Experts acknowledge MORE interventions are needed to reduce maternal mortality

Mother Gravesite

The most tragic of the many ironies of the natural childbirth movement is that the recommendations proposed in good faith to improve outcomes for babies and women has ended up killing them.

This is particularly true in the case of maternal mortality. For years the conventional wisdom has been that outcomes improve as interventions are reduced. Indeed, most midwifery academics and some obstetric academics have insisted in the strongest possible terms that reducing the C-section rate is the key to reducing the maternal death rate.

Childbirth is inherently dangerous. When providers forget that, women pay with their lives.

Sadly, the data has shown precisely the opposite. Women die from lack of high tech interventions, or lack of access to them, NOT too many interventions.

Obstetric experts are finally beginning to recognize that the two greatest threats to women’s health in and after childbirth are low index of suspicion and reluctance to deploy high tech interventions in a timely fashion.

The lead paper in this week’s New England Journal of Medicine is What We Can Do about Maternal Mortality — And How to Do It Quickly by Susan Mann, MD et al.

Dr. Mann and colleagues offer four separate methods for reducing maternal mortality as quickly as possible.

1. AIM bundles

The Alliance for Innovation on Maternal Health … created several “bundles” of best practices for improving safety in maternity care, to help clinicians, the obstetrical team, and facilities consistently manage the care of high-risk pregnant women, including those with the three most common preventable complications identified by the CDC [postpartum hemorrhage, severe hypertension, and venous thromboembolism].

AIM bundles include readiness, recognition, response, and reporting protocols. As part of ensuring facility readiness, the protocols can be customized for the individual unit, posted, reviewed regularly, and made accessible to all clinicians. Although management may vary from institution to institution, each unit can be required to demonstrate readiness to deal with emergencies 24/7. Institution-specific, standard protocols need to meet expectations for rapid treatment response in all hospitals, including small, critical access hospitals… (my emphasis)

2. Preparation for complications, particularly in high risk women

Second, all hospitals can implement multidisciplinary staff meetings or huddles to assess and review each obstetrical patient’s risk factors, including determining the hemorrhage-risk level … Approximately 50% of U.S. hospitals provide care for three or fewer deliveries per day, but the need to identify women at risk is equally important for these small obstetrics services. Indeed, with fewer staff members and resources, it’s important that obstetrical, anesthesia, and nursing staff have a shared mental model of obstetrical patients’ risks and how the needs of those patients, given their risk levels, can be met in the context of the needs of all other hospitalized patients…

3. Drill for emergencies

[I]n situ simulations can elucidate for staff members the critical timing and logistics involved in such emergencies — how long it takes to get products from the blood bank, for example, or where to find a hemorrhage cart or infrequently used medications or devices. Simulations allow staff to review the protocol adopted by the obstetrics service. Because severe maternity-related events are rare and often unpredictable, and because members of the care team may not know each other, it is important to train for low-probability but high-risk events — much as professional pilots’ standard operating procedures include training in flight simulators for such events… (my emphasis)

4. Timely transfer to high resource hospitals

Fourth, hospitals can use the Maternal Health Compact.4 The compact ensures readiness by formalizing existing relationships between lower-resource hospitals that transfer pregnant women when they require higher levels of maternal care and the referral hospitals. These connections can be activated by lower-resource hospitals to get immediate consultation in the event of an unexpected obstetrical emergency whose care demands exceed their resources…

These recommendations involve using more interventions, more quickly and more often.

So how did experts get it so wrong?

In my judgment their were two major errors:

The first was the belief, promoted as forcefully as possible by midwives, in the Panglossian paradigm of natural childbirth, presuming that if something is natural, it must be best. The Panglossian paradigm imagines that everything that exists in nature today is the product of intense natural selection and represents the perfect solution to a particular evolutionary problem. For example, “normal” birth represents the best possible way of giving birth and is to be emulated as closely as possible.

But as evolutionary biologist Stephen J. Gould pointed out, an existing natural feature may not be the result of evolutionary pressure at all; it may be an incidental feature of a solution to an entirely different problem or it may represent the limits of genetic adaptation.

The Panglossian paradigm has led maternity providers to the erroneous conclusion that we should have a low index of suspicion for life threatening complications in childbirth. But the fact that childbirth is natural is entirely compatible with the fact that it is inherently dangerous, representing as it does one of the leading causes of death of young women and THE leading cause of death of children in every time, place and culture.

