More women dying from pregnancy complications; state holds on to report

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The mortality rate of California women who die from causes directly related to pregnancy has nearly tripled in the past decade, prompting doctors to worry about the dangers of obesity in expectant mothers and about medical complications of cesarean sections.

For the past seven months, the state Department of Public Health declined to release a report outlining the trend.

California Watch spoke with investigators who wrote the report and they confirmed the most significant spike in pregnancy-related deaths since the 1930s. Although the number of deaths is relatively small, it’s more dangerous to give birth in California than it is in Kuwait or Bosnia.

“The issue is how rapidly this rate has worsened,” ... “That’s what’s shocking.”

... “current trends and evidence suggest that maternal mortality rates may be increasing in the U.S.”

The alert asked doctors to consider morbid obesity, high blood pressure and diabetes, along with hemorrhaging from C-sections, as contributing factors.

... Shabbir Ahmad, a scientist ... decided to look closer. He organized ... a systematic review of every maternal death in California. It’s the largest state review ever conducted. The group’s initial findings provide the first strong evidence that there is a true increase in deaths – not just the number of reported deaths.

Changes in the population – obese mothers, older mothers and fertility treatments – cannot completely account for the rise in deaths in California ...

... scientists have started to ask what doctors are doing differently. And, he added, it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.

... While the maternal mortality rate among black women is rising, the task force found a more dramatic increase in deaths among white, non-Hispanic mothers ...

... In 1996, the maternal death rate in California was 5.6 per 100,000 live births ... Between 1998 and 1999, the World Health Organization changed its coding system, which may have increased reporting of deaths. The California rate was 6.7 in 1998 and 7.7 in 1999. Because the number of mothers who die is small, the rate tends to fluctuate from year to year.

In 2003, when California revised its death certificate, the rate jumped to 14.6. And in 2006, the last year for which data is available, the rate stood at 16.9.

... When researchers unveiled their initial findings to a conference of the American College of Obstetricians and Gynecologists in 2007, there were gasps from the audience ... The idea that California was moving backward even in an era of high-tech birthing was implausible to some. Confirmation of the trend was noted in the 2008 report ...

The state of California has yet to share the report with the public. Researchers say that, after reviewing the report in 2008, officials in the Department of Public Health asked for technical clarifications. Revisions were complete and approved in the first half of 2009 ...

... it is important for the public to be aware now that these trends are worsening ...

“Even though they tend to be small numbers in terms of maternal mortality, it is important – it’s very important – that these trends be looked at,” she said. “And efforts need to be made to try and reverse them when they are going in the wrong direction.”

Rising C-section birth rate

Nearly one in three babies is now born by C-section. Many scientists have acknowledged that at some point, as the number of surgeries spiral upward, the risks will outweigh the benefits. But the C-section remains a useful tool, and in the middle of labor, doctors say, it’s hard to balance the potential long-term harm against immediate crisis.

Today, doctors face a condition called placenta accreta, where the placenta grows into the scar left by a previous C-section. In surgery, doctors must find and suture a web of twisted placental vessels snaking into the patient’s abdomen, which can hemorrhage alarming amounts of blood. Often, doctors must remove the uterus.

Main said this complication from C-sections has increased eight-to-10 fold in the past decade. Nonetheless, most women survive the ordeal ... the rise in deaths is indicative of a larger problem.

“For every maternal death, there are 10 near misses; for every near miss, there are 10 severe morbidity cases (such as hysterectomy, hemorrhage, or infection), and for every severe morbidity case, there is another 10 morbidity cases related to childbirth,” ...

Inducing labor before term more common

... Dr. David Lagrew ... noticed that a lot of women were having their labor induced before term without a medical reason. And he knew that having an induction doubled the chances of a C-section.

So he set a rule: no elective inductions before 41 weeks of pregnancy, with only a few exceptions. As a result, Lagrew said, the operating room schedules opened up, and the hospital saw fewer babies admitted to the neonatal intensive care unit, fewer hemorrhages and fewer hysterectomies.

All this, however, came at a cost: The hospital had to take a cut in revenue for reducing the procedures it performed. Lagrew doubts that any hospital has increased its C-section rate in pursuit of profit, but he does note that the first hospitals to adopt controls on early elective inductions have been nonprofits.

According to a report issued by the advocacy group Childbirth Connection, “Six of the 10 most common procedures billed to Medicaid and to private insurers in 2005 were maternity related.” On average, a C-section brings in twice the revenue of a vaginal birth. Today, the C-section is the single most common surgical procedure performed in the United States.

“If all these guys were losing money on every C-section, well, what’s the old saying? Whenever they tell you it’s not about the money, it’s about the money,” Lagrew said.

The California task force isn’t waiting to determine the ultimate cause of these deaths. It has started pilot projects to improve the way hospitals respond to hemorrhages, to better track women’s medical conditions and to reduce inductions ...

I think they've missed one key element: midwives! If every woman was cared for by her own midwife (and home birth and birth centre birth was encouraged as the norm for healthy women), the induction and caesarean rates would fall dramatically .... then maybe fewer women would die in childbirth.

Midwifery has an important focus on health promotion and education and would work fantastically for poorer women and women with health issues. The other priority ought to be raising the VBAC rate and reducing the number of elective repeat caesareans. Whilst the first caesarean might be safe, second and subsequent caesareans carry serious risks that are alluded to in this article.

Melissa Maimann, Essential Birth Consulting 0400 418 448