Preventing maternal deaths

As I’ve written about repeatedly, natural childbirth and homebirth advocates have made a fetish of maternal mortality. They’re not actually DOING anything about maternal mortality, but they are complaining about it and insinuating (or even claiming) that modern obstetrics is responsible for maternal deaths and that midwifery care would lower maternal mortality. But as a paper in the forthcoming issue of Obstetrics and Gynecology reveals, the keys to lowering maternal mortality involve MORE interventions, not fewer.

The paper is Preventing Maternal Death: 10 Clinical Diamonds by Clark and Hankins. The authors write:

The death of a mother during or after childbirth is one of the most tragic events in medicine. We have identified 10 specific recurrent errors that account for a disproportionate share of maternal deaths, primarily related to pulmonary embolism, severe preeclampsia, cardiac disease, and postpartum hemorrhage. Attention to these principles and the development and adoption of local or regional clinical protocols that address these issues will help reduce the likelihood and effect of error and of maternal mortality.

What is a clinical “diamond”?

In medicine, a clinical pearl is a short aphorism meant to assist the clinician faced with a complex clinical situation in cutting to the essence of the matter and making a correct decision… Such “pearls” are intended to be default approaches of high value and low risk that the wise clinician will automatically incorporate into practice as a matter of course, barring some exceptional clinical circumstance.

… We present here 10 such aphorisms, elevated to diamond status by virtue of their ability to prevent what is perhaps the most tragic event in all of medicine and by their universal applicability to nearly every patient, every time.

They are:

  1. A pregnant woman with acute chest pain should have an immediate CT angiogram
  2. A patient with preeclampsia and shortness of breath should have a chest X-ray immediately
  3. A hospitalized patient with preeclampsia and a systolic blood pressure of 160 or a diastolic pressure of 110 should receive an IV antihypertensive within 15 minutes
  4. Angiographic embolization should not be used for acute, massive postpartum hemorrhage
  5. Any woman with cardiac disease gets a maternal–fetal medicine consult
  6. If more than one dose of medication is needed to treat uterine atony, go to the patient’s bedside until the atony has resolved
  7. Never treat “postpartum hemorrhage” without simultaneously pursuing an actual clinical diagnosis
  8. A postpartum patient who is bleeding or who recently has stopped bleeding and is oliguric, should not receive diuretics
  9. Any woman With placenta previa and even one previous Cesarean should be delivered in a tertiary care hospital
  10. Every labor and delivery unit should have a recently updated massive transfusion protocol

In other words, to prevent maternal death from pulmonary embolism, severe preeclampsia, cardiac disease, and postpartum hemorrhage, we need increased use of technology, more treatment with medication, more direct physician supervision and access not only to blood banking but to massive transfusion protocols.

In contrast to the insinuations (or claims) of NCB and homebirth advocates, the solution is NOT “trusting birth,” unhindered birth, birth affirmations, nutrition, supplements, chiropractic or indeed ANY care that is exclusive to midwifery.

Maternal mortality is a serious problem that requires serious solutions. NCB and homebirth advocates (like Ina May Gaskin) who exploit this issue for personal gain (and who simultaneously make no concrete efforts to treat it) are worthy of nothing but contempt.

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