Maternal mortality: deliberately looking in the wrong place
Imagine if someone created a publicity campaign to highlight lung cancer mortality and never mentioned smoking, but only referred to deaths associated with chemotherapy. That would make no sense. Yet that is just what Ina May Gaskin has done with the "Safe Motherhood Quilt", which purportedly exists to highlight maternal mortality, but never mentions pre-eclampsia, hemorrhage or pregnancy complications, and instead refers almost exclusively to deaths associated with obstetric interventions.
Gaskins' "Safe Motherhood Quilt" is an appallingly cynical publicity ploy. As I have written in
My safe motherhood quilt:
Ms. Gaskin represents herself as shocked at the current rate of maternal mortality... As far as I can tell, Ms. Gaskin herself, and direct entry midwives in general have done NOTHING (no research, no education, no fund raising and no outreach to victims' families) to reduce the incidence of maternal mortality. Apparently, maternal mortality is not the real issue; criticizing obstetrics (inappropriately and unfairly) is the real issue.
If you visit the
quilt website, you will notice something rather curious. There is NO information about the causes, treatments and research into maternal mortality The site is exclusively devoted to criticisms of American obsterics ("Did you know…that the Centers for Disease Control estimated in 1998 that the US maternal death rate is actually 1.3 to three times that reported in vital statistics records because of underreporting of such deaths.).
Look at the page of "related articles". There are no scientific papers about maternal mortality. There is nothing about the epidemiology of maternal mortality. Twelve of thirteen articles are about medical mistakes. Gaskin wants to leave the impression that maternal mortality is caused by obstetric interventions. Indeed, in her public discussions of the quilt, she is quite explicit.
CafeMom reported:
Most of these deaths are iatrogenic, Ina May explained. Iatrogenic means the treatment of the physician, the drugs administered and the surgeries performed harm rather than heal. The danger warned about in the Hippocratic Oath, which says "First Do No Harm," is as freshly applicable today as it was thousands of years ago.
In reality, as Gaskin almost surely knows, iatrogenic deaths represent a tiny fractions of maternal mortality.
Unfortunately, Gaskin is not alone in caring only about iatrogenic maternal deaths. Research on maternal mortality in industrialized countries has been skewed toward the effects of medical interventions (which results in a small fraction of maternal deaths), as opposed to the major causes of maternal mortality: pre-eclampsia and eclampsia, hemorrhage, infection, complications of pregnancy and pre-existing medical conditions (which are associated with the majority of maternal deaths). Maternal mortality in industrialized countries is primarily a problem of race, poor health, poverty and poor access to healthcare. Who cares about that? Western, white women are interested in what affects THEM.
A recent paper in Pediatric and Perinatal Epidemiology emphasized this point. The authors believe that systematic reviews, being both time and resource intensive, reflect current priorities in research. Their survey of systematic reviews of maternal mortliaty reveals that more than 75% of systematic reviews within the last 5 years focused on harms associated with intrapartum interventions, rather than the causes of maternal mortality that account for the majority of maternal deaths.
According to
Tailoring systematic reviews to meet critical priorities in maternal health in the intrapartum period:
Of the 64 reviews eligible for inclusion, the largest number (17 studies; 27%) focused on mode of delivery. This group of studies focused on identifying the comparative risk of adverse events associated with the mode of delivery... Two addressed caesarean delivery on maternal request or in the absence of indications...
Eleven studies (17%) examined the outcomes of induction of labour... They focused primarily on mode of delivery and secondarily on identifying relative risks of adverse events such as uterine hyperstimulation.
Ten studies (16%) examined pain relief and associated interventions during childbirth... These studies were also largely concerned with identifying the relative risk of adverse events
Nine studies (14%) examined outcomes of surgical techniques... With the exception of the review on preventing shoulder dystocia, all studies focused on identifying the risks of adverse events...
Across all studies included in this paper, 14 (22%) focused on prevention of adverse events rather than the reduction of harm associated with intrapartum interventions. None addressed racial disparities in health outcomes...
The authors conclude:
This analysis of systematic reviews of childbirth conducted in the past 5 years suggests that the majority focus on reducing harm associated with intrapartum interventions rather than preventing adverse events...
If systematic reviews are to address critical issues relating to perinatal health, they will need to address the prevention of adverse events...
I am not suggesting AT ALL that iatrogenic maternal deaths are somehow less important that other maternal deaths. However, the focus on iatrogenic maternal deaths, a very small fraction of maternal deaths, has very little to do with the problem of maternal mortality. Rather, it reflects a preoccupation with maximizing outcomes in privileged, Western, white women rather than preventing the diseases, complications, and racial and economic disparities that account for the majority of maternal deaths.
The Safe Motherhood Quilt is not about maternal mortality. It is a quilt designed to publicize bad outcomes associated with obstetric interventions. Anyone who ACTUALLY cared about maternal mortality would not be criticizing obstetric interventions, since interventions save tens of thousands of maternal lives each year. Anyone who cared about maternal mortality would be drawing attention to the causes of maternal mortality, and to the social and economic conditions that prevent some mothers from getting the interventions that they need.
Labels: maternal mortality
Mother dies at homebirth
It was bound to happen, but it is a horrifying tragedy nonetheless. A British
paper reports the death of a mother from uterine inversion, compounded by midwife incompetence, at a homebirth:
Joanne Whale, 23, from Ipswich, suffered a "massive haemorrhage" because of complications as she gave birth to a healthy baby on September 10 last year.
She was rushed to hospital by paramedics, but an inquest heard today how doctors were not informed of the exact nature of her condition - leading to a delay in getting her into the operating theatre...
Giving evidence at the hearing, held at Ipswich Crown Court, midwife Sarah Hall admitted she did not pass on information that Miss Whale had suffered an "inverted uterus" during labour.
The midwife was also incapable of performing the most basic resuscitation maneuver, insertion of an IV:
The inquest also heard midwives supervising the home birth - along with the technician paramedic who was first to arrive following the 999 call - were not capable of injecting fluids into Miss Whale as she started to lose blood, a procedure known as canulation.
