While the critics of modern obstetrics have been dithering about C-sections and intervention rates, American women have been dying in and around childbirth of potentially preventable causes that have nothing to do with either.
The latest CDC report on maternal mortality confirms that the US maternal mortality rate is high NOT because of C-sections and interventions, but because women haven’t received the lifesaving interventions they’ve needed.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Modern obstetrics has taught us how to prevent many maternal deaths. We just need to do it.[/pullquote]
According to the Washington Post:
The CDC confirmed in a report released Tuesday that about 700 women die each year in the United States from cardiovascular conditions, infections, hemorrhages and other complications related to their pregnancies — up to a year after delivering their babies. In about 60 percent of the cases, the deaths could have been prevented, in part, with proper medical intervention, as well as better access to it, the researchers noted.
The report itself is short and worth reading in full. This paragraph includes the most important findings:
Pregnancy-related deaths occur not only during delivery but also during pregnancy and up to 1 year postpartum. The leading causes of pregnancy-related deaths varied by timing of death. Acute obstetric emergencies such as hemorrhage and amniotic fluid embolism most commonly occurred on the day of delivery, whereas deaths caused by hypertensive disorders of pregnancy and thrombotic pulmonary embolism most commonly occurred 0–6 days postpartum, and during pregnancy and 1–42 days postpartum, respectively. Cardiomyopathy was the most common cause of death in the late postpartum period (43–365 days postpartum). The higher proportion of pregnancy-related deaths in the late postpartum period among black women is likely attributable to higher proportion of pregnancy-related deaths due to cardiomyopathy among these women. Approximately three in five pregnancy-related deaths were determined by MMRCs to be preventable, and preventability did not differ significantly by race/ethnicity or timing of death. Recognizing the major causes of death by timing can help identify opportunities for intervention.
The word “Cesarean” doesn’t even appear in the body of the report and intervention rates are mentioned only to lament that women die for lack of them.
How did we get things so wrong?
We allowed ideology to replace science, specifically the ideology of natural childbirth. The principles of natural childbirth ideology — childbirth is inherently safe, interventions are dangerous and rarely needed, birth should be trusted and allowed to unfold naturally — are fundamentally at odds with reality: childbirth is inherently dangerous, interventions save lives and lots of women die when you allow childbirth to unfold naturally.
The biggest problem, in my view, is a low index of suspicion for complications of childbirth when we should have a high index of suspicion. You can’t diagnose a complication if you’ve been taught that complications are rare and doing nothing is the best response. When providers falsely believe that pregnancy is inherently safe when in reality it is inherently dangerous, nurses and even some doctors will insist that everything is fine even while a woman is dying before their eyes.
Here’s what I proposed back in 2017:
- 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.
- 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.
This 2017 article by Tara Haelle in Consumer Reports recommended almost exactly the opposite. Titled What to Reject When You’re Expecting, it is paradigmatic of how an ideology that primarily benefits natural childbirth professionals led us to ignore and withhold the very treatments that could have saved lives.
Haelle wrote:
Infants in this country are more than twice as likely to die before their first birthday as those in Japan and Finland, and America lags behind nearly every other industrialized nation in preventing mothers from dying due to pregnancy or childbirth. The U.S. is one of only a handful of countries in the world, including Afghanistan and South Africa, whose maternal mortality rate is rising.
Why? There are no doubt many causes. But one likely contributor may be that medical expediency often takes priority over the best outcomes and evidence-based treatments.
She encouraged women to reject C-sections, repeat C-sections, inductions and delivery prior to term. Haelle was hardly alone in that view. But that was ideology NOT science. They were never implicated in infant and maternal mortality; they SAVE lives.
Here’s what the CDC now recommends:
No single intervention is sufficient; reducing pregnancy-related deaths requires reviewing and learning from each death, improving women’s health, and reducing social inequities across the life span, as well as ensuring quality care for pregnant and postpartum women. Throughout the preconception, pregnancy, and postpartum periods, providers and patients can work together to optimally manage chronic health conditions. Standardized approaches to addressing obstetric emergencies can be implemented in all hospitals that provide delivery services. The Alliance for Innovation on Maternal Health (AIM) has provided sets of bundled guidance to provide for such standardization.
Implementation of this guidance is often supported by perinatal quality collaboratives, state-based initiatives that aim to improve the quality of care for mothers and infants. Ensuring that pregnant women at high risk for complications receive care in facilities prepared to provide the required level of specialized care also can improve outcomes; professional organizations have developed criteria for recommended levels of maternal care. CDC has created the Levels of Care Assessment Tool for public health decision makers to evaluate risk-appropriate care. In the postpartum period, follow-up care is critical for all women, particularly those with chronic medical conditions and complications of pregnancy (e.g., hypertensive disorders of pregnancy). ACOG recommends that postpartum women have contact with obstetric providers within the first 3 weeks postpartum and recognizes postpartum care as an ongoing process tailored to each woman’s individual needs.
