Measuring Maternal Mortality Statistics
I write often here about the high rate of the U.S. maternal mortality and how physicians need to be able to see patients as often as needed in pregnancy, not according to some insurance notion of how often pregnant women should see their doctor. Evidence-based medicine is our emperor’s newest clothing. Just exactly how does evidence-based medicine get all that power? Well, you can blame statistics. Statistics can “prove” almost anything you want to “prove.” In 1954, Darrell Huff wrote the book, How to Lie with Statistics. Well, short of lying, he illustrates how you can at least obfuscate, bend the facts, misrepresent them, or have them be meaningless. With the information surfacing now about the suppression of safety data on COVID vaccines, the public is more aware of how scientific studies can be biased or simply skewed in favor of whatever organization is promoting the study. So I thought it was time to look at the source of the data used in the statistics on maternal mortality
While there is no shortage of maternal mortality statistics, it’s difficult to know exactly what the statistics mean and how to carve out a take home message. Many of these studies are done in three or nine states, so it’s hard to tell who was sampled and who is being omitted and what these omissions might mean. After all, you can lie by omission.
The most recent statistics from the Centers for Medicare and Medicaid Services (CDC) report that in Washington state from 2000-2008, the overall maternal mortality rate was 33 per 100,000 births, but what we don’t see the 69.9 per 100,000 births for black women. Nor will the statistics tell us that the death rate for African-Americans has been rising for 100 years.
Besides tracking maternal mortality rates in only some of the states, labeling maternal illness or injury is, believe it or not, subjective. For example, the injury to a patient might be called severe by one provider, but to another it might be called moderate and to another it might be called mild. We also can look at events indirectly like the hospital bill, length of stay, or the amount of antibiotics or blood transfusions given to a patient. Sending a sick patient home who then dies from hemorrhage, infection, or suicide is harder to classify as a maternal mortality.
State-based maternal mortality review committees, (MMRCs) are the gold standard in identifying and reviewing pregnancy related deaths. They are multidisciplinary teams. They review all available data, including prenatal records, hospital records, birth certificates, death certificates, and autopsy reports. The CDC has developed a standardized data collection system for state MMRCs called the Maternal Mortality Review Information Application (MMRIA).
According to the CDC article cited above, data collected from nine state MMRCs (not all 50 state committees) reported around 50 percent of all pregnancy related deaths were caused by hemorrhage, cardiovascular coronary conditions, cardiomyopathy, or infection. For non-Hispanic, black women, the most common underlying causes of death included preeclampsia, eclampsia, and embolism. We are not told why these nine states were chosen to be included in the study and why only nine states were included.
In my experience, preeclampsia eclampsia, hemorrhage, infection, suicide, or homicide should be never events. They should never occur.
Different causes of mortality occur at different times. Hemorrhage most commonly occurs the day of delivery or 1 to 6 days postpartum. Death by infection is most common 7 to 42 days postpartum. Amniotic fluid embolism occurs for the most part the day of delivery.
Obstetric hemorrhage was the cause of 11.5 percent of pregnancy related deaths from 2011 to 2014. Obstetric hemorrhage is preventable and should be a never event. Postpartum hemorrhage also accounts for severe maternal illness and injury, with blood product transfusions rising from 25 per 10,000 deliveries in 1993 to 122 per 10,000 deliveries in 2014.
Some of the increase in prevalence of postpartum hemorrhage is attributed to increasing rates of cesarean delivery. The cesarean rate has increased from 23 percent in 1996 to 33 percent in 2011. There has been no corresponding reductions in maternal mortality.
Obstetricians have known for decades that the internal fetal monitor increases the cesarean section rate and expense without any benefit to mother or baby. Illness, injury, and mortality for mothers associated with cesarean birth includes hemorrhage, infection and thrombo-embolism (blood clots to the lungs). The biggest problem, not included in these studies, is the illness and injury of a very real delayed recovery from a cesarean birth.
When faced with these high maternal mortality rates, it is popular to blame the patient for these rising numbers. Little attention is paid to the patient's poverty, less access to food, and especially, lack of access to medical care. And finally, no attention is paid to dismissiveness (denying a patient's concern is a problem) which many patients now experience.
The American College Obstetricians and Gynecologists (ACOG) has taken steps to reduce the number of cesarean section deliveries by creating guidelines for prevention of primary cesarean sections, although ACOG has been less enthusiastic about vaginal birth after cesarean section (VBAC). As I noted in a previous Substack article, it is important to be sure that bleeding is controlled when the cesarean section is done. Never close the cesarean section incision if you are worried about bleeding.
Infection should also be a never event in our country. Postpartum infection can be the result of a cesarean section because of excessive loss of blood supply (devascularization) in tissue, accumulation of blood, the result of an episiotomy, or tissue damage due to cautery.
