Maternal Death – the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. (WHO)
This is a subject no one really wants to talk about. Mothers die. Mothers die in pregnancy and childbirth and just after birth. The weight of that reality is just so heavy and heart breaking. In our current birth culture, fear reigns. However, fear reigns without reason or knowledge of what really needs fear. And of course – all of us hope to Birth Without Fear. And so, I approach this subject with a heavy heart but hope as well.
Where Does It Happen?
In short, it happens everywhere. However, some areas are more prone than others. This can be due to lack of care – think of sub-Saharan Africa or rural villages in some undeveloped countries. Maternal death in those areas is an unfortunate fact of life (though organizations are striving to change this).
But apart from the “obvious” places, where do you suppose it happens? Perhaps war-stricken places, or those places without advanced medical facilities? Would it surprise you to know that the United States has one of the highest maternal mortality rates in the developed world?
Yes – you read that right. Our current maternal mortality rate is 21 deaths per 100,000 live births as of 2010 (WHO). This rate went up from 2005 (18/100,000). The 2010 “Healthy People” Goal for the United States was set at 4.3/100,000 - we grievously missed that by a large margin. The 2020 goal is 11.4/100,000, which would only be a 10% decrease from what the US considers to be its current statistic (the 12.7/100,000). I find it interesting that the government decided after they missed the 2010 goal that maybe they should try less to save mothers, since their efforts before had no effect and saw a rise in deaths.
The WHO number is adjusted from the number reported by the CDC (12.7/100,000) – this is because the United States does not have a universal system of reporting maternal deaths and the CDC admits that our numbers are drastically under reported due to this lack of uniformity in reporting (See this CDC publication, specifically page 20). Currently, only 25 states make it mandatory to state that a death was pregnancy related on the death certificate – and even this method is questionable due to lack of doctor training in filling out certificates and the great fear of litigation in the medical system. Ina May Gaskin writes about the lack of reporting here.
Other countries have much better standards of reporting. The “gold standard” is considered to the be reporting system in place in the United Kingdom. The UK ensures that not only is every death reported, but they also compile the deaths and reasons for them in a report every three years. This report is available to the public and the locations and names of the deaths remain confidential. This allows the nation and the nation’s health workers to look at the issues without fear of litigation – meaning they have no reason to hide maternal deaths.
To provide some perspective, here are the rates of some other countries:
- Australia: 7/100,000
- Brazil: 56/100,000
- Denmark: 12/100,000
- Germany: 7/100,000
- Israel: 7/100,000
- Japan: 5/100,000
- Netherlands: 6/100,000 – note that about 30% of all births here are at home.
- United Kingdom: 12/100,000
As you can see, we are rather behind many other countries – and don’t worry, I am going to come back to Brazil and why I included that statistic which is very high for an industrialized country (as is the USA’s number).
Why Are Mothers Dying?
This question is hard to answer since as mentioned above the reporting methods are varied and not always followed. We do know that some deaths are simply not preventable, this is just a fact of life. However, looking at the much lower numbers in other comparable nations we know that unpreventable deaths are not the reason for the very high numbers in the United States.
We know that it is not from lack of care in general – reports show that over 99% of all women in the United States receive prenatal care. However, we have to look at the level of care women are receiving. We have to ask, does a 5 minute rushed visit with your actual doctor count as adequate care? Does more diagnostic testing equal better care? Does spending more money equal quality care? (The numbers say no – we spend more than any other country in the world on birth).
We see a HUGE disparity in death rates in regards to ethnicity. An African-American woman is 3.3 times more likely to die in childbirth than a white woman. This is simply not acceptable in a country as advanced as ours, and one that is supposedly equal. Midwives such as Jennie Joseph are helping to implement ways to combat this disparity – her creation of The JJ Way is an example of how we can work to correct this travesty.
A big question that needs to be asked in the United States has to do with who is providing this care – care that is obviously not saving as many mothers as it should. In the United States women overwhelmingly see Obstetricians. While Obstetricians are amazing for complicated and high-risk pregnancies, they don’t have much training in plain old boring pregnancy and birth.