In other words, more high tech care, greater access to high tech care, mandated emergency protocols and more provider visits.
We must learn from our mistakes. While gallons of ink were being spilled on the obsessions of natural childbirth ideologues — the C-section rate, the induction rate, epidurals and electronic fetal monitoring — we were ignoring the deadly problems that are literally killing new mothers: cardiac disease in pregnancy, pre-existing chronic conditions, hemorrhage and blood clots.
Modern obstetrics has taught us how to prevent many maternal deaths. We just need to do it.
Except you’ve completely ignored the fact that c-sections increase the risk of thromboembolism, PPH and infection, and that each subsequent pregnancy after a section is at increased risk of uterine rupture and abnormal placentation (both of which can very quickly lead to hemorrhage and death). Induction of labour and c-sections also increase the risk of amniotic fluid embolism. C-sections are absolutely lifesaving and necessary in many cases and an important tool to have. But to say that the high rate of sections has nothing to do with maternal mortality is ridiculous.
Every pregnancy is potentially fatal to mother and/or baby. And every pregnancy after the fourth birth carries greatly increased risk of all the things you claim are exclusively risks of C/S. The only procedure which has reduced maternal mortalty by more than 90% in the past 150 years is C/S.
Perhaps you’d like to explain why the countries with the lowest c section rates have the highest maternal mortality rates.
Did you know that a study of all births in the UK over a 3-year period (more than 2 million births) found that mothers who gave birth by elective c-section had the lowest death rate of all?
The death rate among vaginal births and emergency c-sections (i.e. attempted vaginal births that end up not being successful) was 0.39/10,000, while the rate for elective c-section moms was only 0.31/10,000. So elective c-section is 21% LESS likely to kill the mother.
When it comes to maternal mortality, the lowest-risk way to give birth is by elective c-section.
https://www.telegraph.co.uk/news/uknews/1584671/Women-choosing-caesarean-have-low-death-rate.html
“The latest CDC report on maternal mortality confirms that the US
maternal mortality rate is high NOT because of C-sections and
interventions, but because women haven’t received the lifesaving
interventions they’ve needed.”
That was my first thought when I read this, thank you
Dr Amy do you think this is part of a bigger picture of mysogyny in medicine? I’m a UK doctor, I’m a GP but work remotely so we get some obstetric emergency training. The consultants were discussing the most recent confidential enquiry into maternal deaths and what was really striking was in most cases the women’s symptoms were dismissed as ‘anxiety’. So chest pain and breathless – diagnosis ‘anxious’ post mortem – pulmonary embolism. Headache and epigastric pain – diagnosis ‘anxious’ post mortem – eclampsia. These are ‘common’ complications of pregnancy so why is anxiety the first thought in a pregnant woman rather than the diagnosis of exclusion. Ditto women having heart attacks being much more likely to be discharged or misdiagnosed. Women’s pain being under treated in A+E compared with mens etc.
Given how much of the medical assessment is based on studies of men, there is an underlying systematic misogyny that gets in the way, I think.
Dr. Nieca Goldberg wrote a book, “Women are not small men” or something like that, to address the issue that so much of medicine is based on treating everyone like a 160 lb man.
I’ve witnessed this too often – a postpartum patient with symptoms such as hypertension and headaches, and the doctor waves them off: “Oh, her. She has anxiety.”
“Well, yes, that is true, too. But her BP is 160/99. Please see her.”
There seems to be little financial incentive in seeing a postpartum patient outslde of the routine global package – so I wonder if ‘caring’ or not caring might be influenced by our standard fee structure for maternity care in the US.
The system never wants to incentivize more treatment and hospitalization, but the flip side is that it dis-incentivizes evaluation and treatment when indicated.
There are both emotional and economic pieces to the misogynist puzzle.
Financial incentives don’t come into NHS treatment, but the system is massively underfunded and short staffed – ironically leading to enormous negligence payouts which leave the system with even less money.
I think doctors are much more likely to dismiss women’s symptoms as anxiety than men’s and pregnant women are treated as especially hysterical. There is a lot of hand wringing here about our high still birth rates but there is no point in telling women to count kicks if you are going to ignore them and treat them as silly and hysterical when they notice a reduction.
When I was full-term with 3rd kid, my OB sent me to the hospital at 11pm the night before my c-section (after moving the c/s up 3 days) because she didn’t like the looks of the labs that had just come through.
