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.
