Reducing Maternal Mortality

A new law to help states investigate deaths from childbirth complications is a start, but experts say what is really needed is reducing C-section rates.

Women in the United States face a far greater risk of dying from childbirth complications than in many other wealthy countries.

Now the federal government has taken a step toward addressing the problem with the Preventing Maternal Deaths Act, signed in December, which will provide federal grants to states to investigate the deaths of women who die within a year of being pregnant.

A report released by the Commonwealth Fund in December that looked at 11 high-income countries found that American women have the greatest risk — 14 deaths per 100,000 births — of dying from pregnancy complications. The Centers for Disease Control and Prevention reports an even higher rate, 18 per 100,000.

Whereas other countries have worked to reduce the risk of maternal mortality in recent decades, including Sweden, where the death rate is 4 per 100,000 births, and England, at 9 deaths in 100,000 births, death rates in America have more than doubled in the last 20 years. The report also concluded that African-American women face similar rates of death to those of women delivering in developing countries, with rates of 40 per 100,000, according to the C.D.C.

Although cardiovascular problems account for the highest percentage of maternal deaths, complications linked to surgical deliveries are among the biggest factors. One in three American mothers delivers her baby via cesarean section, a rate that has increased more than 500 percent since the 1970s. While C-sections can often be lifesaving for both mother and baby, the surgery involved also carries serious risks.

“Caesarean sections are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons,” a 2015 report from the World Health Organization said. The report found that C-section rates higher than 10 percent were not associated with reductions in maternal and newborn deaths.

“We designed the birth environment to resemble an I.C.U., and 99 percent of American women deliver in environments that look like I.C.U.s, surrounded by surgeons,” said Dr. Neel Shah, an assistant professor at Harvard Medical School and the director of the Delivery Decisions Initiative at Ariadne Labs. “And we get a lot of surgery. So, if you look at it that way, it doesn’t really take a rocket scientist to put it together.”

In most countries in the Commonwealth Fund report, mothers deliver their babies in the care of midwives in more relaxed environments. Sweden has one of the lowest C-section rates, around 17.3 percent of all births, and one of the lowest rates of maternal mortality.

Dr. Shah conducted a national study on the variation of C-section rates by hospital. He found that the greatest predictor of a woman’s chances of having a surgical delivery had less to do with her health, the health of her baby or her doctor and more to do with the hospital she delivered in.

“Your biggest risk factor for the most common surgery is not your preferences or your medical risks, but which door you walk through,” said Dr. Shah.

According to a study published in Health Affairs in 2015, rates of C-section delivery at hospitals in the United States vary from 7 percent to 70 percent, which Dr. Shah said has created a buyer beware birthing environment — one that most women are unaware of.

In the United States, each state oversees its medical regulations, death certificates and the surveillances of health care practices, whereas in other countries, the national government regulates such things.

“If a state is doing something wrong and the citizens don’t have the ability to correct it,” said Representative Jaime Herrera Beutler, Republican from Washington, who was a co-sponsor of the legislation, “there’s an area for the federal government to be engaged and help shine the light.”

Marian Knight, professor of maternal and child population health at the National Perinatal Epidemiology Unit at the University of Oxford who is assisting efforts in the United States, said gathering data is an important step toward problem solving.

“For example, a woman dies from hemorrhage,” she said. “Has she died from hemorrhage because there was no blood available for her? Was it because somebody didn’t recognize early enough that she was bleeding? Is it because she was actually anemic throughout her pregnancy and nobody had thought to give her iron?”

In the 1940s, the United States and Britain had similar rates of maternal mortality. Today, Britain has significantly cut its maternal mortality rate, a success that is largely attributable to its willingness to study the problem and make calculated improvements, experts agree.

“We have virtually no deaths from pre-eclampsia and eclampsia-related disorders now, because of very comprehensive guidelines,” said Dr. Knight, citing some of the leading causes of maternal mortality in the United States, involving high blood pressure.

The C.D.C. estimates that 60 percent of current maternal deaths in the United States are preventable.

In Britain, Dr. Knight said, “We have very detailed guidelines about care, about management of high blood pressure conditions.”

In the United States, Dr. Shah said, “There are no protocols for how quickly we have to respond to a woman expressing concerns that could indicate she has a dangerous pregnancy-related condition.”

By comparison, he said, “If a middle-aged man walked into an emergency room with chest pain, there is a rule about how quickly they need to be seen,” Dr. Shah said. “And there’s a metric for how quickly you go from diagnosing a heart attack to going to a cath laboratory, which is the treatment. If a woman walks in with a pregnancy complication, there is no rule for how quickly they need to be seen. And there’s no metric for how quickly you need to respond with a solution.”

Ms. Herrera Beutler hopes the Preventing Maternal Deaths Act will reveal information that can be used to lay the groundwork for future recommendations that reduce these deaths.

“There probably will be some uncomfortable findings,” she said. “But, that’s kind of the point. We’re doing something wrong. We have to correct it.

All the experts agree that pregnant and postpartum women need to trust their instincts. If something feels off, trust yourself and get help.

“It is so important for families to realize, if they’re not getting an answer that reassures them 100 percent and they’re still concerned, they need to go find another person. Or go to the emergency department,” said Ginger Breedlove, a nurse and midwife from Kansas City, former president of the American College of Nurse Midwives. Dr. Breedlove was the editor of the book “Nobody Told Me About That, The First Six Weeks,” to help women better prepare for postpartum life.

Thinking of pregnancy as a marathon, rather than a sprint, is a common analogy used by birthing experts who point out that just as you’d never expect to run a marathon without researching, training and planning for the big day, the same should be done for birthing.

Given the huge variation in C-section rates per hospital, Dr. Shah suggests checking on your hospital’s rates, which are available by calling the facility or on sites like Leapfrog and rankings in Consumer Reports.

“You’d do the same thing if you were buying a car or a house, or something else really important,” Dr. Shah said. “The overwhelming majority of healthy women should be able to have normal, spontaneous, vaginal deliveries when giving birth — we have done a poor job communicating this and, in a world where the C-section always looks like the right answer, we have done a poor job enabling this.”

He added, “A world with more vaginal deliveries than we have now would ultimately improve the long-term health of both mothers and babies. That is the goal.”


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