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?
