03.24.10

Why Are So Many Moms Dying?

New research shows the American maternal death rate is far higher than in other Western nations. From C-sections to the obesity epidemic, Danielle Friedman investigates what’s causing the problem.

After more than a decade leading outdoor expeditions across the mountains of Montana and Utah, Karen Sclafani prepared to face a new challenge: pregnancy and parenthood.

Vibrant and fit, the 37-year-old vegan had originally planned for a natural delivery. A few days before her due date in February 2004, however, she was diagnosed with preeclampsia—a type of pregnancy-induced hypertension—and checked into a hospital near her home in southwest Montana, where nurses gave her medicine to control her blood pressure and induce delivery.

After only four hours of labor, Sclafani delivered a healthy baby girl. Over the next day, however, her condition took a horrific turn. When she didn’t deliver her placenta, her doctors performed surgery to remove it; shortly after, her heart stopped beating. Doctors realized she had suffered a hemorrhage, and despite their efforts to save her, two days later Sclafani was dead.

What began as the happiest week of her husband’s life quickly deteriorated into the worst, as he became a widower and a new parent all at once. “I went into survival mode,” Brian Maffly told The Daily Beast. “I tried to pull as much joy as I could out of parenting this tiny baby, this amazing child,” he said, all the while grieving his wife and grappling with his belief that, if doctors had paid closer attention to her condition, she might have been saved.

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Karen Sclafani and Brian Maffly (Photo courtesy Brian Maffly)

Sclafani’s story is part of a troubling trend: Over the past decade, the U.S. maternal mortality rate has nearly doubled, with about 500 women dying of pregnancy-related complications each year. That’s a tiny percentage of the 4 million American women who give birth annually. But what’s shocking is that among industrialized countries, the U.S. ranks an abysmal 41st on the World Health Organization’s list of maternal death rates, behind South Korea and Bosnia—yet we spend more money on maternity care than any other nation.

“There are guys like me all over the place who become these widowed fathers of infants, who are too grief-stricken to raise a big stink,” Maffly said. “I just wanted to get on with life. But I think a lot of these deaths are avoidable.”

Over the past three months, alarms have begun to sound: On Jan. 26, the Joint Commission, the country’s top health-care standards group, issued a “Sentinel Event Alert” to hospitals about the trend. Amnesty International has designated the U.S. maternal mortality rate a human-rights concern. This month, the organization called on President Barack Obama to address the crisis, noting that two to three women die of pregnancy-related complications in this country every day, as we move further away from the government’s goal of 3.3 deaths per 100,000 live births. The health-care reform bill signed into law by Obama Tuesday could help, as it requires insurance companies, for the first time, to cover prenatal care and some childbirth costs.

Skeptics attribute the rise in the maternal mortality rate to better reporting of maternal deaths—and it’s true that over the past decade, states have revised death certificates to better flag pregnancy-related mortalities. Yet review committees estimate that better reporting only accounts for about 30 to 40 percent of the rise.

More likely, the maternal death rate is going up due to a complex cocktail of factors—causes that reflect a changing population, disparities in poor women’s access to health care, and even Americans’ reliance on cutting-edge medicine. As the public health and medical fields mobilize to reverse the trend, The Daily Beast looks at seven explanations for the unsettling rise.

1. A Skyrocketing Caesarean Rate

Before C-sections became as safe and standard as they are today, pregnant women had few options if they found themselves in an emergency situation; aside from metal forceps, doctors lacked tools to get babies out quickly, which often led to tragedy.

Yet as lifesaving as C-sections can be, an astounding one in three American women now give birth surgically, up from one in five a decade ago. The World Health Organization says that the country’s rate shouldn’t be above 15 percent, which suggests that more than half of U.S. C-sections are medically unnecessary. “When you see that C-section rates have increased, you have to consider [the correlation to the maternal death rate],” Maureen Corry, president of the advocacy group Childbirth Connection, told The Daily Beast. “There are good indicators that there’s some connection between the two.”

That’s because C-sections are major surgery. Healthy women who give birth surgically are 80 percent more likely to be re-hospitalized than healthy women who give birth vaginally; they’re also four times more likely to die. Hemorrhage, infection, and pulmonary embolism are all more common following a surgical birth.

2. More Obese Moms

As the obesity epidemic swept the country, more overweight women have gotten pregnant and given birth, despite serious risks. One in five women in the U.S. are now obese at the beginning of their pregnancy, according to the Centers for Disease Control. Obese women are more likely to develop hypertension, high blood pressure, and diabetes during pregnancy, which can lead to preeclampsia and other fatal conditions. Preeclampsia is responsible for about 18 percent of maternal deaths in the U.S., and over the past decade, the incidence of the condition rose by 40 percent.

