Monday, January 23, 2012


"Women in the United States are more likely to die during or shortly after childbirth than women in nearly all countries in Europe and many in Asia and the Middle East, according to the United Nations.

While maternal mortality declined in most countries over the past 20 years, it has not just increased, but nearly doubled, in the United States.

Experts blame the high death rate partly on the heavy reliance the United States places on technological intervention, particularly when it results, as it so often does, in surgical delivery via cesarean section. They say motivators include both convenience and fear of litigation in the event of a less-than-perfect outcome.

Originally meant to be strictly an emergency action to save a struggling baby, it has become all but routine in the U.S. It is now used in almost one-third of all American births.

“Cesarean section is meant to be sort of a last resort, when there’s no way the baby is going to be born alive otherwise or the mother’s or baby’s life will be endangered,” said medical anthropologist, reproductive biology professor and registered midwife Melissa Cheyney. “Now it’s sort of becoming commonplace, and that’s where the problem lies.”

Cheyney, a member of the biology department faculty at Oregon State University, studies maternal and child health across different cultures. A practicing midwife on the side, she also chairs the state Board of Direct Entry Midwifery. And her experience in both realms convinces her America’s maternal mortality rate is too high.

Another contributing factor, experts say, is lack of access to health care before, during and after childbirth.

That is particularly true for the minority and low-income portion of the population. As a result, black women have, historically, been four times as likely to die in the course of American childbirth than their white counterparts.

“It has to do with the American health care system,” said McMinnville obstetrician and gynecologist Allan Hedges. “The countries with lower rates of maternal mortality, like Canada and Western Europe, have national health care systems. There’s greater access to health care.”

The U.S. seems to lag particularly in post-partum care.

A study by the federal Centers for Disease Control and Prevention found that “34 percent of maternal deaths occurred within 24 hours of childbirth,” while 55 percent occurred “between 1 and 42 days following birth.”

Amnesty International blamed that in part on inadequate postpartum care, noting that in the U.S., it often consists of “a single visit with a physician around six weeks after birth.” That is, many women are not seeing a physician again until 42 days after they give birth -— the end of the period during which women are most likely to die from childbirth complications.

Finally, the age and obesity of American women at childbirth have been rising steadily over the last quarter century. Both factors are associated with higher rates of potentially fatal complications.


Hedges, who is retiring from practice to teach and write, said reasons for the nation’s extraordinarily high Cesarean rate are as complex as the American health care system. It starts, he said, with pervasive fetal monitoring in hospitals.

The practice is intended to let doctors monitor the baby’s health continuously throughout the birthing process. But he said, “Studies show that continuous monitoring doesn’t change anything, except to increase the C-section rate.”

That is, it doesn’t change anything in a positive direction. It does change one thing in a negative direction — it costs some mothers their lives.

That’s because it leads to more C-sections, and a woman is three times more likely to die from a C-section than a vaginal delivery. C-sections also cause substantially more medical complications not resulting in fatality.

If doctors see an abnormality in the readings, Hedges said, they are more likely to perform a C-section, just to be on the safe side in a notoriously litigious area of practice. But he said, “In the vast majority of cases, those babies are fine,” despite the abnormal readings. In many cases, Hedges said, doctors simply don’t know what causes the abnormal readings.

Obstetrician/gynocologyst Dr. John Neeld of the Willamette Valley Medical Center agreed that fear of giant lawsuits is often the driver in such cases.

For example, he said, the fetal heartrate tracing patterns might be slightly elevated, but not necessarily indicative of a baby in trouble. But the combination of a doctor worried about possible lawsuits if his interpretation turns out wrong, and a patient afraid for her baby, and determined to take any action necessary to ensure its safety, often leads to a C-section that, in hindsight, was probably not necessary, he said.

“Those are not small lawsuits,” he said. “I personally have not been sued, but if I get sued for $10 million, I know I’m out of business, because my insurance willl be so high that I won’t be able to continue practicing.”


In March, “Contraception: An International Reproductive Health Journal,” a peer-reviewed medical journal published by the Association of Reproductive Health Professionals, published a landmark editorial on the subject. Titled, “Maternal Mortality in the United States: A Human Rights Failure,” it was authored by Francine Coeytaux of WomanCare Global, Debra Bingham of the Association of Women’s Health, Obstetric and Neonatal Nurses, and Nan Strauss of Amnesty International USA.

The editorial states:

“In contrast to many countries where women lack access to life-saving medical interventions, women and infants (in the U.S.) are often exposed to more procedures than are medically necessary or beneficial. This overuse of medical procedures increases injuries as well as costs.

“Indeed, we are unaware of any study indicating that the 56 percent increase in the rate of surgical births from 1996 to 2008 has improved outcomes. However, there are data to show that the overuse of medical procedures has increased both infant and maternal morbidity.”

Performance of a Cesarean section in one pregnancy also leads to increase the risks in the next. Consequently, doctors have historically discouraged women from attempting to deliver subsequent babies vaginally, a trend that also has helped to increase the national rate of Cesarian sections.

A number of other trends have also contributed, Hedges said.

“There is a litigation concern for many MDs,” he said. “If they don’t deliver a perfect baby, they’re going to get sued, so they’re more inclined to do a C-section sooner rather than later.”

He noted, “There’s also pressure from patients.” More and more, he said, they are coming to view both inducing labor and performing a Cesarean as routine options.

“The induction rate is really high, and that leads to more C-sections,” he said. “It used to be that you only induced someone if there was a problem with the baby. Now, it’s often done for the patient’s or physician’s convenience.”

