Pro Publica learns maternal mortality is a fundamentally different problem than it thought

Funeral with casket carried by coffin bearer

In May Pro Publica, in conjunction with NPR, released a report on US maternal mortality that garnered a lot of attention. I criticized the piece for misrepresenting the problem. Pro Publica framed its story with the tragedy of a well off, healthy white woman who died of malpractice when the reality is that maternal mortality disproportionately affects black women and women with pre-existing medical conditions.

I was not the only one to criticize them, and to its credit, Pro Publica acknowledged the criticism and set out to do better. Today it published new findings, Lost Mothers, profiles of 16 women who died within a year of giving birth.

The problem of US maternal mortality is far more political than medical.

Although their picture, relying as it does on reader submissions, is still incomplete, it is a far better reflection of the actual problem.

I created a chart of the profiles. Even a cursory look shows that the problem is far different than Pro Publica initially presented.

Enlight35

This group of 16 profiles shows that maternal mortality is not really a problem of healthy white women dying of common complications. Fully half the women are not white. Very few were expecting a first baby. Nearly half had pre-existing obstetric or medical conditions. The causes of death ranged from hemorrhage (3 cases) and infection (2 cases), both of which are potentially preventable, to serious cardiac conditions (4 cases) like peripartum cardiomyopathy, heart attack and spontaneous coronary artery dissection, to mental health issues (2 cases), to stroke (1 case) to ectopic pregnancy (1 case), a complication of early pregnancy.

Most of the women who died did so because of LACK of timely access to medical technology, NOT overuse of technology. Contrary to the assertions of natural childbirth advocates like Henci Goer, these deaths could NOT be prevented by midwives, doulas and birth plans.

Goer, like most natural childbirth advocates, positively delights in misrepresenting maternal deaths to promote natural childbirth. Titling a recent piece Preventable Maternal Mortality: Disgrace of the US Maternity Care System, Gore asserts, with no evidence:

The overuse of cesarean surgery contributes (largely by increasing the numbers of women with placental attachment complications in subsequent pregnancies).

But most cases of maternal death profiled by Pro Publica have nothing to do with C-sections and it is not clear that any of the C-sections were unnecessary.

Indeed, contrary to the assertions of natural childbirth advocates that pregnancy is safe and interventions have made it dangerous, this list of maternal deaths makes it clear that pregnancy is dangerous (as it has always been, in every time, place and culture) and only MORE interventions are likely to make it safer. Moreover, pregnancy and childbirth put tremendous stress on many women, often too much for those with pre-existing or existing mental health issues to handle.

There are a number of things we could and should do if we really want to prevent maternal deaths instead of merely talking about them:

  • We must increase access to high tech medical and obstetrical care.
  • We must create a system of maternal critical care triage to parallel the highly effective system of neonatal critical care triage. Just as there are now Level I, II and III neonatal intensive care units, there should be Level I, II and III maternal intensive care units.
  • We must create algorithms and hold drills to prevent and treat common causes of maternal death.
  • We must devote significantly more research dollars to understanding cardiac complications of pregnancy.
  • We must provide more psychological support for women suffering mental health complications of pregnancy.
  • We must ensure that all women have easy access to contraception, abortion, and other gynecological services.

The maternal death rate is NOT a reflection of problems with our obstetric care system so much as it is an indictment of the general contempt in which we hold women’s health in the US.

Any country to seeks to restrict access to contraception and abortion is a country that doesn’t care whether women die.

Any country that restricts prenatal care to only those who can afford it is a country that doesn’t care whether women die.

Any country that predicates access to high tech obstetric and medical technology on whether women can pay for it is a country that doesn’t care whether women die.

The problem of US maternal mortality is far more political than medical. We have the ability to save more maternal lives; we just don’t have the will.

  • doula123

    This article is brilliant.

  • Linda Rosa

    I would add to Dr. Tuteur’s suggestions that adequate nurse staffing helps catch early signs of problems.

  • no longer drinking the koolaid

    I suspect that there are also women who died related to domestic violence. We already know that in some abusive relationships that there is a decrease in violence during the pregnancy and for others there is an increase. All are related to the pregnancy and those deaths should also be counted.

    • The Computer Ate My Nym

      Some abusers sabotage birth control in order to make it harder for the victim to leave.

