Friday, June 06, 2008

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.


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