In some cases, he said, women in late pregnancy declare they’ve simply had enough. Normal human gestation is between 37 and 42 weeks, but some women want labor induced even earlier, he said.

“I’ve had women at 36 weeks come in and say they want to be induced,” Hedges said. “Their back hurts, they’re tired, they have headaches, they can’t sleep. They want to be done.”

There is, he said, a general trend toward wanting to avoid discomfort or inconvenience. Both inductions and C-sections are seen as holding promise in that area.

“Patients ask to have C-sections because they don’t want to go through labor,” Hedges said. And many of them, he said, prefer to schedule the birth.

“Maybe the mother-in-law is going to be there to care for the other kids,” he said. “There’s a lot of pressure. I think it’s a small part, but it’s a part.”


Some of the increase in the death rate recording may be due to better reporting. But the authors of the Contraception editorial said, “While it is unclear how much of the increase is due to reporting, these changes alone do not adequately explain the near doubling of maternal deaths.” And some critics believe maternal death is actually being under-reported in the U.S.

In a 2010 report titled “Deadly Delivery,” Amnesty International said, “U.S. authorities concede that the number of maternal deaths may be twice as high, as reporting of pregnancy-related deaths as a distinct category is mandatory in only six states — Florida, Illinois, Massachusetts, New York, Pennsylvania and Washington,” and there are no federal requirements.

Perhaps because the causation seems so diffused, complicated and unclear, efforts to rein in America’s exceptionally high maternal mortality rate have largely gone for naught so far.

In January 2010, the Joint Commission, an independent non-profit organization that certifies health care organizations, issued a warning that maternal mortality was actually on the increase in the U.S. It quoted Dr. William M. Callaghan of Reproductive Health Division of the Centers for Disease Control and Prevention.

Callaghan noted the U.S. had once set a goal of bringing its rate of maternal deaths down to 3.3 per 100,000 live births by 2010. The country has made no progress toward reaching that goal, he said.

In fact, the government has now given up on it. Now, it proposes to reduce maternal deaths to 11.4 per 100,000 live births by 2020.

While the national rate stood at 12.7 in 2007, and seems virtually stuck there, state rates vary widely.

Only five states met the 2010 standard, and Oregon was not one of them. Its rate was twice as high. Nationally, rates currently range from 1.2 in Maine to 34.9 in Washington, D.C.


In “Deadly Delivery,” Amnesty International noted that a woman is five times more likely to die in childbirth in the U.S. than in Greece, which has the world’s lowest maternal mortality rate.

The United Nations releases a new report every five years. The United States ranked 41st in child mortality in the 2005 report, but had slipped nine spots to 50th by 2010.

The United States averaged 12.7 deaths per 100,000 live births in 2009, up from 7.1 a decade earlier. Nearly every industrialized nation in the world does better than that, as do several developing nations, according to the U.N.

And Amnesty International says that understates the problem in one important respect. While the U.S. averages more than two childbirth deaths a day, it logs even more near-death experiences, some of which lead to lasting impairment.

In the U.S., it said, “Severe complications that result in a woman nearly dying, known as a ‘near miss,’ increased by 25 percent between 1998 and 2005. During 2004 and 2005, 68,433 women nearly died in childbirth in the U.S.A. More than a third of all women who give birth in the U.S.A. – 1.7 million women each year – experience some type of complication that has an adverse effect on their health.”

What’s more, at least half of maternal deaths occurring in this country are preventable, according to the National Centers for Disease Control and Prevention.

Of course, it could be worse — much, much worse. Haiti, where Hedges once did a tour, is one of the places where it is.

“When I worked in Haiti,” Hedges said, “the maternal mortality rate was 700 in 100,000 women. There’s a big difference.”


Hedges said the health of a woman when she enters into childbirth also plays a role. And both age and obesity are factors in that.

In the United States, he said, “Women are having babies at an older age. That increases the risk of complications.”

And he said, “Twenty-five percent of women are obese now in pregnancy. That definitely increases the risk of complications, and the rate of C-sections.”

Obese women, he said, are more likely to suffer high blood pressure and gestational diabetes during pregnancies. Those, he said, are both factors contributing to poor outcomes.

Lack of access to health care is another problem, Hedges said.

If women start out with health problems, and don’t receive care for those problems before becoming pregnant, or at least in the early stages of pregnancy, they are likely to worsen under the stress of late-stages pregnancy and cause complications.

“If they have no access to health care — if they lack insurance, they lack money, they lack access to providers — they’re going to carry those problems into pregnancy,” he said. “It starts pre-conception, even with access to birth control to prevent unintended pregnancies.”

Contraception said nearly half of all American pregnancies are unintended, and they tend to have worse outcomes for both mother and child. That, Hedges said, is partly because many insurance companies don’t cover the cost of birth control and millions of women lack insurance in any event.

In its editorial, Contraception concluded, “Too many women in the United States face shortages of providers and facilities and inadequate staffing; financial, bureaucratic, transport and language barriers; care that is not culturally appropriate or respectful; a lack of opportunity for informed decision-making; and the lack of a system to ensure that all women receive high-quality, evidence-based care.”

The magazine said that affects black women disproportionately, noting, “For the last 50 years, black women who give birth in the United States have been approximately four times as likely to die as white women,” and “studies illustrate that women of color often are less likely to receive beneficial treatments that could have prevented their death or injury.” But it said improvement is needed across the board."

Danger in delivery: Despite technology, U.S. trails entire western world in saving mothers

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