We can prevent maternal deaths by recognizing that childbirth is inherently dangerous

Danger sign, warning plate with red stripes isolated on white

Imagine that we set up our system of cardiology care like this:

Our bedrock assumption is that hearts are to be trusted.
We reduce screening measures since they only lead to more tests.
We deny that risks factors have any relevance.
We put initial cardiac care into the hands of nurses who have limited training in treating heart attacks.
We wait until people develop symptoms like chest pain and shortness of breath before we investigate.
We avoid high tech measures as long as possible.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Everyone who cares for pregnant women must have a high index of suspicion for complications and must treat early signs without delay.[/pullquote]

Would anyone be shocked if cardiac mortality rose as a result? I doubt it since we know that the key to cardiac care is prevention including routine blood pressure monitoring, routine treatment of asymptomatic high blood pressure, additional testing for people with risk factors and high tech investigation at the first sign of potential cardiac problems.

You don’t need to imagine how we’ve set up our maternity care system. We’ve eroded the technocratic model of obstetric care under pressure from the “holistic” midwifery model of care.

The bedrock assumption of midwives, doulas and natural childbirth advocates is that birth is to be trusted.
They deplore screening tests.
They minimize risk factors.
They insist that less professional training leads to better maternity care.
They wait until women develop life threatening symptoms before acting.
They avoid fetal monitoring and demonize C-sections.
They worry about the experience of birth because they assume the safety of birth is guaranteed.
They’ve created an adversarial relationship between women and their obstetricians that has led to decreasing vigilance.

Now everyone is shocked, shocked that maternal mortality has risen. We really have no excuse for our shock. We’ve allowed ourselves to forget that obstetric care ought to be preventive care, constantly assessing for risk factors and problems and aggressively treating early signs of potential complications before they become full blown disasters.

I have been writing about this issue for more than a decade and constantly emphasized four principles of preventing maternal mortality.

1. We cannot forget that pregnancy is inherently dangerous.
2. Certain groups of women are at high risk for complications
3. We must have a high index of suspicion for early signs of complications
4. We must treat those early signs aggressively

None of this is new information but we are in the midst of discovering it all over again and California is leading the way.

California’s maternal death rate fell from 13.1 deaths per 100,000 live births in 2005–09 to 7 per 100,000 in 2011–13, according to a new Health Affairs study…

They looked at why women are dying.

Two key lessons in reversing maternal mortality, [author] Main said, are denial and delay. “People want to deny that she’s as sick as she is. ‘It’s going to get better, the bleeding will stop, blood pressure will come down,'” Main said. “That invariably leads to delay in treatment.”

In other words, everyone who cares for pregnant women must have a high index of suspicion for complications and must treat early signs aggressively.

For example:

…[I]mplementing large-scale interventions by integrating providers with public health services, begins with a bundle, a quality improvement toolkit defining best practices and the creation of learning collaboratives. The largest of CMQCC’s learning collaboratives, which includes 99 hospitals that collectively report more than 250,000 annual births, reduced severe maternal morbidity among women with hemorrhage by 20% using an obstetric hemorrhage toolkit.

If we change the way we view and treat pregnant women, we can save their lives.

According to Becker’s Hospital Review:

1. Hospitals must implement and sustain a standardized approach to managing known obstetric complications and emergencies involved in pregnancy and childbirth.

2. Providers must recognize and modify care for pregnant women presenting with chronic conditions that contribute to pregnancy-related complications, including hypertension, diabetes and obesity.

3. Healthcare leaders and clinicians should have access to comprehensive clinical data on maternal health outcomes. Developing a maternal mortality review board lets providers gather data on known causes of maternal death and harm.

4. Patients, clinicians, nurses and the healthcare agencies that support them should participate in regular educational training sessions on preventing maternal harm and death, including reliable strategies and processes to mitigate unintended outcomes.

In other words, everyone who cares for pregnant women must have a high index of suspicion for complications and must treat early signs aggressively.


Because pregnancy is inherently DANGEROUS. When we forget that or choose to ignore it, women die.

But when we keep that reality front and center, train for deadly complications, drill for deadly complications, have a low index of suspicion for deadly complications and react aggressively to even the earliest signs of potentially deadly complications we can save women’s lives.