Midwife Julie Bates said although she was trained in the process, she had never been called to put it into practice.
"I've got the theoretical knowledge but not the practical knowledge," she told the inquest. "I felt uncomfortable having to do that in this situation..."
The coroner expressed suprise that the midwife did not know how to insert an IV:
He also said the public needed to be better informed about the possible dangers of home births and communication between healthcare professionals improved.
"I think we can see those areas where lessons need to be learned," he said. "It does worry me a lot that mothers are giving birth in the community and the first line of call is the midwife who might not be able to get fluid into her in those crucial early moments. Clearly that needs to be addressed..."
This is exactly why homebirth is never going to be as safe as hospital birth. When a life threatening emergency occurs at home, the midwife is incapable of managing it or even instituting appropriate resuscitation. Usually it is the baby who dies, but that's because neonatal complications are far more common than maternal complications. When a life threatening maternal complication occurs, midwives can do nothing.
Labels: maternal mortality
Oldest remains of woman who died in childbirth
I found this article to be suprisingly moving, perhaps because of the associated picture and because I can easily imagine what happened to this women.
Discovery of oldest remains of woman who died in childbirth:
In ancient times, female death rates were particularly high and generally related to problems in maternity, such as complications during pregnancy, childbirth or the period of breast-feeding. However, in most cases this link has only been established from indirect data, such paleodemographic data and ethnographic references, or based on the poor health conditions normally attributed to ancient human groups...
Joint research between the UAB and the Universidad de Murcia has found a clear example of an ancient burial of a pregnant woman whose death can be linked to difficult birth (dystocia). The archaeological team from the Universidad de Murcia, headed by Maria Manuela Ayala, found the remains in 1996 at the "El cerro de las Viñas" site in Murcia (Spain). Now, the UAB anthropologists, headed by Assumpció Malgosa, have established that it is the oldest case so far described in the paleopathological literature.
The burial dates from the Argaric period, between 1,500 and 1,000 years BC, in the Bronze Age. Argaric culture funeral rituals were characterised by individual inhumations, most of them within the dwelling or its perimeter. This burial is within one of these dwellings. It is that of a young woman, about 25-26 years of age, with a foetus in the 37th to 39th week of gestation in the uterine cavity, in a crosswise position and with part of the right arm outside the uterus...
In line with modern obstetric practices, the study of the two individuals and differential diagnosis has enabled the probable cause of death of the mother, and therefore the foetus, to be established as dystocia due to position of the foetus. Without a caesarean section, the mother probably died of sepsis, haemorrhage and exhaustion during the birth ...
The baby was in a transverse lie and the mother was doomed. At some point, an arm prolapsed through the cervix. The mother undoubtedly labored in agony for days before her death. This is the "true face of birth".
Labels: maternal mortality
Maternal mortality in the UK
CEMACH (the Confidential Enquiry into Maternal and Child Health) has published it's biennial report on maternal mortality. It has been getting a lot of press, for two reasons. Maternal mortality in the UK has risen slightly and the authors of the review put a lot of the blame on obesity.
The report is long, 296 pages, and I just finished reading it. It is sad and sobering reading and I have some preliminary thoughts. First, the title of the report has been changed. Until this version, it was called "Why Mothers Die" which is apt and to the point. Now, the title has been changed, presumably for political reasons to
Saving Mothers Lives. It is not about lives saved; it is about lives lost and it seems disingenuous to change the title.
Second, the report presents so much data, and slices and dices it in so many different ways, that it is bit difficult to figure out what is going on. Nonetheless, we can say certain things about it.
It is unclear whether maternal mortality is truly rising or whether the risk profile of the patients is rising. Pregnant women are older and many have serious pre-existing medical conditions. Older women and women with pre-existing medical conditions are known to have substantially increased risk of maternal mortality.
While obesity is certainly a factor, the report dramatically overplays its significance. It lumps overweight (BMI greater than 25) with obesity (BMI greater than 30) and morbid obesity (BMI greater than 40). A substantial proportion of the population is overweight and it is not clear whether the increase in maternal mortality among this group represents increased risk or increased numbers (probably the latter).
Every case of maternal death is reviewed and categorized based on whether it was a direct obstetric death, and indirect death (caused by pre-existing medical conditions) or a coincident death (such as auto accident). An effort was made to determine whether each death was preventable and whether substandard care played a role in the death.
The majority of preventable deaths occured after substandard medical or midwifery care. To a certain extent, this is a sign of progress in that most life threatening complications were recognized and then treated appropriately. Of course, it also means that many of the women who died did not have to die. The common thread in these potentially preventable deaths is the failure to recognize risk factors and complications. The medical personnel involved insisted that everything was normal when it was not. There were repeated attempts to minimize the seriousness of alarming signs and symptoms. In contrast, as far as I can tell, there were no maternal deaths related to over use of interventions or technology.
The bottom line is that maternal mortality may have risen in the UK, but probably because the risk profile of the patients rose. As a general matter, serious complications are identified and successfully treated. To the extent that there is need for improvement, it is that medical personnel need to be more vigilant about the dangers of childbirth. Modern obstetrics has become so successful in reducing maternal mortality that some people have become complacent, and women die unnecessarily as a result.
Labels: maternal mortality
Birth in nature, the fantasy vs. the reality
Homebirth advocacy is based in large part on mistruths, half truths and outright deceptions. One of the most egregious is the fantasy of what birth was like among indigenous peoples. Supposedly women "know" how to give birth. They "trust" their bodies. Birth is a deeply spiritual experience. Mortality is restricted to "rare" cases because birth is inherently safe. Anyone who knows even the most basic facts about childbirth knows that these claims are absurd.
Consider this article, in the
Chicago Tribune, about the birth practices among traditional women in the mountains of Nepal:
In the mountains of tradition-bound Nepal, women give birth the way they always have: in the cow shed.
