Maternal Mortality in NYC

I can scarcely get my thoughts together after reading this article:

In 2008, black women in New York City experienced 79 maternal deaths per 100,000 live births compared to 10 white maternal deaths per 100,000 live births, and a national rate of 13 maternal deaths per 100,000 live births, according to the latest data available.

I’m utterly speechless.

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World Maternal Mortality Declining!

Now this is wonderful news!! Full article here.

From a study posted in the Lancet, a number of reasons were given for the improvement: lower pregnancy rates in some countries; higher income, which improves nutrition and access to health care; more education for women; and the increasing availability of “skilled attendants” — people with some medical training — to help women give birth. AIDS still remains a big cause of maternal death, however, with the article saying that what is needed in these areas is more drugs to fight HIV/AIDS rather than more skilled attendants.

But here’s the part I don’t quite understand: “[S]ome advocates for women’s health tried to pressure The Lancet into delaying publication of the new findings, fearing that good news would detract from the urgency of their cause, Dr. Horton said in a telephone interview.” Yeah, I understand that these people may fear that the decline in deaths will lead to increased apathy about the problem, but, as Dr. Horton said, “…my feeling is that they are misguided in their view that this would be damaging. My view is that actually these numbers help their cause, not hinder it.” In fact, I can see that if there were no change in the rates, that there could be increased apathy, because “nothing we’ve tried so far works, so why bother?” Exactly!

Yet part of me wonders if there is a darker reason for these unnamed “advocates” to delay publication. They apparently wanted the publication to be delayed until after a couple of big meetings with some powerful people (and lots of money) to put towards maternal health. Why? Maybe it’s because I’m optimistic, but I would think that this news would be a big boon to them, as they could say, “Well, now we know what works, so let’s do this and this and this.” After all, isn’t it part of evidence-based medicine to look at what studies say and go from there? This may not be purely “medicine” (higher income and better female education don’t exactly fall under those categories), but it is at least evidence-based funding so that we can get the most bang for our buck. The negative part of me thinks that these people wanted to delay it possibly because the results didn’t match what they expected, and they wanted to push alternative methods for reducing maternal mortality that have not been proven, but which might line their pockets a bit more. I don’t know how exactly all this funding stuff works, but if you have ten different people or organizations each pushing a different way of improving maternal mortality, but only five of those ways have been shown to actually work, then it is likely that the other five unproven (or perhaps disproven) methods may get their funding reduced or even eliminated. If you’re one of those five whose money is about to be cut, don’t you think you’d want to delay the news that what you’re pushing doesn’t work?

Shame on those who wanted to delay the publication of this research! It shows what works, and should be a boost in confidence — it’s exciting that we can actually say that what we’re doing is helping; now let’s redouble our efforts to keep the trend going in the right direction. And if these people had high and pure motives for their desire to delay publication… I don’t know — get a dose of sunshine, watch Pollyanna, or do something to lift your spirits and restore some positivity to your life. At the least, hire a better spin doctor so that you don’t come off looking like a first-class woman-hating jerk, trying to suppress this wonderful news.

“Safety net” or trampoline?

What if there were no C-sections? What if that simply wasn’t an option? Do you think doctors would practice differently? I do.

No one discounts that C-sections can be beneficial, saving the lives of mothers and/or babies. However, our country is currently experiencing its highest C-section rate, with maternal mortality increasing right alongside the C-section rate (not saying necessarily that it’s causative; however, if these C-sections were life-saving to the mother, one would expect the maternal mortality rate to be decreasing or at least staying the same), and perinatal mortality not doing that much better either. [If you want some state-by-state breakdowns, Jill at the Unnecesarean has compiled several, with the most recent one being California.] Most people agree that the C-section rate is too high, and could safely be brought down. There are many factors going into the increase incidence — some of which may be valid and beneficial reasons, but others that are not.

Carla Hartley recently wrote a note in which she cleared up some misconceptions that have apparently been told about her and “what she believes.” Among other things, it appears that some have said that she thinks midwives ought not take Pitocin with them to home births (for postpartum hemorrhage). She said (paraphrasing), “But what if you as a midwife had no Pitocin in your bag? Would that change your practice style? Knowing that you didn’t have that as a backup, would you be less tempted to act in a way that might cause a postpartum hemorrhage?” That’s food for thought.