      • Roadstergal

        Yup. That’s yet another a reason LARC should be fully covered and easily accessible for all women, ideally. It’s way harder to sabotage. It was very popular in the St Louis ‘choose your method and we’ll fully fund it’ study…

    • Elizabeth A

      Pregnancy is a very common time in a relationship for abuse to begin or to intensify. Frighteningly, many abusers wait until their victims feel “locked in” to begin the abuse, and pregnancy is kind of a classic for that.

      • Mildredmmccaskill


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        • Sarah

          But what are your thoughts on MRCS?

  • J.B.

    I noticed the recent Vox article on California maternal health (https://www.vox.com/science-and-health/2017/6/29/15830970/women-health-care-maternal-mortality-rate) led off with an upper middle class woman who hemorrhaged and then later covered a lower rent hospital, and a mother who was saved by an emergency c section. Crash carts seem like a good tool to have, but by leading off with placenta accreta I think there was an overall c section = bad positioning.

  • PrimaryCareDoc

    So it looks like maybe three of those deaths were preventable- the 2 infections and the hemorrage after c section.

    Now we’re supposed to prevent cardiomyopathy and SCAD and AFE? How, exactly.

    The same people that constantly trumpet “Doctors aren’t gods! They don’t know everything!!!”….seem to want us to be gods and know everything.

    • mabelcruet

      A few years ago, we had a spate of sudden cardiac deaths in young people and children in my area over a short space of time. One was due to cardiomyopathy, one to myocarditis (following chickenpox a few weeks earlier), a couple were children/teenagers who had congenital cardiac disease that had been treated surgically and they both had a lot of scar tissue which probably led to an arrhythmia , and another had a syndrome that caused her coronary arteries to be very abnormal, and she died a few days following a holiday-she had been complaining of jaw pain during the holiday, which in retrospect was probably angina like pain. She had massive myocardial necrosis.

      So this led to a big push to have defibrillators everywhere, teachers and coaches were trained in CPR, there were rules put into place that for every sporting event in schools or colleges there had to be at least 2 people present who had up to date CPR training, and there was a big push to get every school and collage athlete screened for cardiomyopathy. All of this is well and good, and sounds sensible. But…

      One of the deaths I was involved with happened after a lot of this was set up. The kid collapsed at school and didn’t respond to CPR. The local papers absolutely excoriated the staff for not defibrillating him, really vicious articles about how useless they were, that they were responsible for the death. It was much later at the inquest that it came out that there was no shockable rhythm and the staff had followed exactly the instructions the defib had given them. No apology in the press, no explanation as to why defibrillators, whilst good, are not the answer in many cases.

      I blame TV for this-we have a programme called Casualty in the UK, its a very long running medical drama. Cardiac arrests in Casualty go like this: patient clutches his chest and falls over, defib is wheeled out, nurse yells ‘Clear!’ and zaps him, patient comes round and 10 minutes later is sitting up drinking a cup of tea and gets discharged the next day. There is data about how non-medical/non-nursing folk massively over estimate the likelihood of survival after cardiac arrest, and that’s why there is so much horror over discussing CPR status.

      • PeggySue

        Awful. I work in hospice, it’s true, deciding for DNR (do not resuscitate) is sometimes complicated by unrealistic expectations.

        • Dr Kitty

          Sometimes DNR is the easy decision, particularly for elderly, frail people with dementia or multiple comorbidities (COPD, cancer, stroke, diabetes and dementia in one person is not unheard of).

          “Do we call an ambulance and go to hospital in a crisis or not?”
          “Do we start a PEG feed or fluids, and if we do, when do we stop them?”
          “Do we start antibiotics for an aspiration pneumonia for someone who will continue to aspirate?”
          “Do we manage a bowel obstruction actively or conservatively?”
          “Do we organise a blood transfusion at home or not?”
          “Do we want tight diabetic control or avoidance of hypoglycaemia?”
          “Do we want to reduce the risk of stroke with blood thinners, even if it increases the risk of bleeding out?”

          Those are the tough decisions that need a lot more talking through, because with CPR the heart has stopped beating and they’ve stopped breathing- it can be seen as just allowing the person to slip away with dignity.

          It’s altogether harder to say that no, actually, you’re not going to send daddy to hospital or get him a blood transfusion when he has a big rectal bleed from the colon cancer you had all agreed he was too frail to have surgery or chemo for.