When labor begins, they are sent out of the house, because bleeding associated with childbirth is seen as polluting. Most give birth on dirty rags or simply on the shed's cow-dung floor, sometimes with a local midwife helping. After the birth, the midwife routinely pummels or steps on the new mother's abdomen "to get the bad blood out."
In Nepal, as in many other traditional societies, childbirth is not viewed as a "spiritual" experience, it is viewed as "dirty". Women are not even allowed to give birth in the meager comfort of their own homes; they are forced out into cowsheds or other outbuildings so the they won't "pollute" their homes.
Complications of childbirth, including the death of baby and mother, are not rare. They are common. Nepal has been trying to reduce the astronomical death rate of "natural" childbirth.
... [O]ver the past decade, as pregnancy-related deaths have fallen worldwide at a frustratingly slow rate of 1 percent a year, according to the World Health Organization, Nepal has managed to cut its losses by almost 50 percent.
Nepal is an exception in South Asia, which, along with sub-Saharan Africa, has the highest rates of maternal mortality in the world, according to a report released in October by the World Bank, World Health Organization and several UN agencies. Together sub-Saharan Africa and South Asia account for 85 percent of the world's maternal deaths.
Afghanistan is tied with Sierra Leone as the most dangerous place to become pregnant -- with 1 in 6 women dying as a result of pregnancies -- and death rates are high in Pakistan, India and Bangladesh as well.
Today, 281 women die per 100,000 live births in Nepal, down from 540 women a decade ago, according to the UN...
A key to lowering rates of neonatal death is increasing the rate of hospital birth.
Through education campaigns and expanded clinic networks, Nepal also has managed to boost births at hospitals from 10 percent to 20 percent of the total, and increase the number of postnatal visits to clinics by more than 30 percent...
The country is still struggling to get help to the 5 percent of Nepali women who need a Caesarean section to deliver their babies. Many live in remote rural areas and a long walk from the nearest clinic...
Even that is not always enough.
Worse, because a Caesarean can cost $140, a fortune in rural Nepal, some husbands prefer to save the money and let their wives die, health workers say.
"If a woman has to have a Caesarean, husbands say it's cheaper to marry another wife," Pokharel said.
This is the reality of birth in nature. It is not a deeply spiritual experience; it is terrifying and viewed as "dirty". Women do not "know" how to give birth; they either give birth or die, or worse yet, they give birth AND die. Childbirth complications are not rare; they are amazingly common.
If all that were not enough, there is this: the new lifesaving drug in Nepal is Cytotec!
More help is on the horizon for Nepal's rural women, however. A new study in a few districts indicates that delivering a few oral drops of an easy-to-use drug called mistoprostol, which doesn't need refrigeration, appears to have reduced likely deaths of women from postpartum hemorrhage by 85 percent, Locatelli-Rossi said.
With more than half of the country's deaths now attributed to such bleeding, the drug "is extremely promising," she said.
It is difficult to imagine how homebirth advocates' most basic assumptions about childbirth could be any farther from reality than they are. If the fundamental assumptions of homebirth advocacy are so wrong, it is hardly suprising that their conclusions about homebirth safety are wrong, too.
Labels: maternal mortality
My safe motherhood quilt
This caught my eye, because I am a quilter:
Ina May Gaskin started the
Safe Motherhood Quilt Project to highlight maternal mortality. According to Ms. Gaskin, most maternal deaths are iatrogenic, but, of course, she is just making that up. Most maternal deaths are due to complications like pre-eclampsia, hemorrhage, ectopic pregnancy and abortion.
Gaskin copied the idea of the quilt from the AIDS Quilt, which was designed to raise awareness of AIDS, and to generate public pressure for research and prevention. There's a big difference between the two projects, though. The AIDS quilt was designed to raise awareness of a new disease. The Safe Motherhood Quilt is designed to raise awareness of maternal mortality, which has been so successfully reduced by modern medicine, that most people, Ms. Gaskin included, are unaware that it has always been an inherent risk of childbirth. That's why childbirth is and has always been dangerous; so many mothers and babies routinely died. Moreover, virtually all of obstetrics is designed to reduce this natural rate of maternal mortality, and obstetrics has been spectacularly successful in doing so.
The blocks for the Safe Motherhood Quilt must be 12" by 16". Currently, they have 84 blocks, for a combined area of 126 sqare feet. The quilt itself is apparently a virtual quilt. You can see the blocks on the website, but they have not been joined together.
I've decided to construct a virtual quilt of my own. My quilt will highlight the women whose lives have been saved each and every year because of advances in obstetrics. Modern obstetrics has dropped the maternal mortality rate 99% in the past 100 years. The baseline maternal mortality rate would predict approximately 40,000 maternal deaths per year in the US. Instead we have only 400-500. Therefore, my quilt will have 39,500 blocks. The total area will be 59,250 square feet or approximately 1.4 square ACRES. Keep in mind, that represents only the women saved in one year.
Ms. Gaskin represents herself as
shocked at the current rate of maternal mortality. Perhaps that because she is unaware of the inherent dangers of childbirth. The Safe Motherhood Quilt is a publicity stunt. As far as I can tell, Ms. Gaskin herself, and direct entry midwives in general have done NOTHING (no research, no education, no fund raising and no outreach to victims' families) to reduce the incidence of maternal mortality. Apparently, maternal mortality is not the real issue; criticizing obstetrics (inappropriately and unfairly) is the real issue.
Labels: maternal mortality
Did maternal mortality rise in 2004?
Yesterday, MSNBC blared the headline,
More US women dying in childbirth. According to the accompanying article:
U.S. women are dying from childbirth at the highest rate in decades, new government figures show. Though the risk of death is very small, experts believe increasing maternal obesity and a jump in Caesarean sections are partly to blame.
Not exactly. Indeed, the article itself acknowledges:
Some numbers crunchers note that a change in how such deaths are reported also may be a factor.
