BusyMamaMD

There has been a lot of talk lately about maternal mortality.  A recent story published in ProPublica and NPR has been circulating social media, highlighting the problems with our labor and delivery system (Martin 2017).  The story is heartbreaking, describing a preventable postpartum death in a young, healthy mother.  While the article makes many good points, I do believe it is misleading when it comes to the reasons maternal deaths are increasing in our country.  Based on the data from the article, this particular case appears to be one of malpractice.  Although the United States has work to do when it comes to improving safety for mothers, I do not believe this is what is driving the apparent increase in maternal mortality.

Many people have commented since the article was published; claiming that “all the technology” we have at our disposal is not working.  We have advanced fetal monitoring, state of the art equipment, modern laboratory testing, and medications.  Moms should not be dying.  While I agree that the goal maternal mortality should be zero, I do not believe that will ever happen.  Labor and delivery is dangerous.  Childbirth kills and it has killed for hundreds and thousands of years.  Our technology IS working.  Despite what social media and your neighbor may tell you, a hospital is the safest place to be when you are having a baby.  In 1915, according to published records, 608 out of every 100,000 mothers died during or shortly after giving birth (Singh 2010). That is 6 out of every 1000 women, and honestly, the number was probably higher.  Without strict reporting mandates, many maternal deaths were likely missed.  Going further back and examining maternal mortality records in England (which were likely also underreported) the maternal death rate was approximately 5 per 1000 women from 1800-1899 and 10 per 1000 women from 1700-1750 (Chamberlain 2006).  That is 1% of women!  1% of women died while having a baby.  Let that sink in for a minute.

Why was the ProPublica story so shocking?  We don’t hear of women dying in childbirth anymore.  It happens, but it is not as commonplace as it was a century or two ago.  Pregnancy, labor, and delivery is seen as a happy time.  Women do not think bad things can or will happen to them.  People plan their labors like they are planning the party of the century.  The “birth experience” is stressed over safety.  Women write lengthy and detailed birth plans that often restrict the physicians and nurses’ ability to care for them.  They risk themselves and their infants delivering at home or with an untrained professional.  They choose birthing centers over hospitals.  They decline fetal monitoring and intravenous lines and antibiotics.  These women have never seen a term stillborn.  These women have never seen a young, vibrant new mother die.  These women hear stories like the one in ProPublica and tell themselves hospitals are a dangerous place filled with unnecessary interventions. They are better off at home having a nice “natural” birth.

Obviously hospitals and technology are bad, right?  Our maternal mortality rate, although down from 1915, is now increasing.  It is increasing?  To be honest, our data stinks.  We have likely been underreporting for years.  In 18 and 19^th century England, maternal mortality data was gathered from parish registries (Chamberlain 2006).  In the United States prior to 1986, maternal mortality data was gathered from vital statistics, such as death certificates.  Often these certificates did not specifically list whether or not that patient was pregnant, causing underreporting. Then, in 1986, the CDC started “requesting” that states report maternal mortality data.  A little over a decade later in 1999, coding and classification of maternal deaths was improved via the revision of the International Classification of Diseases (Singh 2010).  In 2003, standard birth and death certificates were revised nationwide to capture more data (ACOG 2015).  So although it looks like maternal death has been increasing dramatically, it is possible that much of that increase is due to increased and better reporting.

If you don’t buy that, let’s look at why maternal mortality might be increasing.  To understand that, one first has to look at the cause of death.  While our technology and medical advancements have saved countless mothers from dying of infection and postpartum hemorrhage, we have a new problem.  Moms are not as healthy as they were a few decades ago.  Mothers are obese, older, and have more chronic health problems.  Heart disease is now the number one killer of mothers according to the CDC (CDC 2017).  15.5% of maternal deaths recorded were due to cardiovascular disease and another 14.5% from noncardiovascular diseases (CDC 2017).  This number was nonexistent a century ago.

One can also see by examining the available data that mortality increases with increasing poverty and limited access to care.  States with high poverty levels as well as states with high immigrant populations were shown to have an increase in maternal deaths (Singh 2010).  Women who are unable to receive adequate medical care have worse outcomes.

Bottom line: medicine works.  The cases that make mainstream news are often filled with stories of malpractice and medical errors.  While these things to occur and everyone needs to work to prevent medical mistakes and misses, this is not what is driving the recorded maternal mortality increase.  Many factors are at play.  To say that the hospital is dangerous based on a case you read about on social media is akin to refusing to wear a seatbelt because you heard a story about a seatbelt leading to someone’s death.  Has it happened?  I’m sure it has at some point.  Yet, I am still going to wear my seatbelt.

It amazes me that women still choose to ignore medical advice and deliver at home.  After all “women have been doing it for thousands of years.”  True, but many of them didn’t live to tell about it.  If you want the home birth experience, you unfortunately have to accept the home birth mortality.

References

ACOG Committee Opinion Number 639: The importance of vital records and statistics for the obstetrician-gynecologist.  (2015). American College of Obstetrics and Gynecology.

CDC Pregnancy mortality surveillance system. (2017).  Centers for Disease Control.  Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

Chamberlain G.  (2006).  British maternal mortality in the 19^th and early 20^th centuries.  J R Soc Med.  Nov; 99(11): 559-563.

Martin, N., Montagne, R.  (2017). The last person you would expect to die in childbirth.  ProPublica.  Retrieved from https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system

Singh, G.  Maternal mortality in the United States: 1935-2007.  US Department of Health and Human Services.  Retrieved from  https://www.hrsa.gov/ourstories/mchb75th/mchb75maternalmortality.pdf