Thursday, March 25, 2010

Why Are Moms Dying In Labor?

Over the past decade, the U.S. maternal mortality rate has nearly doubled, with about 500 women dying of pregnancy-related complications each year. That's a tiny percentage of the 4 million American women who give birth annually. But what's shocking is that among industrialized countries, the U.S. ranks an abysmal 41st on the World Health Organization's list of maternal death rates, behind South Korea and Bosnia-yet we spend more money on maternity care than any other nation.

Amnesty International has designated the U.S. maternal mortality rate a human-rights concern. This month, the organization called on President Barack Obama to address the crisis, noting that two to three women die of pregnancy-related complications in this country every day, as we move further away from the government’s goal of 3.3 deaths per 100,000 live births. The health-care reform bill signed into law by Obama Tuesday could help, as it requires insurance companies, for the first time, to cover prenatal care and some childbirth costs.

Skeptics attribute the rise in the maternal mortality rate to better reporting of maternal deaths—and it’s true that over the past decade, states have revised death certificates to better flag pregnancy-related mortalities. Yet review committees estimate that better reporting only accounts for about 30 to 40 percent of the rise.

More likely, the maternal death rate is going up due to a complex cocktail of factors—causes that reflect a changing population, disparities in poor women’s access to health care, and even Americans’ reliance on cutting-edge medicine. Here are seven explanations for the unsettling rise:

  1. A Skyrocketing Caesarean Rate

    Before C-sections became as safe and standard as they are today, pregnant women had few options if they found themselves in an emergency situation; aside from metal forceps, doctors lacked tools to get babies out quickly, which often led to tragedy.

    Yet as lifesaving as C-sections can be, an astounding one in three American women now give birth surgically, up from one in five a decade ago. Healthy women who give birth surgically are 80 percent more likely to be re-hospitalized than healthy women who give birth vaginally; they’re also four times more likely to die. Hemorrhage, infection, and pulmonary embolism are all more common following a surgical birth.

  2. More Obese Moms

    As the obesity epidemic swept the country, more overweight women have gotten pregnant and given birth, despite serious risks. One in five women in the U.S. are now obese at the beginning of their pregnancy, according to the Centers for Disease Control. Obese women are more likely to develop hypertension, high blood pressure, and diabetes during pregnancy, which can lead to preeclampsia and other fatal conditions. Preeclampsia is responsible for about 18 percent of maternal deaths in the U.S., and over the past decade, the incidence of the condition rose by 40 percent.

    Labor can also be more difficult for obese women, as soft tissue can impede delivery. Obese women are also at greater risk for delivering bigger babies, needing C-sections, and developing postpartum infections and heart problems.

  3. Disparities in Access to Care

    As economic disparities in the U.S. health-care system grew wider over the past several decades, fewer women got the family planning, prenatal, and postpartum care they needed. Currently, one in five women of childbearing age are uninsured, Amnesty International reports. In most states, poor women do qualify for Medicaid once they become pregnant; the problem is, six weeks after giving birth, most of these women are dropped.

    From there, a dangerous cycle can begin: If a woman has risk factors going into her first pregnancy—say, diabetes or hypertension—the conditions often get worse through the process. She can’t afford the medical care to treat her conditions. Nor can she afford contraceptives, so she often ends up getting pregnant again, this time facing even greater risks. By the time she’s back on Medicaid for her next pregnancy, she’s in big trouble.

    The good news is that the new health-care reform legislation will expand access to Medicaid for about 15 million people, and will include prenatal and maternal care in the basic package of services private insurers must cover.

  4. Unnecessary Medical Interventions

    Like C-sections, medical innovations such as drugs to induce labor and devices to monitor fetal heart rates can be lifesaving, but they can also lead to complications in healthy women. When an intervention is unnecessary—performed out of convenience or protocol—the harms can outweigh the benefits.

    In many developed countries, induction is used as a last resort, but in the U.S., hospitals induce or accelerate roughly 40 percent of labors. These drugs, in turn, can create more aggressive contractions, which increase the risk of uterine rupture. A woman who is induced is also more likely to end up needing a C-section.

  5. Older Moms

    As the rate of childbearing women over 40 has risen, so has the maternal mortality rate. Moms over 35 are more likely to develop gestational diabetes and other complications; they’re also more likely to have twins or other multiples, thanks both to biology and the wonders of fertility treatment—and multiple births are far riskier than single births, for both mother and babies.

    But Elliott Main, a San Francisco-based OB/GYN and principal investigator of the California Maternal Quality Care Collaborative, says that most American women who die in childbirth are in their twenties or thirties.

  6. Poor Birth Education

    Maternity-care advocates stress that as birth has become increasingly medicalized, American women have become surprisingly uneducated on the topic.

    In particular, low-income women with limited access to health care may not be aware of the risks of taking certain medications or engaging in certain behaviors during pregnancy. Similarly, advocates point out that with C-sections and interventions on the rise, women feel less empowered to take control of their birth experience—they don’t always know their options or trust their instincts. They must rely completely on hospital staff, who are often overworked, exhausted, and juggling many births at once.

  7. Complacency

    Despite the rising maternal mortality rate, pregnancy-related deaths in this country are still rare. Most doctors and nurses will go their entire career without encountering one. Yet as a result, many hospitals have become complacent that mothers just don’t die anymore. Hospitals need to act proactively, paying closer attention to changes in women’s vital signs.