The National Center for Health Statistics provides comprehensive documentation for death rates, so we can look at the actual data ourselves, to see if the headlines are justified. Let's look first at the definitions of maternal death. In February 2007, the CDC published
Maternal Mortality and Related Concepts:
"Maternal deaths" are defined by the World Health Organization as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes..."
"Direct obstetric deaths: those resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above."
"Indirect obstetric deaths: those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy."
Now let's look at the
data for 2004 as compared to the
data for 2003. The first thing you notice is that the absolute number of deaths rose from 495 to 540 deaths, an increase of 45 deaths. Yet a closer look reveals that direct obstetric deaths have changed very little. There were 473 direct maternal deaths in 2003, and 492 direct maternal deaths in 2004, an increase of only 19 deaths. The rate for direct maternal deaths rose from 9.3/100,000 to 9.6/100,000, a change that may not even be statistical significant.
The bulk of the change from 2003 to 2004 occured in two area. There was a large increase in deaths from indirect maternal causes (pre-existing disease aggravated by pregnancy) and deaths from maternal causes more than 42 days after delivery or pregnancy termination. These increases could be real, or they could merely reflect the fact that death certificates now have additional questions on them that are designed specifically to identify late maternal deaths.
Even if these increases are real, they may simply be a result of the increasing age of pregnant women, and the increasing rate of multiple births associated with fertility treatments. According to
Births: Final Data for 2004:
The birth rate for women aged 35–39 years was ... up 4 percent from the rate in 2003. The rate for this age group ... has risen 43 percent since only 1990... From 1990 to 2004, the number of births to this age group rose by 50 percent, compared with a 5-percent increase in the population of women aged 35–39 years.
Women in their forties—In 2004, the birth rate for women aged 40–44 years rose to 8.9 births per 1,000 women .., an increase of 2 percent... Since 1981, the rate for this age group has generally increased and has risen 62 percent since 1990. The number of births to women aged 40–44 years increased by 3 percent during 2003–04, from 101,005 to 103,769, more than twice the number reported for 1990 and the highest number on record for the United States; the population of women aged 40–44 years increased only slightly (by less than 1 percent from 2003 to 2004). The birth rate for women aged 45–49 years was unchanged between 2003 and 2004, at 0.5 births per 1,000 women. This rate more than doubled between 1990 and 2000 but has remained stable since. The number of births to women aged 45–49 years increased 4 percent, from 5,522 to 5,748 between 2003 and 2004, more than three times the number for 1990 ...
Births to women aged 50 years and over—The number of births to women aged 50–54 years increased from 323 to 374 for 2003–04. The number of births to women in this age group has increased dramatically from 144 in 1997,..
The increase in birth rates for women 35 years of age and over during the last 20 years has been linked, in part, to the use of fertility-enhancing therapies... In 2004, 1 out of 18 births to women aged 35 years and over was in a multiple delivery, an outcome associated with infertility treatment, compared with 1 out of 33 births to women under 35 years of age. The incidence of multiple deliveries dramatically increases with the age of mother; for example, one out of five births to women aged 45–49 years and one out of every two births to women aged 50–54 years was a multiple birth in 2004.
The bottom line is that it is unclear whether there has even been an increase in maternal deaths; we may simply be seeing an increase in the reporting of maternal deaths, particularly those that occur long after the delivery. Second, the overall increase in the age of pregnant women, and therefore the pre-existing health problems of pregnant women, may account for any increase in the rate of maternal deaths. As the age of pregnant women increases, and particularly as the number of perimenopausal or postmenopausal pregnant women increases, we should expect to see an increase in the maternal mortality rate. This does not reflect a problem with obstetric care, but rather the increased risk associated with pregnancies of women 45-54.
Labels: maternal mortality
Starting from the wrong place
One of the fundamental problems with homebirth advocacy is that homebirth advocates start from the wrong place. Like many Americans, they have little knowledge of history and little knowledge of life outside the first world. They erroneously assume that what they see is the way things are everywhere and the way things have always been. Hence, they assume that childbirth in nature is inherently safe and that is the wrong place to start. The fact is that childbirth in nature is inherently dangerous and anyone who does not know that, does not know much about birth. Since homebirth advocates start from the wrong place, it is not surprising that they draw the wrong conclusions about what they see.
In order to understand where we are, it is critical to understand where we have been. As I often point out, in the last 100 years, modern obstetrics has dropped the neonatal mortality rate 90% and the maternal mortality rate 99%. This is one of the greatest public health achievements of all time. This success is primarily due to the application of technology, large amounts of it. As I have reviewed in the past, it is NOT the result of improved sanitation, hand washing or improved public water supplies.
The primary causes of neonatal mortality 100 years ago were congenital anomalies and prematurity. The primary causes of neonatal mortality now are still congenital anomalies and prematurity. The difference is that technology has allowed us to save almost 90% of babies who would have routinely died in the past. That technology includes more C-sections, fetal monitoring, pediatric surgery, neonatalogy and other highly technological innovations.
The primary causes of maternal mortality 100 years ago were eclampsia, hemorrhage, obstructed labor, and infection. With the exception of obstructed labor, they are still among the primary causes of maternal death. The difference is that technology has allowed us to save 99% of the women who would have died in the past. That technology includes improved anesthesia, more C-sections, induction and early delivery for pre-eclampsia, medication to prevent eclamptic seizures, blood transfusions, antibiotics and other highly technological innovations.
Starting from the assumption that childbirth is inherently safe is absurd. Any attempt to understand, criticize or reform modern obstetrics must start from a basic fact: Each year modern obstetrics saves approximately 240,000 babies and 40,000 women who would NATURALLY die. When contemplating ways to improve the experience of birth, we must start by acknowledging that each year 240,000 babies and 40,000 women will otherwise die unless we bring the technology of modern obstetrics to bear, AND that we still aim to prevent the approximately 22,000 neonatal deaths and almost 400 maternal deaths that do occur each year despite our best efforts.
