The mainstream press has been buzzing about a joint ProPublica/NPR piece about US maternal mortality. But in crafting the piece to create buzz, they’ve fundamentally misrepresented the problem.
It’s starts with the title, The Last Person You’d Expect to Die in Childbirth. Yes, Lauren Bloomstein was the LAST person you’d expect to die in childbirth and, arguably, she died of malpractice, not childbirth. Therefore, she is not representative in any way of the real issue.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Everyone involved in the care of women giving birth should have a high index of suspicion for life threatening complications and instead they’ve been fooled into developing a low index of suspicion. [/pullquote]
The truth is that black women bear the brunt of pregnancy related deaths and they die for different reasons than white women, including lack of access to the technology that many white women take for granted.
What else did they get wrong?
1. It’s not clear that the US maternal mortality rate has even risen, let alone risen dramatically.
The ProPublica has a very impressive graph that shows US maternal mortality rising gradually from 1990 to 2000, and then rising steeply between 2000 to 2010, an overall increase of more than 56%. What the piece fails to mention is that US death certificates were changed twice over those years (in 1999 and again in 2003) in an effort to capture a greater proportion of maternal deaths and to capture deaths far longer after birth (one year, not 42 days) than previously. Other countries did not institute the same changes.
How much of the purported increase is due to changes in reporting? According to this 2017 paper, Factors Underlying the Temporal Increase in Maternal Mortality in the United States: all of it.
Recent increases in maternal mortality ratios in the United States are likely an artifact of improvements in surveillance and highlight past underestimation of maternal death.
A 2016 paper, Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues, reaches a slightly different conclusion.
most of the reported increase in maternal mortality rates from 2000–2014 was due to improved ascertainment of maternal deaths. However, combined data for 48 states and DC showed an increase in the estimated maternal mortality rate from 18.8 in 2000 to 23.8 in 2014 – a 26.6% increase.
2. What are the leading causes of maternal mortality?
The ProPublica piece presented a bar graph from Report from Maternal Mortality Review Committees. That report looked at data from only 4 states. The data for the entire US is available from the CDC:
Hypertensive disorders of pregnancy, which is what killed Lauren Bloomstein, used to be a leading cause of maternal death, but has dropped down to seventh. 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. And that reflects the fact that pregnant women are now older, more obese and suffering from more chronic diseases than ever before. This is yet another way that Lauren Bloomstein’s story is not representative of the issue of maternal mortality.
3. The dirty little secret about pregnancy: it’s dangerous.
If you have been reading the mainstream media over the last few years, you might have come away with the impression that pregnancy is safe and technology is being overused. Millions of gallons of ink have been spilled over the C-section rate (which is a process) and relatively little has been written about maternal mortality (which, as an outcome, is far more important).
ProPublica notes that 60% of maternal deaths are (potentially) preventable. But in order to prevent a death you have to suspect that something is going wrong, diagnose it and correct it. In other words, you have to use technology. There has been a relentless trend in the US and other developed countries to promote “normal birth.” Hospitals emphasize their decor and the availability of waterbirth, women bring their doulas and their birth plans, and doctors are cautioned repeatedly to reduce the routine application of technology like fetal monitoring and C-sections. It’s as if everyone has developed collective amnesia of the fact that pregnancy, in every time, place and culture (including our own) has ALWAYS been one the leading causes of death of young women.
Everyone involved in the care of women giving birth should have a high index of suspicion for life threatening complications and instead they’ve been fooled into developing a low index of suspicion. As ProPublica notes:
Earlier this year, an analysis by the CDC Foundation of maternal mortality data from four states identified more than 20 “critical factors” that contributed to pregnancy-related deaths. Among the ones involving providers: lack of standardized policies, inadequate clinical skills, failure to consult specialists and poor coordination of care. The average maternal death had 3.7 critical factors.
Lauren’s death involved a myriad of these factors, but the most important is the one that isn’t mentioned: the low index of suspicion. In other words, no matter what happened, the doctor and nurses kept insisting that everything was fine while she was dying before their eyes. Instead of investigating her symptoms, everyone kept assuring her that she was fine. There’s a word for that kind of complacency: the word is malpractice.
The state of California has set out to eliminate complacency and their results have been impressive, particularly in cases like Lauren’s. In their initial assessment of maternal deaths in their state they found that the most preventable deaths were from “hemorrhage (70 percent) and preeclampsia (60 percent).”
The California researchers created a series of “tool kits” for doctors, nurses and hospitals and achieved impressive result. Yet the limiting factor in rolling out these programs to other hospitals is complacency.
“It’s very hard to get a hospital to provide resources to change something that they don’t see as a problem,” ACOG’s Barbara Levy said. “If they haven’t had a maternal death because they only deliver 500 babies a year, how many years is it going to be before they see a severe problem? It may be 10 years.”
4. The central role that race plays in maternal mortality.
ProPublica didn’t ignore the role of race, but by framing the piece with a story of a white woman who died as a result of malpractice, they fundamentally misrepresented the issue.
Black women bear the brunt of maternal mortality. When it comes to conveying the remarkable disparity, a picture is worth a thousand words:
And it’s not just a matter of socio-economic status. According to Predictors of maternal mortality and near-miss maternal morbidity:
…In multiple regression analysis, this difference could not be explained by other risk factors… These included age, obesity, history of a chronic medical condition, prior cesarean delivery and gravidity. Education level, marital status and public medical insurance status, factors traditionally associated with socioeconomic status, could not explain the disparity…
Considerable controversy exists about the biological reality of race. Nevertheless, in our study, as in others, race or ethnicity, as defined in ordinary social terms, is identified as a substantial risk factor for adverse maternal outcome. Since race and ethnicity rather consistently emerge as important factors in both obstetric and other medical situations, investigation of the causation is strongly indicated…
This finding has been reported in women of African descent living in other countries as well. It has considerable importance when comparing maternal mortality among countries. Though ProPublica implied that countries that have lower maternal mortality rates than the US provide better care, that is not necessarily the case. It’s hardly a coincidence that the countries with the lowest maternal mortality ar the “whitest” countries. The US has the highest proportion of women of African descent. Maternal mortality may just be a proxy for race not a measure of quality of care.
The take home message about maternal mortality in the US is a lot more nuanced than the ProPublica/NPR piece implied. It’s not a problem of privileged white women who are victims of malpractice. It is a problem with profound racial disparities and changing causes of death. And it’s also a story about what happens when people forget that pregnancy is inherently dangerous and demonize technology instead of using it to save lives.
