By Aeman Nishath
Recently, a woman in Iowa was referred to a university hospital during childbirth because of possible complications. At the university hospital it was decided that a cesarean section should be done. After the cesarean section was completed and the woman was resting in her hospital room, she went into shock and died. An autopsy showed that, during the cesarean section, the surgeon had accidentally nicked the woman's aorta, the biggest artery in the body, which led to internal hemorrhage, shock, and death.
A cesarean section can save the life of the mother or her baby, or both. A cesarean section can kill a mother or her baby, or both. Every procedure or technology used during pregnancy and birth carries risks for the mother and baby. Whether or not to use any procedure or technology will be a judgment based on balancing the chances that it will make things better against the chances that it will make things worse.
We live in the age of technology. Since long before human beings landed on the moon, we have believed that technology can solve all of our problems. It should come as no surprise that doctors and hospitals are using more and more technology and invasive interventions on pregnant and birthing women. Has all this technology solved the problems surrounding birth? Let's look at the record. Is the increasing use of technology saving the lives of more pregnant and birthing women? In fact, the risk of a woman in this country dying from maternal mortality (i.e., causes related to pregnancy) has not decreased in more than 25 years. Each year, nearly 1,000 women die during pregnancy, during birth, or in the first week after giving birth. Nearly half of these deaths could have been prevented with better access to higher-quality maternity care. Hundreds of thousands of other women experience medical complications from pregnancy.2
The data also suggest an increase in recent years in the number of women dying during pregnancy and birth in the US.3 We have known for some time that maternal mortality in the US is underreported--in one state in one year, a third of the maternal deaths had not been reported.4 But the latest evidence suggests that "The actual pregnancy-related death rate could be more than twice as high as that reported for 1990."5
WHY ARE MORE AMERICAN WOMEN DYING?
It is difficult to pinpoint why more American women are dying before, during, and after giving birth--the data give only the leading or immediate cause of death, not the underlying causes. But if we look at the six leading causes of pregnancy-related deaths in the US, three--hemorrhage, anesthesia, infection--are often the result of invasive obstetric interventions.6 For example: Although the immediate cause of death is frequently given as "hemorrhage," in many cases the hemorrhage is associated with cesarean section (as in the case cited in the first paragraph). There is good research, both in the US and the United Kingdom, showing that the maternal mortality rate for cesarean section is four times higher than for vaginal birth.7-9 The rate of maternal mortality is still twice as high as for vaginal birth even when the cesarean section is routine, or "elective"; i.e., it is not an emergency procedure. With nearly twice as many cesarean sections as are necessary being done today in the US, the procedure could be a significant part of the reason for the country's rising rate of maternal mortality.10
Another possible cause of rising pregnancy-related deaths in the US is the markedly increasing use of epidural blocks for normal labor pain. Administering an epidural block doubles the risk that the woman will die; "anesthesia complications" are documented as one of the leading causes of maternal mortality in the US.11
There is good reason to believe that other obstetric technologies also contribute to the rising number of women who die during childbirth in this country. Data from the Centers for Disease Control (CDC) show that in the past ten years the number of women given powerful and dangerous drugs to induce labor has gone from 10 percent of all births to 20 percent.12 In the same ten years, the drug Cytotec, not approved by the FDA for labor induction because of insufficient scientific evaluation of risk--a warning often ignored by doctors--has become the single most popular labor-inducing drug. New scientific data show that inducing labor with Cytotec causes a marked increase in uterine rupture, an obstetric catastrophe in which a quarter of all babies die, many women die as well, and, of the women who survive, almost none can ever have another baby.
Why has the rate of Cytotec-induced labor doubled when the ability of women's bodies to begin labor has not decreased? Further CDC data show that the answer is doctor convenience. In those same ten years, the number of births taking place Monday through Friday greatly increased.13 Like taking prenatal X-rays in the 1930s, prescribing the drug di-ethyl-stillbesterol (DES) to pregnant women in the 1950s, and thalidomide in the 1960s, inducing labor with Cytotec in the 1990s is another obstetric intervention that has gone into widespread use without adequate scientific evaluation, with tragic consequences for thousands of women and babies.