Childbirth did not "naturally" become as safe as it is now, and it did not magically become as safe as it is now. It became safe and remains safe only because of the diligent efforts of obstetricians, nurse-midwives, nurses, neonatologists and other professionals and the continuing application of large amounts of technology. Now that we have achieved this extraordinary feat, we have the luxury of turning out attention to the "experience" of childbirth, but ONLY while continuing to repeat this achievement each and every year.
Labels: maternal mortality, neonatal mortality
A minimum C-section rate of 10% is needed for low maternal mortality and stillbirth rates
A recent article on the quality of obstetric care in developed and developing countries demonstrates that childbirth is inherently dangerous and that C-section is the most important lifesaving intervention. This paper suggests that a minimum C-section rate of 10% is required to reduce maternal mortality and stillbirth to low levels. Indeed, the ability to perform C-sections and other high tech interventions like blood transfusions is more likely to lead to low maternal mortality and stillbirth rates than low tech interventions like skilled birth attendants and increased prenatal visits.
In
Maternal mortality, stillbirth and measures of obstetric care in developing and developed countries in the International Journal of Obstetrics and Gynecology, McClure et al. explore the relationship between maternal mortality and stillbirth rates and the relationship between obstetric care and rates of maternal mortality and stillbirth.
Of the strategies in the emergency obstetric package designed to reduce maternal death, the ability to provide a timely cesarean section is among the most important to prevent a substantial number of maternal deaths and stillbirths. While it is difficult to pinpoint the exact etiology, in developing countries, prolonged labor is frequently the event leading to the maternal death or stillbirth. Associated infections and hemorrhage kill the mother, and fetal infection, asphyxia, and trauma kill the fetus. A timely cesarean section prevents many of the maternal and fetal deaths from infection and hemorrhage as well as fetal deaths from asphyxia. In cases of eclampsia/preeclampsia, a timely cesarean section will also reduce both maternal and fetal mortality.
In developing countries, for C-section rates:
<10% an increase of 1% of births by cesarean section leads to a decrease of 116 maternal deaths per 100,000 births
≥10% an increase of 1% of births by cesarean section leads to a decrease of 1 maternal deaths per 100,000 births
<13% an increase of 1% of births by cesarean section leads to a decrease of 1.72 stillbirths per 1000 births
≥13% an increase of 1% of births by cesarean section leads to a decrease of 0.05 stillbirths per 1000 births
The authors conclude:
Although in geographic areas with very high maternal mortality and stillbirth rates, community-based strategies such as training traditional birth attendants may still have a role in reducing both mortality rates, Koblinsky et al have emphasized that no evidence exists that maternal mortality below 100 per 100,000 births can be achieved through community-based strategies without access to emergency obstetric care. Some authors have estimated that to achieve an optimal reduction in maternal mortality, cesarean section rates of 5 to 15% are necessary, with 5% likely being the lowest rate associated with a maximum reduction in maternal mortality. These analyses support the view that significant reductions in maternal mortality and stillbirth may be achieved only through access to emergency obstetrical care, including cesarean section.
The clear implication is that maternal mortality rates of more than 100/100,000 births NATURALLY occur in childbirth. So contrary to the claims of homebirth advocates, childbirth is INHERENTLY dangerous. Moreover, C-sections appear to be the most important intervention needed to lower maternal mortality and stillbirth rates to low levels.
Labels: C-section, maternal mortality, neonatal mortality
"A possible death sentence came with every pregnancy."
One of the most glaring deficiencies in the arguments of homebirth and "natural" childbirth advocates is the lack of even the most basic knowledge about the historical dangers of childbirth. Modern obstetrics has been so stunningly successful at reducing maternal mortality that many people actually believe that it has always been this way.
Judith Walzer Leavitt explores the ways in which this constant fear of death in childbirth, and the frequent experience of the deaths of sisters and friends in childbirth, shaped the lives of women in the 19th century. It illuminates the inherent dangers of childbirth in a way that the statistics cannot.
In
Under the Shadow of Maternity: American Women's Responses to Death and Debility Fears in Nineteenth-Century Childbirth, Walzer Leavitt writes:
Maternity, the creation of new life, carried with it the ever-present possibility of death. The shadow that followed women through life was the fear of the ultimate physical risk of bearing children. Young women perceived that their bodies, even when healthy and vigorous, could yield up a dead infant or could carry the seeds of their own destruction... Nine months' gestation could mean nine months to prepare for death. A possible death sentence came with every pregnancy.
Walzer Leavitt is particularly concerned with the ways in which the experience of maternal death shaped women's lives and relationships:
Perhaps more valuable to our understanding of the reality of maternal death is the observation that most women seemed to know or know of other women who had died in childbirth. One woman, for example, wrote that her friend "died as she has expected to" as a result of childbirth as had six other of their childhood friends. Early in the twentieth century approximately 1 mother died for each 154 live births. If women delivered, let us estimate, an average of five live babies, these statistics can mean that over their reproductive years, one of every thirty women might be expected to die in childbirth. In another early-twentieth century calculation, one of every seventeen men claimed they had a mother or sister who had died as the immediate results of childbirth.
Homebirth and "natural" childbirth advocates are glaringly unaware of the reality of permanent disability due to childbirth:
In the past, the shadow of maternity extended beyond the possibility and fear of death. Women knew that if procreation did not kill them or their babies, it could maim them for life. Postpartum gynecological problems - some great enough to force women to bed for the rest of their lives, others causing milder disabilities - hounded the women who did not succumb to their labor and delivery. For some women, the fears of future debility were more disturbing than fears of death. Vesicovaginal and rectovaginal fistulas .., which brought incontinence and constant irritation to sufferers; unsutured perineal tears of lesser degree, which may have caused significant daily discomforts; major infections; and general weakness and failure to return to prepregnant physical vigor threatened young women in the prime of life. Newly married women looking forward to life found themselves almost immediately faced with the prospect of permanent physical limitations that could follow their early and repeated confinements.