Taking this out of the birth realm, we see that when there is a safety net, it changes people’s behavior — how many of you would walk across a tightrope without a safety net below? Some do; but far fewer people would risk crossing if they knew that there was a real risk of death, as opposed to a slight risk of death and a real likelihood of safely bouncing on a net if they fell. There are always adventurous people, daredevils, pushing the envelope — doing things that are dangerous or downright deadly, just because they can. But most people only do something if they think or know that there is a reasonable chance for them to succeed and come back alive.

In another, much more mundane vein, we see banks and other companies loaning people money for various reasons, including education, buying a house, buying a car, etc. The more collateral you put up, the more they’ll lend you; the more you earn, the more they’ll give you; or if the government guarantees that they’ll pay the loan should you default or die, they’ll gladly loan you the money you ask. Why? There really isn’t that much risk involved, if the government is the guarantor; and the risk to the lender is dramatically lowered if you have something valuable that they can take if you can’t pay your bills. It’s a safety net for them.

Back to birth — I wonder how it would affect doctors’ practice style if they knew that there was no “safety net” of a quick, easy, safe Cesarean. I’m reminded of something one of my email doula friends said — she’s attended hundreds of births, many of which became necessary C-sections, but none of which were necessary at the outset of labor. This is not to say that the only time C-sections become necessary during labor is if they were interfered with — sometimes the most natural labors end up requiring C-sections, and sometimes interventions can help preserve a vaginal birth when otherwise a C-section might be necessary; but frequently, it is the interventions which lead to a C-section then becoming necessary. We all have heard of “Pit to Distress” — the practice of increasing the dosage of Pitocin until the baby is born, or becomes so distressed by the unnatural labor that the doctor then has a reason to call for a “necessary” C-section. What if doctors didn’t have easy access to surgery, in the event the baby was distressed? Do you think they’d be so quick to give Pitocin to a baby that is tolerating labor, just to speed things up? I don’t. It’s relatively easy to say that it’s no big deal if the baby becomes distressed due to X, Y, or Z, because “she can always be given a C-section.” But what if she can’t? Then, if the baby becomes distressed because of something the doctor did, it’s all on him if the baby is injured or dies.

If there were no C-sections, doctors would still be taught how to best manage vaginal breech births and vaginal twin births. I think of one snippet of media coverage I saw in the aftermath of the Haiti earthquake. An American woman (probably an OB, maybe not), was attending births in the street “hospital,” and a Haitian woman was in labor. Probably the baby began “crowning,” except that it wasn’t the head, but the rump that was presenting. The American wailed, “It’s breech! I don’t know what to do!!” She had probably never seen a vaginal breech birth before — even assuming she was a trained and practicing obstetrician, she likely was trained in100% C-section for breech, rather than how to safely assist a vaginal breech birth. All well and good for America, with plenty of hospitals and operating rooms, technology and antibiotics — but when the OB is removed from all of that, what skills does she really have to help make birth safe?

If there were no fetal monitors, doctors would not feel safe with administering Pitocin, particularly in high doses, because they would have no way of knowing how the baby was tolerating it. If there were no C-sections available should the baby become distressed, doctors would be more cautious to keep the baby from distress, don’t you think?

I’m afraid that our safety net of technology and interventions has become more of a “trampoline” — rather than being used only to save someone’s life or health in rare events, it is being used on a regular basis, as if it’s meant to be bounced on. And, no, I’m not calling for a complete ban on the use of Pitocin, C-sections, or any other intervention — they have their place. However, if they were reduced only to what was necessary (which we as fallible humans cannot know with 100% certainty which are truly necessary and which are not, so we could not truly reduce the rate of unnecessary intervention to zero; but looking at some things like mortality and morbidity with and without C-sections, and retrospective studies showing that most inductions were not medically necessary [and failed inductions certainly increase the rate of C-sections], we can see that it certainly can be reduced), we would see a very different (and, I think, better) picture in labor and birth, compared to what it is now.

