Maternal mortality has been one of the biggest health stories of 2017.
A superb and evolving series of articles written by ProPublica in collaboration with NPR has focused a spotlight on the rising US maternal mortality rate. The latest piece is Nearly Dying In Childbirth: Why Preventable Complications Are Growing In U.S.
Each year in the U.S., 700 to 900 women die related to pregnancy and childbirth. But for each of those women who die, up to 70 suffer hemorrhages, organ failure or other significant complications. That amounts to more than 1 percent of all births. The annual cost of these near deaths to women, their families, taxpayers and the health care system runs into billions of dollars…
Better care could have prevented or alleviated many of these complications, experts say…
Why have we allowed this to happen?
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We turned toward the goal of reducing interventions before we secured low rates of maternal mortality.[/pullquote]
Yes, allowed; with the exception of cardiac complications, none of these complications are new, and we’ve been treating them successfully for decades. We haven’t forgotten what to do; we’ve just stopped doing it and women are injured and dying as a result.
In my view, we’ve committed the medical equivalent of the classic football receiver’s mistake. We started heading up the field before securing the ball. The receiver is so excited to reach the goal line that he turns toward it assuming that making the catch is a foregone conclusion. In obstetrics, we’ve turned toward the goal of reducing interventions, assuming that the catch — a safe outcome to pregnancy — is a foregone conclusion. In football, losing focus and dropping the ball results in missed opportunities to score. In obstetrics, losing focus and dropping the ball results in preventable injuries and deaths.
How can we improve maternal health in 2018? We can start by returning to fundamentals.
1.Focus on outcome, not process
If we want to decrease maternal morbidity and maternal mortality, we need to focus on what’s causing them.
The most important message in this graph is that fully 41% of US maternal deaths are caused by cardiovascular (including cardiomyopathy) and non cardiovascular diseases. That reflects the fact that pregnant women are now older, more obese and suffering from more chronic diseases than ever before.
2. Stop obsessing about C-section rate; it’s not a metric of maternal health
Sadly, we’ve allowed the natural childbirth industry to dictate our priorities with disastrous results. The natural childbirth industry is focused on what will benefit them; in other words, they are focused on reducing C-section rates and interventions rates and providing employment opportunities for midwives, doulas and childbirth educators. The bedrock assumption of the natural childbirth industry is that childbirth is inherently safe. Unfortunately, childbirth is inherently dangerous and it is ONLY C-sections and interventions that prevent injuries and deaths.
Do iatrogenic injuries from interventions occur? Of course they do, but as a glance at the chart above demonstrates, that’s not what’s injuring and killing pregnant and postpartum women. If we want to prevent severe maternal morbidity and mortality, we have to focus on what’s causing it.
3. Improve access to health care in general and prenatal care in particular
Chronic diseases, complications of pregnancy, obesity and advanced maternal age pose serious risks to pregnant women. Management of chronic diseases (high blood pressure, heart disease, kidney disease, etc.) before pregnancy is critical to improving pregnancy outcomes. Managing obesity related problems like adult onset diabetes is also very important.
Good prenatal care allows providers to anticipate and prepare for potential complications and have staff and services in place before disaster strikes.
4. Increase high risk specialists
We’ve experienced a tremendous increase in high risk pregnancies without a concomitant increase in perinatologists (specialists in high risk pregnancies). Too many women die because they don’t have access to the doctors who are best prepared to treat them.
5. Create more obstetric ICUs
Critically ill obstetric patients are often transferred to the ICU, but the ICU doctors don’t have experience with the physiology of pregnancy or the pathophysiology of complications. In contrast, the dramatic decrease in perinatal mortality over the past 50 years reflects the creation specialty units for the care of critically ill newborns (NICUs) and a rating systen for hospital nurseries (levels I, II, and III) to facilitate triage and transport of critically ill newborns to hospitals that have the experts and equipment to to treat them. We need a similar system of ICUs, rating systems and triage for critically ill pregnant women.