Homebirth and "natural" childbirth advocates also seem to have no understanding that the notion of painless or "empowered" childbirth was completely made up in the 20th century. It is diametrically opposed to the way women actually viewed childbirth:
Women who had already had children were more likely than first-time mothers to worry about the possible aftereffects of labor and delivery. They remembered how long it took them the first time to recover from the birth, they remembered how they had suffered, and they were particularly loath to repeat the ordeal. As one woman wrote about her second pregnancy: "I confess I had dreaded it with a dread that every mother must feel in repeating the experience of child-bearing. I could only think that another birth would mean another pitiful struggle of days' duration, followed by months of weakness, as it had been before."
Apart from their concern about resulting death and physical debility, women feared pain and suffering during the confinement itself. They worried about how they would bear up under the pain and stress, how long the confinement might last, and whether trusted people would accompany them through the ordeal. The short hours between being a pregnant woman and becoming a mother seemed, in anticipation, to be interminably long, and they occupied the thoughts and defined the worries of multitudes of women. Women's descriptions of their confinement experiences foretold the horrors of the ordeal.
Josephine Preston Peabody wrote in her diary of the "most terrible day of [her] life," when she delivered her firstborn, the "almost inconceivable agony" she lived through during her "day-long battle with a thousand tortures and thunders and ruins." Her second confinement brought "great bodily suffering," and her third, "the nethermost hell of bodily pain and mental blankness. . . . The will to live had been massacred out of me, and I couldn't see why I had to. Another woman remembered "stark terror was what I felt most."
"Between oceans of pain," wrote one woman of her third birth in 1885, "there stretched continents of fear; fear of death and dread of suffering beyond bearing."32 Surviving a childbirth did not allow women to forget its horrors. Lillie M. Jackson, recalling her 1905 confinement, wrote: "While carrying my baby, I was so miserable... I went down to death's door to bring my son into the world, and I've never forgotten. Some folks say one forgets, and can have them right over again, but today I've not forgotten, and that baby is 36 years old." Too many women shared with Hallie Nelson her feelings upon her first birth: "I began to look forward to the event with dread-if not actual horror." Even after Nelson's successful birth, she "did not forget those awful hours spent in labor..."
Many women walked ...under the shadow of maternity, experiencing repeated and agonizing births in unrelenting succession with no relief throughout their fertile years. Many women suffered physical complications through their confinements that stayed with them the rest of their lives. For many women the physical hardships of childbearing determined the parameters of their lives and defined their social destiny. Although it is also true that childbearing and the ensuing motherhood held many happy times for women, it is the difficult part of the experience that created the boundaries within which most women had to construct their lives.
That is the reality of childbirth, not the airbrushed, made up fantasy of homebirth and "natural" childbirth advocates.
Labels: maternal mortality
Let them eat cake!
One of the most pressing global health problems is the issue of maternal mortality. Therefore, it is quite suprising to see the editor of Midwifery Today publish an
editorial criticizing the world wide effort to stem the tide of unnecessary maternal deaths. In an article informed by nothing more than personal opinion, Jan Tritten criticizes this comprehensive effort because .... it doesn't have homebirth as the centerpiece! Imagine that. All those doctors, epidemiologists, public health workers and women's health advocates think that saving lives is more important than promoting homebirth!
According to an editorial in the Lancet:
"Making sure women throughout the world can give birth in a health facility, in the presence of a midwife, is the best strategy for substantially reducing maternal mortality worldwide, according to a landmark series of papers. The authors are calling on governments and donors to prioritize this strategy over alternatives, such as homebirths with a relative, traditional birth attendant, community health worker or midwife, to save the lives of over half a million women who die in pregnancy or childbirth each year"
These conclusions are the result of a comprehensive study of newborn, child and maternal survival extending over 3 years and comprising more than 100 scholarly papers written by hundreds of experts in maternal and child health.
To this body of scholarly work, Ms. Tritten responds with this absurd and inane comment:
In a series of papers, The Lancet recommends implementing its own plan, rather than working within communities in villages to find appropriate, committed individuals to train. I always find interesting how imperialism rears its ugly head with the idea that "we know what is best for you."
Ms. Tritten, I have some questions for you:
What is the maternal death rate in underdeveloped countries? Your editorial mentions nothing about how many women die of "normal" birth each and every year.
What are the leading causes of maternal death in underdeveloped countries? In order to know whether home based care would be effective in lowering maternal death rates, you would need to know, at a minimum, what the actual causes are?
What are the treatments that are needed to reduce mortality from the leading causes of maternal death? In order to know whether home based care would be effective, you would need to know what treatments are needed.
Can these treatments be implemented within the setting of a home? In order to know whether home based care would be effective, you must know whether the specific treatments can be delivered effectively within a home based setting.
The self absorption of homebirth advocates reminds me of nothing so much as Marie Antoinette. When informed that the common people had no bread to eat, she responded with "Let them eat cake!" When informed that homebirth with traditional attendants is resulting in the deaths of millions of women from lack of blood transfusions, lack of antiseizure treatments, lack of anesthesia and lack of operative facilities, the editor of Midwifery Today responds with "Let them
train traditional attendants!" as if that could possibly address the problem.
I have argued repeatedly that the homebirth advocacy community suffers from a fundamental lack of knowledge about human birth as it truly occurs in nature (as oppose to the fantasy constructed by advocates). That the editor of Midwifery Today could condemn a massive world-wide effort to save the lives of millions of women, without so much as a shred of data, only confirms this devastating lack of knowledge.
Labels: maternal mortality
"Nothing else in medicine has saved lives on the scale that obstetrics has"
Dr. Atul Gawande is probably the best writer in medicine today. He takes a fascinating look at childbirth in this week's issue of
The New Yorker. The entire article is terrific, recounting the history of modern obstetrics and much of what we have discussed on this blog for the past several months. The most important quote from the article is as follows:
The Apgar score, as it became known universally, allowed nurses to rate the condition of babies at birth on a scale from zero to ten. An infant got two points if it was pink all over, two for crying, two for taking good, vigorous breaths, two for moving all four limbs, and two if its heart rate was over a hundred. Ten points meant a child born in perfect condition. Four points or less meant a blue, limp baby.