The hospital bed was uncomfortable and I was uncomfortable, so the nurse took off the belt monitor, and said “you wouldn’t have this if you were home, so you don’t need it”. Then suggested a shower when I said my back hurt and it rather felt like back-labor to me. Finally, hours later, another nurse checked in on me and I said I was in a lot of pain and thought I was in labor. Yep, 5 cm dilated, and still hours to go until the scheduled c/s. They called my OB in and she did the c/s at 5 am.
I ended up on a mag drip after labor for sky-high blood pressure. And back in the hospital 2 weeks later for 2-3 days for post-partum pre-eclampsia and more mag drips and constant monitoring.
Would a c/s a few hours earlier have prevented my complications? I doubt it. But, keeping the belt on, as my OB had ordered, and listening to me would have saved me from quite a bit of pain and the frustration of neglect. Essentially happy ending, my kid is 10 and healthy and happy and I’m basically healthy although still on 3 meds for blood pressure.
I certainly wouldn’t have done better with LESS medical interventions. In fact, I’d be dead.
Dr. Tuteur, did you see an article in the May issue of Obstetrics & Gynecology by Caughey and Cheney about birth in community settings? I thought parts of it were downright misleading, such as the following:
“Another confusing issue is that the United States uniquely has three credentialing routes to becoming a professional midwife: the CNM (Certified Nurse Midwife), CM (Certified Midwife), and CPM(Certified Professional Midwife). Although largely distinct, these credentials share key similarities. For example, all credentialed midwives are distinguished from “lay,”
“traditional,” or “plain” midwives who practice without having demonstrated the ability to meet formal training and certification requirements. Uncredentialed midwives (a distinct minority) attend only homebirths [and]…may also remain unlicensed because there is no path to licensure in their state. In contrast, all professional, credentialed midwives have standards for nationally accredited certification. As many physicians (and most patients) do not understand these different pathways, there can be confusion about their colleagues’ training and knowledge base when physicians are interacting with midwives.”
Nothing else is mentioned about the various levels of credentialing needed–not a word about the skimpy requirements to become a CPM. “Colleagues,” indeed.
I saw it and was deeply disappointed, both that it was written and that it was published.
Why do you think they published it? Ignorance? Someone on the editorial board who is pro NCB?
How can there be no path to licensure? Don’t all states allow people to earn the license of CNM?
Yes, but not all states give licenses to people who pretend to be midwives.
Yeah, what the author means is “some states won’t give licenses to inexperienced incompetents”.
“Uncredentialed midwives (a distinct minority) attend only homebirths”
…as do CPMs, since their training and education is nowhere near sufficient to be allowed hospital privileges – notice they didn’t say that though.
I haven’t read the article yet, I made an attempt, then tossed it aside.
CPMs are more than happy to glom onto the AMCB credentials and falsely equate themselves with adequately trained midwives. ACNM is complicit in this narrative. This serves to further deceive and confuse the public about midwives in the US.
Disappointing that this was published. But, like I said, I haven’t read it yet. So my opinion, as of right now, is insufficiently informed.
And it’s awesome in the accompanying Vital Signs publication (https://www.cdc.gov/vitalsigns/maternal-deaths/index.html) they have four pics of childbearing people, two of whom are Black, one of whom is White, and one whom I think is Indigenous (they do mention the high numbers of deaths in AI/AN communities).
I think the idea that natural / doing nothing is automatically safer and better has pervaded other areas of well. My middle child had awful constipation from about 12-24 months. I took him to our family doctor several times and she just kept saying to try to increase his fiber (via his meals) and to bicycle his legs. I finally found guidance online from a pediatric gastroenterology office which said you cannot correct constipation at that age through fiber intake alone. He then saw a pediatric gastroenterologist and started taking a TINY dose of stool softener which solved the problem.
My point is, doing nothing and letting nature take its course is NOT risk free! There are pros and cons to every decision even the “natural” ones.
My gran naturally has diabetes; I’m not entirely certain, but I think she’s had it since she was fairly young, possibly before my mother was born. Had it never been treated, she would be dead, and my mother and I would never have existed. All the members of my immediate family need and wear glasses; left naturally, several of us would be dead by accidents by now. Almost all of us are on medication for something.
Left to nature, my bunny would be dead by now; she has had a few episodes of her own tummy troubles, all of which required intervention, all of which would have killed her. There’s also a high probability (60 – 80 %) that, as she’s now over four years old, if she hadn’t been spayed, she would have developed cancer by now, cutting her life very short.
I’m extremely grateful for science, technology and medical care keeping everyone I love alive. I hope your kid is doing well now.
thanks. He is totally fine now. He doesn’t even take the stool softener anymore!
Both of my granddaughters have the same problem [oddly, my grandson does not]. The older went through hell with diets, etc. until medication was prescribed, took it until she was about 6 and outgrew the problem. Younger granddaughter went straight onto medication when the symptoms were observed, and she’s fine.
It always amazes me that people resist medication when it will benefit them.