The scientific evidence strongly suggests that the increasing use of obstetric interventions and technologies--cesarean section, epidural anesthesia, and drugs to induce labor--is not saving more women's lives, but ending them. Medical care was responsible for some of the earlier decreasing mortality of pregnant and birthing women, not because of high-tech interventions but because of basic medical advances, such as the discovery of antibiotics and the ability to give safe blood transfusions. There has never been any scientific evidence that such high-tech interventions as the routine use of electronic fetal monitoring during labor decrease the mortality rate of women.14 There is also no scientific evidence to prove that the fall in maternal mortality was because birth was moved into the hospital.15 The evidence does show that, as long as a system is in place that can transport women in labor within 30 minutes to a facility where antibiotics, blood transfusions, and necessary cesarean sections are available, there should be very little maternal mortality. For example, in the Netherlands, a third of all births are planned homebirths attended by midwives that refer women to doctors when necessary. The rate of maternal mortality in the Netherlands is far lower than in the US.
THE IMPORTANCE OF QUALITY CARE
The US spends twice as much as any other country on maternity care, and yet 15 other countries have lower rates of maternal mortality. There are at least two reasons for this, both having to do with access to quality care. More than 40 million Americans have no health insurance; many of these are women needing maternity care. If a woman applies for Medicare support for her maternity care, she must have means testing, which necessitates that she jump through many bureaucratic hoops before she can receive care. This can be a disaster. Furthermore, women receiving publicly funded care go to overcrowded hospitals staffed by interns and residents who are overworked and insufficiently trained.16 In addition, when poor women qualify for their maternity care to be funded by Medicare, they may be referred to a private practitioner, and receive this care in the doctor's private offices and private hospitals. There they often receive less attention than the women whose care is being funded by private insurance instead of public funds, in part because of the cultural and socioeconomic gaps between the poor women and their doctors. The delays and crowding, and lack of understanding and skill of some doctors, can all lead to pregnancy-related deaths.
The second reason the US has a higher rate of maternal mortality than 15 other countries is the way birthing women are cared for here. American doctors insist that women need to be in the hospital when giving birth, yet these same doctors who need to provide maternity care for them are not in the hospital when the women actually give birth, but in their offices doing prenatal checkups on healthy women, or in another hospital doing gynecological surgery, or at home eating dinner.17 So when the birthing woman who is in the hospital (or transported to the hospital) needs urgent attention for developing complications, the obstetrician is often not there, must be called, and may come too late. Research shows that, in more than 70 percent of cases, the main factor in the death of babies at birth is the doctor's absence.18
The US and Canada are the only countries in the world in which obstetricians provide primary birth care for the majority of normal births. The American obstetrician tries to be all things to women: a primary provider of maternity care for healthy pregnant and birthing women; a provider of preventive care for women; a specialist in women's diseases; and a highly skilled surgeon. No other doctor anywhere in healthcare tries to maintain competence at all of these levels and in so many areas because it is unreasonable to expect this from one human being. It's unlikely that an obstetrician can perform a six-hour gynecological surgical procedure on a woman with extensive cancer, then rush to his or her office and do the best job of quietly, patiently counseling a pregnant woman about her sex life. If you are considering a hospital birth with an obstetrician as your primary birth attendant, ask the doctor how much time he or she will spend with you during your labor. One of the reasons a midwife, rather than an obstetrician, is generally a better choice to attend your hospital birth is that, assuming a normal pregnancy, midwives have been shown statistically to be safer birth attendants than doctors.19 This is, in part, because the midwife is there in the hospital with you throughout your labor, while the obstetrician is not.
For more than 50 years now the US has had a system of maternity care that often boils down to this: A woman goes into labor, goes to the hospital, and is admitted by the labor and delivery (L&D) nurse, who examines her. The L&D nurse then calls the obstetrician, who gives orders over the telephone to the nurse. The obstetrician may or may not come by the hospital during the labor to check the woman. It is the job of the L&D nurse to monitor the labor and call the obstetrician when the birth is imminent so that the doctor does not have to hang around the hospital waiting for the birth.
