Ina May Gaskin on Maternal Death

Last year, Ina May Gaskin published an article in the Journal of Perinatal Education entitled “Maternal Death in the United States: A Problem Solved or a Problem Ignored?” Very well worth reading.

This stood out most to me:

A recent article in a major obstetrical journal revealed a 93% underreporting rate of maternal death in Massachusetts (Deneux-Tharaux et al., 2005). It is very likely that a similar rate of error could be found in the other 49 states. Not only do we have a comparatively high death rate for women from causes directly related to pregnancy or birth, we are almost certainly failing to gather most of the data. Because of this, we literally have no idea how many U.S. women die from pregnancy- or birth-related causes every year. The CDC’s most recent guess is that they could be missing as much as 2/3 of the maternal deaths (Johnson & Rutledge, 1998). How can we prevent those deaths that are preventable when we don’t really know why all of these women are dying? [emphases mine]

She then goes on to explain how easy it is for maternal deaths to be not reported — most easily if the person in charge of filling out the death certificate does not even know that the woman had been pregnant in the previous year, and/or if the state does not have a check-box for the M.E. or coroner or whoever fills out the death certificate to state whether or not the woman was pregnant in the preceding year.

As an addendum, I recently read this article which was disturbing — apparently an anesthesiologist had meningitis and passed it along to two patients through their spinal/epidurals, killing one. The article said it’s not uncommon for anesthesiologists not to wear a mask. That will probably change. I assume the anesthesiologist did not know he was sick or contagious; and that can happen — remember “Typhoid Mary” of the 1800s? — although she was never sick with typhoid herself, she passed it along to numerous people who died. Many diseases can be carried on or in a person without making the carrier sick. Or the disease can be not yet big enough in his system to make him feel sick even though he is. You can take steps to reduce or prevent infection.


6 Responses

  1. I cannot speak for other hospitals, but I know that a big investigation occurs everytime a Mother dies in the hospital from complications of birth. And that has happend once in my hospital in the last 5 years.

    My question is, why would a woman being pregnant a whole year from death indicate a complication of pregnancy? I can’t think of one instance where it would.

    Also I have never, never seen a Doc do an epidural or spinal without a mask. I wear a mask also and whoever else is in the room.

    I have to ask “where is Jacho for this kind of behavior? Where is the board of registration? ANd/ or the Department of public health?

    Is Ina May Gaskins trying to help the situation or just throw stones? I am curious. What is she doing to make birth in the hospital better? Again curious. We can’t just stomp our feet and say oh isn’t it awful. You find an injustice or a problem, you need to help fix it.

    I am constantly trying to help improve it so that is why I get a little pissed. But also nurses who see injustice or poor medicine have a duty to report these actions and use the chain of command if they do not get satistaction.

    I feel a post coming on.

  2. I am all for trying to lower the maternal mortality rate in the country. I happen to work in one of the states that has mandatory reporting and inquiries into any maternal death a year after giving birth. So I am part of the better reporting end of the spectrum, and I actually do the reporting for my hospital.

    One thing I just could not get over in the Ina May Gaskin’s article was the story about 28 year old “Angela” who died after childbirth. Ms. Gaskin made it sound like the hospital killed her. Correct me if I’m wrong L&D nurses, but this woman was high risk. She had 8 pregnancies in 11 years, with the last one being twins. This puts her at a pretty high risk for maternal hemorrhage. She was a Jehovah’s Witness and refused all blood products, yet she put herself at risk by becoming pregnant 8 times in 11 years. The first twin delivered vaginally, the second twin had a prolapsed cord and was sectioned. Ms. Gaskin then states the mom died from bleeding from the SURGERY! WTF! Wouldn’t she have died from refusing blood products? Wouldn’t she have died from having a hypotonic uterus from having 9 babies in 11 years? Then Ms. Gaskin goes on to say it could have possibly been prevented if the doc did a vaginal breech delivery on the second twin. I don’t get it. Should you be delivering a prolapsed cord vaginally?

    I am not trying to victim blame, but Ms. Gaskin (who I like BTW, and read her books during my own pregnancies), was very quick to lay blame on the hospitals. But, there has to be some patient responsibility here. Maybe Ms.Gaskin should have used a better example than the one she gave.

