better with her than my mom because she quite spoiled me. And she said, “If grandmothers could raise children, they would give birth to them.” This was about 25 years ago and my grandma doesn’t have any special education in biology. I cannot believe that nowadays, average woman doesn’t know that age is a risk factor for success.

          • Danielle

            Ha, that’s totally us, when we were 34/35. That’s hardly geriatric. But its old enough that people forward you those articles about professional women and infertility. I discounted such warnings; but I still half expected to have trouble. What are the chances of no accidents in 10 years of marriage with protection, right?

            I was off birth control for less than a month when it occured to me I might need to take a pregnancy test.

            I don’t deny that infertility goes up as people age — but really, its not the boogeyman some people want to make it. People should ttc when the time is right for them. Period.

          • The Bofa on the Sofa

            We did not try to have kids before then because we weren’t ready to have them yet. We would not have been able to do as well as we wanted as parents or as people if we had kids earlier.

            If we had discovered that we were not able to conceive at that point, it would have meant that we wouldn’t have had kids. It would not have meant that we should have had them when we weren’t in a proper situation for them.

          • Danielle

            Exactly, Bofa.

            I do not deny that women should know the risk of infertility and of complications rises as one ages. It is one of many factors to consider when planning a family.

            However, I don’t like that fact being trotted out as a ammunition against the idea that people ought to wait until they are ready to have kids before ttc, or as a prediction that women pursuing education means the decline of society. Given how much a settled family situation and earning power can contribute to children’s well-being, the benefits of waiting arguably out-weigh the risks of being childless.

          • Young CC Prof

            I still remember the doctor who told me that if I wanted children, I should start soon. I was 23, working odd jobs, no health insurance, and living with my boyfriend in his parents’ basement while he tried to finish college.

            Yeah, NO.

          • The Bofa on the Sofa

            When we were younger, I used to have the opinion that there was really no “good” time to have kids, and, whenever you do it, there is going to be something problematic about it.

            I don’t believe that any more, not exactly. Then again, we had the advantage that we didn’t have any age-related issues. By the time we had kids, it was the perfect time to do it – we had gotten to the stages of our lives where having kids was actually a good thing to do.

            But as I said, the reason I can say that is because we didn’t have any age-related complications (aside from the fact that trying to chase a 3 yo around when you are 45 is pretty trying). Fortunately for us, when it came to be a good time to have kids, we were still able to do it.

          • Young CC Prof

            I also felt that way. How could I possibly get tenure, afford a proper home, and still have babies while young enough to produce them?

            But in the end it turned out OK. I was approved for tenure when I was two months pregnant, and officially got it a couple days after he was born, at age 33. First pregnancy wasn’t perfect, but it went well enough that going back for another round in a year or two doesn’t seem medically imprudent.

          • The Bofa on the Sofa

            Ours kind of went in stages. I had the issue of tenure, but by the time that happened when I was 36 and my wife 34, my wife was in vet school. She had classmates who were pregnant in vet school, but it seemed mental to us. Then she finished vet school and needed a couple of years of work experience. Next thing you know, I’m pushing 40 and she’s 37.

          • Ceridwen

            I think the problem is that some people are waiting not for a good time to have kids but for the perfect time to have kids. And that time in terms of biology doesn’t always line up well with that time in terms of money, job stability, etc.

            Certainly you need to have the latter factors in line to some degree before you have children, but there tends to be a lot of wiggle room in there for many people, where starting earlier to avoid problems with the biology might be a good idea. Certainly my husband and I will be *more* financially secure and have better jobs in 5 or so years from now. But we were secure enough now to go ahead and start a family. And that decision was partly made because we did not want to run into problems conceiving or deal with the increased risks of pregnancy and birth with a 5 years older mother.

            It is important to inform people of the risks that come with waiting. It doesn’t mean they all need to rush out and have kids when they aren’t financially able to support them. But there are certainly a lot of people who do end up wishing they’d started trying earlier because they were stable enough that they could have handled it but just didn’t think think the biological part was going to be a problem.

          • Alexicographer

            Conversely, I remember the doctor who told me at about the same age that I was a fool to have unprotected sex, ever, with my then-(serious)-boyfriend because OMG what if I got PREGNANT? I was self-supporting (as was he; he owned a home, I didn’t and was renting — not living with him) and had a Master’s degree, working on my Ph.D. And both sets of would-have-been-grandparents lived in the same town as we did and are sane, lovely, stable people who would have been delighted to have welcomed a grandchild.

            Now in retrospect she was right, in the sense that I’m glad I didn’t end up stuck with that S.O.B., or trying to parent with him. But as disastrous-OMG-you-cannot-possibly-become-a-parent-given-your-circumstances examples go, I wasn’t it.

            My sense is that having an M.D. does not qualify one person to map out another’s life course.

          • Renee

            Taking the risk of childlessness for factors you may not even be able to control, and which can be temporary, may not end up worth it. Careers stall or go downhill, unemployment happens, bankruptsy happens, savings gets depleted, problems crop up in marriages, etc. Younger parents don’t necessarily do worse, and their struggles may be no harder.

            You like to think you will be better off, more stable, have a better career at 35, 38, and that will offset the fact that you will be 55 when your kid graduates. You assume you will be more mature and have more reserves of strength and financial well being.

            However, this is no guarantee, especially in todays economy. We waited until we were 34 to have our first. We did what middle class people do- we had been together 7+ years, had a bunch of savings, thought we were mature and well past the mistakes of youth, I had an excellent career, and a nice place to live.

            But, Life happened.
            We are right back to where we were at 19. Low income work, crappy apartment (which we haven’t had to live in for well over a decade!) Crappy job prospects, failing car, zero savings, and 2 small kids that need things everyday.
            But now I am pushing 40, facing ALL of the SAME struggles I would have had if these kids had come at 19, 21 instead. I’m tired.
            Restarting everything and having these 2 little ones at this age sucks. My parents did everything to help when I was 20, but cannot help now that I need it. And who wants to ask parents for cash at 38?

            I know its not for everyone, but economics are often fleeting, so making choices based on them may not always be wise. If you want a kid, waiting forever for the right time can be a trap. If nothing else, its worth considering.

          • Guestll

            The thing is Danielle, when you’re at that point where your specialist is looking you in the eyes and saying, “Your eggs suck” (I’m paraphrasing) and absent donor eggs, your chances of having a baby are poor, what do you say? What do you wish for? How do you feel? Can you rationalize it away and say, I was doing two grad degrees, working, travelling, and didn’t meet the right guy until I was 37? Maybe. I couldn’t.

            And there’s nothing you can do about it, because you realise that ART is not the magic bullet in your case because while we have figured out how to aspirate sperm from men who ejaculate none, and we can bypass blocked tubes, and we can manipulate the who cycles of anovulatory women, there is NOTHING that can be done when your eggs are shit and you don’t have a lot of them left. All you can do is try, spend, and hope.

            I got to be one of the 1 in 3 — those were the odds my RE gave women in my particular bracket. I’ve stayed in touch with many women in my age group who were trying. Out of a group of 27 of us who started 5 years ago, 12 have had a baby. All pursued ART. If you ask the other 15 how they feel, will they say they’re happy being childfree, with how their lives have played out? No. Because if you’re at that point where you’re willing to spend $$$, you’re at the point where it matters more than just about anything.

            I hate that it is what it is but I also hate the notion that women expect this to be fair and to play out like they want it to. I wish I’d understood more about the profound effect of age on fertility before I was at the point where there was nothing I could do about it. Would it have altered my path? I can’t say for sure, but at least I would have known.

          • Danielle

            Thanks (to you and to Renee) for sharing the details of your particular journey. I won’t dispute anything either of you said; the tradeoffs are certainly there, and it’s important for people to understand them when they are trying to plan. I also think the question you pose–will I be devastated if I am childless?–is highly individual and may affect a person’s plans. I was OK with a somewhat increased risk of being childless or only have one baby, so the educational/economic gamble simply made sense to me. That gamble might not be as well suited to someone else.

