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.


Conflicting studies

Ok, so long story short, I happened across these two articles from the UK, both from the same woman, Medical Editor Rebecca Smith, which had conflicting results. The first report, written almost exactly a year ago, was titled, “Death Risk Higher for Women ‘Too Posh to Push’“; and the second report, written this past April, was titled, “Women Choosing Cesarean Have Low Death Rate.” I’ll see if I can find something like the actual study, and not just go by what the author said about the study, but just had to say this while it was fresh on my mind.

The first report was published in the BMJ (which if I remember correctly has all of its articles available free online, so it should be easy to find), and Ms. Smith reported that the study found that

the risk of maternal death was three to five times higher compared with natural deliveries. The risk of requiring a hysterectomy after a caesarean section was four times higher than for a natural birth and twice as high for being admitted to intensive care and needing a hospital stay of more than seven days.

For babies in a breech position, a caesarean section was safer but for those in a normal head-first position the risk of the baby dying or suffering serious problems was raised by one and a half times. Experts said the study was a “reality check” that caesarean sections carry risks and are not ‘just another delivery option’.

The second report was attributed to “The Birth Trauma Association”, an organization in the UK, and I’m not sure if the report was actually published anywhere, but I’ll try to find it.

The Birth Trauma Association found that of the 2,113,831 women who delivered a baby after 24 weeks gestation between 2003 and 2005, one in 10 had a caesarean before labour had begun.

Seven women died, giving a mortality rate of 0.31 per 10,000.

This compared to 74 deaths amongst the remaining women who had a natural birth or an emergency caesarean section, giving a mortality rate of 0.39 per 10,000.

Since reports published in well-respected peer-reviewed medical journals such as the BMJ typically analyze the results to see if they are statistically valid, I will assume that the data reported in the BMJ article is statistically significant; I’m not sure about the other — we’ll have to see.

The question that weighs most heavily on my mind is, what is the maternal mortality rate among women who had a vaginal birth? And the morbidity rate of the infants?

Most studies that are undertaken to look at mortality and morbidity in birth will typically restrict participants to be only those in the term period (unless they are looking specifically at pre-term births). There is no definition of “emergency” C-section given, so I am going to assume that it just means any unplanned C-section. I will accept that surgeries performed under stressful situations (such as an absent fetal heart-rate, in which the baby will need to be cut out immediately) may predispose the mother to extra risks due to the probability that the doctor is cutting faster and not taking as much time as in a scheduled C-section. So, what things can be done to reduce the rate of fetal distress? I’m unsure if other factors play into this — such as if having a pre-term C-section may cause more problems than having a term C-section; or a failed induction for non-medical reason ending in an “emergency” C-section. Also, I’m curious if only 10% of women had planned C-sections. It seems probable to me that there would be many women who planned a C-section but actually went into labor before the date of the scheduled surgery, so were automatically included in the 2nd group, which combined women who gave birth vaginally with those who had a C-section after labor began.

There may have been many women who had pre-term labor and had their babies by C-section because their babies were so small that they may have been traumatized by such an early vaginal birth. I seem to remember reading somewhere that in very early pre-term births, C-section is the preferred birth mode because of the delicate condition of the baby, specifically the head trauma he may endure being so fragile, going through the birth canal; plus the fact that many babies are still in the breech position in early pregnancy, and would be put at severe risk if allowed to be born vaginally — their heads are much more out of proportion to their bodies that term babies (this means that there may be more complications like head entrapment in a partially dilated cervix). If women at 24-30 weeks present to the hospital in pre-term labor that the hospital can’t stop, it is likely in their babies’ best interests to be born by C-section. Since the women were in labor before the C-section began, they would not be included in the first group, yet it isn’t exactly fair to include them in the planned vaginal birth group since they didn’t even make it to term, and most C-sections done prior to the beginning of labor would take place during the term period. It makes a difference for the babies; it might make a difference in the mothers. There are some preterm C-sections that do take place prior to labor beginning, such as some for twins or other multiples, or those in which the baby seems to be not developing well in utero, or he stops moving or something.

Anyway, I’m looking forward to trying to find this report, and seeing if it answers some of the questions, or if they give a statistical analysis to back up their claim of a lower maternal mortality for planned C-sections. Comparing it to the BMJ (which is almost certainly statistically significant), it surprises me that such a large difference noted by the BMJ article is contradicted but with only a slight difference by this other report. It may mean nothing more than that C-section after failed induction is a hidden risk factor for higher maternal mortality; or that an emergency C-section done because the baby’s heartrate plummeted after the mother’s blood pressure took a nose-dive after she got an epidural helped to increase the MMR. The BMJ reported that maternal death was 3-5x higher for C-sections (but the article I read did not say whether that looked at planned vs. unplanned C-sections), whereas the higher rate of maternal death for vaginal births and C-sections which took place after labor began was only 8 per million higher (3.1/100,000 vs. 3.9/100,000) — very slight. Considering all of the other risks of C-section (especially repeat C-section, with the higher rate of complications including placental problems with future pregnancies and hysterectomies, not to mention things like maternal hemorrhage and blood transfusions and risk of infection and pain), I think that women need to look at the full picture of both what vaginal and surgical birth have to offer and what the risks and benefits of each are.