The score was published in 1953, and it transformed child delivery. It turned an intangible and impressionistic clinical concept-the condition of a newly born baby-into a number that people could collect and compare. Using it required observation and documentation of the true condition of every baby. Moreover, even if only because doctors are competitive, it drove them to want to produce better scores-and therefore better outcomes-for the newborns they delivered.
Around the world, virtually every child born in a hospital had an Apgar score recorded at one minute after birth and at five minutes after birth. It quickly became clear that a baby with a terrible Apgar score at one minute could often be resuscitated-with measures like oxygen and warming-to an excellent score at five minutes. Spinal and then epidural anesthesia were found to produce babies with better scores than general anesthesia. Neonatal intensive-care units sprang into existence. Prenatal ultrasound came into use to detect problems for deliveries in advance. Fetal heart monitors became standard. Over the years, hundreds of adjustments in care were made, resulting in what's sometimes called "the obstetrics package." And that package has produced dramatic results. In the United States today, a full-term baby dies in just one out of five hundred childbirths, and a mother dies in one in ten thousand. If the statistics of 1940 had persisted, fifteen thousand mothers would have died last year (instead of fewer than five hundred)-and a hundred and twenty thousand newborns (instead of one-sixth that number).
There's a paradox here. Ask most research physicians how a profession can advance, and they will talk about the model of "evidence-based medicine"-the idea that nothing ought to be introduced into practice unless it has been properly tested and proved effective by research centers, preferably through a double-blind, randomized controlled trial. But, in a 1978 ranking of medical specialties according to their use of hard evidence from randomized clinical trials, obstetrics came in last. Obstetricians did few randomized trials, and when they did they ignored the results. Careful studies have found that fetal heart monitors provide no added benefit over having nurses simply listen to the baby's heart rate hourly. In fact, their use seems to increase unnecessary Cesarean sections, because slight abnormalities in the tracings make everyone nervous about waiting for vaginal delivery. Nonetheless, they are used in nearly all hospital deliveries. Forceps have virtually disappeared from the delivery wards, even though several studies have compared forceps delivery to Cesarean section and found no advantage for Cesarean section. (A few found that mothers actually did better with forceps.)
Doctors in other fields have always looked down their masked noses on their obstetrical colleagues. Obstetricians used to have trouble attracting the top medical students to their specialty, and there seemed little science or sophistication to what they did. Yet almost nothing else in medicine has saved lives on the scale that obstetrics has
. On obstetricians and interventions:
In obstetrics, meanwhile, if a strategy seemed worth trying doctors did not wait for research trials to tell them if it was all right. They just went ahead and tried it, then looked to see if results improved. Obstetrics went about improving the same way Toyota and General Electric did: on the fly, but always paying attention to the results and trying to better them. And it worked. Whether all the adjustments and innovations of the obstetrics package are necessary and beneficial may remain unclear-routine fetal heart monitoring is still controversial, for example. But the package as a whole has made child delivery demonstrably safer and safer, and it has done so despite the increasing age, obesity, and consequent health problems of pregnant mothers.
The Apgar score changed everything. It was practical and easy to calculate, and it gave clinicians at the bedside immediate information on how they were doing. In the rest of medicine, we measure dozens of specific things: blood counts, electrolyte levels, heart rates, viral titers. But we have no measure that puts them together to grade how the patient as a whole is faring. It's like knowing, during a basketball game, how many blocked shots and assists and free throws you have had, but not whether you are actually winning. We have only an impression of how we're performing-and sometimes not even that. At the end of an operation, have I given my patient a one-in-fifty chance of death, or a one-in-five-hundred chance? I don't know. I have no feel for the difference along the way. "How did the surgery go?" the patient's family will ask me. "Fine," I can only say.
The Apgar effect wasn't just a matter of giving clinicians a quick objective read of how they had done. The score also changed the choices they made about how to do better. When chiefs of obstetrics services began poring over the Apgar results of their doctors and midwives, they started to think like a bread-factory manager taking stock of how many loaves the bakers burned. They both want solutions that will lift the results of every employee, from the novice to the most experienced. That means sometimes choosing reliability over the possibility of occasional perfection.
On patient choice C-sections:
A measure of how safe Cesareans have become is that there is ferocious but genuine debate about whether a mother in the thirty-ninth week of pregnancy with no special risks should be offered a Cesarean delivery as an alternative to waiting for labor. The idea seems the worst kind of hubris. How could a Cesarean delivery be considered without even trying a natural one? Surgeons don't suggest that healthy people should get their appendixes taken out or that artificial hips might be stronger than the standard-issue ones. Our complication rates for even simple procedures remain distressingly high. Yet in the next decade or so the industrial revolution in obstetrics could make Cesarean delivery consistently safer than the birth process that evolution gave us.
Currently, one out of five hundred babies who are healthy and kicking at thirty-nine weeks dies before or during childbirth-a historically low rate, but obstetricians have reason to believe that scheduled C-sections could avert at least some of these deaths. Many argue that the results for mothers are safe, too. Scheduled C-sections are certainly far less risky than emergency C-sections-procedures done quickly, in dire circumstances, for mothers and babies already in distress. One recent American study has raised concerns about the safety of scheduled C-sections, but two studies, one in Britain and one in Israel, actually found scheduled C-sections to have lower maternal mortality than vaginal delivery. Mothers who undergo planned C-sections may also (though this remains largely speculation) have fewer problems later in life with incontinence and uterine prolapse.
This article is an excellent history of how obstetrics got to be where it is today. It also debunks the central myth of the homebirth movement, that childbirth is inherently safe because it is natural.