Labor can also be more difficult for obese women, as soft tissue can impede delivery. Obese women are also at greater risk for delivering bigger babies, needing C-sections, and developing postpartum infections and heart problems.

3. Disparities in Access to Care

As economic disparities in the U.S. health-care system grew wider over the past several decades, fewer women got the family planning, prenatal, and postpartum care they needed. Currently, one in five women of childbearing age are uninsured, Amnesty International reports. In most states, poor women do qualify for Medicaid once they become pregnant; the problem is, six weeks after giving birth, most of these women are dropped. “Medicaid’s job is to deliver a baby,” said Gene Declercq, a maternal-health expert at Boston University’s School of Public Health. “These women are just vessels for delivering babies.”

From there, a dangerous cycle can begin: If a woman has risk factors going into her first pregnancy—say, diabetes or hypertension—the conditions often get worse through the process. She can’t afford the medical care to treat her conditions. Nor can she afford contraceptives, so she often ends up getting pregnant again, this time facing even greater risks. By the time she’s back on Medicaid for her next pregnancy, she’s in big trouble.

The good news is that the new health-care reform legislation will expand access to Medicaid for about 15 million people, and will include prenatal and maternal care in the basic package of services private insurers must cover.

4. Unnecessary Medical Interventions

Like C-sections, medical innovations such as drugs to induce labor and devices to monitor fetal heart rates can be lifesaving, but they can also lead to complications in healthy women. When an intervention is unnecessary—performed out of convenience or protocol—the harms can outweigh the benefits. “We’re doing more and accomplishing less,” Corry said.

In many developed countries, induction is used as a last resort, but in the U.S., hospitals induce or accelerate roughly 40 percent of labors. These drugs, in turn, can create more aggressive contractions, which increase the risk of uterine rupture. A woman who is induced is also more likely to end up needing a C-section.

5. Older Moms

As the rate of childbearing women over 40 has risen, so has the maternal mortality rate. Moms over 35 are more likely to develop gestational diabetes and other complications; they’re also more likely to have twins or other multiples, thanks both to biology and the wonders of fertility treatment—and multiple births are far riskier than single births, for both mother and babies.

But Elliott Main, a San Francisco-based OB/GYN and principal investigator of the California Maternal Quality Care Collaborative, warned against pegging the rising maternal mortality rate solely to changing demographics: Mothers over 40 have a higher death rate than younger mothers, he told The Daily Beast, but most American women who die in childbirth are in their twenties or thirties.

6. Poor Birth Education

Maternity-care advocates stress that as birth has become increasingly medicalized, American women have become surprisingly uneducated on the topic. “I don’t believe that women have all the information they need to make truly informed decisions,” said Corry of Childbirth Connection.

In particular, low-income women with limited access to health care may not be aware of the risks of taking certain medications or engaging in certain behaviors during pregnancy. Similarly, advocates point out that with C-sections and interventions on the rise, women feel less empowered to take control of their birth experience—they don’t always know their options or trust their instincts. They must rely completely on hospital staff, who are often overworked, exhausted, and juggling many births at once.

7. Complacency

Despite the rising maternal mortality rate, pregnancy-related deaths in this country are still rare. Most doctors and nurses will go their entire career without encountering one. Yet as a result, many hospitals have become “complacent that mothers just don’t die anymore,” said OB/GYN Main. “There’s been a little relaxation,” and women’s lives are sometimes lost as a result.

Most pregnant women are healthy, Main explained. But “rather than saying, we can get away with a lot because women are basically young and healthy and can withstand a lot before they get into trouble,” hospitals need to act proactively, paying closer attention to changes in women’s vital signs.

Although Karen Sclafani was deemed high-risk because of her preeclampsia, her widower believes that because she appeared fit and healthy, physicians did not heed potential warning signs as they should have.

“They weren’t really looking at this patient, they were looking at a series of interventions,” said Maffly, who received a settlement from Karen’s doctors and has since remarried. “If they had been treating her more as a human being, they would have seen that something was wrong.”

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Danielle Friedman has worked as a nonfiction book editor for Hudson Street Press and Plume, two imprints of Penguin Group. Her writing has been published in the Miami Herald, the Seattle Post-Intelligencer and on CNN.com. She is a graduate of the Columbia University Graduate School of Journalism.