A news story came out yesterday that inspired me to vary from my original plan of introductory blog posts. It is just too important and interesting to pass up. Plus, as a new blog, I want to give you a picture of what kind of posts you are going to see here. I’m not so interested in celebrity pregnancies, though I am pleased when they say positive things about birth. I am very interested in public health. I’m interested in the trends and patterns of health outcomes and how that information can help both individual women and broader communities.
Yesterday the San Francisco Chronicle published an article about the increasing maternal death rate for California women. The story is not a shock to most birth professionals, as people who have been paying attention have been watching the creep of the statistics for years. Ina May Gaskin, professional midwife extraordinaire, has been talking about maternal death for over a decade. California is doing a better job of counting all the complicated ways that maternal death can be calculated and with over a half million babies born in California each year, many in public health look at the trends in the California population as a harbinger of national changes.
But while it may not be a shock, the numbers are sobering. The Maternal Mortality Rate (MMR) in California has climbed from 7.7 per 100,000 births in 1999 to 16.9 in 2006 (it takes a long time to process public health data, so that is the last year they have calculated). The national numbers are also disturbing if less extreme – 9.9 per 100,000 in 1999 to 13.3 in 2006. Risks for non-Hispanic Black women are four times greater than other population groups, with California numbers of 28.7 per 100,000 for 1999 and 54.9 for 2006. (Health disparities like this one are a huge issue that I’ll address in another post, it deserves its own discussion)
Since I don’t want this to be a fear-mongering blog let me just clarify the MMR for you a bit. While any deaths are tragic and the goal of reducing maternal deaths is an important one, remember that the rate of 16.9 is spread over 100,000 live births. That means the percentage of women dying is 0.0169%. Very, very small.
So the reason this is an important topic is not because “Oh no, be afraid, you could DIE if you have a baby, pregnancy is SO dangerous!!!” Please no. This is an important topic not because of the risk to one woman as an individual but rather the growing risk to women as a population. When a negative outcome is trending up, it means that something is changing to make pregnancy and birth more risky.
What is it that is making birth more risky to women? The official answer at this point is “We don’t know.” Certainly we know the causes of death but what is the cause of the cause and why they are increasing, that part is still unknown.
We do know that the demographic of women having babies has changed over the last 20 years or so. Childbearing women are, in general, older and more likely to have overweight. But we also know that while these changes indicate an increased risk, they cannot account for all the change in the MMR. According to the Chronicle, “Changes in the population - obese mothers, older mothers and fertility treatments - cannot completely account for the rise in deaths in California, said Dr. Elliott Main, the principal investigator for the task force.” So this isn’t one that is going to be blamed on the women. Whew!
The data in the article was compiled by the California Maternal Quality Care Collaborative and released in a newsletter-type publication by an accrediting body for hospitals. Last week the Joint Commission published a Sentinel Event Alert that highlighted the report on MMR increases by the CMQCC. The Joint Commission reported data from several sources including theCDC and the Hospital Corporation of America.
Additionally, the Sentinel Event Alert stated recent studies had found that 28-50% of maternal deaths were preventable. HCA found that “better individual care” is a key to preventing those preventable deaths. The most common preventable errors that were identified in the HCA study were:
1. Failure to adequately control blood pressure in hypertensive women
2. Failure to adequately diagnose and treat pulmonary edema in women with pre-eclampsia
3. Failure to pay attention to vial signs after a Cesarean section.
4. Hemorrhage after a Cesarean section.
And this is not just about preventing death. In the Joint Commission alert Dr. Callaghan from the Centers for Disease Control and Prevention reminded us that it isn’t just about the 0.0169% risk, “For every woman who dies, there are 50 who are very ill, suffering significant complications of pregnancy labor and delivery.” For most women, this isn’t about life or death, but it is about improving your quality of life and reducing your risk of getting a dangerous infection or hemorrhaging and needing a blood transfusion.
HCA also found that “The data showed the individual causes of death to be very heterogeneous [with only one cause] amendable to nationwide systematic prevention efforts.” That means that the circumstances of each woman’s case were unique, that there isn’t a specific change that can be implemented to prevent all their deaths.
So what can be done? Well, if there isn’t one systematic prevention effort to make a difference, then it will have to be many small prevention efforts that keep women from becoming very ill and dying as a result of the care they receive (or don’t receive) during labor and birth.
Remember that you are a part of your care, that being treated as an individual, not as a statistic can have a significant impact on the way your labor & birth unfold.
What I am talking about here is reducing medical errors. The good news is that this is something that women can do something about. Something that patients are encouraged to be a part of. According to the Agency for Healthcare Research and Quality, the number one thing that you can do to prevent medical errors is “Be Involved in Your Health Care”. Ask questions, insist on answers, when you have concerns, don’t let yourself be dismissed.
There is a lot you can do before you go into labor as well. Hire a midwife or doctor you trust – someone you can ask hard questions of and get satisfying answers. Know what to expect – learn about hospital procedures and standards of care from your midwife or doctor. Take an independent childbirth education class so that you can triangulate your information and learn what is necessary for good care and what is just hospital procedure. Hire a doula who can help you have the best communication possible with your hospital care team. Get educated, make a plan and get support.
Remember that you are not a statistic so there is no reason that you should be accept being treated like one.