            I think the main difference in our responses is that we’re fleeing different demons. I’ve been in communities where relatively early marriage and home making were cardinal virtues and the fertility card was generally brought out as a way to temper women who seemed to leaning too “feminist” in their philosophy or career ambitions. It’s not that I don’t concede the truth at the center of that argument; it’s that this is card used to come out in conversations with women who were only half way through college. The suggestion implicit in these conversations was that a woman’s worth was related to child-bearing and that this should not be traded for something as trivial as personal growth, let alone that child-denying evil: women in the professions. You’re approaching the conversation from another vantage point–women who think or are told that they’ve got to wait until their 30s and have every little duck in a row before they should try to have kids, even though in their case that decision might not have been the right one, after all. In both situations, we’ve got a common problem: people’s ability to make a fully informed decision that is appropriate for them based on their individual situations gets compromised when the facts aren’t known or other people’s advice cuts against a person’s ability to consider the implications of all the facts related to her particular case.

            From either perspective, information is an ally here.

          • Guesteleh

            Speaking as someone who easily got pregnant at 40, it’s not that simple. I have friends who became infertile in their late 30s, others who got pregnant only after major struggles and ART. Women need to make informed decisions around these issues. I got lucky in getting pregnant easily, but not so lucky when I developed a major, life-threatening complication after giving birth–one that is much more likely to occur after 35. It’s not sexist to inform women of these risks. You don’t have to become a mother, but if you really want a family then you need to understand that it may not happen if you wait too long.

          • Young CC Prof

            Some sources say that, oh, you really should have your children before 30. That’s not true, the latest research shows that for most women, fertility doesn’t seriously drop until after 35. But yeah, expecting to start your family at 40 and still end up with two children is not a great plan.

          • The Bofa on the Sofa

            I think my position is that there is no problem trying to start your family at 40, just don’t expect it to go according to “plan.”

            Much like the rest of parenting life.

          • Amazed

            This thread was quite informative for me. I’ll know that if my gyn tries to raise the topic with me sometime (I am almost 33 and hell, in the moment I am not becoming a mother), I’ll know that it’s due to the fact that there are average women like me who don’t know age is a factor and not that he thinks me illiterate.

            Seriously, until now I figured everyone knew how things went and made their plans according to this.

          • Young CC Prof

            Just remember, according to a CDC study, in 2009, 24% of babies in the USA were born to people who did not intend to get pregnant, but were not using contraception. (To be fair, some babies were to women who thought they were infertile, and some arrived only slightly earlier than their parents wanted.)

            Some people plan more…intensely than others.

          • Trixie

            The commenters here certainly skew older and more educated, and more likely to grapple with these issues. Reading these comments make me feel like a baby because I got pregnant the first time on my 29th birthday. But I think the US average is around 25?

          • Guesteleh

            I agree with this. When I decided to go for it, my husband and I agreed that if it didn’t happen we’d accept it and get on with our lives. I’m sure I could’ve been happy without having a child. I love being a mother but I had a good life before motherhood.

            But I know women who are crushed and devastated by infertility, and if you are someone who feels that they must have children to feel fulfilled, then you need to get on it sooner rather than later.

          • Alexicographer

            “…if you are someone who feels that they must have children to feel fulfilled,…”

            I wasn’t someone who felt that way (at all), until I was told I couldn’t have children genetically related to me. Then suddenly I was, with an intensity I could never have predicted.

            I don’t know what anyone (else) should do with that information, but it turns out that things that seem like future possibilities can seem perfectly fine, until they ARE your future. And then, not so much.

          • Guestll

            But don’t you think it’s easy to say this with the benefit of having children? What if you were 50, 55, 60, and you had tried but couldn’t?

            I was someone who said “never” to ART, having witnessed a few friends go down that path. I said we’d try and if it didn’t work out, then…but I’m not the only factor in that equation, there was my husband, too. And when I tried and kept trying and it didn’t work, suddenly, ART didn’t seem like such a bad idea. If it was only Clomid or something. And then you find yourself doing your third IVF, and saying, what next, if not this?

            I had a great life before my husband and daughter came along. It’s really easy to say that I didn’t need children to be fulfilled, because I didn’t have any and I didn’t know the depth and magnitude (good and bad) of what motherhood would bring to my life.

          • Guesteleh

            Well, I have child, not children. I couldn’t have more because I was told that it could kill me if I got pregnant again. I felt sad but not devastated. But I know two women who experienced secondary infertility as a major tragedy, who were practically destroyed that they would only have one child. Meanwhile, another friend of mine with no children tried in her 40s, didn’t get pregnant, and didn’t opt for ART. So I don’t know. It’s hard to predict in advance how you’ll react to something like that.

            Re: ART, I worked with a medical ethicist who wrote a lot about the industry, which strongly influenced my belief that I wouldn’t go down the road if I were infertile. But who knows what I actually would’ve done if confronted with the choice.

          • Renee

            There is so much more to whats the best age to have kids, people may not really consider the other stuff.

            My parents adopted us at the same age I had my kids, which was mid/late 30′s. Now, my mom is dead, my dad is 73, and my kids are still 2,3. We have no one to help. Even though my mom would have loved my kids, she didn’t live to see the second one, and was in too bad of shape at 70 to do much with the first one.

            We think of our parents as forever young, and I know there are some people that are 70+ and still in as good shape as a 40yr old. But that is not to be expected. Then of course, YOU will also be the 60 yr old parent of a 25 yr old. It sucks. I wish I had really considered this.

          • Jessica S.

            That’s the one “regret” I have (I was 34 when my first was born, I’ll be 37 when this one comes in July – and that’s all we plan for is the two) but honestly, there really isn’t any other way I could have or would have wanted things to go. So what go you do, I guess, but try to soak in what’s now? It’s the biggest challenge in life, in my opinion. :)

          • Young CC Prof

            Actually, that’s one of the biggest reasons we’re not sure about a second child: my husband just turned 40. It’s not just the creating, it’s the raising. Even if we moved really fast on kid #2, he’d still be 62 years old by the time that child graduates high school.

            Then again, both of my grandfathers were even older! One became a father at 42 and 45, the other at 45 and 50. The first lived to see me married, but the second saw me only as a baby, and his youngest grandchild not at all.

          • Guesteleh

            I think of this too. My MIL passed away when my son was two and my FIL was already dead. My mother is still pretty young, thankfully. And I’m sad that I will have far fewer years with my son than other people get with their kids. But I don’t regret waiting because the alternative would’ve been having kids with my irresponsible first husband instead of the wonderful man I did have a kid with. (I do regret marrying the first husband but that’s a whole ‘nother story…)

          • Karen in SC

            I had my kids at 36 and almost 40. It’s true what you say, of course. Since I didn’t get married until age 30, I couldn’t start my family that much earlier. My parents died when my boys were young and I grieved their loss each milestone. We are grateful that the paternal grandparents have been close to them and are still alive.

            On the other side of the coin, I am old enough now to see friends in their 50s and 60s have to deal with aging parents who are 70+.

          • Amy M

            I was infertile regardless of age…I don’t ovulate, or at least not very often. I might have a few times as a teenager. It was going to be IVF for me no matter what, but I was 31 at the time, and had plenty of good quality eggs according to the RE, so that probably helped.

          • Guestll

            …said the woman who wasn’t trying to have a baby at 37 and beyond…

            There’s a big difference between 34/35 and 37/38/39/40/etc.

            It is the boogeyman, it’s bigger than most people make it out to be. People should try for a baby when the time is right for them, but with the caveat that the time that is right for you may not be the right time for your ovaries. Time is the one thing you can’t get back. Ask me how I know.

