The ability to protect the health of mothers and babies in childbirth is a basic measure of a society's development. Yet every year in the U.S., 700 to 900 women die from pregnancy or childbirth-related causes, and some 65,000 nearly die -- by many measures, the worst record in the developed world.American women are more than three times as likely as Canadian women to die in the maternal period (defined by the Centers for Disease Control as the start of pregnancy to one year after delivery or termination), six times as likely to die as Scandinavians. In every other wealthy country, and many less affluent ones, maternal mortality rates have been falling; in Great Britain, the journal Lancet recently noted, the rate has declined so dramatically that "a man is more likely to die while his partner is pregnant than she is." But in the U.S., maternal deaths increased from 2000 to 2014. In a recent analysis by the CDC Foundation, nearly 60 percent of such deaths are preventable.While maternal mortality is significantly more common among African-Americans, low-income women and in rural areas, pregnancy and childbirth complications kill women of every race and ethnicity, education and income level, in every part of the U.S. ProPublica and NPR spent the last several months scouring social media and other sources, ultimately identifying more than 450 expectant and new mothers who have died since 2011.The list includes teachers, insurance brokers, homeless women, journalists, a spokeswoman for Yellowstone National Park, a cofounder of the YouTube channel WhatsUpMoms, and more than a dozen doctors and nurses like Lauren Bloomstein. They died from cardiomyopathy and other heart problems, massive hemorrhage, blood clots, infections and pregnancy-induced hypertension (preeclampsia) as well as rarer causes. Many died days or weeks after leaving the hospital. Maternal mortality is commonplace enough that three new mothers who died, including Lauren, were cared for by the same ob/gyn.The reasons for higher maternal mortality in the U.S. are manifold. New mothers are older than they used to be, with more complex medical histories. Half of pregnancies in the U.S. are unplanned, so many women don't address chronic health issues beforehand. Greater prevalence of C-sections leads to more life-threatening complications. The fragmented health system makes it harder for new mothers, especially those without good insurance, to get the care they need. Confusion about how to recognize worrisome symptoms and treat obstetric emergencies makes caregivers more prone to error.
The DOH examined Lauren's records, interviewed her caregivers and scrutinized Monmouth's policies and practices. In December 2012 it issued a report that backed up everything Larry had seen first-hand. "There is no record in the medical record that the Registered Nurse notified [the ob/gyn] of the elevated blood pressures of patient prior to delivery," investigators found. And: "There is no evidence in the medical record of further evaluation and surveillance of patient from [the ob/gyn] prior to delivery." And: "There was no evidence in the medical record that the elevated blood pressures were addressed by [the ob/gyn] until after the Code Stroke was called."The report faulted the hospital. "The facility is not in compliance" with New Jersey hospital licensing standards, it concluded. "The facility failed to ensure that recommended obstetrics guidelines are adhered to by staff."
Among our key findings:More American women are dying of pregnancy-related complications than any other developed country. Only in the U.S. has the rate of women who die been rising.There's a hodgepodge of hospital protocols for dealing with potentially fatal complications, allowing for treatable complications to become lethal.Hospitals -- including those with intensive care units for newborns -- can be woefully unprepared for a maternal emergency.Federal and state funding show only 6 percent of block grants for "maternal and child health" actually go to the health of mothers.In the U.S, some doctors entering the growing specialty of maternal-fetal medicine were able to complete that training without ever spending time in a labor-delivery unit.
Greater prevalence of C-sections leads to more life-threatening complications.
I'm on my phone and don't have access to it but I recentlty saw a blurb from a conference for OB/GYNs that showed a drastic difference in # of C sections between hospitals in a way that suggests whether you have one depends more on where you go rather that your actual situation. We still have doctors who are maybe too quick to go to C sections, which come with their own set of risks.
At 36, Shalon had been part of their elite ranks -- an epidemiologist at the Centers for Disease Control and Prevention, the preeminent public health institution in the U.S. There she had focused on trying to understand how structural inequality, trauma and violence made people sick. "She wanted to expose how peoples' limited health options were leading to poor health outcomes. To kind of uncover and undo the victim blaming that sometimes happens where it's like, 'Poor people don't care about their health,'" said Rashid Njai, her mentor at the agency. Her Twitter bio declared: "I see inequity wherever it exists, call it by name, and work to eliminate it."Much of Shalon's research had focused on how childhood experiences affect health over a lifetime. Her discovery in mid-2016 that she was pregnant with her first child had been unexpected and thrilling.Then the unthinkable had happened. Three weeks after giving birth, Shalon had collapsed and died.
Underneath the numb despair was a profound sense of failure -- and an acute understanding of what Shalon's death represented. The researcher working to eradicate disparities in health access and outcomes had become a symbol of one of the most troublesome health disparities facing black women in the U.S. today, disproportionately high rates of maternal mortality. The main federal agency seeking to understand why so many American women -- especially black women -- die and nearly die from complications of pregnancy and childbirth had lost one of its own. Even Shalon's many advantages -- her B.A. in sociology, her two master's degrees and dual-subject Ph.D., her gold-plated insurance and rock-solid support system -- had not been enough to ensure her survival. If a village this powerful hadn't been able to protect her, was any black woman safe?