One time my sister was talking to a police friend of ours, and sort of complaining about getting pulled over for speeding tickets. [At the time, she did have a “cop magnet” — a sweet little black T-top Thunderbird.] And our friend said, “Always drive like there’s a cop behind you.” That’s good advice, isn’t it? We often don’t — relying on radar detectors just to keep from getting caught; but if we drove safely and cautiously, within the speed limit, and obeying all laws, we’d likely never get a traffic ticket, and we’d reduce the likelihood that we’d end up in an accident. Maybe if doctors, midwives, and nurses would “practice like there are no C-sections,” we’d be able to safely reduce the C-section rate much closer to the minimum necessary.

Just the facts, ma’am…

Using the World Health Organization’s 2005 maternal mortality statistics, and this summary of abortion laws, I put together the chart below, which I ordered from lowest to highest maternal mortality rate. The figure I used for maternal mortality was the official number or estimate, although many countries had a wide “range of uncertainty” (for instance, Laos had an official MMR of 660, but the range was from 190-1600). You can read more about what the different numbers and letters mean in the abortion laws portion of the chart by clicking on the above link, although they are pretty self-explanatory, with Y meaning abortion is legal, 1 meaning legal in the first-trimester only, R is legal but with significant restrictions, etc.

The abortion laws portion transferred easily to the spreadsheet, but the MMR portion did not, so I entered those numbers in by hand (so I possibly made some typographical errors — you’re welcome to double-check me). Since they were both in alphabetical order, I then had to go through and match up the lists, because some countries were listed on one but not the other. There were also several countries that were named differently in the two lists (the Republic of Congo vs. Congo, as an example), and many of these I deleted, not realizing that they were actually listed, only further down on the list. I did not take the time to go back and figure out which ones I could have matched up, so I know the list is slightly incomplete (probably fewer than half a dozen countries in this group, although probably another half-dozen or so were deleted that could not have been matched up — Vatican City, for one). I divided the list into six roughly equal portions, to make it easier to see the abortion laws of the countries.

Then, because I’m a glutton for punishment, I organized the countries by type of abortion law. Unfortunately, they often don’t fit into nice, neat little packages, so while I tried to group them, it was quite difficult. Where they were the same (for instance, no legal abortion; or only for the life of the mother; or legal for any reason), I kept them together; where they were similar (YYNNNNN and YY?NNNN), I put them under the same heading, but with a blank line between. Some countries allow abortion only to save the mother’s life and health while other countries allow abortion only to save the mother’s life and in cases of rape. Since these both had two “yeses” I put them under the same heading, but with two or more blank lines between, to show that they were separate. While I tried to be consistent, it’s possible that there are numerous inconsistencies in there, but I mostly erred on the side of assuming a restricted abortion status for question marks. There were some weird things in there — Mozambique, for instance, which supposedly allows for abortion “on demand,” but it is not legal in cases of rape, fetal defect, or for “social” reasons. I don’t know if that’s a typo — nor do I know the difference between “demand” and “social” reasons for abortion.

So, those are the facts. Why am I presenting these facts? To show that there’s more to maternal mortality than just restrictive or relaxed abortion laws, because I’ve heard numerous abortion advocates talk about liberalizing abortion laws as if it is some sort of magic panacea for maternal mortality. But if you look at the group of countries where abortion is legal on demand, you’ll see that the MMR ranges from 3-830/100,000; and countries where abortion is absolutely outlawed (or illegal except in restricted circumstances) the MMR ranges from 8-1100/100,000. Some people look at the problem of “unsafe abortion” and try to remove the “unsafe” part of it. But abortion is a symptom of a problem. The root causes of abortion run far deeper than just legality and illegality. Just making abortion “safe” does little to help the underlying causes of why women seek abortions. If a child is being raped by her uncle, giving her an abortion and then returning her to the same conditions will not really help her, because she’s just being returned to that abuse (and will likely get pregnant again, and “need” another abortion to solve her “problem”). Ditto women in abusive relationships (married or unmarried), or those that abuse drugs or alcohol.