During my 15 years as Director of Women's and Children's Health for the World Health Organization, I frequently visited the industrialized countries of Europe. I observed that in the 15 countries that lose fewer pregnant and birthing women than the US does--including those countries with the world's lowest rates of maternal mortality--obstetricians remain in the hospitals, ready to jump in and treat serious complications. In those countries, it is the midwives who are out in the community, giving prenatal and postnatal checkups, and who are also in the hospitals as the only health professionals at the births of 80 to 90 percent of women who give birth without serious complications.
It cannot be overemphasized that American women's lack of access to quality, immediate obstetrical attention in the hospital is a major reason so many of them die unnecessarily during pregnancy and childbirth. Put differently, every one of the 15 countries that have lower rates of maternal mortality has universal healthcare coverage for all pregnant and birthing women (with no bureaucratic hoops to jump through), and all obstetricians are hospital-based, ready to care for these women should they develop complications. Furthermore, maternal mortality is not higher in those countries where there are large numbers of planned homebirths with midwives, because there is a system in place for transporting birthing mothers to the hospital, and for managing complications with mutual respect and collaboration between out-of-hospital midwives and hospital staff.
Data from many states in the US show maternal mortality to be four times higher for African-American women than for Caucasian women, and nearly twice as high for Hispanic women.20 The markedly greater risk that African-American and Hispanic women will die during pregnancy and childbirth is because this group includes a higher proportion of uninsured women, poor women, and women who go to hospitals with insufficient and/or poorly trained staff. In short, African-American and Hispanic women have less access to quality maternity care.
WHERE'S THE DATA?
Occasionally, a group of obstetricians tries to get a handle on maternal deaths in their locale. In a study of ten hospitals in the greater Chicago area, reported in 2000, the maternal mortality rate there was twice as high as reported by the CDC.21 Furthermore, on investigation of each case, these Chicago obstetricians found that 37 percent of the deaths were preventable. In the preventable cases, mistakes by doctors and nurses were determined to be the cause of death more than 80 percent of the time. Unfortunately, as is nearly always the case, the study made no attempt to determine how many of the deaths were related to obstetric interventions such as induction of labor, epidural block, and cesarean section. Lamenting that state maternal mortality committees, which carefully review all maternal deaths, are now largely defunct in the US, the study urged that these committees be revived to investigate causes and develop programs of intervention and education.
There is an urgent need for careful auditing of every single maternal death in the US, with a thorough analysis of causes--including underlying causes--and presentation of the results to the public. The Federal Aviation Authority could not set policies for safe flying if they were unaware of half of the planes falling from the skies, and couldn't retrieve the "black boxes" of most of those planes they knew had fallen. But this is analogous to the CDC trying to set policy for safe motherhood when they have limited data on maternal mortality. Federal policy prohibits the CDC from making surveys of what is happening in all states with maternal deaths.22 At the state level, there are enormous pressures from state and local medical societies to prevent adequate investigation of all maternal deaths.23 It's not easy to get information about the nearly 1,000 women who die each year in the US around the time of birth. To begin with, it's difficult to track maternal deaths, as death certificates in only 16 states include a question concerning whether the deceased had been pregnant within a year of her death. Although some states have regulations requiring that such deaths be reported, in no state can anyone, including scientists who want to study why these women die, gain access to information about individual cases of maternal death. If there is an investigation of a maternal death by a hospital, it is a longstanding policy that this happen behind closed doors, which protects the doctor and hospital involved. There is no public accountability. Public knowledge of pregnancy-related deaths does not fit well into any HMO or healthcare facility's marketing efforts. Employees of most hospitals know that their job security often depends on their willingness to keep silent, and the tribal loyalty of doctors is a powerful deterrent to accessing information. The CDC is doing everything it can to push states to improve their maternal death audits. It has had some successes, but today only a few states conduct thorough audits of all maternal deaths, and only one state, Massachusetts, has a law, passed after intense lobbying by consumer groups, mandating that newspapers report maternal deaths.
We know that at least half of these maternal deaths are not reported anywhere, that nearly all of these women die in the hospital, not at home, and that, with adequate medical attention, close to half of these women need not have died. The possibility of liability due to inadequate medical attention has doctors terrified of litigation, and reluctant to release information concerning maternal mortality. American women need to know that their chance of dying around the time of birth is increasing. They have a right to know why.
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