The disproportionate toll on African Americans is the main reason the U.S. maternal mortality rate is so much higher than that of other affluent countries. Black expectant and new mothers in the U.S. die at about the same rate as women in countries such as Mexico and Uzbekistan, the World Health Organization estimates.What's more, even relatively well-off black women like Shalon Irving die or nearly die at higher rates than whites. Again, New York City offers a startling example: A 2016 analysis of five years of data found that black college-educated mothers who gave birth in local hospitals were more likely to suffer severe complications of pregnancy or childbirth than white women who never graduated from high school.
Weathering can have particularly serious repercussions in pregnancy and childbirth, the most physiologically complex time in a woman's life. Stress has been linked to one of the most common and consequential pregnancy complications, preterm birth. Black women are 49 percent more likely than whites to deliver prematurely (and, closely related, black infants are twice as likely as white babies to die before their first birthday). Here again, income and education aren't protective. The effects on the mother's health may also be far-reaching. Maternal age is an important risk factor for many severe pregnancy-related complications, as well as for chronic diseases that can affect pregnancy, like hypertension. "As women get older, birth outcomes get worse," Lu said. "If that happens in the 40s for white women, it actually starts to happen for African-American women in their 30s."This means that for black women, the risks for pregnancy likely start at an earlier age than many clinicians -- and women-- realize, and the effects on their bodies may be much greater than for white women. This doesn't mean that pregnancy should be thought of as inherently scary or dangerous for black women (or anyone). It does mean, in Geronimus' view, that "a black woman of any social class, as early as her mid-20s, should be attended to differently" -- with greater awareness of the potential challenges ahead.
Until recently, much of the discussion about maternal mortality has focused on pregnancy and childbirth. But according to the most recent CDC data, more than half of maternal deaths occur in the postpartum period, and one-third happen seven or more days after delivery. For American women in general, postpartum care can be dangerously inadequate -- often no more than a single appointment four to six weeks after going home. "If you've had a cesarean delivery, if you've had preeclampsia, if you've had gestational diabetes or diabetes, if you go home on an anticoagulant -- all those women need to be seen significantly sooner than six weeks," said Haywood Brown, a professor at Duke University medical school. Brown has made reforming postpartum care one of his main initiatives as president of the American Congress of Obstetricians and Gynecologists.
Between 2004 and 2014, the percentage of rural counties that lacked hospital obstetrics (OB) units increased from 45 to 54 percent, according to the university's Rural Health Research Center, one of 10 such centers funded by HRSA nationwide.Financial pressure, insurance problems and doctor shortages forced more than 200 hospitals to close their birthing units, leaving 9 percent of U.S. rural residents with no in-county services. In all, the study found, 179 counties are affected.The finding comes at a time when nearly 80 small, rural hospitals have closed their doors completely due to similar constraints."Having access to OB services in rural communities is crucial for women and children, and this study demonstrates the need to continue to identify alternative health care models that can be used to provide these services," said Tom Morris, Associate Administrator of the Federal Office of Rural Health Policy. Over 28 million reproductive-aged women live in rural U.S. counties.
The closure of Providence's labor and delivery unit, as well as two other recent changes to maternal services in the District, has disproportionately affected low-income women -- including in some of the poorest areas of Washington, where access to care already was scarce.In August, the city shut down deliveries at United Medical Center in Southeast Washington over several critical mistakes, including failing to take necessary precautions to prevent an HIV-infected mother from passing the disease to her baby.The Northeast hospital closed its obstetrics unit Oct. 16, including all prenatal care, in what was largely seen as a cost-saving measure. In August, the city shut down deliveries at United Medical Center in Southeast Washington over several critical mistakes, including failing to take necessary precautions to prevent an HIV-infected mother from passing the disease to her baby.Now no labor and delivery services exist on the east side of the city, leaving "a maternity care desert," as the D.C. chapter of the American College of Nurse-Midwives called it.
Yet for many women in the U.S., the ACOG committee opinion notes, the postpartum period is "devoid of formal or informal maternal support." This reflects a troubling tendency in the medical system -- and throughout American society -- to focus on the health and safety of the fetus or baby more than that of the mother. "The baby is the candy, the mom is the wrapper," said Alison Stuebe, who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine and heads the task force that drafted the guidelines. "And once the candy is out of the wrapper, the wrapper is cast aside."
Under the new ACOG guidelines, women would see their providers much earlier -- from within three days postpartum if they have suffered from severe hypertension to no later than three weeks if their pregnancies and deliveries were normal-- and would return as often as needed. Depending on a woman's symptoms and history, the final postpartum visit could take place as late as 12 weeks after delivery and ideally would include "a full assessment of physical, social, and psychological well-being," from pain to weight loss to sexuality to management of chronic diseases, ACOG says.In another significant change, ACOG is urging providers to emphasize in conversations with patients the long-term health risks associated with pregnancy complications such as preterm delivery, preeclampsia and gestational diabetes. "These risk factors are emerging as an important predictor of future [cardiovascular disease]," the recommendations state. " ... [But because these conditions often resolve postpartum, the increased cardiovascular disease risk is not consistently communicated to women."