Unsafe abortion is unsafe, whether legal or illegal; and there are far better things to do for women than to promote the legalization of abortion, especially where it is inherently unsafe: working on the infrastructure so that health services are more available and reliable, improving food and water supplies, increasing the number of midwives, educating the populace (in general, as well as in particular about safe vs. unsafe health practices, including sticking non-sterile objects into your uterus to try to terminate a pregnancy), etc. It falls under the category of “give a man a fish, and you feed him for a day; teach a man how to fish, and you feed him for a lifetime.” Far too much time and energy is focused on “giving people fish,” and not near enough is focused on improving quality of life, which will help in many more and more far-reaching ways. An example — giving someone a condom may help that person keep from conceiving a baby one time. But they need condoms every time, so it is a continual and ongoing need and expense. Teaching a couple how to avoid pregnancy using ways that do not require ongoing expense (fertility cycles, cervical mucus to tell if she’s ovulating, etc.) can help even when condoms are not available. Giving people food is good; giving people the ability to grow their own food is better. Changing “unsafe abortion” by taking away the “unsafe” part may save some women’s lives; but changing “unsafe abortion” by taking away the real or perceived need for the “abortion” part will save even more lives, of both mother and child. This involves more than just drugs and technology and “things.” Changing men’s hearts so that they do not demand sex from their wives, nor rape children or women, nor are in other ways oppressive or abusive, but are good and godly men and husbands is the real answer, but those kinds of changes are not exactly easy to implement. There are similar changes that may need to take place in women, but it will take more than just throwing money and abortions at the problem, to make the real problem go away.

Abortion and Maternal Mortality

In response to my previous post about feminism, someone wrote (in part) why she supports abortion:

And wanting to dismantle those structures is why I support reproductive rights. In a different world, abortion would be unnecessary. Women’s lives would never be endangered by a pregnancy, no woman would ever be forced to get pregnant by her abusive partner, no woman would ever be raped, 10-year-olds would not get pregnant, there would be comprehensive sex education and free and unlimited access to birth control and free high-quality daycare and a year of paid maternity leave. These are, to me, highly feminist goals.

But we don’t live in that world; in this world, unintended pregnancies occur and a myriad of forces conspire to cause them and punish women for them. A system in which abortion is criminalized does nothing to help women; it makes their lives worse. If the only goal is to have somewhat fewer abortions, then banning abortion is probably an effective thing to do. There will still be abortions, of course: women with money will always find access to them, and women with less money will sometimes find a way, safe or unsafe, to access abortions; and sometimes they won’t, and those are the abortions the ban will have prevented. But it will also be causing maternal deaths (unsafe abortion is one of the top five causes of maternal death around the world, and causes an especially large percentage of maternal deaths in Latin America), and their fetuses won’t be carried to term; and when women are caught and prosecuted (and those will almost certainly be the women with less money), their other children will suffer (as so many women seeking abortions already have children). There is an excellent article about the consequences of what a full abortion ban looks like, as El Salavdor actively enforces one. It doesn’t seem like a good solution to me. To me, the feminist act is to dismantle the structures that make pregnancies unwanted, and that hurt women in myriad other ways as well.

Because this is an important topic (and because I recently read about Chile’s maternal mortality rate and abortion laws), I wanted to repost my answer here, slightly expanded:

The El Salvador link didn’t come through; you can re-post it if you want. It’s been some time since I’ve thought of El Salvador, but I remember being in a discussion some time ago in which I found out that they have an abortion ban in place which would prohibit abortions even for ectopic pregnancies as long as the fetus/embryo is still alive. Once fetal/embryonic death is confirmed (or the tube bursts), an abortion or other surgery can be performed to save her life. I think this is a bit too stringent, with the probability of a diagnosed ectopic resulting in a life-threatening if not a life-taking situation for the mother. In abortion cases such as these, the intent is to save the life of the mother, *not* to take the life of the child. It is the unfortunate inevitable result that the baby dies; but the likelihood (probably 99% or greater) is that the baby could never survive, so it is saving one life instead of taking two.

And, yes, I agree that we should be looking at ways to make pregnancy wanted. Often, when faced with an unwanted pregnancy/child, the solution offered is to get rid of the child. Most pro-life people would say that we need to get rid of the “unwanted” portion of the equation instead.