The problem with an infected episiotomy is that they are hard to identify, and if they continue without effective treatment, either with draining a hematoma or giving antibiotics or both, there can be something called necrotizing fasciitis. Necrotizing means the death of tissue. Fasciitis is difficult to treat once it’s infected because fascia doesn’t have its own blood supply. If an infected episiotomy is not treated effectively and in a timely manner, death can occur.
Because non-medical causes, in particular unintentional overdoses, are important contributors to pregnancy associated mortality, we should not narrow the focus of maternal mortality on medical causes alone. Unfortunately, there are still obstetricians who don’t even want to count non-medical causes of maternal mortality and maternal injury or illness. We still have a long row to hoe relating to non-medical causes of maternal mortality and maternal illness or injury.
The Edinburgh Depression inventory is commonly used during and sometimes after pregnancy. It is designed to find moms and dads who are depressed. In my experience, the physician doesn’t need to be beaten over the head with a club to recognize that somebody is depressed. However, in order to recognize depression without a test, you actually have to sit down and listen to the patient and engage in a real conversation.
In my experience prenatal and postpartum visits are a great way to recognize depression. There is the almost magical opportunity to prevent eclampsia, manage preeclampsia successfully and steer patients in the right direction to avoid suicide, homicide, and drug overdose. Years ago, I started inviting husbands and significant others as well as children to prenatal visits. Since many behavioral problems revolve around practical issues such how to manage existing children and their relationships with parents, observation of these relationship dynamics allowed problems to be observed and postpartum problems could be avoided or mitigated early on.
At this time, the fastest and best way to infuse value into the obstetric relationships and to therefore decrease maternal morbidity and mortality is to have fewer restrictions on physician time and paperwork. Put simply, fewer electronic medical records (EMRs) and more time with patients. When the chart becomes more important than the patient, patient care suffers and as a result, so does the patient.
As physicians, we can choose to lower maternal illness, injury, and mortality, but choosing is more easily said than done. Training young physicians to make use of prenatal visits to mitigate or prevent the problems of preeclampsia, suicide, homicide, and drug overdose is a hard sell. Even if physicians want to use prenatal visits to prevent problems contributing to maternal mortality, they face the problem of being allowed to do so in an overly policed medical world. Yes, we are forever being told to do more with less and then being punished if we are prevented from providing the care to prevent problems. My personal physician has his nurses ask the stupid but required questions so when I get to see him, he has the information he needs to address the reason for my visit without EMR distractions.
In short, much could be accomplished in reducing maternal mortality rates if physicians were simply allowed to do our jobs without the political maneuvering of corporate medicine, insurance companies, and government medical policing agencies.
Thanks Liz, you have brought up many important points. I would not dare to speculate about the reason for female OBs raising the C-section rate. Most of us have known for many decades that the EFM increases the rate for C-sections and the cost of OB care without any benefit at all. EFMs are sometimes hard to watch. One must be very calm, confident, knowledgeable and compassionate to resist the temptation to do a C-section. There are two HUGE problems which you have NOT listed. The doc is the captain of the ship, but there is often nursing mutiny. While some some nurses listen and fall in line with the care being given, others are either incompetent or hysterical. If they are incompetent you can't trust their judgment, and if the are hysterical that spreads to the patient and her family. The MD can't have either situation. They are both intolerable. Nurses today are trained to sabotage care IF they think there is a reason to, but that is just my experience and might not generally be true. I have also worked with exceedingly good nurses...most of the time, but I've had some nurses who threaten to call in a doc who they know will do a C-section if I don't. That's also intolerable. My son, who is also an obstetrician has actually removed hysterical or sabotaging nurses...I have not, because one needs to understand that there is a great likelihood of working with that nurse again.
Yet another very real reason, seldom discussed, is that juries LOVE C-sections, as do liability insurance carriers. Their idea is that the doc has done everything that needs to be done or can be done to have a good outcome. So no matter the outcome the general idea is that nothing more could have been done, so a bad outcome is "forgiven" and penalties are a lot less. Then there is MD convenience. A C-section is more money and a lot less work. So rather than being up all night and all day, it might be easier under some circumstances to do a C-section at 0100 hrs (1:00am). My own C-section rate varies between 10% and 15%, but sometimes taking care of OB patients is very lonely. I take great pride in having a healthy vaginal birth.
And… the cesarean rate was 5% in 1970 - a 500% increase over about 50 years.
I read an interesting book on the history of cesarean by a medical historian (Jacqueline Wolf) who traces the explosion in the rate here in the US to some interesting factors, including the rise of female OBs and of course EFM; which lead to being sued for cat II tracings; which lead to cesareans done defensively to avoid being sued.
I often wonder if the widowers of accreta patients who bled to death in the OR could sue the OBs who roundly assured their wives cesareans have virtually no risks.