Active Management vs. Expectant Management

Simply, active management is doing something to everyone, regardless of circumstances; expectant management is waiting to see if that something is necessary, and using it only if needed.

An example: My first birth was at home, attended by a Certified Nurse Midwife. I ended up having PPH (postpartum hemorrhage), and she gave me a shot of Pitocin to stop the bleeding. I don’t know how much blood I lost, but it was enough that I had to lean against the wall for support when I went to the bathroom about a half hour after birth or so, and felt like I was about to faint. She used “expectant management” — that is, she did not give me a shot of Pitocin until it was obvious that it would be beneficial. Most hospitals use “active management” in this area — they give a shot of Pitocin to the mom as soon as the baby’s anterior shoulder is born, whether the mom needs it or not.

I read an excellent article in the Journal of the New Zealand College of Midwives about the use of active vs. expectant management of postpartum hemorrhage (beginning p. 25). Quite thought-provoking. Among other things, the author notes significant differences between the average Western woman (who will be healthy, well-fed, have access to clean water and medications) and the average woman from a developing nation (who will likely not have access to clean water, may not have sufficient food, may be suffering from illnesses, and may be “at the bottom of the totem pole” when it comes to getting medications). She notes that Western women who are least likely to suffer from ill effects of pregnancy or birth to start with, are also going to be most likely to have drugs used on them (actively, whether needed or not); while women who are most likely to have problems, will have the least access to drugs — either not being able to afford them, or what little supply of drugs the country has will be given to men who are considered more important, or (in the case of uterotonic drugs like Pitocin) may be put on the black market for use in abortions and therefore not available to the women who need them.

She questions the usefulness of active management in the healthy low-risk women, but not necessarily its usefulness in the high-risk women. However, she makes the point that because these women are not getting the full active-management package, then what they are getting may be making problems worse. For instance, they may not have Pitocin for the reasons stated above; yet their health professionals are being taught to use active management of the third stage (after the birth of the baby — the birth of the placenta), which includes immediate clamping of the cord and cord traction. She notes that immediate clamping of the cord may seriously damage the at-risk baby in these poor countries of the world by depriving him of his full supply of placental blood; but more importantly, she says that controlled cord traction (CCT) in the absense of uterotonic drugs may actually increase the rate of PPH. But these things are aggressively being promoted as being beneficial (since they are part of the active management package) without regard to the fact that these people do not have the drugs. It should be noted that the World Health Organization‘s “Safe Motherhood” Guidelines place all three aspects of “active management of the third stage” into the category of “Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue.”

Yet she calls into question the use of active management for your average, healthy Western woman, because we are unlikely to benefit from it, and puts forth a few studies which demonstrated a lower rate of PPH in expectant management (also called “physiologic management”) of the third stage, as opposed to active management. I was reminded of a discussion I read among midwives about cord clamping, and one midwife noted that it was her practice to leave the umbilical cord alone until it stopped pulsing at least, possibly until the placenta was actually born, and that the only case of PPH that she had personally had among her clients was the one time she had to clamp and cut the cord because of a tight nuchal cord. While that is anecdotal evidence, it stuck out in my mind, because I knew that that flew in the face of what is commonly accepted in obstetrics — that PPH happened without active management (immediately cutting the cord, giving a shot of Pit, and pulling on the cord to get the placenta out). Yet this is in accord with the studies the New Zealand midwife mentioned.

Why is expectant management not used more? Oh, I know the typical OB’s answer — “Because years of research has shown that active management reduces PPH.” Well, maybe — in high-risk, unhealthy women. Or in births that have had the normal, physiological, natural actions circumvented. Let’s say that the above midwife’s reasoning, based on her anecdotal account, is accurate — that the majority of cases of PPH in healthy women occur because the umbilical cord is clamped too soon. What if that is true? Immediate clamping began decades ago when childbirth went industrial, without any studies on its safety, risks, or benefits. I can assume that it happened in lock-step with the rest of the medicalization and mechanization of childbirth, along with general anesthesia and forceps for all births — that doctors prided themselves on getting the baby out as fast as possible, and then cutting the cord immediately in a rite to signify his complete independence of the mother. Only recently have questions been raised about whether it causes any problems, for instance, with depriving the baby of the full amount of blood which rightly should be his, or whether immediate clamping causes problems because of the oxygen deprivation that occurs when it is done before breathing begins. What if most of the cases of PPH in healthy women in America and other developed countries are caused by active management? — which then necessitates more active management to “cure” it. What if PPH could be almost entirely avoided by the simple matter of leaving the cord intact? Quite an interesting train of thought, and one which I hope will be studied. It is already recognized that delaying cord clamping has no risk to the baby, and in the case of premature infants carries with it some benefit. I strongly suspect that delayed cord-clamping has benefits to all babies, but whether this will ever be studied remains to be seen. Isn’t it sad that immediate cord clamping became the norm without any studies whatsoever, but now keeping the cord intact even as long as two minutes, which is only natural, has to be the action that is proved before it is used? [The WHO document I mentioned above says that “physiological” treatment of the umbilical cord — i.e., delayed clamping or not clamping at all — should be considered normal, while early clamping should be made to defend itself.]