    As I side note, I have only seen one maternal death related to delivery in 16 years. The mom went into sickle cell crisis hours after delivery and bleed to death. Completely unpreventable.

  3. I wrote that JPE article, not to throw stones, but because I do want to remedy the situation. The trouble is, it’s not something easy to fix. It’s going to take a lot of people understanding it from a several different angles to create a system that works better for everyone. It’s not just a matter for individual caregivers or hospitals, although each of these plays a vital role.

    A year ago, I wrote another article, this time for Mothering magazine, with a slightly different focus (our lack of insurance-paid postpartum home visits). will take you there, or if you’d rather see it with the full layout and photos, you can get it from (“Masking Maternal Death”) In it, I relate some stories of women who died at home after hospital discharge because our insurance companies in this country don’t pay for routine postpartum home visits. It’s not just high-risk women who suffer from this policy, as the article points out.

    Pinky and realityrounds are lucky to work in hospitals (and states) which are actively working to keep maternal deaths at a minimum. I appreciate what you do, and I applaud everyone who works hard at their jobs for their efforts in this area. What I want people to understand is that our infrastructure is lacking in ways that leaves mothers, nurses, physicians, and midwives vulnerable. If I had the power to change everything myself, I’d certainly be doing that and spend my time making a happier quilt.

    I began the Safe Motherhood Quilt Project about a decade ago, because of the CDC’s own admission that it was having trouble collecting figures from the 50 states that were anywhere near accurate. See MMWR 1998;47:34,705-7. The situation has become worse since then, with the maternal death rate rising nearly every year since 2000. (7.5 per 100,000 birth in 1982; in 2005, 15.1 per 100,000). Shouldn’t we be getting at the reasons for this? This means that we have to think about all of the hospitals in the country and how data are gathered in every state. (I live in a state that still doesn’t follow the US Standard Death Certificate, which has 5 questions about a deceased woman’s pregnancy status. Why have a standard document if it’s not mandatory?)

    The first 20-block panel of the quilt (there are now 9 panels) was exhibited at a summit meeting held in 2001 in Atlanta sponsored by the CDC, ACOG and ACNM. Epidemiologists and several ob.gyns have told me that I should keep working on this, because they too see the problems that are bound to crop up when as many as 1/2 to 2/3 of the actual deaths are misclassified because of the ways death certificates are filled out.

    Most people (I’m not referring here to Pinky or realityrounds) think that maternal deaths happen only when women decide to give birth at home, as these are the deaths that are most likely to be reported in the media. Google “Misty Horner”, for instance. She belonged to a religious group in Missouri, whose leader (her brother-in-law) preaches that women should submit to their husbands and that going to a hospital indicates lack of faith in God. Her gruesome death (sorry, but I’ll spare you the details in this posting) resulted in a death certificate that stated that she died from “natural causes.”

    What I’m trying to point out with the project ( is that we in the US lack the infrastructure that physicians, nurses and midwives (and mothers) need to reduce the maternal death rate (now climbing and still underreported). We can’t learn how to prevent the preventible deaths if we don’t learn from past mistakes. To do that, we need complete ascertainment, and those states that still don’t have m/m review committees and that still don’t use the US Standard Death Certificate (such as my own state) need to conform to the standard.

    I wasn’t blaming the hospital or the doctor for Angela’s death. That doesn’t go to the root of our problem. One of things I was trying to point out is that insurance companies actually control what physicians are allowed to learn (and do). Bad idea. Learning the breech skills that every physician used to be required to learn back when I was a new midwife has been made very difficult. Of course, a doctor is going to be scared of assisting a vaginal breech delivery (even an easy one as Angela’s should have been) if they’ve never been taught the maneuvers.

    The one situation in which a prolapsed cord is not very dangerous is the one I brought up by telling Angela’s story. The baby’s feet and legs don’t pinch off the flow of blood through the cord that the presenting bottom or the presenting head would, so there should have been no reason to panic in this situation. That baby could almost certainly have been gently pulled out by the feet, and mother and baby both should have survived. My partners and I were taught this skill by a family physician back in the 70s. Nowadays, ob.gyn residents in the best teaching hospitals are rarely exposed to learning breech skills; most ob.gyns I know are frustrated by this, but so far haven’t been able to change the situation. Insurance companies have more power than they should, in my opinion.

