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.

Everyone who cares for pregnant women must have a high index of suspicion for complications and must treat early signs without delay.

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.

Why?

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.

  • Merrie

    Another thing a lot of people seem to be unaware of is that a lot of a professional education is background information. There is a ton of stuff I learned in pharmacy school that I will not directly, personally use in practice, but it’s valuable background information to understanding my scope of practice and how to do the stuff that is actually my job. I read an article by a CPM where she talked about why she was glad she wasn’t a CNM because she didn’t need to learn how to do Pitocin inductions since she’d never be doing them at home, etc… and I was like, even if you plan to never do this personally you still need to recognize the situation where it is done since you may run across it in practice and need to be aware of how to respond.

    • Mel

      I’m a firm believer that knowledge is power. I figure I’ll try and learn anything someone is willing to teach me because you never know when it will be useful in the future.

      • PeggySue

        When I was a hospice chaplain I listened closely in any meeting with an educational component. It paid off. One day, to test general knowledge, our medical director asked the team why a patient with cancer was on anti-seizure meds. No one said anything. I said, “because he has brain mets?” He did. Always listen to your chaplain.

    • Gene

      I went out of my way in residency to learn how to perform a circumcision. (Peds do circ on the west coast, OBs on the east coast, and I’m the latter). I’m never going to perform them in my practice (circs aren’t exactly an emergency procedure). But I need to know how to take care of the potential complications.

      • Mel

        My first teaching job was with “risky” (that’s what I call formerly at-risk students who didn’t turn off the path in time) students from urban, low-ses populations including a large subpopulation of teens in foster care.

        The same program had an adult ELL program as well as a newcomer teen ELL program geared at getting the teens competent enough in basic English to start learning academic English.

        None of my students at that point were ELL – but the teachers were phenomenal and the students were neat so I absorbed as much information and techniques for teaching ELL students as I could.

        That district faced lay-offs so I ended up finding a job in the next district over where something like 90% of my students were either ELL, FLEP (which is what you are tracked as for a few years after exiting the ELL program) or functionally bilingual in Spanish and English at the conversational level but way behind in academic English and Spanish. So…that came in handy.

  • Cartman36

    This is what irks me about the BFHI. The focus is all breastfeeding and bonding without recognizing that appropriate monitoring is CRITICAL to patient health and safety (both mom and baby).

    • PeggySue

      Yeah. In order for mom and baby to bond they both need to be ALIVE.

  • But women have birthed naturally for eons! Our bodies are designed tomgive birth!

    https://modernalternativemama.com/2018/08/30/why-are-we-afraid-of-natural-pregnancy/

    (See how much you can read before your eyes roll out of your head. Pretty much every natural childbirth cliche is in there.)

    • Cartman36

      Ugh

      Why Are We So Afraid of Natural Pregnancy? Um dummy, because millions and millions and millions of women and babies have died in childbirth.

      • My favorite quote: “Reality is that all doctors perform a service, and just like getting your nails done, you have the right to direct them, reject their suggestions, and not pay if they do not do what you want.”

        I have a comment on that post. How long will it take for it to be removed?

        ETA: Gone within 11 minutes. Very impressive scrubbing! (Note that I said nothing insulting–merely that I was afraid of childbirth in the same way that I’d be afraid of a polar bear if I met one in the wild.)

        • Heidi

          Ooookay. I don’t think that way about nail technicians! Or anyone else that has a license in the aesthetics industry. If my hair dresser told me she wouldn’t do x-thing I wanted because it was dangerous to my scalp for example, I wouldn’t be like, “I have the right to make you do this! I’m not paying for any services you’ve done today.”

          • Then again, nail tech licenses appear to be harder to obtain than a CPM.

          • And in order to practice, you need to have professional liability insurance in most places! It’s a LOT cheaper than midwife professional insurance for obvious reasons, but you still have to have it and that means you’re paying for it if you fuck it up.

          • Heidi

            “Every state in the nation requires that hairstylists, barbers and cosmetologists be licensed to legally provide their services. One exception to the rule is for shampooers, who do not need formal education, but only basic on-the-job training and hairstylist supervision.” Looks like you should expect to be in school for at least 9 months, too.

            Yeah, I’m pretty sure that can’t be said about CPMs. I also feel pretty sure if you were known to cause skin infections in people you provided services for, word would get around through reviews and such, and no one would be posting Go Fund Me’s while the state board looked into the cases.

          • I’m sure Modern Alternative Mama considers childbirth less dangerous than getting one’s hair and nails, but those of us in the real world would like slightly more stringent requirements for our birth attendant, thank you.

          • RudyTooty

            What the author misses, is that licensed professionals have a duty to practice in a certain way – whether that’s a nail technician or a garbage hauler or a health care professional. And our responsibility is to protect the public – not to honor their asinine wishes.

          • Merrie

            I’m paying my hairdresser to understand more about hair growth and cutting than I do and to help come up with a plan that works for me and to execute it. What’s the point otherwise? If she tells me that she doesn’t think something will work for me, based on her knowledge and experience, that’s what I want her for. I’d rather that than she does something that doesn’t work that she already thought wouldn’t work. And nobody dies if I have a bad haircut.

        • RudyTooty

          What was your comment?

          (Wait – sorry, I see the parenthetical comment.)

          THAT’S WHAT THEY REMOVED?
          Sheesh.

        • PeggySue

          Hahahahaha you fear-mongering person you! I’m kind of afraid of nail technicians actually.

      • Mel

        Because the Michigan Death Records Search categories include “Childbirth”. Duh. (Directed at MAM, not cartman36)

    • RudyTooty

      You’re right. I’m 2-3 paragraphs in … and I already need a break from the eyerolling.

    • Mel

      My short list?

      A natural pregnancy would have killed me and my twin when we were born with TTTS at 29 weeks.

      My mom developed severe postpartum preeclampsia a few hours after we were born. So…let’s give her a 50% chance of survival (with or without morbidity) after that in a natural birth.

      It was quite natural for my liver (or something) to go to war with Spawn’s placenta (or something; HELLP syndrome is still rather fuzzy in terms of what the hell causes it).

      Spawn would have been dead in real time since this war happened when he was 26 weeks gestation.

      And let’s be honest, I doubt I would have survived much longer than he did. My liver was going bonkers, I was developing neurological symptoms, I had no platelets left – but my uterus and cervix knew it was not time to go into labor yet. I had the lovely tightly closed, thick cervix that a 26 week pregnancy should have. I managed to have two really unorganized contractions in the 4 hours before I was on magnesium sulfate so I’m not at all confident that my body would have figured out how to give birth before a major organ failed in a terrible way.

      I’m Team Modern Medicine all the way.