But back to the article… the author is promoting the idea of teaching physiological management in these low-resource countries, because she understands that, while it’s all nice and good in Pollyanna’s world that all women who need drugs will get them, in the real world that’s not the case; and if more harm than good is done by half-measures of active management, then another way should be promoted. Active management of the third stage of labor will reduce maternal deaths due to PPH in women in developing countries; but if it is true that in the absence of Pitocin, that the rest of active management will increase deaths due to PPH, then something else must be done. You can’t just blithely say, “Let them eat cake” when they have no bread. And if immediate clamping of the cord and controlled cord traction increase PPH in the absence of uterotonic drugs, then birth attendants in other parts of the world need to understand this, so that they don’t make maternal mortality worse. Active management may not increase maternal mortality in high-resource countries, because we’ve got the ability to keep PPH from turning deadly, in the form of easily available drugs, and quick access to hysterectomies if required. They don’t. And I think it’s time to start recognizing that there is a difference between the United States and Sierra Leone, and trying to work with what they’ve got, and improve the quality of care with the resources they have, not just some sort of “pie in the sky” wishful thinking of what might be the case if they had X, Y, or Z. Because they don’t. And if active management without Pitocin increases PPH (which will increase maternal mortality, because they can’t handle the blood loss like we can), then continuing to spread it without ensuring that they have all the pieces of AML, is causing the deaths of women all over the globe. And it needs to stop.

Checking dilation without a vaginal exam

Yeah, this piqued my interest, too.

First, there are many reasons why it would be beneficial or helpful or preferable to be able to check your progress without having a vaginal exam. The most obvious is the discomfort of having someone (as I read on another blog) “search for my tonsils via my lady parts.” Also, vaginal exams increase the risk of infection if the water has broken — even when sterile gloves are used, there are bacteria on your body that get on the sterile gloves and then are given a free ride up to your cervix. Before sanitation (even simple hand-washing) was practiced by birth attendants, it was common for women to die of “childbed fever” due to germs being introduced directly into the uterus this way.

[As an aside, when you hear people decry modern homebirth because “women used to die all the time before they started having their babies in the hospital,” you now know that the high maternal death rate was at least partially attributable to doctors’ dirty hands infecting scores of women. It was common practice to teach medical students how to do vaginal exams by using cadavers — dead women (who frequently were victims of childbed fever) — and then to go down the hall to where women were laboring and without washing their hands, perform vaginal exams on them, directly introducing the germs from a dead person into the body of a living person.]

But another reason would be to assess where you are in your dilation so that you know when to go to the hospital (if you’re planning a hospital birth). A frequent concern of women is that they’ll go to the hospital (or call the midwife) too soon…. or else too late. In the first case, they may be turned away until they are dilated more; and in the second case, they may have a harrowing ride to the hospital with a white-knuckled husband fighting his way through traffic while she tries not to push.

On this thread at Midwifery and More, there are a few different ways mentioned, but the one I want to talk about most is one that Anne Frye wrote about in Holistic Midwifery, Vol. II, p. 376. Sarah Wallbaum mentioned it on our childbirth educators email list, and it intrigued me. Here’s how it works:

During a contraction and with mom on her back, determine how many fingerbreadths of space are between the fundus [top of the uterus] and xiphoid process [the triangular tip of the breastbone] at the height of a contraction.

5 fb = no dilation
4 fb = 2 cm
3 fb = 4 cm
2 fb = 6 cm
1 fb = 8 cm
0 fb = complete

She said that she has practiced this for accuracy with a midwife, and has both found it to be fairly accurate, but that if a mom is very obese, it would be difficult to use. Even if it just gives a “ballpark figure” it just feels empowering to me to be able to know this information without having somebody else’s hand stuck up inside me. Remember also, that the World Health Organization’s guidelines for Safe Motherhood says that vaginal exams should be kept to a strict minimum, and in the first stage of labor once every four hours should be enough (3.3).

Update: Here is another blog post that has other ways of checking dilation.

Updated again to add this link to an image of the xiphoid process method of estimating dilation.

And yet another update (7/27/10) for this link

Updated again to add this abstract (9/24/10): a study on the colored line that usually appears between a woman’s buttocks as she dilates

The Safe Motherhood Quilt Project

From the Safe Motherhood website:

The Safe Motherhood Quilt Project is a national effort developed to draw public attention to the current maternal death rates, as well as to the gross underreporting of maternal deaths in the United States, and to honor those women who have died of pregnancy-related causes since 1982.

This is a wonderful visual adjunct to my previous post on maternal mortality, with additional statistics. This project is the vision of Ina May Gaskin, who nearly single-handedly brought back midwifery, home birth, and normal birth in the 70s. She also wrote an article about this, “Masking Maternal Mortality,” in the current issue of Mothering magazine. I think it is an important reminder of how much further we have to go. Please visit this site, and if you know of someone who died of pregnancy-related causes within 1 year of the end of her pregnancy (whether miscarriage, abortion, or birth), you may there find out how to add a quilt block in her memory.