On March 4th (2010), ABC News ran a story proclaiming: “Maternal Mortality Rates Rising in California -- New Study Shows More Women are Dying After Childbirth, but Most Deaths are Preventable”

It’s good that the media picked up this long-neglected story, but unfortunately the article draws the wrong conclusions, while failing to identify the real issue. According to this article, the increase in maternal deaths is being brought on mothers themselves – more women are dying because so many pregnant women are obese and so many women are foolishly demanding risky surgical deliveries. According to this theory, the obstetrical profession is just the helpless victim of the poor judgment of childbearing women who are forcing doctors to perform dangerous procedures.

ABC’s fact-checkers also misunderstood the crucial statistics on so-called ‘maternal choice’ Cesareans – they were wrong by a factor of *30*. Worse yet, the article only mentions the connection between fatalities due to surgical delivery and the sky-rocketing rate of elective Cesarean deliveries in a headline. However, the article itself never acknowledges the overuse of C-sections based on “physician preference” and hospital policies.

Many healthy women with normal twin, breech or VBAC pregnancies being required by their OBs or by hospital policy to have so-called "elective" C-sections, when in fact, the mother did not choose or prefer a surgical delivery. In other instances, obstetricians are doing C-sections for reasons not justified by the medical science – older or overweight mother, a post-date pregnancy, slow progress, a fetal monitor tracing that is other than perfect, or in a misguided attempt to prevent shoulder dystocia in what the provider fears may be a big baby.

When the article does suggest a remedy, it’s to recommend that every hospital have several $4,600 dollar medical devises to prevent blood clots, which are used AFTER the C-section is performed – never a whisper to suggest that the best way to prevent unnecessary maternal deaths from post-operative complications is to prevent medically unnecessary Cesarean surgeries.

Here is the jest of the ABC article [emphasis mine], followed by additional comments:

“According to the World Health Organization, the U.S. ranks behind more than 40 other countries when it comes to maternal death rates, with 11 deaths per 100,000 pregnancies when measured in 2005. More women die in the U.S. after giving birth than die in countries including Poland, Croatia, Italy and Canada, to name a few.

A new report out of California found the number of women who died in the state after giving birth has nearly tripled over the past decade, from 5.6 deaths per 100,000 to *16.9 per 100,000* in 2006. The report was commissioned by the California Department of Health but has not yet been publicly released. ABC News first learned of its existence from a watchdog group called "California Watch." www.californiawatch.org

Death after childbirth is still rare, but experts say many of those deaths could have been prevented. "We've been able to double-check the data so we can truly say there is a rise," said Dr. Elliott Main, chairman of the California Maternal Quality Care Collaborative, which worked on the report.

The Joint Commission, the leading accreditation and certification group in the United States for hospitals, issued an alert Jan. 26, 2010 stating that "current trends and evidence suggest that maternal mortality rates may be increasing in the United States."

"As many as half of maternal deaths are preventable," said Dr. Mark Chassin, president of the Joint Commission. "The rate of maternal death today is not acceptable in the United States. We need to work much harder than we have been to reduce it."

In some cases, the chances of maternal mortality rise simply because important warning signs are missed. [New father] Jim Scythes knows first-hand how important those warning signs are and how tragic the consequences of missing them can be.

"I just think it's unbelievable that in our country today people still die of childbirth," said Jim Scythe. "I had no idea that anything like that could've happened when we went to the hospital that Friday morning."

It was March of 2007. Jim's wife Valerie had a scheduled cesarean section that seemed to go well. Their daughter Isabella was born. But by the next day, Jim started to notice clues that all was not well. He says his wife's legs felt hard to the touch. "She sat in her bed for 30 hours after her surgery and then got herself up and collapsed," Scythe said. A blood clot in Valerie's leg had moved to her brain and caused a stroke. She later died.

Doctors Say Obesity & C-Sections May be Increasing Risk:

Doctors say it's hard to pinpoint exactly why the numbers are rising. Experts have cited the *growing number of obese mothers* as a big factor -- 20 percent of all pregnant women in the U.S. are now obese at the start of their pregnancy, according to the Centers for Disease Control. These women are more likely to have underlying health conditions, including diabetes or asthma, which can lead to pregnancy-related complications.”

