Exploring the dramatic rise of maternal mortality

The U.S. pays more for health care than any other country, but that’s not buying good health for many Americans. We’re going to look, now, at one example of the paradox. There is a perplexing increase in deaths related to pregnancy. The words “died in childbirth” may evoke an earlier time, or perhaps another place. They’re not usually associated with developed nations.

But, in this regard, as Nathanael Johnson reports from KALW’s archives, the U.S. is starting to look less and less like a first-world country.

*    *     *

NATHANAEL JOHNSON: To see how much birth has been transformed by technology, you only have to go to YouTube.

UNIDENTIFIED MAN: We're moving right along here at a fever pitch, getting close to being inside where the baby is ...

These days it's common for dads to bring handheld video cameras into operating rooms, showing scenes that were once only visible to the obstetricians and nurses who worked there.

This one is labeled "My Awesome C-Section."

UNIDENTIFIED MAN: Ooh, big shoulders, I'm telling ya. Supposed to be a boy? (baby crying) ...

The mise-en-scène of these movies is full of gadgets: fetal heart monitors, IV towers, surgeons in green scrubs. All of these improvements have come at a price – an average cost of $7500 if there are no complications. It costs more to give birth in the U.S. than anywhere else in the world, and you'd think with all this money and technology we'd be getting better at birth. But we're not. One statistic has doctors particularly worried – more and more women are dying in childbirth.

DR. ELLIOTT MAIN: Unfortunately, maternal mortality has doubled. Over the last five years in California for the first time in 50 years, we've seen a significant rise.

Dr. Elliott Main is a high-risk pregnancy specialist at the California Pacific Medical Center in San Francisco. We don't know exactly what is causing the increase, but Main says there's enough information to start making hypotheses.

MAIN: What I call the "usual suspects" are certainly there, in that mothers can be older, mothers can have more underlying medical problems and mothers are heavier than they used to be. However, when we looked at those factors in the data analyzed so far, those only account for only a modest amount of the increase. We are also looking at what else has changed in the last ten years in obstetric practice and we have to analyze carefully such things as the rapidly rising cesarean birth rate.

The c-section rate has gone up more than 50% since the 90s. The parallel spikes in cesareans and maternal deaths stand out like double exclamation points when researchers like Debra Bingham, chair of the Lamaze Institute for Normal Birth, look at the data.

DEBRA BINGHAM: I see the rates of maternal mortality more likely going up before they go down until we get less c-sections happening.

C-sections are wonderfully effective at solving the short-term problem – they get the baby out. But in the long-term, they can be dangerous. Sometimes the next placenta will grow into an old c-section scar in the uterus. In the worst cases, the placenta breaks through and sends blood-seeking vessels into the woman's organs.

These conditions are called placenta accreta, percreta, and increta in order of increasing severity. And they are all severe. If something goes wrong, a woman can bleed out, even in a well-equipped operating room. The state has already started pilot projects to better prepare hospital staff for hemorrhages, to reduce the number of labor inductions and to give low-income women control of their medical records so they can carry their charts from one doctor to another.

The state isn't bringing new techniques to lower the cesarean rate, but at a national level, the CDC has been pushing for fewer c-sections since 1990. That hasn't changed things, says high-risk pregnancy specialist Dr. Elliott Main.

MAIN: Doctors are saying, "Well, the patients want more c-sections." Patients are saying, "Well, the doctors are introducing the concept of c-section." No one wants to take risk.

Last year, the Childbirth Connection, a non-profit advocacy group, released a report showing that much of what ends up happening in this country's delivery rooms is not based on evidence. To quote: "Practices which are disproved or are appropriate for mothers and babies in limited circumstances are in wide use."

Odd as it may sound, the key to healthier births may simply be less -- less technology, less health care, less money.

For Crosscurrents, I'm Nathanael Johnson.

Hear Nathanael Johnson's full report on maternal mortality, which aired July 20, 2009.