First Do No Harm

I have wanted to do this post for awhile now. But everytime I sat down to type it, it just didn’t feel right. So I would do other things.

Well, in my book, I was reading about it, and it all just clicked. The missing link to my post. I was so excited I wrote 4 pages in my ‘doula’ notebook I bring to work. (This is what I write everything down in, then I transfer it to here to blog about).

So, here it is, my long awaited post. (Not that any of you really care haha).

The maternal mortality (deaths of mothers in childbirthing age from results of pregnancy or delivery or the postpartum period) has had no decline since 1982. From 1930 to 1982 it declined every year. And then it stopped. It stayed consistant at about 7.5 deaths for every 100,000 births. In 2000, it was at 11 in every 100,000 births.

In the US, if you are African American, you are actually 4 times more likely to die, and there is a 70% greater chance for hispanic women. And this is just in comparison to white women.

The CDC (Center for Disease Control) collects, analyzes, and publishes data and statistics of births and deaths. They say that the numbers are so underreported for maternal deahts that it is probably 1.3 to 3 times more than that of reported.

In Michigan, they reviewed their data, and found that their reported 7.6 should have actually been 18. That is more than 2 times as much!! And if one state found errors, I’m pretty sure all of them will.

The one problem with our country, is that the CDC researchers don’t have access to records, not all women that die have an autopsy, records are lost, the records are sloppy or inacurate, doctors are rarely trained in how to report it anymore, and they may be worried of medical/leagle concers, and the death might occur in early pregnancy and it is not linked.

Fewer than half of the states have committees for maternal morbidy and mortality (these are review committees that actually discuss and research why patients die, mainly pregnant women). In the rest of the states, there is no effort to see why women die. This stopped in the 1980s when fears of lawsuits were at a high level. It has never been picked back up.

In 2000, we were ranked 31st in the world for maternal mortality. Now we are 40th. And to make it worse, since ours isn’t accurate, we are probably a LOT worse. For a first world country, our stats suck.

CDC has stated that half of the deaths of the ones that were reported were preventable.

I have two examples of countries that have better mortality rates, and they have amazing systems that help with this.

Example #1: Germany and Austria

In these countries, an autopsy is required for every death of a woman of childbearing age. Each autopsy generates a record that respects confidentiality, but is provided for analysis, evaluation and feedback. We have no such requirements in our country.

Example #2: Wales, Scotland, and Northern Ireland

The Dept. of Health in these countries works with the Royal College of Obstetrics and Gynocology. Every 3 years, they analyze the data of the last 3 years and research every single maternal death, and then publish a book on their findings. It is sold in bookstores so if you wanted to lower your risk, you can see what the most prevelant cause was in the last 3 years. The women in this country are considered so important, the government actually mandates this study of the 110 deaths to prevent further deaths to women in their country.

The CDC has been urging states to put a checkbox on death certificates that would ask if the woman was pregnant within the year before her death. 2 states have this. 15 have boxes refering to 3 months after pregnancy. The rest have absolutely nothing, so they miss at least 10% of deaths.

In the US, we have a group called the Safe Motherhood Initiatives – USA. The ACNM, ACOG*, MANA, APHA, the March of Dimes, etc, are all members of this group. (*The ACOG pulled their membership in 2002). They work together to raise awareness, set priorities, stimulate research, mobilize research, provide technical assistance, and share information. They have two main groups: The Model Program where they recognize states and hospitals with great statistics and those working to prevent maternal death, and the Safe Motherhood Quilt Project, which recognizes women who have died since 1982.

There are 3 main risk factors I just want to discuss briefly.

1. Cytotec: This has been known to have a side effect of Amniotic Fluid Embolism. It also led to hundreds of dead babies and a dozen or more dead mothers from uterine rupture in the 1990s. It is not meant for VBAC, so please don’t take it!! And despite all the risks and issues, doctors still use it to augment labor.

2. Amniotic Fluid Embolism: This is a rare mysterious thing. Textbooks say it is 1 in 50000 to 80000 births. The ‘official’ death rate is 1 in 5000, but this cannot be true. That would be over 300 dead women in one year. It only kills about 30-100. It has a 50% mortality. It happens during or just following labor and in about half of the reported cases, it is associated with excessively strong, closely spaced contractions from inductions. It happens when part of the aminotic fluid gets into the maternal blood stream, and it gives her either a stroke or a heart attack. It happens so fast, and you never know it will be coming, that you have to be treated within minutes.

3. Single Layer Suturing: In the 1990s they thought that it would be cheaper, faster, and give women a shorter hospital stay if they sutured the cesarean incision with one layer instead of two. It did do all those things. But since it is only in one layer, the uterus is thinner than it should be, so your risk of placenta percreta (placenta grown over and through the scar, sometimes attaching to your other organs) is more likely. In a 3 year time span, one San Diego hospital saw 30 cases of this extreemly rare condition. Once they stopped doing the single layer suturing, it completely went away. It is sometimes the only one taught in some schools, and so if you don’t want this, please put in your birth plan that if you have to have a cesarean, you would like to have double layer suturing.

The Hippocratic Oaths first line says, “First Do No Harm.” As I see the death rates of our country, I don’t think this is being upheld in obstetrics. We are the most advanced country on the planet, and yet we have one of the worst maternal mortality rates of the first world. This should not be acceptable.

You need to report maternal deaths. You shouldn’t be finding loopholes so you don’t get in trouble. These are people. Human lives. And these women are treated like their death doesn’t matter. No one researches why she died. No one does anything about it to stop it from happening again.

And the thought of this just makes me so sad. What would you do if it was your sister, your wife, your daughter? How would you feel if the system passed over her death and then handed you the bill?

We need to find a way to make this better. These are lives of mothers. Where will our country be in 100 years if the death rate keeps getting worse and worse?

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2 Responses

  1. Great post, Kayce! My sister (pregnant with her baby #4 and planning her 4th NCB) just wrote a research paper on this exact subject for a college project and you hit it right on the head. Scary…

  2. Very interesting post. It's fascinating to look at the history of medicine and see how or even if it's been a benefit. I have my doubts about obstetrics, and I feel medical interventions are over-utilized. I hope that changes someday.

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