U.S. Maternal Mortality Rate Continues to Climb
When experts talk about maternal mortality in the U.S., we constantly hear the the problem is getting worse. Agreed. The problem is getting worse and will continue to get worse for a long time. Why? Because the solutions to the problem interfere with insurance and corporate medicine profits. As a result, collecting and studying data is all the further we have gotten in solving the problem of increasing maternal mortality.
I am fortunate to be an old doctor who practiced the way I grew up, when the patient-doctor partnership was important. With my pregnant patients, I enjoyed having mom, dad and children come to the office where we talked about almost nothing or anything. “Just chewing the fat,” as we used to say on the ND countryside. This was not a waste of time. By listening, I could learn a great deal about how things worked at home for my patients. I could glean mountains of information about my patients and their families very quickly provided the atmosphere remained relaxed, non-threatening, and inviting.
In contrast, I cannot get much information from somebody who is partially covered up in a paper gown sitting in a cold room perched on the end of the cold, hard exam table. As a matter fact, all this person is probably thinking about is getting her clothes back on and getting out of the room. Many nurses believe presenting a patient this way moves patients through the office quickly. It does. But patients can’t wait to get out of the paper gown and leave as quickly as possible. I once had a new nurse inform me that we would save so much time if she could undress them before we talked. That nurse was gone the next day. Listening actively is the most important part of the exam and visit.
The problem with medicine today is that physicians no longer see patients in an environment which is conducive to just talking, and of course, just listening. That’s where you get your information. So hurrying patients through their office visit creates a clinic environment which prevents the doctors from knowing what they don’t know. In medicine, we used to say that the physicians who didn’t know what they didn’t know was a definition of incompetence.
In an office conversation with a patient’s family, I learn how the relationship between the couple works. With this information, I can better prepare the family for pregnancy, birth, and going home with their new baby. So who reflects the most resistance to change as opposed to who is most willing to change so the family dynamics work better? Who is going to give up first for the sake of preserving the peace and order of the family?
Years ago, a 100-year-old man walked into my office from his home. I listened as he talked. His wife had died a few years earlier and we were talking about her. He said she was the little girl who grew up half a mile down the road. So he had always known her. He said there is an old German saying which translates to “The smart one gives up first.” It’s also important in the relationship to figure out who is the “smart one.”
Since many suicides, homicides, drug overdoses, strokes, death from infection or hemorrhaging occur after delivery (postpartum), ignoring the postpartum preparation that must occur during pregnancy is a large missed opportunity to introduce safety into a pregnancy and prevent maternal mortalities.
The real problem that so-called experts need to worry about is the amount of time and commitment we have allotted to prenatal and postpartum care in the hospital, learning to anticipate what will happen at home and preparing families for the changes that will come. Insurance companies have been reducing maternity-related hospital care for years. We are paying for that curmudgeonly care with the illness and death of young moms, dads, and kids. Insurances and big business medicine like to point out the money saved by denying care, but they don’t provide any data on the costs of care when patients become sicker for lack of care and wind up back in the hospital. I sincerely doubt that in reality any money is saved that way. In fact, I suspect denying prenatal and postpartum care to women and their families costs much more in the long run as sick and sicker patients are readmitted to the hospital.
The six or 12-week rule is a fine example of denying needed care. Insurance and the American College and Obstetricians and Gynecologists (ACOG) support one postpartum visit. The sole purpose of this one postpartum visit is to document that the patient’s uterus has shrunk back to its normal size. Attention to the “behavioral” aspect of pregnancy healthcare has to start before families leave the hospital postpartm. That 6 or 12 week postpartum visit is way too late to be useful for behavioral health issues. The first postpartum visit should be no more than one week after leaving the hospital.
The second most common cause of maternal death is bleeding from complications of preeclampsia and infection. These deaths are preventable if physicians spend enough time monitoring their patients. According to National Public Radio (NPR), many of these deaths result from misreading the symptoms and missing the opportunity to prevent deaths. Many times patient complaints are considered unimportant and are ignored or misread by the medical staff. Some call it dismissiveness.
