Maternal Death is No Mystery

The news of a young woman’s pregnancy related death is always sad. What’s even sadder is that the news isn’t new. Tori is the latest news story on maternal death, but there have been others. Propublica reported on Lauren, a neonatal intensive care nurse, who died in 2017 from a stroke after giving birth. In 2020, Dr. Chaniece Wallace, in her fourth year of residency in pediatrics, died two days after giving birth to her daughter. We’re seeing this news more, not just because it is gathering attention, as it should, but also because, unfortunately, these deaths are actually becoming more common. The U.S. maternal mortality rates are increasing.

Overall, the maternal mortality rate is 25/100,000, but for Native Americans and Native Alaskans the rate has increased from 30/100,000 to 45/100,000. For Americans of color, the rate has increased from 45/100,000 to 75/100,000. No other developed country has maternal mortalities in these numbers. Indeed, the Scandinavian countries have 2 to 3 maternal mortalities per 100,000 births. The U.S. on the other hand, is on a part with Iran for maternal mortalities.

According to the CDC, four in five of these deaths are preventable.  So what’s happening?

The articles about Tori’s death contain precious little information about why Tori died. According to what was reported, Tori was 35 or 36 weeks pregnant and in labor, with her baby nearly born when she died. With preeclampsia and high blood pressure, the pushing during delivery can cause strokes from the high blood pressure.

Another large question remains about the weight of the baby, reported to be 1.8 pounds. If this information is accurate, this baby was way too small for its gestational age. Babies at 35 or 36 weeks should weigh 5 3/4 to 6 3/4 pounds. A baby weighing 1.8 pounds is more the size of a 25-week baby, not a 35 or 36 week baby. There is no explanation why Tori’s baby was 10 weeks behind schedule in weight or whether Tori was seeing a doctor.

The is issue of trust is raised. According to one article, Tori didn’t like hospitals and maybe she didn’t like doctors either. Based upon what was reported in the news, it is possible she had had no prenatal care. There are many good reasons to be suspicious of medical care today, and most reasons have nothing to do with doctors. They are systems problems. But the systems problems are blamed on doctors.

With “team” care, the patient has no opportunity to build a trusting relationship with the doctor the patient sees on every prenatal visit and the doctor who will deliver the patient’s baby.  

Did Tori seek medical care? If she were seeing a doctor, her baby’s weight could have been recognized and corrective action taken. Maybe Tori’s blood pressure was too high? For whatever reason, Tori appears to have not sought needed medical care, according to the news reports. This could have been a result of her lack of trust in available healthcare.

While the CDC has now indicated that approximately 80 percent of pregnancy-related deaths can be a prevented, the CDC does not say how that should be done. Neither has the American College of Obstetricians and Gynecologists developed a concrete plan for lowering maternal mortality.

The state of California has developed a plan using a maternity care team of five members. This team approach has reduced the California maternal mortality rate somewhat. So, how does the team help reduce maternal mortalities? A team of five people commit to doing what’s needed in labor and delivery at the right time for the right reason for each patient? In an emergency, at least one of the team of five should be able to be present with the patient.

Trust and the feeling of safety which grows out of that trust, is the fundamental basis between a patient and doctor in any care setting, but in pregnancy a patient’s ability to see the same doctor on every visit and for delivery is the foundation of a safe pregnancy. A woman shouldn’t have to show up at the hospital to deliver her baby only to be faced by a doctor she has never met.

I practiced obstetrics for approximately 45 years and delivered about 6000 babies without any maternal mortalities. I’ve also never had a patient seize or have a stroke related to pregnancy. I have much experience avoiding the complications of preeclampsia. How did I do that, you ask? I saw most of my patients for every prenatal visit and did my own deliveries. I made plans to manage preeclampsia during pregnancy and delivery, as well as managing very high blood pressure in labor and delivery. With teams, there is confusion about who is in charge. I saw my patients with every visit and we all knew where the buck stopped. My patients trusted me, worked well with me, and felt safe under my care.

When it comes to managing preeclampsia effectively, I have one Golden Rule. Every high blood pressure matters and sometimes necessary changes in the pregnancy course need to be made. I didn’t learn this in medical school, but instead learned this in my own practice after residency. This was in contrast to what I had learned in medical school where nurses keep checking a high blood pressure until a low blood pressure is found and then record the lowest blood pressure, leaving the high blood pressures unrecorded or ignored. In this way, preeclampsia seems to be surprising and mysterious, but from 50 years of experience I know that preeclampsia is neither surprising nor mysterious. Preeclampsia often raises its ugly head as a slow increase in blood pressure of as little as ten points which may well go unnoticed by doctors, possibly because no one is looking for it.

The whole point of prenatal care is to detect and manage preeclampsia effectively and to avoid eclamptic seizures, strokes, and death. Start with monitoring slow increases in blood pressure and treating hypertension effectively, and you will not find preeclampsia surprising or mysterious. Now, if only those studying how to reduce maternal mortality could grasp this concept.