6. Research cardiac complications of pregnancy
No one really understands why cardiac disease has become the leading cause of maternal mortality. We won’t find out unless we fund and perform the research that will answer that question.
7. Have high index of suspicion for complications
In order to prevent complications, you have to understand who is at greatest risk and take appropriate steps to address the risk factors. In order to treat complications, you must recognize when they are happening, the earlier the better. The natural childbirth industry has deformed our efforts to do both by pretending that complications are rare and interventions and treatments are dangerous. They’ve made a concerted effort to undermine trust between doctors and patients, encouraging women to refuse testing, refuse interventions and lie about risk factors. They are wrong, dead wrong. Childbirth is and has always been, in every time, place and culture a leading cause of death of young women.
The pernicious effect of the natural childbirth industry can best be understood by analogizing to firefighting. Fire, like childbirth, is entirely natural. Fire, like childbirth, injures and kills. Imagine a “natural” firefighting industry that counsels people: fires are rare; don’t bother taking precautions, don’t pull the fire alarm until the house has almost burned to the ground; don’t tell firefighters about the presence of highly flammable fluids within the house; and make the firefighters wait to use hoses until efforts at putting out the fire by spitting on it have been exhausted. Would it be any surprise if injuries and deaths from fire increased as a result?
8. Drill for common complications (hemorrhage, pre-eclampsia)
Once you recognize complications, you must treat them as expeditiously as possible. That means having easy access to interventions, medications, and transfusions and lots of practice using them. In life threatening complications, every second counts. Practice reduces the time needed. Fire fighters drill. Doctors and midwives must drill, too.
9. Provide extra monitoring for black women
Maternal morbidity and mortality disproportionately affect black women. Therefore, it only makes sense to given them extra time, extra attention, easier access to care, greater funding for care and more research on the specific complications that they are likely to experience. Instead, we do the opposite, obsessing about the “birth plans” of privileged women and brainstorming on marketing techniques to attract them.
10. Prioritize improving outcomes for the disadvantaged over catering to the whims of the privileged
To go back to the firefighting analogy: if we ignore fire traps in poor neighborhoods, fail to build and maintain fire hydrants, and place fire stations miles away, should we be surprised that there are more fires and more deaths among the most vulnerable?
Then why are we surprised that pretending pregnancy complications are rare, having a low index of suspicion for them, failing to drill for them, and demonizing the people who are experts in treating them has led to an increase in preventable injuries and deaths, particularly among the most vulnerable?
This is an honest question about csection rates. In 2013 Brazil csection rates for mothers who had private health insurance was 83%. If you count both public and private hospital, it was aproxomatelly 50%. Is this too much? In the last few years that has been a push here to reduce this number, but not much has changed.
I had 2 csections, one at 41 weeks after a failed induction (failed as in I didn’t have a single contraction during the 8 or so hours I was on pitocin, it didn’t even hurt). The second as a maternal request at 39 weeks because I was feeling very uncomfortable and my son was in “true transverse”. I was afraid I would go into labor and he would push his hand out first and get stuck… he was born buttocks first! I think both csections potentially saved my babies and I… I don’t have a horror story of an emergency csection to tell (which seem to be kind of common in the US).
The c/s rate in Brazil is primarily cultural. It’s driven by patient demand, not by medical necessity. I could go into it, but it’s a thing without much relevance to this article.
As for your personal experience, it sounds like you made good choices and had good outcomes. All good, right?
The latest ProPublica/NPR article asked how so many complications are being missed that result in maternal death. The answer they found was “delay and deny”. In CNM school it was referred to as “wishful management”.
I have seen this frequently in the home birth community among undereducated midwives, childbirth educators, doulas, and families. It has probably been a problem in hospitals too, but with more maternal complications from preexisting conditions it is becoming a more common problem there also.
We need a high index of suspicion and then the willingness to take action.
Excellent article.
I just want to give this post a big thumbs up.