The CDC has something they call near-death and severe maternal morbidity (Illness) and they estimate that for every death there are 30 to 50 near deaths. Of course, nobody knows for sure because there is no ICD-10 code for “near death” and how would one even know. To avoid or prevent these deaths, patients need to be told what to look for and then they must be taken seriously by the doctor or midlevels when they call the doctor’s office or show up in the emergency room.
Complications of preeclampsia, including severe hypertension, liver capsule rupture, and stroke can be avoided. Like behavioral health, which is neither mysterious nor surpising, preeclampsia is also neither mysterious nor surprising. In my experience, the first sign of preeclampsia is one elevated blood pressure. The present standard of care for measuring blood pressure is to recheck a high blood pressure several times until one lower pressure is found and that is the blood pressure reading which is recorded. It may experience, it’s not the blood pressure going back down that’s important, but that first bood pressure reading that is high. Remember: treat that first high blood pressure. This is the way to avoid eclampsia (seizures) and permanent injury or death.
There appears to be some women who are at higher risk for suicide or homicide. The key to having adjustment problems postpartum is the desire to have nothing change. This is not a conscious decision. The key to successfully navigating postpartum is to understand that there will be necessary changes, but that changes can actually improve your life, not ruin it. Research indicates there are three groups of women who seem to be at higher risk for postpartum adjustment problems:
Highly educated, Caucasian women.
infertility patients (could be hormone fluctuations or unrealistic expectations or a bit of each).
Moms who have obsessive-compulsive disorder (OCD). In general, OCD people want to control everything. It’s very difficult to control babies. Everything about a newborn requires spontaneous, committed, and unplanned attention.
So yes, while it is possible to decrease all causes of maternal mortality and illness, we are presently making few or no changes in that direction because no one will take on changing the system. There are a number of important players involved here. Certainly insurance companies have their share of blame because they are the ones who restrict the amount of healthcare received.
Charging less for care is very difficult when you’re working for a large clinic or hospital because owners and administrtators need to change their mindset from making money any way possible to trying to provide needed care. As I have done in the past, I have chosen to ignore insurances and not get paid for some visits and procedure in order to give my patinets better care. For example, rather than charging $5000 for a hospital induction I charged $125 for my clinic induction, which was actually safer too because I was always present.
And then there’s the notion that CEO’s actually earn their 12 million dollars per year salaries.
Then we have big Pharma, who always make a lot of money from almost anything they do. Once BigPharma runs a generic drug through FDA testing, BigPharma radically raises the cost of the medication. For example, Depo-Provera went from $12.00 a dose to $250 a dose once DepoProvera, which had been around for years, ran the drug through the FDA approval process. A removable prostaglandin for cervical ripening went from 50 cents a dose before FDA certification to $350.00 per dose.
Elizabeth Rosenthal in her 2017 book An American Sickness provides a detailed examination of how our healthcare has been taken over by the moneymongers who are not going to let go of the reins to their cash flow.
“High-priced healthcare is America’s sickness and we are all paying, being robbed. When the medical industry presents us with the false choice of your money or your life, it’s time for us all to take a stand for the later.” (p. 239)
She tells us it’s up to patients to press for the changes needed in the system:
“…we [patients] will need to change our ways too. We must become bolder, more active, and thoughtful about what we demand of our healthcare and the people who deliver it. We must be more engaged in finding and pressing the political levers to promote the evolution of the medical care we deserve.” (p. 328)
Thirty years ago when I wrote Modern Medicine: What You’re Dying to Know, I had advised patients that the only recourse to what was happening with the hijacking of their healthcare system was to talk to their senators and representatives. I agree with Elizabeth Rosenthal that this is the only way to take back our healthcare system and stop the delusion by congressional representatives that “the market” will fix our healthcare system.
So, it is within our grasp to make effective, reasonable, and sustainable changes for the better. We know what needs to be done. We also know the big players in the high cost of healthcare are not going to voluntarily fix the problems they are causing. These problems play a big part in our ever-increasing maternal mortality rate because many women have no access to the healthcare they need. As Ewe Reinhardt said, “It’s the cost, stupid.”
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Note: The illustrations in this post are by Trygve Olson who illustrated our book Modern Medicine: What You’re Dying to Know