The second major error was the willingness to pretend that correlation is causation. The C-section rate rose during the same years that the maternal mortality rate rose. Ergo, C-sections cause maternal mortality. Women who experienced numerous interventions are more likely to die than women who didn’t. Ergo it must be interventions that are killing women.

Both are plausible, but have repeatedly been demonstrated to be wrong. Women aren’t dying because of too many interventions in childbirth; they’re dying because there are not enough.

We’ve made significant errors, but we can fix those errors.

Every woman, no matter how few risk factors, faces the possibility of death in childbirth. When maternity providers lose sight of that reality — or worse, deny that reality — women pay with their lives.

  • RudyTooty

    One statement that is being bandied about like a motto lately (I’ve heard it now from Melissa Chaney and maybe Holly Kennedy in separate media interviews … Neel Shah may have said it too, now that I think about it) is;

    “Too little too late, too much too soon.”

    In regards to reasons for maternal mortality and morbidity in pregnancy and birth.

    SIGH.

    It’s catchy – I’ll give them that. But I don’t believe the risks are equivalent at all.

    It’s clear that this is their new catchphrase and the focus of their messaging.

    • Amy Tuteur, MD

      It seems never to occur to them that their emphasis on too much too soon has LED to too little too late!

  • MWguest

    Nonsense from the ACNM yesterday:

    ““Midwifery is a relationship-based profession. One of the reasons we probably do have better outcomes is because we listen to women,” said Holly Kennedy, professor of midwifery at Yale School of Nursing. ”

    https://www.facebook.com/ACNMmidwives/posts/10156753958839725?__xts__%5B0%5D=68.ARA1TR_oUI_a7QsnYUK5C3JTAzYu9EnE4wjxKCXkuG6uzYOMkv3NIOqLthRLGHmeANx5yrfKNJ5EKNrlV2I6edlPaljPm1Fbh9cYDrwJXFom6h9eEySQx90tCKlMMp__RHapX2z5M8qYxZmhlpcG7LUvAymrx1OGyo5t3warNkJ_gMSRx9DRVwONZISRX2C6x8WF_yXJUqjmjcYORu4l6BU1jXPGOw&__tn__=-R

    • fiftyfifty1

      Ugh, so stupid. I’m a family physician. I could make very similar claims: The diabetic patients I manage have better outcomes than those managed by an endocrinologist, my patients with migraine have better outcomes than those managed by neurologists, and all my patients have lower rates of cardiac death than patients managed by a cardiologist! My patient listening skills must be amazing, right? No, it’s that I manage only the easier cases. I refer on the severe and complex cases to specialists. Duh.

      • Mel

        Your comment reminded me of how my son’s medical history is viewed very differently depending on the broader patient pool of the doctor:

        Family Doctor: with vague nervousness Wow! He’s such a little miracle! He’s been through so much already! Do you mind if we have the residents listen to his PDA (when he was much younger)? We’ve been discussing how best to monitor him as a growing former micropreemie….

        Pediatric cardiologist: happily It’s nice to start the day with an easy case. He looks great. Let’s see him when he’s three. Three years.

        Peds pulmonologist: Oh, wait, what? He’s on our caseload? Really? Oops. Yeah, no, he looks great. Um….maybe we should see him in like….6 months.

        Peds opthamologist: No ROP? Cool. Yeah, his eye is still lazy. We’ve got an outpatient surgery for that now. The risks are pretty much none – but there’s a risk he’ll need it redone at some point in his life. Oh, not in the next 5 years. I’m talking like as a middle-aged man.

        PT: “Spawn, look. Cody likes being on the swing. Many kids like swinging with their therapist.” Spawn’s response: “Cody is a tool. I’ll stop screaming when you stop messing with me. You know I want you to give me cuddles and unlimited toy play time – and you are purposefully preventing that from happening. Get with the program, PT – and you too, Mother!”

        Spawn’s the “complicated kid” at his primary care office and the “easy-peasy kid” at his specialists.

        • MelJoRo

          Your son’s journey and your parenting of him make me so happy. Yay science! Yay loving parents! Your pregnancy complications were the stuff of nightmares for me dying pregnancy, and to see such a wonderful outcome (though obviously challenging, and I am sure expensive and taxing on your time) is so cool!

        • Braitty

          Spawn sounds like a handful in the best way(s) possible.

          Also yeah, there is definitely different approach in regards to Specialized versus General practitioners. An easy “take two and get some rest” from a Specialist is typically a “put under observation just in case” to a Generalist.