While unreliable data may call into question the accuracy of CDC statistics, it's likely that maternal mortality rates are rising in the U.S. From obesity to advanced maternal age, an increase in C-sections to unequal access to care, here’s a look at contributing factors and how we can manage them.
A study released last year by the California Department of Public Health maintained that the state’s rate of death among women giving birth had risen from approximately 8 to 14 per 100,000 between 1999 and 2008. This corresponds to data released by the Centers for Disease Control showing a rise in U.S. maternal mortality rates after the year 2000.
However, the CDC’s numbers are only currently compiled through 2007, and more than a few in the field say that official statistics are not definite proof of an upward trend in the number of fatalities. One who acknowledges the likelihood of an increasing problem while questioning the reliability of the statistics is Portland-based ob/gyn, Nicole Marshall, MD.
Marshall says that the American Congress of Obstetrics and Gynecology (ACOG) has reported that there were 548 such deaths in 2007, but she pointedly comments that there is “no good way to track the numbers. Each state has different procedures for death certificates and some include cases from up to a year from the time of delivery.”
Marshall cites several factors as possible causes of the increase. First, she says more and more women with congenital heart disease are living to an age at which they become pregnant. Second, there are more women with complications from placenta accreta – the attachment of the placenta to the uterine wall following birth – after Caesarian sections. Third, there are increasing numbers of obese mothers and these women face a greater number of risks, most especially of pulmonary embolisms. (Pregnancy and high estrogen levels are additional risk factors for pulmonary embolisms as they may place a patient in a hypercoagular state.) Fourth, as the average age of maternity increases, more underlying hazards for older mothers come into play, including co-morbidities like diabetes.
Marshall’s colleague, Mary Anna Denman, MD, points to placenta accreta as a particularly troubling issue, anecdotally observing that during her time as a clinician in training in Philadelphia she saw a jump from one such case per year to one every few months. These cases become increasingly likely when a third C-section has been performed, Denman notes, and still more frequent with each additional procedure.
For this reason, she says patients must be counseled before or after conception and informed about methods of bringing about a birth without a C-section even when the patient has had a prior one. Marshall also suggests that the nation should follow the recommendations of ACOG and the CDC and mandate a standard method of reporting on maternal mortality so that present trends can be more effectively evaluated.
One issue that leaps out with regard to current data is that of race. Black women are between three and four times as likely to suffer maternal mortality in the U.S. as White women. One study of maternal mortality in New York found that 82 percent of women who had died in the city from pulmonary embolisms after giving birth were Black but none were Caucasian.
Risks of maternal mortality rise dramatically for women over forty, too.
In third world countries, of course, maternal mortality remains a leading cause of death – as it was in the industrialized world throughout the nineteenth century and into the beginning of the twentieth. The World Health Organization reports that worldwide there were 287,000 case of maternal mortality in 2010 – 800 per day.
Denman says that in poor countries the problem is not only a matter of the absence of trained doctors but of trained lay people. Knowing how to massage the fundus so that there is a more active delivery of the placenta can play a critical role in prevention of the sort of undue bleeding that can prove fatal. In the same way, she notes, it’s important to get the drug pitocin, a single use of which reduces bleeding, to care facilities. In 2010, the CIA’s Fact Book reported that Chad, Somalia, the Central African Republic, Sierra Leone and Burundi all still had more than 800 maternal fatalities per 100,000 live births.
Here in the U.S. there is wide divergence of opinion about the role that access to care, poverty and level of education play in mortality rates. One recent New York Academy of Medicine analysis of state assessments questioned whether any of these are co-factors.
Plainly, more and better data are needed, and greater care must be taken in treating high risk patients, especially those who have had repeated C-sections.