The Ultimate Price of Unnecessary Interventions: Part 2

This week, Dr. Marsden Wagner, a well-known perinatologist, perinatal epidemiologist, and birth outcome advocate, addresses the seriousness of maternal mortality in the U.S. He illustrates the crucial need for expectant mothers to know the risks associated with common birth interventions, in order to empower healthier birth outcomes.

Every year, the equivalent of three jumbo jets full of women — that is nearly 1000 of our sisters, daughters and mothers — die before, during or after giving birth. And, around half of these deaths could have been prevented with access to better-quality maternity care, based on information from the Centers for Disease Control (CDC).

Most frightening, data suggests an increase in recent years in the number of women in the U.S. dying during pregnancy and around the time of giving birth. Public health officials have always known maternal mortality in the U.S. to be underreported — but the evidence suggests a recent rise: “The actual pregnancy-related death rate could be more than twice as high as that reported,” cites the CDC.

Why are more American women dying before, during and after giving birth?

It is difficult to pinpoint the causes, because current data provides only the leading or immediate cause of death, and not the underlying causes. But if we look at the six leading causes of pregnancy-related deaths in the U.S., three causes (hemorrhage, anesthesia and infection) are often the result of interventions. So, for example, although the immediate cause of death is frequently given as hemorrhage, in many cases the hemorrhage is associated with cesarean section.

There is strong research, both in the U.S. and in Great Britain, showing that the maternal mortality rate for cesarean section is four times higher than for vaginal birth. And, the rate of women dying is still twice as high when it is a routine or “elective” cesarean section without any emergency. With at least twice as many cesarean sections as are necessary done today in the U.S. — around 30 percent of all births, rather than the World Health Organization’s suggested 15 percent, unnecessary cesarean section is undoubtedly a significant part of the reason for more and more women dying around their childbirth in the U.S. With all of the statistics taken into account, we can calculate that a cesarean section rate of 30 percent means a minimum of 600,000 unnecessary c-sections each year (more than 1640 every day), leading to a minimum of 60 avoidable maternal deaths each year (more than one each week).

Another cause of the rising pregnancy-related deaths of women in the U.S. is the markedly increasing use of epidural block for normal labor pain. Epidural block for normal labor pain carries a scientifically-proven increased risk the woman will die, and “anesthesia complications” is documented by the CDC as one of the leading causes of maternal mortality in the U.S.

There is good reason to believe that other technologies also contribute to the rising number of women dying during childbirth in this country. Data from the Centers for Disease Control (CDC) shows that between 1990 and 2000, the number of women given powerful drugs to induce their labor had gone from 10 percent of all births to 20 percent. During this same 10 years, the drug cytotec became the most popular drug for such inductions of labor — in spite of having never been approved by the FDA for induction of labor, and the best scientific opinion in the world (Cochrane Group) strongly advising against cytotec induction. A more recent survey, completed in 2006, shows that 44 percent of births in the U.S. have pharmacological induction and augmentation. New scientific data shows that for women with a previous cesarean section, cytotec induction causes a marked increase in uterine rupture, a catastrophe that can result in the death of the mother, the baby — or both. Nearly all women who survive will never be able to have another baby.

Is the excessive use of birth interventions and technologies killing more women and babies than it saves?

This possibility has a reasonable scientific explanation, since caesarean section, epidural anesthesia and drugs to induce labor all have been used more and more in the U.S., and scientific evidence proves these interventions can result in the death of a pregnant or birthing woman.

The U.S. spends twice as much as any other country on maternity care, and yet is at least ranked 15th in the world for the pregnancy-related deaths of women. How do they do it in the 14 countries losing fewer pregnant and birthing women than we do? In every industrialized country in Europe (including the countries with the world’s lowest maternal mortality rates), obstetricians are hospital-based specialists who do not attend normal pregnancies and births, but remain in the hospital to “jump in” and treat the serious complications. Meanwhile, it is the midwives who are out in the community giving prenatal and postnatal checkups, and also in hospitals as the only health professional at the births of more than 80 percent of women without serious complications during pregnancy. The U.S. may want to reconsider the required presence of obstetricians at most normal births, as midwives are more than prepared to handle them.

There is an urgent need for careful audit of every single maternal death in the U.S., with a thorough analysis of causes — including underlying causes — with feedback to the doctors and hospital involved in the death, and presentation of overall results (no names of patients or doctors, of course) to scientists and the public. The FAA couldn’t set policies for safe flying if they were unaware of half of the planes falling from the skies, and couldn’t get to the black box of most of those they knew fell. But this is the situation with the Centers for Disease Control and Prevention trying to set policies for safer maternity care when they have limited data on pregnancy-related deaths of women.

Whether it is because of bureaucratic red tape, political motivations, or some other reason, federal bureaucratic orders prohibit the CDC from making surveys of what is happening in all states with maternal deaths. And at the state level, there are enormous pressures from medical societies to prevent adequate investigation of all maternal deaths. Regardless, it is imperative that practitioners and scientists concerned about the safety of women during pregnancy and childbirth have access to complete information on every case in which a woman dies from pregnancy-related causes. In addition to professionals, American women need to know that their chance of dying around the time of birth is increasing — and they have a right to know why.

Marsden Wagner, MD, is a perinatologist and perinatal epidemiologist, and an outspoken supporter of midwifery. He was director of Women’s and Children’s Health in the World Health Organization for 15 years. Marsden travels the world to talk about improving maternity care — including addressing the appropriate use of technology in birth and utilizing midwives for the best outcomes. His books, “Born in the USA,” “Creating Your Birth Plan,” and “Pursuing the Birth Machine,” are invaluable for anyone involved in birth. Marsden also raised four children as a single father.

Do you feel the risks associated with birth interventions are made clear to expectant mothers?

Mother’s Advocate wants to facilitate a safe and supportive community for birth advocates, educators, and expectant mothers. You’re welcome to share any thoughts about or experiences with maternal mortality.

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