Maternal mortality rates are increasing, not decreasing, in the United States, according to several recent reports. Deadly Delivery, a 2010 report by Amnesty International (http://www.amnestyusa.org/dignity/pdf/DeadlyDelivery.pdf), notes that the likelihood of a woman dying in childbirth in the U.S. is five times greater than in Greece, four times greater than in Germany, and three times greater than in Spain (Block J. Time March 12, 2010). Black women are four times as likely as white women to die from pregnancy-related causes in the U.S. Following on the heels of the Amnesty International report, a Sentinel Event Alert, “Preventing Maternal Death,” issued by the Joint Commission, the leading accreditation and certification group for hospitals in the U.S. (Joint Commission News Releases, January 26, 2010) points out that in 2006 the national maternal mortality rate was 13.3 deaths per 100,000 live births, which is double that in 1987 (6.6 deaths per 100,000). “There clearly has been no decrease in maternal mortality in recent years, and we are not moving toward the U.S. government’s Healthy People 2010 target of no more than 3.3 maternal deaths per 100,000 live births,” said William M. Callaghan, MD, MPH, senior scientist, Division of Reproductive Health, Centers for Disease Control and Prevention.
In California the maternal mortality rate has nearly tripled since 1996, according to California Watch, a project of the Center for Investigative Reporting (Health Release“Alarming Increase in Maternal Mortality Rate,” February 2, 2010), and reported by ABC World News, March 4, 2010. In 1996 the maternal death rate was 5.6 per 100,000, and since then it has steadily risen to 16.9 per 100,000 in 2006 (http://www.cmqcc.org/maternal_mortality). The California Department of Public Health has commissioned a soon-to-be released investigative report by the California Maternal Quality Care Collaborative (CMQCC). “We haven’t seen these rates of maternal death since the 70s,” said Christine Morton, a member of the CMQCC. “You don’t expect childbirth outcomes to go backward. That’s concerning,” she said.
In 2008, the Hospital Corporation of America looked at individual causes of maternal deaths among 1.5 million births within 124 hospitals in the previous 6 years (Clark SL, et al: Maternal death in the 21st century: Causes, prevention, and relationship to caesarean delivery. Am J Obstet Gynecol 2008;199(1):91–92). The study concluded that most maternal deaths are not preventable, but noted that the most common preventable errors are:
- • Failure to adequately control blood pressure in hypertensive women
- • Failure to adequately diagnose and treat pulmonary edema in women with pre-eclampsia
- • Failure to pay attention to vital signs following cesarean section
- • Hemorrhage following cesarean section
Nearly half of all births in China are delivered by cesarean section, the world’s highest rate, according to a global survey focusing on Asia by the World Health Organization (WHO) (Lancet 2010;375:490–499). It warned that a boom in unnecessary surgeries is jeopardizing women’s health and that rates of cesareans have reached “epidemic proportions’’ in many countries worldwide. In China, 46 percent of births reviewed in a survey of hospital records were cesarean deliveries, one fourth of which were not medically necessary; they were partially motivated by hospitals eager to make more money, the report said. The WHO reviewed nearly 110,000 births in nine Asian countries in 2007–2008. Similar results were reported by WHO in 2005 from Latin America, where 35 percent of pregnant women surveyed gave birth by cesarean section. “The relative safety of the operation leads people to think it’s as safe as vaginal birth,’’ said Dr. A. Metin Gulmezoglu, from the WHO, who coauthored the report. The most important finding of the Asian survey was the increased risk of maternal mortality and severe morbidity in women who underwent a cesarean section without medical indication. Reasons for elective cesarean sections vary globally, but increasing rates in many developing countries coincide with a rise in patients’ wealth and improved medical facilities. The authors concluded that “Caesarean section should be done only when there is a medical indication to improve the outcome for the mother or the baby.”
Australia’s cesarean delivery rate has stabilized, with only a 0.1 percent rise from 30.8 percent in 2006 to 30.9 percent in 2007, according to the report of Australia’s Mothers and Babies 2007 from the Australian Institute of Health and Welfare (AIHW National Perinatal Statistics Unit, December 2009). Over the past 10 years the cesarean birth rate has shown an overall upward trend. Australia’s baby boom continued with 12,036 more births (4.3%) than reported in 2006 and 14.4 percent more than in 2004. Of all women who gave birth in 2007, 57.9 percent had a noninstrumental vaginal birth, and 2.0 percent (n = 16,969) gave birth in a birth center. In 2007 the primary cesarean section rate was 21 percent, reported for the first time. “This is an important measure to monitor as it is a risk factor for subsequent caesarean births, with 83% of women who had previously given birth by caesarean section giving birth by caesarean section in 2007,” said Dr. Elizabeth Sullivan, Director of the AIHW National Perinatal Statistics Unit. The rate of primary cesarean births was higher among first time mothers at 32 percent compared with 10 percent for mothers who had previously given birth. New data on pain relief showed that 74.8 percent of women had analgesia in labor. The most common type was nitrous oxide (49.7%), followed by epidural or caudal (28.2%). Labor was induced for 25.3 percent of mothers, and augmented for 20 percent. A total of 12 percent of women had an episiotomy in 2007. Approximately 3 percent of women who gave birth in 2007 received assisted reproductive technology (ART) treatment. The full report is available free of charge from the AIHW website at http://www.aihw.gov.au.