          Quite often all the family talk through everything and make a decision for minimal intervention, only for someone less involved (daughter-in-law or adult grandchildren, typically) to panic and phone 999 in a crisis- and often the elderly person then dies surrounded by strangers in an ER, instead of at home with family.

          I’ve also had the unsettling experience of a family telling me that their relative was taking too long to die. The person was unconscious, on a syringe driver and was both peaceful and dignified- the three days they took to die was in no way inhumane for THEM. Apparently the family were getting a bit bored sitting around, and wanted to just get moving with the funeral arrangements, so could we do anything to speed it up?

          The weird family dynamics are why I much prefer paediatrics to geriatrics.

      • Azuran

        TV is just horrible about anything medically related. They do defib for just about anything.
        And they have this absolutely ridiculous obsession about how suturing the skin is absolutely necessary to avoid dying of blood loss and how it instantly cures any kind of injury.

        • StephanieJR

          TV is trying to kill us.

        • Sue

          Formal studies have been done on the success of defib on TV vs real life.

          Here’s one from the NEJM going back to 1996:
          Cardiopulmonary Resuscitation on Television — Miracles and Misinformation
          http://www.nejm.org/doi/full/10.1056/NEJM199606133342406#t=article

          I suspect the survival rate on TV is higher than that now.

          Considering that many cardiac arrests are aystolic (flat-line), for which defibrillation is ineffective, and that many people get no CPR before the ambulance arrives, the TV outcomes are dramatically skewed.

          • Azuran

            I actually have a pretty good rate of initial CPR success. I think I manage to get the heart beating again in about 1/3 of my cardiac arrest patient back.
            However, I’ve never been able to bring back an animal who wasn’t right next to me when they went into cardiac arrest.
            And every single one of those that I brought back who had a cardiac arrest due to health problems ended up having another cardiac arrest in the next 5 minutes. Eventually, they just don’t come back.
            The only cardiac arrest patient that ever walked out of the clinic are those that where healthy and had cardiac arrest while under anesthesia, who were already intubated and already had an IV catheter. Even then, we manage to save about half of those, and they all still ended up with some form of brain damage.

          • Mishimoo

            Is it possible to cause a heart murmur in a dog with successful CPR or is it more likely to be an underlying issue? A breeder I was going to adopt a dog from (returned due to an abusive husband) did rescue breathing and CPR on a puppy after a difficult birth, and he developed a heart murmur which unfortunately ended in euthanasia.

          • Azuran

            Congenital heart disease are very common in dogs. Both where probably unrelated issue. But it’s hard to say for sure without more info.

          • Mishimoo

            Thanks! I was curious because I feel bad that she was guilty over reviving the puppy, as she thought it was her fault and should have just let him go. He made it to 3 before he had to be euthanised and didn’t have the life she wanted for him.

      • Roadstergal

        That same thing plays out on US TV all the time. Grab chest, collapse, “Clear!”, zap, person is all fine again.

        It’s as bad as the ‘hit person over head, they go unconscious for a few minutes and then have no long-term complications’ trope.

        • swbarnes2

          You mean a frying pan to the head is not effective treatment for amnesia? But video games told me so!

      • Tigger_the_Wing

        Neither of my heart attacks remotely resembled the kind always depicted in film or on TV, and as a result I carried on working through them, both times, having no idea that the pain was cardiac related; until four and a half hours into the second one (ten years after the first) I could carry on no longer and collapsed.

        it was discovered that I had two serious heart disorders, both of which had been misdiagnosed for decades.

        We need more information being put out there that shows what heart attacks are really like, especially for women.

        • Chi

          My mother’s heart attack was similar. She’d been having chest pains all week before she came up to visit me, and she just attributed it to indigestion.

          When she complained of indigestion pain here, I knew something was wrong because she hadn’t eaten recently enough to have indigestion/heartburn. Then she went clammy and complained of feeling short of breath. I called the ambulance at that point.

          She was lucky, it wasn’t a major attack and was easily corrected with a stent. I’m just grateful she had the attack as she was preparing to leave and not on the 1 hour drive home…

      • Mac Sherbert

        You expect the press to admit they were wrong?