          • Danielle

            I acknowledge your point–fertility declines over time and the fall is precipitous after 37. And I fully agree that women should consider the data relating to fertility and age seriously when they think about their life plans. My point is simply that this fact is nothing more or less than one factor in many that should determine when a women tries to become pregnant.

            Again, my objection is to the way this data is used: it’s been brought up in articles and interpersonal conversations for eons as an argument about the malaise of women being educated too long or “selfish” couples waiting to feel settled. (I’ve been hearing warnings about my potential difficulties with childbearing since I was in my early ’20s, and it was always brought up as a kind concern about my enrollment in a Ph.D. program.) I dislike this use of the data, because many times people are waiting for perfectly rational reasons. But of course people shouldn’t stick their head in the sand and pretend age is no factor at all. It’s a factor…it just shouldn’t be the determining factor for most people.

          • Young CC Prof

            Exactly. Women should realize that the longer they wait to have children, the more likely it is that they will suffer infertility, pregnancy complications, and possibly wind up with fewer children than they want or none at all.

            However, if the choice is between maybe not producing children and producing children at a time when you know perfectly well that you are not equipped to provide for their basic needs, it’s not so simple.

          • Guestll

            Danielle, I’m curious: at what age do you think a woman’s fertility starts to decline?

          • Guesteleh

            You would be surprised. There are women who are really fit and active and look very young at 40, and they are gobsmacked when they discover they’re infertile. “But I eat organic! My blood pressure is low!” They don’t get that your ovaries don’t give a shit. The NY Times wrote about this:

            Are You as Fertile as You Look?

          • The Bofa on the Sofa

            “I’d based a lot of my self-worth on looking young and fertile…”

            eeeeeeek!

          • Amazed

            How can one look “fertile”? In olden days, they had physical hallmarks that at least made sense. The fact that I have slender waist and wide hips doesn’t make me look “fertile”, it just makes me look like what Edward III sought in a bride: good hips for childbearing.

            Of course, even he probably knew good hips were no guarantee.

          • The Bofa on the Sofa

            Of course, even he probably knew good hips were no guarantee.

            This is the key.

            I’m not even sure that her conception of “fertile looking” is all that accurate. In olden times, the “fertile look” was not what we would consider healthy. One of the few things I remember from Human Anthropology is that the fertility appearance was summed up as “big boobs, big butts.”

            Hollywood skinny it was not.

          • Amazed

            “One of the few things I remember from Human Anthropology is that the fertility appearance was summed up as “big boobs, big butts.”

            This. Plus, the interesting thing is that the “fertile looks” quite contradicted to the reality of men’s preferred bedmates: slender slave girls.

            Isn’t Hollywood all about making us believe that being fertile MEANS being desirable?

          • Renee

            No wonder Im so fertile….

          • Alexicographer

            I think, too, that there is a widespread (but incorrect) perception that age doesn’t matter so much, in the age of ART. It’s hard to drag my mind back to my own need for ART and a big concern was affording it, but knowing that I needed it anyway (DH’s failed vasectomy reversal), I was not the LEAST bit prepared for the thought that at 34 I might not respond well to IVF (wouldn’t produce lots of eggs).

            My sense that one message that *is* majorly missing from much public discourse is that ART is not a solution to the problems associated with maternal age — very much the contrary. The use of donor eggs (when the fact that they were used is kept private) only exacerbates the perception that ART can readily help women who are having trouble conceiving to do so (if one considers the decision to use donor eggs to be a separate decision from the one to use ART — if one is ready to use both, of course, then ART can indeed make it much easier for older women to become pregnant and bear children — but even then, ART does nothing to mitigate the risks associated with pregnancy and childbirth, of course — just allows a higher-risk group of women to experience them).

          • Amazed

            God. And those are women with education, some of them actually have contacts with this fashion/Hollywood world and should know firsthand that things there are not glamour alone.

          • Renee

            The irony is how many of us aren’t fit or particularly healthy, but have the fertility that creates a baby when you are in the same room with a sperm. I wish people would realize there are just some things you cannot control completely.

          • Rabbit

            No, because given the state of sex-ed in the US, most teenagers only get the “if you have sex you will get pregnant, and/or a horrible disease, and die” lectures, not actual health information. Acknowledging the actual risks of pregnancy or STDs would go against that teaching.

          • Amazed

            I am not talking about sex-ed. Also, I am not in the US. At 14, we had almost an year of studying about human body and the processes in it. Bones, marrow, you name it. And yes, eggs and sperm were a part of it.

            I don’t think education should be the same everywhere – but surely American teenagers should be taught at least the basics of how human body WORKS?

          • AlisonCummins

            Because she doesn’t feel old and infertile! Other women might be old at 40 but she is a young 40! Also she really wants to.

          • Guestll

            Sadly, I found this to be very true.

        • http://thefresstyler.blogspot.com/ Hannah

          Yup. I am 29 and the number of people who have told me ‘oh, but you’re SO YOUNG, why didn’t you wait?’ is surprising. Even my husband has been asked much the same thing, and he is 35.

          I don’t think people should rush into having kids when they aren’t ready (are you ever?) or that women becoming educated or having careers is the death of society but equally I think women have been sold rhetoric about fertility that is simply inaccurate. The number of educated, worldly women I know who have been completely unaware of the realities involved in fertility in your 30s and 40s, or who have been surprised to find that fertility treatment is not a guarantee, is kind of startling.

          • http://www.antigonos.blogspot.com/ Antigonos CNM

            Women are, in the main, not well served by the biologic clock, which tells them the best time to begin having children is around 19, when they almost always are too immature to really cope well with raising a child [not to mention that in today's world, they are very likely still in school] By 40, they may be mature and successful, but their eggs are rapidly edging into senility.

          • Renee

            If I knew then what I know now, I would have had mine at 19 and 20, not 34 and 36. I think its easier, and less disruption, to have then before going to college and starting your career, than to try to do it right at a high point in your carer. Especially if you want a year or two to spend with them (since there is no leave.)… Having kids at 34-36 was a career killer. The health issues from the pregnancy, plus the time off, really hurt my earnings.

            Having kids is never easy, but the advantage I would have had with youth would have made college with them more possible. I would also have had parents to help, as they are too old to help now. And I don’t del so much more mature that it outweighs the difference in energy by age.

            YMMV, this is just for me.

          • http://thefresstyler.blogspot.com/ Hannah

            Yeah, it feels like a bit of a Catch-22, honestly.

          • The Anti-Woo

            That’s so funny. I work in a low income area, and there is definitely a culture shock between my “real life” and my work one. A woman overheard me talking about my pregnancy (my baby is 10 days old). She says “You’re pregnant? How old are you??” I told her I was 33. She then told me that I was too old to be having babies! But then, in the neighborhood I work in, there’s a lot of women who are grandmothers by the time they’re my age. Different cultures hehehe

          • Young CC Prof

            I had a very similar experience at work, carrying my first baby at 32. We didn’t have too many 32-year-old grandmothers, but 36? Sure. That population had a lot more grandmothers that age than first time mothers, anyway.

          • http://thefresstyler.blogspot.com/ Hannah

            Congratulations on your baby’s arrival – I am 24 weeks today, cannot wait for her to arrive safely!

            It’s definitely a cultural thing, I think. I am Jewish and this seems pretty average in my generation but I think culturally, at least in Australia, there is an emphasis in the community on marriage and kids despite the ‘other’ emphasis on education and career. A lot of my friends in general felt a bit like I was a child bride when I got engaged at 27, haha. Diffrn’t strokes, right? :)

        • The Computer Ate My Nym

          My one and (I hope) only pregnancy was at age 34/35. I had definite fertility issues. They’re probably not age related, though, since…um…well…to tell the truth, I wasn’t always perfect with my use of birth control as a young woman and never had an unintended pregnancy. Mind you, workup for cause of low fertility was essentially negative and I had a spontaneous pregnancy. It just took a couple of years. Would it have been faster 10 years earlier? I don’t know, but suspect not…

          OTOH, 7 women in my HS class had babies in their 41st or 42nd year. They probably didn’t all air their fertility issues on our facebook group, but be that as it may, they got pregnant.

        • S

          Interesting. My Asian-American family members have been reminding me of my declining fertility since i hit my mid-20s. The first random comment from a cousin (American, of Asian descent) came on my 24th birthday when i was not seriously dating anyone. When i was 28, my mom, apparently getting desperate, told me it was okay with her if i became a single mom. (I hadn’t asked.)

          • auntbea

            My uncle – in – law spent every dinner for a year trying to convince me and all the other female cousins to freeze their eggs.

        • carr528

          I had my first at 27, and my last at 37. I’d take pregnancy at 27 over 37 any day. While I didn’t have any major complications with any of my pregnancies, with my last one, I was miserable from about 18 weeks on. Sciatic pain, heartburn, nausea, etc. Every minute of the last month was brutal. I still joke that there’s a reason women have babies in their 20′s.

        • T.

          Yep, because it isn’t like there are other kind of setback in having a baby before being sure to have the money to actually taking care of it… I mean, it is not like being a poor child, for your long-term possibility in life, is worse than pretty much anything else (save alchool in pregnancy). And it is not like more than half of US children live technically in poverty already. What we need is more 20-something having babies, cutting away all of their possibilities for their own future careers AND being more likely to have poor children.
          Meeh. Having good possibilities in life is SO overrated after all.

          • Amazed

            Oh cut off the moral arguments. She isn’t arguing that everybody should have their kids at 19-23. But biology is biology and it’s clearly quite underrated. Your post is a fine example of that.

            Let’s leave women make their decision with all the right information – CPMs are not safe of safer than an OB and generally, a woman at 40 isn’t as fertile as a woman at 40.

            End of story.

          • T.

            It is not a moral argument. Having a baby in your teens, 20s, 30s is the same morally speaking. It is an economic argument. Money. Economic is amoral, like biology.
            Biologically it is better to have a child in your teen. Economically it is better to have a child later on.
            Make your own choices. But telling a woman that she will have the same career options and the same amount of money* if she has a child in her late teen or early twenties as she would if she had waited is JUST as wrong as saying that a woman in her 40s is as fertile as a woman in her 20s.
            End of story.
            *Which ends up in things like, say, a college fund for the kid, too, aside from things like “being sure next month you will eat and you will have a roof over your head”. I grew up without knowing those things. It is not pleasant.

          • Guestll

            “But telling a woman that she will have the same career options and the same amount of money* if she has a child in her late teen or early twenties as she would if she had waited is JUST as wrong as saying that a woman in her 40s is as fertile as a woman in her 20s.”

            Except no one here is saying that. And not everyone values the same things in the same way.

            My eldest niece is 28 and is about to have her third child. She married at 22, in her last year of university. They live in the city in a 2 bedroom apartment, and in about 8 years, they will have enough money to afford the down payment on a townhouse. She got an education, she has a career, she has a family. They are not wealthy. They have a happy marriage and happy children.

            Women like her, where do they fit in to your world view?

          • Young CC Prof

            And if you can make it work, awesome. But they live in an apartment, not a leaky basement or a cardboard box. You don’t have to be rich, it’s certainly OK to put parenthood ahead of career, but it’s really NOT a good idea to have children without a certain minimal amount of resources and stability.

            There are no guarantees. People get sick, people die, marriages fall apart, solid careers get derailed. A family that started off stable and comfortable can be thrown into chaos. There’s no sense waiting until the perfect time, that’ll never come. But it makes sense to start off when things are basically good enough.

          • T.

            As any other woman who is making her own choices, which (likely) do not include a personal career and earning money. If she is happy, I am glad for her.

            Would I personally make the same choices? No.
            Do I think everybody should make my same choices? No.
            Do I think that financial and economic consideration should be thought before making such a decision as having a child? Yes, absolutely. I am happy if some people can earn enough on one income to support a family. Most people can’t, though, or at least this is the impression I get from the current job market.

          • Guestll

            Your post is a good representation of a discussion amongst a couple of my friends this past weekend — it’s now taboo to have a baby in one’s 20s, when we are most likely to be able to conceive and deliver successfully. We look down on women who prioritize having a child over their career or education or self-actualization.

          • T.

            I happen to believe that a woman self-actualization is just as important as that of her child(ren), since the woman is too a human being, she doesn’t become an incubator the moment she get pregnant. But that is for another time.
            You are more likely to conceive in your 20. Everybody knows that. You are also more likely to live in poverty (or nearby) if you are a teen mother or if you have a child in your early 20s. Everybody knows that too. Being poor is not good for children, neither. As a matter of fact being poor during childhood correlates with doing badly later on. Which is obvious if you think of it.
            People have to balance the two things, and many decide to wait. Some decide not to. I personally have decided to opt out of children altogether. That too is possible.
            Thinking that women need to be “educated” about such a thing is like saying that a woman who bottle feed needs to be “educated” about breastfeeding. Chances are she already know and has made her choices.

          • Guesteleh

            Except that most of the women I know don’t understand the tradeoffs. It’s not their fault. I don’t think it’s something that’s clearly communicated in our culture. And of course life circumstances, sometimes you’re aware but there’s not much you can do to change your circumstance. But in terms of knowledge of the physical and economic limitations and tradeoffs around pregnancy and childbirth: no, I don’t think many women understand.

            Also, no one here is advocating for teen or early 20s pregnancy–or any pregnancy at all. But I have friends in their 30s in stable marriages and financial
            circumstances who say they want a family but are postponing pregnancy when maybe that’s not such a good idea.

          • T.

            I am Italian. So our cultures may be different in this regard (this is also the reason why sometimes my English is not perfect).. I have never known a woman who was not aware of the steep decline of fertility after her thirty.
            It may be that those friends of yours don’t really want children. In my experience, which is of course partial, women rarely come out and admit “No, I don’t desire to have children” either because it is not culturally acceptable or because it is considered as the baseline state for a woman to desire/have children and as such they have never really thought of it. Many more women than ever pass their fertility years without having children at all after all but it is still somewhat of a taboo, much like atheism. 16% of the people in the US are not-religious, only 2% or thereabouts identifies as “Atheist/Agnostic”, because Atheism has a bad name. For women, admitting (to themselves and others) that they don’t want children is the equivalent. If somebody is in her 30s, with stable marriage and financial situation, it may be she Is like one of those 14% that are not religious but don’t go right out to admit atheism or agnosticism.

          • Guestll

            “Chances are she already know (sic) and has made her choices.” And I’m telling you, no, there is a vast segment of women out there who don’t know. This is hardly a brand new finding, either. http://www.npr.org/2011/12/01/142725547/many-women-underestimate-fertility-clocks-clang

        • Kelly

          I know I am not the norm in that I looked at the information and figured that if I waited, I would be a part of the statistic that would not be able to have children as I am paranoid about my fertility. My husband and I decided that we would rather have our kids earlier so that we could have as many kids as we wanted and give up my career and put off buying a house. I know this was our decision and it works for us, but I think that women need to consider that they will be on the negative side of the statistics and whether or not that they will be ok not having kids in the future if that is when they decide to have them. It seems like women get to the point of wanting a child and then are shocked that it is a struggle or that they are unable to have one.

        • Jessica Atchison

          I’m 42, and people are STILL telling me “It’s not too late you know!” Um for me? Yeah it is. Actually, I was ready to call it quits on wanting a kid by 35. When I was in my 20′s I desperately wanted to be a mom. Now? Good lord the thought of chasing after a toddler exhausts me. And having already raised my sister’s two kids, the idea of having a teenager in my 60′s is just terrifying. No thank you.

  • guest

    I know nothing about anything, but if you treat women with a short course of blood thinners, don’t you risk that hemorrhage bar shooting up?

    • Amy Tuteur, MD

      No, the dose for prevention is much lower than the dose for treatment.

      • guest

        Oh! Good. Thank you.

      • Dr Kitty

        Except, if you’re very petite, like me, and they don’t adjust the dose for weight.

        I got a bit fussy and made them reduce it for me.

  • http://www.antigonos.blogspot.com/ Antigonos CNM

    In 1999 I spent six weeks at the University of North Carolina Medical Center (as a midwifery consultant for an Israeli hi-tech firm developing computer programs for L&D units). It was an extremely high risk unit; I thought it amazing that most of the women had survived long enough to become pregnant, let alone reach term, or close to it.

  • Busbus
  • Helen

    Why are women still dying from hemorrhage in the US? I presumed that if you were in a hospital then PPH was not something that would kill you.

    • Amy Tuteur, MD

      There’s more to hemorrhage than postpartum uterine bleeding. Hemorrhage can be caused by placenta previa, placental abruption, ruptured uterus, ruptured ectopic pregnancy, not to mention clotting disorders associated with pre-eclampsia/eclampsia.

    • Young CC Prof

      Apparently it’s about 2 deaths per 100,000 births, so that’s 80 per year. Pretty good, given the “natural” rate of fatal PPH.

    • no longer drinking the koolaid

      With placenta previa they try to get the woman as close to term as possible, or 3 episodes of bleeding, whichever comes first. We aren’t talking little spotting bleeds or just barely filling a maxi pad. I have seen bleeds that were easily 400 cc and as much as 2000. The mom would need blood transfusions, so you can imagine what the baby may have lost. But as long as baby and mom could be kept stable enough, the docs tried to eek out another few days. More blood transfusions were needed after the birth because frequently when there is a previa there is also the potential for an abruption.
      So, no, it isn’t just the PPH that is the etiology for hemorrhage.

      • Helen

        Thanks for all the replies. Pregnancy and birth really are scary. So much can potentially go wrong. My sister had a massive hemorrhage due to uterine inversion. She had to have 8 pints of blood. Normal, 2nd pregnancy, normal birth. And then that happened out of nowhere, right after the baby was born. Doctors said that if she’d been at home she was have almost certainly been dead from the quick and large loss of blood. I know things like this are rare but why increase your risks of a bad outcome when that outcome is so catastrophic?

        • Helen

          *would* have almost, not “was have almost”

      • EmbraceYourInnerCrone

        That’s pretty much how my mother’s last pregnancy went, in 1966. She went into labor a little while before her scheduled CS was supposed to happen and hemorrhaged at home, family drove her to the hospital(with my grandma driving like Mario Andretti apparently) and she abrupted. Emergengt CS and IDK how many units of blood later and my annoying little brother has arrived. Mom had to have a hysterectomy as they could not stop the bleeding. My mom and my baby brother are still around and doing great. I love blood donors…

        • EmbraceYourInnerCrone

          To correct myself she suffered a ruptured uterus, placental abruption is sort of a given with a full previa if you go into labor, I believe.

      • Haelmoon

        Placental abruption and placenta previa cause maternal bleeding. Vasa previa and feto-maternal hemorrhage cause fetal bleeding. The fetal risk due to maternal bleeding is loss of exposure to oxygenated blood, either due to separation of the placenta or significant hypoperfusion of the uterus due to maternal blood loss.

        • no longer drinking the koolaid

          Dr. Amy could you clarify this point. I had always thought that abruption was associated with fetal hypovolemia.

          • Amy Tuteur, MD

            The bleeding in abruption comes from the mother, not the baby.

          • Haelmoon

            On in very rare cases is there an associated feto-maternal hemorrhage. Some babies may be born hypovolemic or anemic when emergency c-sections are done, but that is because we cut into the placenta and disrupt the feto-placental circulation. The level at which the placenta separates from the uterus is all maternal blood (the two don’t mix, they only get close to each other).

          • no longer drinking the koolaid

            In the interim I went and checked a couple of OB texts. I was about to come back and post that I stand corrected. The risks to the baby are from hypoxia.

    • The Computer Ate My Nym

      Women who give birth at home might not get to the hospital in time for timely transfusion. There might not be enough blood available for a massive bleed, especially at a small hospital and/or with a rare blood type. The patient may be a Jehovah’s witness and refuse blood, even on the point of death. She may have multiple antibodies making transfusion effectively impossible. If there is blood loss sufficient that the massive transfusion protocol is required, the MTP might not be implemented properly and the bleeding therefore not stopped. An incompetent care giver might not recognize the problem in time. Massive, sudden bleeding could cause hypotension and brain death in seconds. Any one of these things would be extremely rare, but any can happen.

      • Young CC Prof

        And every once in a great while, PPH starts days or even weeks after a perfectly normal birth, when the woman is at home. I know of a couple women who had to go back to the hospital for excessive bleeding, and I can see how someone might not realize what was happening until it was too late.

        Rare, but we’re talking about rare events here.

  • ngozi

    I am going to go out on a limb in order to learn something. If I get flamed, at least I will have learned something in the process.
    Couldn’t the increase in maternal mortality/morbidity be caused by women having babies who in years past would have been told by their doctors not to have children because of certain health problems? Many of these women who are experiencing maternal mortality/morbidity complications in 2014 would have been counselled against having children because of diabetes, heart problems, etc back in the 1960s/70s. I have a medical reference book published in the 1960s that states women who have diabetes shouldn’t conceive at all.
    Also the population of women having children is getting older, and whether they or anyone else wants to admit it, older women are prone to (but not certain) medical conditions that would make pregnancy and labor/delivery more difficult. As my current OBGYN put it “pregnancy is a stress test on the body.”

    The interventions that are being vilified by certain groups are probably the interventions that are saving the lives of these medically vunerable women and babies. As I will say again, it was a NST that helped save my newborn’s life, this after a “good” ultrasound performed about 20 minutes prior.

    • Amy Tuteur, MD

      Absolutely!

      Previously women with certain health problems were advised not to get pregnant, or couldn’t get pregnant, or couldn’t carry a pregnancy to term. Infertility treatment has made a big difference in helping older, sicker women get pregnant.

      For example, I was taken aback to learn that cancer in pregnancy is becoming a significant problem, both cancers that are diagnosed during pregnancy and pregnancies in women who have had cancer in the past.

      • ngozi

        Are some doctors hesitant to tell a woman she shouldn’t conceive because of her health? We live in such a “I’m-going-to-do-what-I-want-when-I-want” society (in the USA).

        • Rochester mama

          As someone who is now 34 and taking clomid when I said I would NEVER do fertility treatments for a second child I can say it’s easy to say you wouldn’t do something until you are in the situation.

          • ngozi

            I am not saying what I would or wouldn’t do. I was just asking if doctors are hesitant to tell a woman that she shouldn’t have children due to her health. I am asking if it is possible that some doctors are trying not to hurt a patient’s feeling, or avoid a conflict (even though those two things pale in comparison to good health). I was pointing out that in American society people are not always open to being told what to do, even if it might be in their best interest. I am sorry if that came off offensively.

          • Rochester mama

            I think most women know the risks, but are willing to try for a family. That’s just my opinion I don’t have any data to back it up

          • Haelmoon

            There are a few women who I have recommended that they never get pregnant because of the significant risk to their health. Other women I have met and we worked out ways to optimize them before getting pregnant. My major concern is high risk women who are not seen preconceptually, and we are left picking up the pieces once they are pregnant – sometimes we don’t even know the full extent of their condition and some tests may be contraindicated in pregnancy. I am a strong believer in preconceptual counseling for all women. Know what to expect and plan ahead
            .

          • PrimaryCareDoc

            I have some, too. I have one who needed a CABG in her early 30′s due to premature CAD. She also has ischemic cardiomyopathy. She is also incredibly non-compliant with her meds and follow up. Last time I saw her she was trying to get pregnant. I begged her not to. I set her up for an MFM consult, but she never followed up with them, and I never heard from her again.

          • Haelmoon

            Hmm, I wonder if I have me her?? I recently had two cardiac patients who had not previously been seen by MFM, but really were not good candidates for pregnancy due to significant acquired cardiac disease. I see as much CAD and other acquired disease as I do adults with congenital heart disease. Its a little sad, frequently due to drugs.

          • LadyLuck777

            Some doctors still have the “do what I tell you” mentality, but many of us see healthcare as more of a team process. I tell my patients that I am here to make recommendations based on my training and education, but it is ultimately up to the patient to make the decision. It is as simple as telling a patient “You need to lose weight” versus “your health and well-being would improve if you lost weight.” That is what has changed in the new era of patient autonomy.

          • Guesteleh

            I was strongly advised not to get pregnant again after a serious pregnancy-related complication. But I was already 41 so maybe the doctor felt freer to warn me bluntly. I’m glad he did.

      • ersmom

        In our small, rural hospital, we have had 2 women dx’d with cancer while pregnant in less than a year.

      • Elizabeth A

        I’ve occasionally contemplated having a third child post-cancer. I don’t know if it would be possible, and I don’t know what factors would complicate the pregnancy if I did. It’s not something my doctors discussed with me, because I didn’t ask. But my doctors did ask if I had future reproductive plans before beginning chemo, and they were willing to schedule egg retrieval if I wanted to freeze some cells before starting. That does lead me to the conclusion that a fair population of cancer survivors are at least trying to go on and have babies after treatment. So, um, what are the complications of that course of action?

      • The Computer Ate My Nym

        Same with sickle cell disease. Used to be the advice was don’t get pregnant or you’ll die. Now the advice is think carefully before getting pregnant because you’re high risk. A very different message.

    • Anaesthetist

      I specialise in high risk obstetrics and we are seeing a generations coming through of mothers who had cardiac surgery as children – and who thanks to their treatment are surviving with comparatively normal lives compared to previous generations, who would have died young or been significantly functionally impaired by their congenital conditions. And entirely understandably these women have exactly the same set of ambitions and aspirations for their lives as those without congenital heart disease – including children. This is likely true of many other chronic conditions

      • Young CC Prof

        And substantial numbers of childhood cancer survivors are now old enough to have children. And women who were themselves born severely premature…

        • Amy Tuteur, MD

          And women who have had organ transplants, women with cystic fibrosis …

          • Awesomemom

            I follow the blog of a woman with CF that had a baby. She is on a brand new medication for it that had not been tested in pregnancy. She ended up with a csection after a rough labor but the baby seems fine so far, no effects from the medication are apparent.

    • EmbraceYourInnerCrone

      Sure, my niece had a heart condition that made pregnancy somewhat more risky. She decided she wanted to have children and was willing to risk it. She developed pre-eclampsia with both pregnancies, had premature babies (6/7 weeks early) in both cases.

      Both of her her daughters are fine, but sadly my sister in law passed away due to a stroke at 42. She knew the risks and decided that she was willing to take them. She however got great medical care and took every precaution her doctors advised to give her daughters a chance.

  • Ellen Mary

    Regarding increased age of childbearing women: it is certainly true that my mother’s generation had children early in life, and my grandmother’s generation, to a lesser extent (2/4 grandmothers had babies in their early 40s), but the generation prior to that was also prior to the pill. So nothing was in place to stop conception close to menopause other than withdrawl, sterilization (but not laparoscopic) & maybe condoms & diaphragms. Indeed my great grandmother had her last child at 48. So I am just questioning the idea that women have never given birth en masse in their late 30s & early 40s before in history, although I am sure maternal mortality was also high then . . . And that these would have been women who had weathered multiple earlier pregnancies.

    • Ellen Mary

      Also did the conference mention Placenta issues at all? I think the non-existence of high risk services for mothers vs. neonates does show that our society systemically undervalues maternal welfare . . .

    • http://Www.awaitingjuno.blogspot.com/ Mrs. W

      But they weren’t giving birth for the first time at 42, 44, 46 or 48…that’s an important distinction.

      • Guest

        This is a VERY important distinction. The risks are much different for a women having a subsequent child in her late 30′s or 40′s than for a woman having her FIRST child at that point in time.

        • Alissa

          Not that I don’t believe you, but why would the risks be so different?

          My mother had my younger siblings (#3 and #4) at 36 and 38. I’m staring down the barrel of being 35 before it’s financially feasible for #1andonly. Aside from a proven pelvis, what’s the real difference between multip and primip at that age?

          (Assuming, as we can in this case, somewhat similar genetics and overall similar health.)

          • anion

            I’d really like to know the risk difference, too. Everything I’ve found relates to women having first babies; there’s very little info for women who already have a couple under their belt and are just wanting one more before the shop closes for good (which is my situation).

      • Sullivan ThePoop

        My grandmother gave birth to my mother, her one and only child at 47 years old. They had actually told her they didn’t think she could get pregnant, but couldn’t find a reason and then when she got pregnant they thought it was a tumor.

    • Young CC Prof

      Yes, 3 out of my 4 great-grandmothers had a child after 40, and the other one was already a widow. BUT, even then it was considered riskier, and maternal death was a common fact of life at that time. I know one of them was quite anxious when she realized she was expecting her sixth child.

      • Guestll

        In 1956, my maternal grandmother bore her last child at age 40, 8 years after the one who preceded him. According to my mother, who was 13, he was somewhat ruefully referred to as a “late baby.” There’s been a huge cultural shift, obviously.

        • Deborah

          Many of the babies born to women over age 45 were unofficial adoptions of illegitemate babies born to other members of the family . . . .

    • Guestll

      They also “ceased relations”, as in the case of my paternal grandparents. My grandmother bore 13 children in the early 1900s/10s (9 made it past childhood) beginning at age 22 and ending at age 42. After that, she closed up shop to my grandfather, and from what I’ve read, this was not uncommon.

      It’s never been unusual for AMA women to bear children, but as Mrs. W wrote below, the difference now is the age at which women begin to bear children has increased. This has profound implications on fertility as well as pregnancy and delivery.

    • Dr Kitty

      When I was a med student we had a natural conception in a 53year old.
      She was newly divorced, recently back on the dating scene, assumed herself to be menopausal and …oops.

      Her elderly mother accompanied her to all her appointments, because the father wasn’t involved, everything went fine, but I don’t think it was exactly in her game plan.

      While fertility is very low after 45, the official advice is still contraception for two years after a last period if under 50 and 1 year after a last period if over 50. Women do get caught out (known in Ireland as a “wee late one”).

  • expat

    Does an increased cesarean rate correlate with a decreased hemhorrage rate or vice versa?

    • expat

      I ask, because the hemorrhage (and pre e) death rate goes down while the cesarean rate has gone up. I know, teasing out the rate of hemorrhage due to the cesarean itself and excluding the condition which necessitated the cesarean is tricky, but what other causal factor might there be? More agressive use of pitocin? This study claims that hemorrhage risk is higher for planned vaginal delivery compared to planned cesarean: http://www.uptodate.com/contents/cesarean-delivery-on-maternal-request/abstract/23

  • Ash

    OT: Saw this article today. http://www.medscape.com/viewarticle/819879_6

    I was amused by the conclusions section. Maybe it’s because I’ve never read the lactivist websites, but pumped milk is “potentially at the cost to the special relationship between a mother and her infant.”? So now women are supposed to worry that pumping will affect her relationship with her kid? Sheesh.

    • Danielle

      That is the message I received, and I resented it.

      I had a hard time getting my son to latch. Then we had problems with my letdown being too aggressive. And I went back to work when he was three months. This meant that I employed the pump part-time—and later nearly full-time. I loved pumping. It allowed me to get breastmilk for my son even when we were having problems, and even after I had returned to work. It even gave me special time at work to do something for him and feel close to him.

      So there, I am, working so hard to get breastmilk (and succeeding thanks to the wondrous Ameda pump) … and all this literature is implying that pumping is somehow different from and inferior to breastfeeding.

      It was annoying.

      • Trixie

        Pumping is really tough work, in my opinion. Anyone who does it is a champ in my book!

        • Danielle

          Thanks! I’m probably an outlier in liking to pump …

          I’m a nerd, so I can say things like “Nature! Cower before the Power of my Milking Machine! Mwhhaahaha!”) …

          But seriously, I got to make milk for my baby AND we got bottle/cuddle time without lots of choking and screaming. Sounds like bonding time to me!

          • Kelly

            I can’t say that I necessarily like pumping except that I have an excuse to get away from my family when I visit them, but I think that I am like you, Danielle, in that I am an outlier in that I would rather pump than nurse. I am glad that I am not the only one. People look at me like I am weird but it works so much better for me and I haven’t cried in three weeks!

    • Young CC Prof

      I found the main “relationship cost” to pumping was a reduction in the amount of time I could spend cuddling my baby! Can’t imagine there’s any other downside, especially if direct breastfeeding didn’t work well.

      • Trixie

        The cost of pumping is one of time and inconvenience, and, in the case of EPing, potentially more difficulty in maintaining a full milk supply over the long term compared to mostly having a baby at the breast (assuming the baby is an efficient nurser to begin with, which of course, may not be the case). But yeah, the mother-child relationship itself isn’t contingent on breastfeeding.

        • Young CC Prof

          My baby was a pretty inefficient nurser, but he managed to at least bring the milk in initially. When I switched to the pump, I got exactly the right amount of milk for a one-week-old, but then I couldn’t seem to increase it no matter what I did, and my baby’s appetite doubled over the next month. One of the reasons I gave up.

          • Trixie

            Yeah, that’s pretty common. You’d have to have been pumping a good 8-10 times a day and cluster pumping to mimic how a 3 week old nurses (which is all the damn time).

    • anne

      It’s also kind of a backhanded slap aimed towards fathers. I mean if pumped milk from a mom can harm the relationship then dads, adoptive parents, and others don’t stand a chance.

    • LadyLuck777

      Meh. The pump gets in the way of me bonding with my baby much like a condom gets in the way of me having sex with my husband. The same goal is achieved and there is less for me to have to worry about afterwards.

  • The Computer Ate My Nym

    I’d like to point out one that you didn’t highlight: infection. The mortality from infection is decreasing (at least relatively). This is the ONLY cause of mortality that could possibly be reduced by home birth (dubious, but there’s at least an argument to be made for it.) So I think we can pretty strongly conclude that staying away from the hospital because you fear MRSA is not a good move. Also, for every low risk woman who says, “but cardiomyopathy isn’t me–I don’t have heart problems” I must tell you: You DIDN’T have heart problems. Pregnancy can destroy your heart in a number of ways. Had one horrific case recently where the pregnancy activated an autoimmune state that slowly destroyed the patient’s heart. Very low risk woman. It was awful.

    • Sullivan ThePoop

      Hospitals have learned a lot about the importance of separate ventilation systems and the importance of make up air. There was a period of time when hospitals were growing very large very rapidly and sometimes when you are adding on to old buildings they will let you get away with things that you wouldn’t be able to in new buildings and contractors often use these loopholes to make lower bids to get the job. No one realized how little short cuts on engineering could lead to big problems with infections. No one wants that to happen so it was investigated and changes are being made. That is not saying that there are not other problems but infections rates have improved.

      • The Computer Ate My Nym

        That’s also why there are little bottles of hand sanitizer everywhere in the hospital* and new regulations about what doctors can wear: to reduce the risk of spreading infection. In the mean time, CPMs have done…what exactly?…to reduce their incidence of infection?

        *Bonus result: Everyone in the hospital runs around rubbing their hands as though they’re contemplating the success of their evil plans…

        • Sullivan ThePoop

          I know, but these people are silly to think that in a modern US maternity ward you are going to get an infection from another part of the hospital. Unless your guest are bringing from other parts of the hospital it is extremely unlikely.

        • http://www.antigonos.blogspot.com/ Antigonos CNM

          I often wonder about the efficacy of these alcohol-based hand sanitzers, since, in my experience they dry out the skin of the hands so badly that it cracks, which actually creates portals for infection.

          • Ainsley Nicholson

            And the alcohol doesn’t kill C. difficile spores.

          • The Computer Ate My Nym

            That’s why you’re advised to wash your hands with soap and water after interacting with a possible C. diff patient. Sinks are everywhere too. I tend to prefer washing with soap and water personally, but not sure that, apart from C diff, there’s any good evidence for this preference.

          • araikwao

            But seriously, how can you possibly comply with WHO’s 5 moments for hand hygiene if you were washing with soap and water?? IIRC, alcohol gel is more effective, can’t remember if it’s because people are more likely to use it, or more likely to use it properly compared to handwashing..

          • The Computer Ate My Nym

            I wonder about that too. And the long term consequences of the low grade inflammatory state produced by constant hand cleaning…I guess we’ll know in a couple of decades.

        • Mel

          Years ago, I had a healthy teenage student on hospital bed rest for 89 days due to short – then tissue short – cervix. I washed in and out using soap and water just to be on the safe side – for her….

        • The Bofa on the Sofa

          “It’s amazing how many supervillains have advanced degrees… Graduate schools should do a better job of screening those people out.” – Sheldon, Big Bang Theory

    • Ainsley Nicholson

      Actually, there is MRSA in the community also, and it is a more virulent strain (USA300) than the one typically acquired in the hospital (USA100). The hospital-acquired strain tends to be resistent to more differant antibiotics, but it usually lacks the PVL gene that makes the community-acqurired strain so mean.

  • The Bofa on the Sofa

    I’m not sure if the first graph is as useful as could be. Dr Amy, do you know the overall maternal mortality for the three time periods shown? I want to check something.

    • Amy Tuteur, MD

      The overall maternal mortality rate rose from 10.4-14.5/100,000.

      • The Bofa on the Sofa

        What was it in the middle period? Somewhere in-between?

  • EastCoaster

    THIS is the kind of discussion we need to have. NBC advocates wax on and on about the dangers of interventions and how many women are dying because them. But have they ever looked at solid data outlining the actual reasons women are dying during birth and pregnancy? Of course not.

    This article highlights that woo-pushes really don’t know what they don’t know. The ignorance is both willful and disgusting.

    • no longer drinking the koolaid

      It’s the same as saying “babies die in the hospital too.” When you ask how many term babies die during labor in low risk mothers who are being appropriately monitored in hospital, and ask for numbers or specific cases, the response is a blank stare. It’s as though the statement by itself is self-supporting. It doesn’t require them to know the facts.

    • anne

      My sister in law was obese and had high blood pressure when she headed into her pregnancy. She developed postpartum preeclampsia and tried to turn down magnesium sulfate because it was an “intervention”. She also told me epidurals cause autism.

      • ngozi

        She might would have thought differently if her condition turned to enclampsia.

      • Anj Fabian

        [shakes head slowly]

      • araikwao

        She cannot possibly understand the situation if the concept of “intervention” is more scary than that of “death of mother and baby”. But that’s playing the dead baby card, I suppose. Please tell me she came around before something awful happened..

        • anne

          She did, although my brother complained that the doctor would not leave them alone to discuss their options and do their “research.” I’m not sure what ultimately convinced them.

    • Amy Tuteur, MD

      The facts don’t matter to them because the primary product homebirth midwives and advocates are selling is distrust of modern obstetrics. They are quite explicit about it, constantly bewailing the rate of infant and maternal mortality and claiming that mortality rates are evidence that obstetricians don’t know what they are doing.

  • Elizabeth A

    This article is incredibly informative and I love it.

  • Ash

    Very informative post, Dr. A. I wonder what NCB advocates would say about maternal deaths from cardiomyopathy&cardiovascular conditions. I don’t even know how many would say “I would risk out women with these conditions and refer to OB/GYN”. Or if they are getting care only through a HB midwife, how would they know to recognize these conditions! One old post on a HB website had a midwife googling what kind of medication warfarin was! I have real doubts that all the posters on the Midwifery Today FB would say “Yes, I would transfer care to OB/GYN.” Your comment in a previous post about MANA not having clinical practice guidelines on their website is a good one. No standards!

    • moto_librarian

      See, this is why having a nursing background is so important for a midwife! How many times have we heard lay midwives bitch and moan about basic nursing educational requirements because “I’m never going to be treating patients with heart disease, cancer etc.” No, they won’t be treating these conditions, but they damned well better have enough education to know when a woman is showing symptoms of an underlying condition that may be aggravated or caused by pregnancy. They also need to quit eschewing basic diagnostic testing for things like pre-e and GD so they can be certain that their patients are really low-risk.

      • ngozi

        They also need to quit eschewing basic diagnostic testing for things like pre-e and GD so they can be certain that their patients are really low-risk.

        That is a very good point!! The NCB community is also attempting to brainwash women into thinking these test, especially things like the glucose tolerance test, serve only to fatten the OBGYN’s pockets!! I was almost wooed into such thinking by a book about childbirth written by a Dr. Sears (can’t remember the exact name of the book or his name, I don’t have it in front of me). I failed my 1-hour test and 2 of my 4 results of the 3-hour test were not good. According to NCB thinking, I probably should have questioned whether or not I had gestational diabetes or not. I am glad I didn’t, because my numbers became really difficult to control by the time I was about 30 weeks pregnant. If I had of ignored my doctor’s advice, I am positive I would have been walking around with blood sugar numbers in the 400s, and would have not known it!
        The skeptics of the glucose tolerance test don’t tell women that borderline glucose numbers at around 24/28 weeks of pregnancy can turn into skyrocketing numbers later in their pregnancy.

        • Poogles

          ” I was almost wooed into such thinking by a book about childbirth written by a Dr. Sears (can’t remember the exact name of the book or his name, I don’t have it in front of me).”
          Probably “The Baby Book”?

          • ngozi

            I think that was it!

          • Aki Hinata

            Or “The Birth Book.” Not sure what a pediatrician is doing writing a book on how to birth.

    • http://www.antigonos.blogspot.com/ Antigonos CNM

      Women, even in the care of OBs, do not always give full histories. i remember one woman, who almost died in childbirth, who had told her doctor she had always been healthy–when her mother visited her in the ICU, said “Didn’t you tell the doctor about that terrible kidney disease you had in high school?”. to which her daughter replied, “But that was YEARS ago! I thought it didn’t matter now”. Good thing that woman didn’t register with a CPM.

      • Jessica S.

        Reminds me how I forgot to tell anyone at the hospital that I had been diagnosised with mild sleep apnea when I was a teenager. I’ve never treated it with oxygen at night or whatever else would help, so it totally slipped my mind. After my c-section, I was dozing off and each time I did, alarms would sound, apparently something having to do with my blood oxygen level dropping? I honestly don’t remember, my husband remembers better, b/c he was freaked out by all of it. Long story, I finally roused enough to say “oh yeah! sleep apnea!” and they gave me a little oxygen. Side note: I had the best little nap of my LIFE with that oxygen on. Maybe I really should look into the mask at night!

      • Haelmoon

        My favourite quote ever:
        Doctor: “Any heart problems?”
        Patient: “Nope, this one is great”
        Patient had had a heart transplant, but didn’t think to mention it.

        • Amy Tuteur, MD

          We had something similar happen when a patient came in 25 weeks pregnant with a temp of 105. She was asked if she had a history of any medical problems and said that she didn’t. Her physical exam reveal a very large scar over her sternum. When the resident asked about it she said it was from her heart transplant.

          The resident was flabbergasted and asked her why she said she had no medical problems and she patiently explained that she USED to have a heart problem, but the transplant fixed it.

          • PrimaryCareDoc

            That’s like my patients who say they don’t have high blood pressure anymore, because they take medication for it.

          • Dr Kitty

            “Ever had an operation?”
            “Nope”
            “So this very large scar would be from?”
            “Car accident, I was in my teens”
            “Did they take anything out?”
            “Oh, yes, a kidney, my spleen and part of my liver”.
            “I thought you said you’ve never had an operation?”
            “I forgot that one”.

            Real conversation I have had.
            If it happened a long time ago, and they feel fine now, it didn’t happen.

          • Young CC Prof

            Isn’t that like the old joke:

            “Are you sure you aren’t sexually active?”

            “No, I just lie there.”

        • akm

          Doc: Do you smoke?
          Pt: Not anymore. I quit.

          Doc: When?

          Pt: Yesterday.

  • moto_librarian

    So what we really need is more intervention to deal with the preexisting conditions that are much more common in pregnant women today. Do you think that all of this emphasis on catering to the NCB/lactivist crowd has actually been detrimental to improving maternal outcomes? A lot of money has been spent on “improvements” to birthing suites, breastfeeding initiatives, etc. Perhaps that money should have been spent on developing a system for getting women referred to hospitals that have the capability to manage complex health problems that are aggravated by pregnancy.

    • Amy Tuteur, MD

      We haven’t had our eyes on the ball, but I suspect that the NCB crowd hasn’t had much to do with that. I imagine that it has much more to do with the fact that childbirth is so much more dangerous for babies than for mothers, so we focused all out attention on babies.

      Childbirth is simply more dangerous for the older, heavier, sometimes chronically ill pregnant women than it was for previous generations.

      That’s not to say that there isn’t room for improvement in the use of interventions. There’s been a great deal of talk about placenta accreta in the wake of previous C-sections, but from other sessions at the conference I was alerted to the rise is Cesarean scar ectopics, which is becoming a very serious problem. A Cesarean scar ectopic occurs when a pregnancy implants over the old scar and burrows into the muscle of the uterus instead of the overlying endometrial lining, leading to rupture of the uterus and massive hemorrhage during the pregnancy (e.g. second trimester).

      • lola

        What would be the risk factors for that? Too short an interval between pregnancies?

      • Busbus

        Something interesting for me is how this discussion highlights (once again) how inane Ina May-Gaskins assertion is that maternal mortality could be helped by more homebirths!

        • ngozi

          OMG I don’t know whether to faint or throw up!!!

        • The Computer Ate My Nym

          Well, a woman who dies of obstructed labor in her first pregnancy rather than get a c-section certainly won’t die of complications of the c-section during her second.

      • moto_librarian

        Jesus! Is it possible to diagnose this with ultrasound?

        • Amy Tuteur, MD

          Yes, and if you have had a previous C-section and are having an ultrasound, they should look for it specifically.

          • moto_librarian

            A good friend of mine is pregnant with her second child now. She had fibroid removal that required a uterine incision, and her OB recommended that her children all be delivered by c-section. This will be her second section in just over 2 years, but I know she is getting regular ultrasounds.

          • araikwao

            Whoa…something else to look up today! Is it just a handful of cases, or are there some incidence figures?

      • Trixie

        Ack!

      • Haelmoon

        And myommectomy scar ectopics . . . they don’t turn out well for mom or baby in some cases.

      • AlisonCummins

        Atil Gawande believes it’s because there are Apgar scores for babies but not for mothers. Having a numerical score to quantify outcomes allows [motivates] obstetricians to improve their care.

        http://www.newyorker.com/archive/2006/10/09/061009fa_fact?currentPage=1