A majority of the time pregnancy will proceed in a normal fashion, and birth will follow in the normal fashion. When we use care providers who are trained to search for problems there tends to be a trend of finding problems whether they exist or not, or whether they are actually emergencies or not. As the saying goes, “Give a boy a hammer and he will find something which needs to be hammered.”
We can see that in countries were the majority of care is given by midwives (or that country’s equivalent care provider) the maternal mortality rate is lower (and the infant mortality rate is lower as well). The United Kingdom is a great example of this. They are comparable to us in many ways (general health and population structure), and yet consistently have better maternal outcomes. And they use the midwife model of care in which all women start with midwives and only transfer if problems arise. (Note that a woman can opt for an OB to start with, however most do not).
Now for the elephant in the room: the United States cesarean rate. Our current cesarean rate is 32.8% (CDC). Yes – basically 1/3 of all babies in the US are born through cesarean. So are 1/3 of all US women somehow “broken”? Unable to birth? Producing massive or stubborn babies? NO - of course not. If 1/3 of all women in the US were “broken” then those numbers would be reflected all over the world, and the statistics show this is not the case. In the same vein, we are not producing massive babies either – in fact the average birth weight has gone down as the cesarean rates have gone up (and is independent of that rise or that of induction).
Remember when I said I would come back to why I included Brazil? Brazil has a rather good medical system and is considered a developed country, so why the massive maternal death rate (56/100,000)? Take a look at their cesarean rate – 52.3%. Yes – over 50%. Brazil is an interesting case since most of these surgeries are elective, even for the first time mothers. The fear of childbirth is so deeply engrained in Brazilian culture that women jump at the opportunity to have a cesarean and avoid labor totally. A vaginal birth is seen, culturally, as something only poor women do because they can not afford a cesarean.
That mortality rate could be the United States’ future. We see a fear of birth in the US, and a huge cultural love of telling horror stories about labor and birth. We see more interest in elective cesareans (though elective first time cesareans are not significantly altering the rates). As VBACs are “allowed” in fewer and fewer places and malpractice issues continue to rise we see more and more women forced into surgeries they do not want or need. Our rates are heading right up to that of Brazil’s, and our maternal mortality rates will be sure to follow. A Cesarean increases the risk of death significantly in comparison to vaginal birth.
In comparison, the rate of cesarean in the UK is 25%, the Netherlands has a rate of 14%. As I stated before, the UK has 12/100,000 rate and the Netherlands 6/100,000 – rather interesting that as the rate of cesarean is almost half in the Netherlands and their rate of maternal death is also half that of the UK. While in some countries a higher cesarean rate does not correlate to a significantly higher mortality rate, those countries with very high rates of cesarean typically have higher (or rising) mortality rates.
We also cannot forget postnatal care. The postpartum period is one that needs care just as much as the prenatal time period. In the US, typically a woman is seen in the day or two after birth, at two weeks or so, and then at six weeks…and that is about it. This is simply not enough during this time of life when hormones are changing, the body is attempting to heal from creating another life, and things like retained placenta or clots can cause major issues. A much better plan of postpartum care must be put in place.
What Can We Do?
Be Educated. That is the number one thing you can do to not only help yourself have a safe pregnancy and birth, but also to help the women around you as well. When you learn, share the information. Break down the myths that pervade this culture – break down the assumption that VBACs are dangerous, or that “big babies” need surgical birth. Share the studies and articles you read.
Be Fearless. Help to eradicate fear of birth. Can birth end in tragedy? Yes. Unfortunately is does happen. But with proper and evidence-based care we give ourselves and our babies the best chance. Share the positive birth stories you hear. Share your positive birth. How does this help? It helps women to not fall into a fear based decision that increases her risks of complications – namely induction and cesarean. When a woman can start her pregnancy and birth journey from a positive place it gives her more space for growth and research. Absence of fear is not ignorance of risks – it is not being beholden to the fear of risk.
Those two things hand-in-hand – education and fearlessness – can go a long way towards helping this mortality rate go down. An educated woman is better able to avoid situations or care providers that increase her risks, and a fearless woman is better able to stand up for herself and decipher what is really in need of intervention and what is not without cultural fears clouding her view. Lets do our part to save mothers.