In April, a New York Times article cited a study from the medical journal The Lancet that indicated for the first time in decades, researchers are seeing a significant drop worldwide in the number of women dying each year from pregnancy and childbirth, to about 342,900 in 2008 from 526,300 in 1980.
Several reasons were noted for the improvement: lower pregnancy rates in some countries; higher income, which improves nutrition and access to health care; more education for women; and the increasing availability of "skilled attendants" - people with some medical training - to help women give birth. Improvements in large countries like India and China helped to drive down the overall death rates.
Other groups disagree with the rosy outlook and argue that much work remains to be done. After all, over 340,000 women still die each year because of pregnancy-related causes. This is, in our assessment, a major indication that efforts need to continue and, in some areas, intensify.
A January 2010 Sentinel Report from the Joint Commission stated that current trends and evidence suggest that maternal mortality rates may be increasing in the US. The most common preventable errors include failure to adequately control blood pressure in hypertensive women, failure to adequately diagnose and treat pulmonary edema in women with preeclampsia and two more causes related to Cesarean section deliveries. The report goes on to explain that the maternal deaths are really only the tip of the iceberg and that behind every death are scores of “near misses” that warrant equal scrutiny.
In March, Amnesty International released their shattering report, Deadly Delivery. According to their analysis of US statistics, maternal mortality ratios have increased from 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006. The United States spends more on health care than any other country in the world, and the highest percentage of those dollars (about $86 billion) is spent on maternity care; yet, two to three American women die per day of pregnancy-related causes, making women in the United States - particularly minorities - more likely than their counterparts in 40 other countries to die having a baby. Significant media coverage resulted from the publication of Deadly Delivery including CNN, the Washington Post, and Time magazine.
In his opening remarks at a Congressional briefing, Dr. Larry Cox, the executive director of Amnesty International U.S.A., called the current situation "a human rights crisis" and called for the establishment of a federal office of maternal health, among other measures. So which is it - are maternal mortality rates improving as The Lancet study suggests, or are the risks associated with pregnancy in a state of "crisis" in this country, as Deadly Delivery suggests?
Over the past decade, we have worked with the Centers for Disease Control and Prevention (CDC) to try to get a handle on the role of preeclampsia and related disorders on the maternal mortality rate in this country and one thing is quite clear: maternal death rates are severely under-reported in the US due to huge fluctuations in how individual states report maternal deaths and their causes.
Often a maternal death is categorized based on the downstream impact (or "sequela" in medical terms) of preeclampsia. For instance, cause of death may be reported as disseminated intravascular coagulation (DIC), which means the woman bled to death; however, the precipitating event was development of HELLP syndrome, a variant of preeclampsia. And, in very few instances are the maternal death cases aggregated and examined to identify common points of failure in diagnosis or care which could provide a benchmark for improving health care practices.
Our experience was validated by the Amnesty International report, although we know of at least one instance where their report data was in error. Kentucky, noted as a state that is 22nd in maternal mortality and which the report indicates has no accountability practices in place, actually is one of the few states in the country that has implemented a stringent reporting and review system.
According to Dr. Stanley Gall, chair of the state's Maternal Mortality Committee, Kentucky has a pregnancy checkbox on its Death Certificate, has a Maternal Mortality Committee that reviews every maternal death that occurs in the state, publishes its findings, and conducts annual postgraduate courses to alert and remind the obstetricians of the medical events that are occurring.
In the year ahead, the Preeclampsia Foundation will be calling attention to the lack of reliable data and the impact it has on gaining a greater understanding of risks associated with preeclampsia. We applaud the progress made in Kentucky and hope to spearhead similar advocacy efforts in other states. If you haven’t already, please take our Advocacy survey to help us set our priorities for the coming years.