    • The Computer Ate My Nym

      The ectopic pregnancy death could likely be prevented with earlier diagnosis and treatment of the ectopic pregnancy. The suicide was probably related to post-partum depression, though with this being the 6th pregnancy, I’d look into whether there was spousal abuse or pressure contributing. Either way, intervention may have helped. Overdose should be entirely preventable, unless it was deliberate, in which case see above re PPD. I don’t see any deaths that could have been prevented by less use of reproductive technology unless maybe one of the “unknown” causes was iatrogenic. Maybe the overdose? But overdoses should be avoidable with adequate monitoring, much like transfusion reactions due to the wrong blood being given have a near zero rate in well run hospitals.

      • PrimaryCareDoc

        According to the article, the overdose was a recreational drug overdose.

        • BeatriceC

          I didn’t see that. So completely ignore everything I said above.

        • The Computer Ate My Nym

          Definitely not avoidable with less intervention then.

      • BeatriceC

        And really, just “overdose” doesn’t give us a lot of information. Did a nurse miscalculate a dosage? Did a doctor fail to take other medications into account when prescribing something? Did the mother intentionally take a larger dose? Did the mother unintentionally take a double dose of something (exhaustion leading to memory issues leading to her not recalling if she took something and taking it again)? There’s just so many ways an overdose can happen. That particular entry just doesn’t really give us any useful information.

      • PrimaryCareDoc

        Also, the ectopic was not a delayed or missed diagosis. The woman was 42 and overweight and didn’t even know she was pregnant. The first symptom of her ectopic was severe abdominal pain and collapse.

        • The Computer Ate My Nym

          Ah. I had assumed that this was a case where the pregnancy was confirmed chemically only and no one had checked whether it was properly implanted. Or a deliberate failure to treat at a Catholic hospital. I should read the article before commenting.

      • PrimaryCareDoc

        The suidicide patient had had a two-week inpatient hospitalization, so it certainly wasn’t lack of intervention. According to the article, she had been doing better and was taking meds, and then suddenly decompensated again.

      • PeggySue

        These are heartbreakers. Not sure how one could prevent them, unless (perhaps for the woman who had the ectopic), there was a problem with access to medical care overall. So very sad.

        • BeatriceC

          One all to common theme I’ve seen is difficulty in accessing mental health care. Another all to common theme is not being treated appropriately when care *is* accessed. For example, a person with active suicidal ideation presenting in the ER, but being sent home with a referral to see a psychiatrist instead of being admitted, and the psychiatrist having a 3 month long waiting list. Another example is an unwillingness to prescribe medication to pregnant or breastfeeding mothers in spite of the fact that we know that there are many medications that are safe for fetuses and breastfed infants.

          • PeggySue

            Well, or releasing with a 3 day supply of some new whiz-bang drug that is not in the formulary of the patient’s insurance.

          • Empress of the Iguana People

            Pregnant women are supposed to thrive on love for their unborn alone! Duh.

  • Krista

    ((STANDS AND APPLAUDS))

  • mabelcruet

    I think looking at maternal deaths is one area where the UK should be proud of itself-we’ve had national surveillance for more than 60 years. Initially this was Confidential Enquiry into Maternal Deaths/CEMD, then morphed into CEMACH (maternal and child health), then got taken over by MBRRACE-UK. National reports are produced frequently, and information gathering is from all possible sources, including coroners. We have a pretty clear picture of why mothers are dying, and its predominantly heart disease and mental health causes. Sepsis deaths are continuing to reduce, and we thankfully hardly ever have a maternal death due to pre-eclampsia.

  • Cody

    “We must provide more psychological support for women suffering mental health complications of pregnancy.”

    This. I’m sure the other suggestions are important too, but this one hits home for me.

    • Empress of the Iguana People

      Aye. I was lucky that my husband’s insurance does psych pretty well, that my OB caught it at 4 months along, and that i had retired friends who were okay with giving me rides to the counsellor’s and watch my kids

    • mabelcruet

      In the UK, after maternal cardiovascular disease, mental health issues/suicide are one of the most common causes of death. The provision of perinatal psychiatric services is hugely variable throughout the country, but it mirrors what is happening in wider psychiatric provision. Psychiatric services in general are woefully underfunded, and perinatal mental health support is patchy.

    • BeatriceC

      My PPD support group on Facebook is frighteningly close to 3000 members. We’re days away from our real one year anniversary (The group was formed and stagnated at 20 members for a couple months, and didn’t really get going until the end of July last year). The lightning fast growth of just one group goes to show just how common this is, and how much the needs of new mothers are not being met.

    • Roadstergal

      And not contribute to mental health issues with practices that increase sleep deprivation.