There have been so many tragic stories in the news this year about maternal deaths (especially due to cardiac complications), and women losing their access to prenatal care in the United States.
We can do so much better.
11. Increase, rather than decrease, access to birth control and abortion. Maternal mortality and morbidity has skyrocketed in parts of the US where access has been restricted most severely.
Glad you have written this list. It comes at a good time. I was upset to see a recent Facebook post by the former director of my training program with a link to a program purporting to be working toward lowering the maternal mortality rate in African American women. I clicked on it, and was appalled to find it was a CPM homebirth business. I wrote back asking how encouraging African American women to give birth out of the hospital, removed from trained medical care, was going to decrease death from the things that kill women: cardiovascular, hypertensive dz of pregnancy, bleeds etc. The director replied that the obstetric system had traumatized black women for so long that the only way to help them was to remove them from the system entirely! Glad you are presenting the voice of reason.
How does that work? As patronizing as medicine has been to whites in this country and a million times worse for blacks and other folks of color, there’s some things that you absolutely need a hospital for.
Especially because they encourage high risk births like VBAC and waterbirth right there on their homepage!
VBAC has enough extra risk that standard of care is to do them only with an OB, anesthesiologist and OR team in house the entire labor. But CPMs are glad to encourage you to do them out of hospital. And there have been enough deaths and near deaths at waterbirth (drownings, snapped cords, sepsis) that the official recommendation is that they be offered only in the context of controlled clinical trials. But CPMs have no problem filling up the kiddie pool right in the middle of a living room.
CPMs literally have nothing to lose but a paycheck. They rarely face any repercussions at all if things go south. There is no risk for them in taking on this new client population; the risk is all on the mothers’ and the babies’ side.
Yes, and the gain is big. It’s not just getting this new client population, it’s also free publicity among their traditional client population–well off white women. Now both the CPMs and their white clients can pretend they are fighting racism with out of hospital birth.
We tried something similar in education soon after No Child Left Behind – take students who had been disadvantaged by giant systematic issues like poverty, repeated moves, placement in foster care, home language of anything besides English AND were already falling severely behind in high school and place them in alternative education programs to get them remediation in system that could meet their individual needs.
The main trick is to under-fund the new programs, penalize the alternative program students by refusing to allow them to participate in after-school activities and have the process of being transferred between schools be heavily weighted towards moving kids into the alternative program while having no clear path for the kids to move back to the traditional program.
What was the outcome? Well, the average test score at the traditional school jumped – which was the point.
The test scores at the alternative education schools plummeted – but that was the point, too. It’s easier to relaunch an alternative education school under new administration than deal with systematic problems.
People can wrap up toxic and hateful plans in sugary-sweet jargon all day long. Encouraging African-American women to exit the modern medical system during pregnancy will lead to deaths and injuries – but as long as they are outside of the system their suffering won’t count against the system’s rates.
“as long as they are outside of the system their suffering won’t count against the system’s rates.”
I honestly don’t think that is the driver because the maternal mortality rate counts all women who die during the pregnancy/postpartum time period, not just the ones who die in hospitals.
I think what is driving it is self interest on the part of natural birth promoters (which Dr. Tuteur has been saying all along.) There is a midwife/academic at our local university promoting this program (reminds me of Melissa Cheyney.) When I explored this program sure enough it eventually came down to $$$–a plea to make sure we tell our elected officials to increase insurance coverage for childbirth educators, doulas, midwives and out of hospital birth. Sure it’s dressed up in concern for low income African American women, but guess who it really helps?
And I think (I hope!) that people like my former program director are supporting it only because they don’t know any better. They don’t know that CPMs are lay midwives dressed up with a fake credential. They hear this acedemic’s presentation about poor outcomes for POC and racism in the medical system and feel rightly bad. But then instead of doing the hard work of drilling down and addressing these systemic problems it’s like quick fix! Somebody else has a plan! If it’s “against racism” I support it! Sadly it is a true example of the classic Conservative critique of Liberals–“Their minds are so open their brains have fallen out.”