However, there is some equivocation about abortion. Often, “unsafe abortion” is juxtaposed against “legal abortion,” as if the two were opposite or mutually exclusive, when that is not the case. There are numerous unsafe legal abortions, as there are numerous safe illegal ones. [Safe for the mother, anyway.] Just recently, a woman in New York City died from an abortion when the abortionist lacerated her cervix during the procedure and she apparently bled to death. Legal, but unsafe. Ireland has the lowest maternal mortality rate in the world, and it also has strict laws against abortion. Illegal, but safe.

The reality is, that often in countries where abortion is illegal, health services in general and maternity services in particular are horrible, with high rates of death and disease from things that barely raise a blip on the radar of developed nations. I can’t speak for the current climate in these other countries, but I know that in America, about 90% of all illegal abortions were performed by a doctor or midwife, with most of the remainder being performed by someone else who had some medical training (veterinarian, nurse, etc.), and only a small minority being either self-induced abortions or by a complete amateur. [The term “back-alley abortion” does not refer to the place of the abortion, but rather that the pregnant woman would enter the doctor’s office through the back door in the alley, often at night, so as not to be seen and raise suspicion.] These abortions were unsafe, not because they were illegal nor because they were done by unqualified personnel, but because they were unsafe by their very nature. Up until the development of antibiotics, if a woman got sepsis from childbirth or abortion, there was precious little that could be done for her. Maternal mortality dropped like a rock with the advent of sulfa drugs and penicillin, because it gave doctors for the first time the ability to fight infection. Maternal mortality dropped below 600/100,000 in 1934, and was in a free-fall for decades after, dropping to 75/100,000 in 1951 when abortion was still quite illegal, and continuing to fall to 18.8 in 1972, the year before Roe and Doe were decided. Legalizing abortion did not alter its safety; good health practices did. [In highlighting antibiotics, this does not exclude other advances, such as safer anesthesia, better technology in recognizing and treating maternal illness, a higher standard of living, etc.] MMR did fall below that, but is now on the upswing again — all with abortion still very legal. In countries where antibiotics and other health-saving measures are not easily available, we still see high rates of preventable deaths from all sorts of reasons, including abortion.

Here are abortion laws by country for 2007. As you can see, El Salvador does not allow for abortion for any reason. It has a maternal mortality rate of 170/100,000. However, what you may not have noticed from those same sources is that Chile also does not allow abortion for any reason, even to save the life of the mother, yet its maternal mortality rate is 16/100,000 — about the same as the United States’ rate.

While one might say (as is often said of Ireland), that women are merely going across the border to neighboring countries where abortion *is* legal, I would point out that their neighbors (Argentina, Bolivia and Peru) all have abortion restricted only for the life and health of the mother, and sometimes for rape. Plus, all three of these countries have *much* higher MMRs than does Chile: 77, 290, and 240/100,000 respectively. In fact, as you can see, El Salvador has a much lower maternal mortality rate than Bolivia and Peru, which both have abortion legal in the case of saving the mother’s life and health. Somehow, even with a full abortion ban, Chile enjoys an MMR comparable to that of the United States.

Don’t just do something — stand there!

We’re used to the saying, “Don’t just stand there — do something!” and many times it’s true. Many times, however, it’s not. We value action — as measured by clichés like “He who hesitates is lost.” But we also understand the value of assessing a situation, to determine the best course of action — “Look before you leap.”

The father of a former coworker is a good example of not rushing into doing the first thing that pops into your mind. One time, there was a small kitchen fire that somehow started and caught the window curtains on fire. He rushed in, saw the fire, and pulled the curtains down. With his bare hands. Severely burning his hands, and if I remember correctly, requiring hospitalization. Far better would it have been for him to pause half a second longer, and grab a broom or some other object to get the burning curtains away from the walls and into the sink. Other similar stories abound of people throwing water on a grease fire, and spreading the fire instead of stopping it. They just reacted to the immediate situation… and reacted wrongly.

