When you think about women dying in childbirth, you probably conjure up an image of something ancient, maybe even biblical. Perhaps you imagine a woman squatting in a straw hut, bleeding out during a time before the invention of modern medicine. If you even imagine a woman dying in childbirth these days, chances are, you picture her somewhere in rural Africa.
But in reality, women are dying before, during, and after labor in greater and greater numbers right here and right now — in American hospitals.
When I heard that the U.S. is one of only 17 countries worldwide where more women are dying in childbirth than in decades prior, I was stunned. Yeah, I know our healthcare system and the medical industrialization of childbirth is problematic and all, but really? How can it be that an estimated 60,000 women nearly be dying of pregnancy and childbirth complications in this country every year?
I spoke with Dr. Priya Agrawal, of the maternal health initiative Merck for Mothers, to find out what on earth so many American women are still dying in or right after childbirth in the year 2015. Her answers reveal that the problem of America's high maternal mortality rate is deeply systemic — and largely fixable, if only there was enough initiative.
1. There's No Standard Protocol For Childbirth Emergencies
It seems unbelievable, but while doctors have a standard protocol to follow during emergencies like heart attacks, there's no standard treatment for emergencies that take place during childbirth at most hospitals. That's a huge problem, especially because the highest risks women face — postpartum hemorrhage, preeclampsia, and pre-obstetric emergencies —are widely known.
"If you were having a fire in your house, you don't want the fire team to all be figuring out what to do on the spot. There is a protocol in place," Dr. Agrawal says. But as it stands now, there's no standard plan of attack for handling birthing emergencies — and that variation in care contributes to worse outcomes.
"Standard protocols mean that every woman will receive the best-practice intervention in the case of an emergency, no matter where she gives birth. It's important to remember that in the case of emergencies, every minute matters, so when a team works together because they are all working to the same protocol and can be proactive, prompt care ensues ... That lack of a clear protocol seems to have hospitals fumbling — what we do know is that roughly 40 percent of pregnancy-related deaths are potentially preventable."
It seems like a pretty easy problem to fix: hospitals should just put standard protocols in place for common obstetric emergencies, so that no time is ever wasted fumbling around for a game plan.
2. Many Maternal Deaths Aren't Being Counted
"[In America], we don’t count our maternal deaths in any systematic fashion, let alone review them," Dr. Agrawal says.
That the majority of states do not have a formal process to review cases of maternal deaths in order to understand what happened and how they can be prevented — in 2015 — is truly absurd. "Further, most of the data compiled by individual state’s review boards are not standardized or shared, making it hard to compare across states and uncover national trends," Dr. Agrawal explains.
"Maternal deaths are being measured to some degree, but not in all states, and not in all the same way — and definitely not quickly enough (in some situations we are only just getting data from 2010!)." Because of this, what mortality and morbidity statistics we do have about maternal mortality in this country are probably underestimates, which is very bad news.
3. There Isn't Enough Focus On The Mother's Health
The majority of maternal deaths actually occur after childbirth. An estimated (again, because we don't have exact numbers) 70 percent of women who die from complications during pregnancy and childbirth don't die during labor, but actually after their baby is born.
"Look at all the apps that are out there, the reading materials, even perhaps your own behavior when you go see a new mom and baby — it is all about the baby. That focus on the baby is actually very dangerous, because the majority of deaths are happening in that post partum period," Dr. Agrawal says. More attention needs to be paid to the health of the mother, including by the new mom herself.
The most common causes of death after labor are well known — severe bleeding (obstetric hemorrhage), pregnancy-related hypertensive disorders (preeclampsia/eclampsia), blood clots in the lung (thrombotic pulmonary embolism), cardiomyopathy, and infections — so there should be a focus on monitoring these risks after a woman gives birth. Instead, the focus tends to be almost entirely on the baby.
4. Obesity And Heart Disease Are On The Rise
The lack of attention to the mother's wellbeing is a major problem, especially since women are now more at risk for complications than ever before: 1 in 5 women this year will enter pregnancy with obesity and diabetes.
In fact, the leading cause of maternal death in the U.S. is actually cardiovascular disease, which increases the risk of pregnancy-related hypertensive disorders like preeclampsia/eclampsia and cardiomyopathy. Obesity is also a major problem when it comes to pregnancy, since it means the mother will have more of a propensity towards gestational diabetes and heart problems. "Chronic disease is on the rise in this country — obesity, diabetes, and hypertension — it means that women are entering pregnancy sicker, and are sicker during pregnancy, and are leaving pregnancy sicker," Dr. Agrawal says.
5. Women Are Having Children Later
Women are having children later than ever — and it is great that we have that option — but it also puts them at a higher risk for complications. "In some areas of America, women are entering pregnancy older, and they have to be aware that is a high risk pregnancy," Dr. Agrawal says. The older you are, the higher your risk of being in poorer health and developing certain complications during pregnancy like gestational diabetes, preeclampsia, placental abruption, and placenta previa.
"It is not just a high risk pregnancy medically, it is the impact to women postpartum. They are older and their bodies are older, and I hate to say that — I am going to be an older mom — but it is a fact that we need to take into account." These are higher-risk pregnancies, and they need to be treated as such.
6. We Don't Value Women Enough As A Culture
Black women are three to four times more likely to die during pregnancy and childbirth than white women. Even when you control for income and education, black women still face a far greater likelihood of dying than anyone else — and researchers don’t even know why. And, as Dr. Agrawal pointed out, more than half of states don’t even examine why a maternal death happens in the first place.
When it comes to countries where the maternal mortality rate has gone up, "the U.S is the only industrialized country in that list — not Sierra Leone, not Afghanistan, not India," Dr. Agrawal says. "The deaths are the tip of the iceberg. For every single death, there are 60 women in America — so one woman every 8 to 10 minutes — experiencing what we call a 'near miss' [nearly dying]."
That there isn't more research on a national scale being done to figure out why — and what can be done to prevent that — is indicative of the ways in which women's health is often sidelined. It seems that the real reason so many women are still dying in America is that we just don't prioritize maternal health enough as a culture.
"The public does not realize that women are dying during pregnancy and childbirth in this country, which leads to little public pressure to make change. Investment in maternal health also requires us to recognize and value women," Dr. Agrawal says. "As one of the maternal health visionaries, Mahmoud Fathalla, said, 'Women are not dying of diseases we cannot treat ... They are dying because societies have yet to make the decision that their lives are worth saving.'"
I know I think their lives are worth saving — so let's ask that these fatalities be counted, and that more research be done to protect our new mothers.
You can sign the petition for mandatory reporting of maternal mortality here.
Images: ABC; Giphy