Home births in the United States rose 5 percent in 2005–2006, after a 15-year decline, according to a new report from the National Center for Health Statistics, Trends and Characteristics of Home and Other Out-of-Hospital Births in the United States, 1990–2006 (MacDorman M, Menacker F, Declercq E. Natl Vital Stat Rep 2010;58(11):1–16). Data were based on birth certificates for the approximately 4.3 million live births registered in the United States in 2006. There were 38,568 out-of-hospital births in the United States in 2006, including 24,970 home births and 10,781 occurring in a free-standing birth center. After a gradual decline from 1990 to 2004, the percentage of out-of-hospital births increased by 3 percent from 0.87 percent in 2004 to 0.90 percent in 2005 and 2006. The pattern was similar for home births. After a gradual decline from 1990 to 2004, the percentage of home births increased by 5 percent to 0.59 percent in 2005 and remained steady in 2006.
Compared with the U.S. average, home birth rates were higher for non-Hispanic white women, married women, women aged 25 and older, and women with several previous children. Home births were less likely than hospital births to be preterm, low birthweight, or multiple deliveries. The percentage of home births was 74 percent higher in rural counties of less than 100,000 population than in counties with a population size of 100,000 or more. The percentage of home births also varied widely by state; in Vermont and Montana more than 2 percent of births in 2005–2006 were home births, compared with less than 0.2 percent in Louisiana and Nebraska. Approximately 61 percent of home births were delivered by midwives. Among midwife-delivered home births, one-fourth (27%) were delivered by certified nurse-midwives, and nearly three-fourths (73%) were delivered by other midwives. The report is available free of charge at: http://www.cdc.gov/nchs.
Restriction of fluids or food in labor is not justified for women at low risk for complications, according to a recently published Cochrane review (Singata M, Tranmer J, Gyte GML, Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD003930. DOI: 10.1002/14651858.CD003930.pub2). Restricting fluids and food during labor is common practice in many birth settings and countries, with women often only allowed sips of water or ice chips. The review noted that “Restriction of oral intake may be unpleasant for some women, and may adversely affect their experience of labour.” The review examined five studies involving 3,130 women. Selection criteria for the studies included randomized controlled trials and quasi-randomized controlled trials of restricting fluids and food for women in labor compared with women who were free to eat and drink. The review “identified no benefits or harms of restricting foods and fluids at low risk of needing anaesthesia.” The authors therefore concluded that “given these findings, women should be free to eat and drink in labour, or not, as they wish.”
Two landmark reports have recently been released by the advocacy group, Childbirth Connection. Together, they create a framework for revamping maternity care in the United States and advancing health care reform: 2020 Vision for a High Quality, High Value Maternity Care System and Blueprint for Action. The reports were developed through an extensive multi-year collaboration with more than 100 maternity care leaders representing industry stakeholders—from hospitals and health plans to health care consumers and providers.
Maternity care is the runaway leader in hospital charges and is the number one reason for hospitalization in the country, the authors report. Maternal and newborn hospital charges alone exceeded $86 billion in 2007. Although most childbearing women and their babies are healthy and at low risk, the current style of maternity care is technology-intensive. Costly and risky childbirth procedures are overused and wasteful, while proved ones that are generally safer and less expensive are underused. Significant disparities in access, quality, and outcomes persist, with many maternal and newborn health indicators moving in the wrong direction.
The Blueprint for Action answers the question “Who needs to do what, to, with and for whom to improve the quality of maternity care over the next five years?” Actionable strategies to improve maternity care quality and value are centered on eleven critical focus areas for change:
- • Performance measurement and leveraging of results
- • Payment reform to align incentives with quality
- • Disparities in access and outcomes of maternity care
- • Improved functioning of the liability system
- • Scope of covered maternity care services
- • Coordination of care across time, settings and disciplines
- • Clinical controversies
- • Decision-making and consumer choice
- • Scope, content and availability of health professions education
- • Workforce composition and distribution
- • Development and use of health information technology
The Blueprint for Action is the first step in a long-term initiative to undertake collaborative national, regional, and local endeavors to improve maternity care quality and value. The 2020 Vision and Blueprint for Action reports are freely available on the Women’s Health Issues website at: http://www.sciencedirect.com/science/issue/5192-2010-999799998.8998-1591119.
Reports of forced sterilizations in Uzbekistan, formerly part of the Soviet Union, have been made by a human rights group Najot and independent Uzbek think tank, according to the Associated Press (Mirovalev M. Google/Associated Press, March 2, 2010). The groups allege that the government Health Ministry has instructed government doctors to perform hysterectomies on women as an “effective contraceptive” to help control the nation’s population. In mid-February a government decree was passed recommending hysterectomy and persuading “at least two women per month” to have the procedure. Doctors who fail to follow the decree face reprisals and fines. According to a 2009 Najot report, hospital doctors often sterilize women after their second child without their consent. In 2007, the United Nations Committee Against Torture reported a “large number” of cases of forced sterilization and removal of reproductive organs in Uzbek women, often after cesarean sections. Some women were abandoned by their husbands as a result, it said. Uzbekistan has a population of 27 million that has been growing quickly. The practice of forced sterilization dates back to 1999, when Uzbek President Islam Karimov expressed dissatisfaction with the high birth rate and ordered measures to curb it.