Labels: maternal mortality, neonatal mortality
Maternal mortality
Making Motherhood Safer, a report prepared by the Population Reference Bureau in 2002, contains some very enlightening statistics about maternal mortality. They have direct implications for the contention among natural childbirth advocates that childbirth is inherently safe:
"Women's Lifetime Risk of Death From Pregnancy, 1995
Sub-Saharan Africa 1 in 13
South Asia 1 in 54
Middle East and North Africa 1 in 55
Latin America and the Caribbean 1 in 157
East Asia/Pacific 1 in 283
Central East Europe/Commonwealth
of Independent States and Baltic States 1 in 797
Industrialized countries 1 in 4,085"
"The most recent figures from the World Health Organization, which releases revised global maternal mortality estimates about every five years, estimate that 515,000 women die annually from maternal causes...
Tragically, these deaths are just part of the picture. For every woman who dies, approximately 30 more women suffer injuries, infection, and disabilities during pregnancy or childbirth - at least 15 million women a year. The cumulative total of those affected has been estimated at 300 million, or more than a quarter of adult women in the developing world. These pregnancy-related health problems include severe anemia, infertility, and damage to the uterus and reproductive tract sustained during childbirth. Obstetric fistula (tears between the vagina and the urinary tract or rectum that cause permanent incontinence if not treated) are especially devastating."
"The majority of maternal deaths occur after childbirth - most within 24 hours. About a quarter take place during pregnancy, and about 15 percent happen at the time of delivery. The most common medical cause is hemorrhage, a swift and severe loss of blood before, during, or after delivery..."
"Skilled Care at Delivery and Maternal Deaths, Regional Comparisons
Sub-Saharan Africa 45% of women receive skilled care/967deaths per 100,000 births
South Asia 59%/430
East Asia and Pacific 73%/189
Middle East and North Africa 77%/175
Latin America and Caribbean 83%/146
Central & East Europe/CIS(Russia)/Baltic 97%/45
North America 100%/9"
What does this tell us about the inherent safety of human childbirth? It tells us that it is not very safe at all. In countries where there is limited access to modern obstetrics, the lifetime risk of death from pregnancy and childbirth is 1 in 13; every woman has a 1 out of 13 chance that she will die of a pregnancy related complication. That has been reduced to 1 in 4085 in countries where every woman has access to modern obstetrics. This is the reason why most natural childbirth advocates think (erroneously) that childbirth is inherently safe. Modern obstetrics has been so spectacularly successful, that most Western people have no clue about the dangers of childbirth.
The most common cause of maternal death is hemorrhage. Whatever herbs or natural techniques are being used, they cannot prevent 100,000 maternal deaths per year. Only pitocin, methergine and blood transfusions can do that - all products of modern obstetrics.
There are those who might argue that it is not medical care that is responsible for the dramatic disparities in maternal deaths around the world, but poverty, malnutrition and sanitation. However, the relationship between modern obstetrics and decreasing maternal death is emphasize by examination of the proportion of women seen by skilled attendants and the number of maternal deaths. The above figures demonstrate that maternal mortality is directly related to proportion of women who received skilled care.
Labels: maternal mortality
Maternal mortality
The homebirth movement propounds a variety of myths and lies about obstetrics in an attempt to deny obstetricians credit for their tremendous successes. One of the biggest lies is that 99% drop in maternal mortality achieved in the last century was due to "public health" measures like improved sanitation and handwashing.
The following information was taken from an article about
maternal mortality in the underdeveloped countries. The focus of the article is applying what we have learned about maternal mortality in the US and Britain to save lives in poor countries:
During the 19th century, living conditions (nutrition, sanitation, etc.) in Europe and North America improved, and this resulted in sustained and impressive declines in infant mortality, and in deaths from infectious diseases among adults (e.g. tuberculosis), well before medical technology to fight these was developed.
During this period, however, maternal mortality remained high. For example, from 1840 (when the first maternal mortality statistics were available in Britain) to the mid-1930s, maternal mortality remained as high in Britain as it is in many developing countries today. Then, after nearly a century of stagnation, maternal mortality declined so sharply that within 15 years it was no longer a major public health problem. Why? Because the technology to treat obstetric complications became available, including antibiotics (first sulfa drugs and then penicillin), banked blood and safer surgical techniques. In 1934, there were 441 maternal deaths per 100,000 births in England and Wales. By 1950, there were 87, and in 1960 there were 39. Similar patterns obtained in other European countries and in the United States ...
In other words, it was not that women were less likely to develop obstetric complications, or more likely to survive complications in the absence of medical care, that led to low levels of maternal mortality in developed countries. Rather, it was the fact that women had access to treatment for complications... [F]or decades the focus of maternal health programmes was on antenatal care, screening of pregnant women, and training of traditional birth attendants to do clean deliveries. These activities were based on the assumption that most life-threatening obstetric complications can either be prevented or predicted...
The first antenatal clinics, which were introduced between 1910 and 1915 in Australia, Scotland and the United States, represented a new concept of care for pregnant women – the monitoring of apparently healthy women for signs of illness. It was generally believed ... that widespread use of antenatal care would reduce maternal deaths. But this did not happen...
The problem was (and still is) that the major causes of maternal death cannot be detected and averted during pregnancy. Post-partum haemorrhage, the leading cause of maternal deaths, can be caused by a number of events, such as a small piece of placenta being retained in the uterus, or the woman being exhausted after delivery. These problems cannot be predicted, even late in pregnancy, because they only happen during labour and delivery, or the post-partum period. Prolonged labour can be managed by medical intervention, such as use of drugs or caesarean section, but it cannot be prevented...
While some cases of infection will be prevented through clean delivery techniques, other cases of infection will still occur because infection can arise without being introduced from outside the woman’s body. For example, in the event of prolonged labour or prolonged rupture of the membranes without delivery, infection often arises from the damaged tissue itself.
So the 99% drop in maternal mortality achieved in the last century was due to the technology to treat obstetric complications such as antibiotics banked blood and C-section. It was not due to improvements in public health.
Labels: maternal mortality