    Sorry to be so long-winded, but I wanted you all to know that our maternal death problem has no easy solution, and we’re all going to need to help with it if we’re see improvement during our lifetimes. I’m sure that we can’t do better if we’re afraid to discuss it. I appreciate any help I can get with this.

  4. Ina May — thank you so much for weighing in. I am honored that you visited my blog. Please do not apologize for the length of your comment — I’ve read your two books, and wouldn’t mind reading more! 🙂

    Pinky, I can think of a reason why a death nearly a year after pregnancy would be considered maternal mortality, or at least a death sometime after 6 weeks past the end of a pregnancy — a maternal complication that requires readmittance to a hospital with serious treatment for something like infection. A friend of mine would have fallen into this category, had she died — she had a pre-term C-section (I think for pre-eclampsia, perhaps IUGR, maybe both, maybe something else as well — she was fairly overweight, so was at risk for pregnancy problems anyway, and either she or her baby was worsening, so she had a C-section), and the incision became infected. She was readmitted to the hospital a few weeks after birth and had to stay in for several weeks; she developed blood clots in her legs, and there was the possibility of death due to a dislodged blood clot traveling to her brain, heart, or lungs. I forget exactly the procedure she had, but they put something in her veins to catch a clot should it dislodge when they gave her clot-busting drugs. I think. It’s been several years, and I didn’t get the details first-hand, so am always skeptical of what really happened in cases like this. Whatever it was, it was more than 6 weeks past the birth when the danger was completely past, but it definitely would have been related to pregnancy or childbirth.

    One problem I’ve seen when looking at this topic is the many variations of definitions in this category — “pregnancy-related” refers to any woman’s death within a year of having been pregnant, regardless of how her pregnancy and her life ended — she could have had a deadly reaction to eating kiwi the day before her child’s first birthday, and it would count as pregnancy-related. Most other definitions are stricter, requiring that the condition be actually related to some medical condition of pregnancy or childbirth. One definition would allow for a maternal death to be counted for if her boyfriend murdered her for having (or refusing to have) an abortion, even though the death wasn’t technically due to a medical condition of pregnancy, but was definitely caused by the pregnancy (or the termination thereof), though not in a medical sense; and another definition would not allow such a death to be counted. But again, as Ina May pointed out, the only way we can know for sure is for every death to be accounted for, which would entail greater scrutiny when women of childbearing age die.

  5. Thanks to Ms. Gaskin for clearing up the Angela case she presented. (why do I feel like I was caught talking about the teacher behind her back at school? :). )

    Yes, I am lucky to work in a state with a very thorough maternal mortality reporting system. We are also actively working to decrease the maternal mortality rate. We have recently implemented a massive state wide initiative called the maternal hemorrhage project. Anyone (in hospitals) who attends deliveries is mandated to attended a 4 hour training session on preventing and treating maternal hemorrhage. As you know, maternal hemorrhage is the leading cause of preventable death for mothers. Our hope is that we can prevent mom’s from bleeding to death. If anyone is interested in the nuts and bolts of this training, they can contact me at Reality Rounds. I will speak to the state powers that be about how to share this initiative with other states.

  6. What a great discussion to have going. I love discussions that get to the meat of the issue and help expand all of our knowledge. What I personally thought Ina May was doing with this project was giving light to Maternal Death in general. I am also a midwife and can’t count how many times people say to me, “You mean people still die giving birth”. So many people think because we have modern technology and hospitals, death doesn’t occur. Its good to remind people it does. I am all for not placing blame on people and better yet to learn from our mistakes. Wouldn’t it be great if we could view each maternal death not under the guise of who will be sued or blamed but rather as a platform as to what we can do better next time.

    There is a fantastic set of videos at a website called where Ina May is featured talking about The Safe Motherhood Quilt Project and Preventing Loss. It is definitely worth checking out.

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