A great medical example is that of a nurse, pharmacist, or anyone else handling medication to double-check to verify that the medication they are dispensing is the medication they are intending to dispense to that patient. Or do an ultrasound to make sure that the baby really is breech before doing a C-section for a supposed breech baby (who may have flipped sometime in the past few minutes or few days).

Sometimes, it is better to pause, take a breather, and really think before acting. Or not to act at all.

What is commonly trumpeted by obstetricians is that maternal, neonatal and infant mortality dropped during the 20th century, for which they claim sole credit; what is not commonly told is that in the first part of the century, maternal and infant mortality increased under the care of doctors and particularly with births in the hospital. There are numerous quotes which demonstrate this, and show that it was known by some of “the powers that be” at the time, but I’ll just include a few [emphases mine]:

~ “Why bother the relatively innocuous midwife, when the ignorant doctor causes many more absolutely unnecessary deaths”. [1911-B; Dr.Williams,MD,p.180]

~ “In NYC, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives’”. [Dr. Ira Wile, 1911-G, p.246]

And from the same source, later quotes from a 1975 study on the topic:

~ “Whether because midwives provided more skilled care or because obstetricians were too eager to interfere in labor and birth, obstetric mortality rates often rose as … midwife practice declined.” [DeVitt, MD; 1975]

And then from this document, quoting a conclusion made about midwives, a report presented to the White House,

“…untrained midwives approach and trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child.

On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course.”

While the doctors’ motto was, “First, do no harm,” the reality was that oftentimes, they caused harm by acting, when less harm would have come to mother and/or child had they not acted. “Well,” you might say, “that was then! A lot of things have changed since then.” Yes, and no.  Sometimes waiting patiently is still the best course of action:

Sometimes acting and intervening and speeding things up is the best course of action; but how often is slowing down and waiting on nature to take its course much better! When you have technology and gadgets and other things at hand, it’s easy to use them even when unnecessary. “When all you have is a hammer, everything looks like a nail.” And the ever-excellent quote from Jurassic Park via Jeff Goldblum, “Yeah, but your scientists were so preoccupied with whether or not they could, they didn’t stop to think if they should.”

First make sure you’re right, then go ahead. — Davy Crockett

Mary Breckinridge, the first American CNM

At a time when maternal mortality was 800/100,000 and infant mortality claimed one in ten lives, Mary Breckinridge was a true life-saver. She established Frontier Nursing Service in 1925, which brought quality care to rural (and typically, impoverished) Kentucky women. Frontier still trains nurse midwives. Here are a few articles about Mary Breckinridge, in honor of National Midwifery Week:

In many ways, Ms. Breckinridge was to nurse-midwifery what Ina May Gaskin is to non-nurse midwifery. Most of us are probably more familiar with Ina May than Mary Breckinridge, for many reasons — we home-birthers tend to hire CPMs rather than CNMs (who many times cannot legally attend home births); we’ve read her engaging books; she’s still alive and giving interviews, and working hard promoting midwifery and awareness of maternal mortality, etc. But there are many similarities between the two women — both saw a need and filled it; both popularized midwifery; it’s possible that without Mary Breckinridge, there would be no “CNM” at all, and perhaps without Ina May Gaskin there would be no CPM either. There have been many other influential figures, and many other necessary players, in the realm of midwifery; but in each of these cases, they were at least the starting point in their respective fields, and in so doing, saved midwifery and/or home birth. In some ways, Ms. Breckinridge had a harder role, perhaps, living at a time when doctors were on a full-court press to eliminate midwives as dirty and incompetent (in contrast to their sterile hospitals and/or sterile technique, in addition to their high-falutin’ education). The fact that maternal mortality increased with the increase in hospital births was not widely known; and the fact that these “dirty” and “incompetent” midwives had lower maternal mortality attending home births than doctors attending home births; and home birth had lower maternal mortality (and morbidity) than hospital birth, was actively suppressed by obstetricians of the day, in their PR campaign to drive out midwives and midwifery. For a woman to consciously and willingly step into a demonized role, roll up her sleeves, and get to work, should be recognized and given full credit. In some ways, I think it might be like the wife or daughter of a plantation owner going to live in a slave hut, and working the fields, instead of living a pampered life of ease and enjoyment.

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