The *popularity of scheduled C-sections* has also been cited by public health experts as a possible cause for rising maternal mortality rates. The *latest data from the CDC shows that 31 percent of the mothers now choose to have C-sections, up 50 percent since 1996*. Studies have repeatedly shown a higher rate of mortality in mothers who have a C-section delivery, especially those who have multiple C-sections.

"If the risks of a Cesarean birth are small, they're magnified greatly when you add many more Cesarean births each year," said Main, adding that "not that many women actually choose to have an elective C-section at the beginning, but it's easy to fall into a pattern of care that ends up resulting in a C-section."

While no one can know for certain in Valerie Scythes' case, simple devices called compression boots could have helped. The boots are worn around the calves and keep blood pumping to hopefully prevent clots.

Mt. Sinai Hospital in New York is at the cutting edge of preventing maternal mortality, trying to turn the trend around in the United States. For women who have a C-section at Mt. Sinai, inflatable boots are standard practice, but providing the extra treatment can be expensive.

While the compression boots cost only $14, the machine that inflates them costs $4,600. Dupree admits that the costs and lack of awareness of the technology might be keeping some hospitals from using compression boots, but a good portion of what Mt. Sinai does costs nothing at all.

Doctors and nurses at Mt. Sinai work constantly at improving communication and training to make sure that staff members ask patients the right questions and that patients are empowered to speak up when something doesn't feel right.

For more on maternal mortality and pregnancy complications, visit the CDC's page on the topic by clicking here.

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Here is my reply as posted on the ABC blog:

This overuse and misuse of Cesarean surgery is not the result of women 'demanding' C-sections.

Post-operative maternal mortality is not primarily a consequence of the mother’s age or weight.

ABC's facts are just wrong -- 31% of childbearing women do NOT choose an elective C-section -- 31% is the *total* C-section rate in the US, not the rate of so-called "maternal choice" Cesareans.

The real number for women who elect to have a medically unnecessary or ‘elective’ C-section is less than 1%. Research done by Childbirth Connection's "Listening to Mothers Survey" 2006 found only 1 new mother out of 1,600 who requested a C-section (www.childbirthconnection.org).

Sociologist Raymond DeVries, professor of bio-ethics at the U. of Mich School of Medicine, has done extensive research on this issue with similar results, as has Gene Declercq, PhD and professor in the department of Maternal-Child health at Boston University. A powerpoint PDF document with this data can be downloaded at:

www.motherfriendly.org/pdf/2008_CIMS_Gene_Declercq.pdf

Additional scientific information on the risks of Cesarean is also available @ www.motherfriendly.org.

The way to eliminate preventable post-operative complications and death after elective reproductive surgery is not by spending more money for more expensive equipment like the special $14 compression boots that require a $4,600 machine. This suggestion sounds like an info-mercial for the medical equipment lobby and the hospitals buying such expensive products.

On a practical level, no new post-op patient should ever be just "sitting in bed for 30 hours". Good nursing care requires that post-op patients get up and walk around within a few hours of surgery and continue to move about on a regular schedule to prevent pneumonia and deep vein blood clots associated with surgery. This is a time-tested and inexpensive method to prevent DVTs. For women with unusual risk-factors, the use of compression boots may well be warranted, but this technology is not a replacement for using common-sense when it come to elective use of major abdominal surgery.

The only good reason for a risky medical or surgical procedure is a serious health problem that makes the potentially life-threatening complications of surgery less of a danger than the disease being treated. In the absence of a potentially life-threatening condition, potentially life-saving medical interventions are themselves life-threatening.

There is no getting around the facts: Cesarean surgery, as the route of delivery, is associated with 33 serious complications – a number 8 times greater that the risks of vaginal birth. Not only is the risk of maternal death 3 to 5 times greater during or after operative delivery, but for every post-Cesarean maternal death there are a 100 new mothers who suffer a serious complication, such as emergency hysterectomy, secondary infertility or stillbirth in a subsequent pregnancy.

The lives of mothers and babies are depending on us to replace the well-meaning but ill-advised ‘pre-emptive’ use of technology and routine interventions with a genuinely evidence-based and cost-effective mother-baby-father-friendly model of maternity care.

Tomorrow I’ll comment on the unnecessary medicalization of normal birth, with its emphasis on elective procedures such as induction and scheduled Cesarean, and identify the only antidote to routine medicalization. Stay tuned….