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Hullabaloo


Friday, May 12, 2017

 

Rising U.S. deaths in childbirth

by Tom Sullivan

"The way that we've been trained, we do not give women enough information for them to manage their health postpartum. The focus had always been on babies and not on mothers."
One of the glories of modern medicine is that it reduced the mortality rate women faced from childbearing since the beginning of time. It is one measure of a civilization's advancement that infant mortality falls. Sadly, the survival of mothers is less of a focus, an afterthought. A report from Pro-Publica and NPR this morning examines just how that has gone wrong:
As a neonatal intensive care nurse, Lauren Bloomstein had been taking care of other people's babies for years. Finally, at 33, she was expecting one of her own. The prospect of becoming a mother made her giddy, her husband Larry recalled recently— "the happiest and most alive I'd ever seen her."
That's enough for you to know what comes next. Lauren, a nurse married to a doctor, died of complications from childbirth in her own hospital twenty hours after giving birth to her daughter.
In the U.S., unlike some other developed countries, maternal deaths are treated as a private tragedy rather than as a public health catastrophe. A death in childbirth may be mourned on Facebook or memorialized on GoFundMe, but it is rarely reported in the news. Most obituaries, Lauren's included, don't mention how a mother died.
It's a gut-wrenching story chronicling the hours of pain leading to her death. The research shines a light on a trend that further discredits the lie that the U.S. has the best health care system in the world. NPR has audio here. "America is the most dangerous place in the developed world to have a baby," it begins. The emphasis has been on infants, leaving mothers almost an afterthought.

There are not even good records kept. In the United Kingdom, however,
... maternal deaths are regarded as systems failures. A national committee of experts scrutinizes every death of a woman from pregnancy or childbirth complications, collecting medical records and assessments from caregivers, conducting rigorous analyses of the data, and publishing reports that help set policy for hospitals throughout the country. Coroners also sometimes hold public inquests, forcing hospitals and their staffs to answer for their mistakes. The U.K. process is largely responsible for the stunning reduction in preeclampsia deaths in Britain, the committee noted its 2016 report — "a clear success story" that it hoped to repeat "across other medical and mental health causes of maternal death."
The U.S. has no comparable system , the report finds.
The reasons for higher maternal mortality in the U.S. are manifold. New mothers are older than they used to be, with more complex medical histories. Half of pregnancies in the U.S. are unplanned, so many women don't address chronic health issues beforehand. Greater prevalence of C-sections leads to more life-threatening complications. The fragmented health system makes it harder for new mothers, especially those without good insurance, to get the care they need. Confusion about how to recognize worrisome symptoms and treat obstetric emergencies makes caregivers more prone to error.

Yet the worsening U.S. maternal mortality numbers contrast sharply with the impressive progress in saving babies' lives. Infant mortality has fallen to its lowest point in history, the CDC reports, reflecting 50 years of efforts by the public health community to prevent birth defects, reduce preterm birth, and improve outcomes for very premature infants. The number of babies who die annually in the U.S. — about 23,000 in 2014 — still greatly exceeds the number of expectant and new mothers who die, but the ratio is narrowing.

The divergent trends for mothers and babies highlight a theme that has emerged repeatedly in ProPublica's and NPR's reporting. In recent decades, under the assumption that it had conquered maternal mortality, the American medical system has focused more on fetal and infant safety and survival than on the mother's health and wellbeing.

"We worry a lot about vulnerable little babies," said Barbara Levy, vice president for health policy/advocacy at the American Congress of Obstetricians and Gynecologists (ACOG) and a member of the Council on Patient Safety in Women's Health Care. Meanwhile, "we don't pay enough attention to those things that can be catastrophic for women."

At the federally funded Maternal-Fetal Medicine Units Network, the preeminent obstetric research collaborative in the U.S., only four of the 34 initiatives listed in its online database primarily target mothers, versus 24 aimed at improving outcomes for infants (the remainder address both).

Under the Title V federal-state program supporting maternal and child health, states devoted about 6 percent of block grants in 2016 to programs for mothers, compared to 78 percent for infants and special-needs children. The notion that babies deserve more care than mothers is similarly enshrined in the Medicaid program, which pays for about 45 percent of births. In many states, the program covers moms for 60 days postpartum, their infants for a full year. The bill to replace the Affordable Care Act, adopted by the U.S. House of Representatives earlier this month, could gut Medicaid for mothers and babies alike.
And you wonder why people at town halls are shouting down their congressmen.
When women are discharged, they routinely receive information about how to breastfeed and what to do if their newborn is sick but not necessarily how to tell if they need medical attention themselves. "It was only when I had my own child that I realized, 'Oh my goodness. That was completely insufficient information,'" said Elizabeth Howell, professor of obstetrics and gynecology at the Icahn School of Medicine at Mount Sinai Hospital in New York City.

"The way that we've been trained, we do not give women enough information for them to manage their health postpartum. The focus had always been on babies and not on mothers."
If a nurse married to a doctor can die of complications from childbirth in her own hospital, how about the average expectant mother? But no worries. This guy is going to fix everything. You're gonna love it: