Maternal Mortality in the United States: WHERE
ARE THE DOCTORS?
-by Marsden Wagner, MD, MSPH
The reason the maternal mortality fell in the
US this century was because of the advent of antibiotics
and blood transfusion more than anything else.
There is simply no scientific evidence to prove
the falling mortality was because birth was moved
into the hospital.(1) The evidence does show that
as long as there is a system in place to transport
women in labor to a facility within 30 minutes
where there are antibiotics, blood transfusion
and cesarean section capacity, there should be
very little maternal mortality.
Maternal mortality is quite different from perinatal
mortality and infant mortality. The latter two
are much influenced by socioeconomic factors while
maternal mortality is much more directly a function
of the quality of the health care available. If
midwives (traditional, direct entry, or nurse-midwives)
are trained to know the signs of serious complications
and have the means of transport, there is no need
for a doctor at the site of primary care of pregnant
and birthing women who have had no complications.
But at the site of the place where the woman is
transported, there is need for a doctor who has
surgical skills and, ideally, obstetrical skills,
to manage the complications.
There are at least two reasons why the US is
16th in the world in maternal mortality and both
reasons have to do with access to quality care.
First, the large numbers of women without health
insurance in the US have to jump through so many
hoops to get care that there is likely to be delays
in receiving the care and this can be a disaster.
Furthermore, the women receiving publicly funded
care go to hospitals which are overcrowded and
with overworked doctors without sufficient training
(ie interns and residents). The delays and crowding
and lack of skill of doctors all can lead to maternal
mortality.
The second reason the US does poorly in maternal
mortality is a huge irony. US doctors scream that
women need to be in hospital at the time of birth
and yet the doctors who need to treat them are
NOT in the hospital but in their offices doing
prenatal checkups and postnatal checkups on healthy
women. So when the woman who is in the hospital
(or transported to the hospital) needs urgent
attention for developing complications, the obstetrician
is not there and must be called and may come too
late.
In every industrialized country in Europe (including
the countries with the world's lowest maternal
mortality rates), obstetricians are hospital based
specialists who remain in the hospital and are
there to jump in and treat the complications.
Meanwhile it is the midwives who are out in the
community giving the prenatal checkups and postnatal
checkups to women without complications. It cannot
be overemphasized that this lack of access of
American women to immediate obstetrical attention
in the hospital, for whatever reason, is a fundamental
difference between maternity care in the US and
the rest of the world and is the reason for the
poor US maternal mortality. Put differently, the
countries which do better than the US in maternal
mortality all have universal health care coverage
for pregnant and birthing women (without any hoops
to jump through) and all have hospital based obstetricians
ready to care for these women.
Midwives are crucial to these systems in other
countries by being skilled and alert for the early
signs of maternal complications, referring themquickly
and continuing to provide support to these women
even when they are receiving treatments from the
obstetricians. Maternal mortality is not higher
in those places where there is planned home birth
with an experienced midwife because there is a
system in place to transport and to manage complications.
Data from many States in the US show the maternal
mortality to be at least four times higher for
African American women. The graph shows this for
New York State for one recent year, based on data
provided by the New York State Health Department.
This markedly higher maternal mortality among
African American women in the US is because this
group has more uninsured women, more women in
hospitals with desperate situations of understaffing
and care from not fully trained staff -- in other
words, these women have less access to quality
care. This situation will not be solved by simply
putting African American women into private care
systems or managed care systems because the latter
systems are doctor centered, and doctors do not
know how to communicate with these women. The
result is little prenatal care and poor access
to all maternity care due to poor communication.
And of course there is then victim blaming, saying
it is the stupid women's fault when it is the
system's fault.
Perhaps the most alarming data are those showing
a rise in the maternal mortality rate in the US
in recent years. ( 2, 3) We have always known
maternal mortality in the US to be underreported
-- in one State in one year 5 of the 16 maternal
deaths had not been reported.(4) But the latest
evidence suggests a recent rise; "The actual
pregnancy-related death rate could be more than
twice as high as that reported for 1990."(3)
Because the data give only the leading cause of
death and not underlying causes, it is quite possible
that the leading cause of death, namely hemorrhage
is, in many cases, hemorrhage associated with,
for example, cesarean section. There is good research
showing the maternal mortality rate for cesarean
section is four times higher than for vaginal
birth(5) and is still twice as high when it is
a routine repeat cesarean section without any
emergency.(6) With all the unnecessary cesarean
section done today in the US(1), this could be
part of the problem of rising maternal mortality.
Another possible cause of the rising maternal
mortality rate in the US is the epidemic increase
of epidural anesthesia for labor pain. This is
notfar fetched since epidural block carries a
maternal mortality risk and, for example in Great
Britain where there is a careful audit of all
maternal deaths including underlying causes, epidural
block is one of the reported causes. Again, the
fact that the woman who died received an epidural
block for labor pain may not appear in the maternal
mortality statistics. There is an urgent need
for careful audit of all maternal deaths in the
US with a thorough analysis of causes, including
underlying causes, and presentation of results
to the public. American women need to know that
their chance of dying around the time of childbirth
is increasing and they have a right to know why.
References
1 Wagner, M 1994 "Pursuing the Birth Machine"
ACE Graphics, London,Sydney
2 Obstet Gynecology 1996 Vol 88, pp 61 - 67 McCarthy
M 1996 US maternal death rates are on the rise.
3 The Lancet, Vol 348, pp 394 Rubin et al 1981
Maternal death after cesarean section in Georgia.
4 American Journal of Obstet and Gynecol. vol
139, pp 681 - 5 Petitti, D et al 1982 In hospital
maternal mortality in the United States.
5 Obstet. Gynecol vol 59, pp6 - 11 Petitti, D
1985 Maternal mortality and morbidity in cesarean
section.
6 Clin Obstet. Gynecol. vol 28, pp763 - 8
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