Pre-term births are on the rise. Nearly one-third of women have major abdominal surgery to give birth. And compared with other industrialized countries, the United States ranks second-to-last in infant survival. For years, these numbers have suggested something is terribly amiss in delivery wards. Now there is even more compelling evidence that the U.S. maternity care system is failing: For the first time in decades, the number of women dying in childbirth has increased.
The Centers for Disease Control and Prevention last month released 2004 data showing a rate of 13.1 maternal deaths per 100,000 live births. For a country that considers itself a leader in medical technology, this figure should be a wake-up call. In Scandinavian countries, about 3 per 100,000 women die, which is thought to be the irreducible minimum. The U.S. remains far from that. Even more disturbing is the racial disparity: Black women are nearly four times as likely to die during childbirth than white women, with a staggering rate of 34.7 deaths per 100,000.
These high rates aren't a surprise to anyone who's been investigating childbirth deaths. Physician researchers who have conducted local case reviews across the country consistently have found death rates much higher than what the CDC has been reporting. In New York City between 2003 and 2005, researchers found a death rate of 22.9 per 100,000; in Florida between 1999 and 2002, the rate was 17.6. Other reports by CDC epidemiologists have acknowledged that deaths related to childbirth are probably underreported by a factor of two to three.
What's to blame for the poor U.S. showing? True, we are the only industrialized country without universal healthcare. But when it comes to childbirth, we basically have it. Ninety-nine percent of women give birth in a hospital with access to all the bells and whistles -- high-tech machines that continuously monitor the baby's heart rate, drugs that can control the speed of contractions like the volume on a stereo, instruments that can coax a reluctant head out of the birth canal, and surgeons at the ready to perform the mother of all interventions, the caesarean section.
The C-section, now used to deliver 30% of American babies, is such a norm these days that, in some places, doctors and women have taken to calling it "C-birth" or even just "having a 'C.'" Pet names aside, the procedure is major surgery, and although it saves lives when performed as an emergency intervention, it causes more harm than good when overused. Here's why: Caesareans are inherently riskier than normal, vaginal birth. They also lead to repeat caesareans. And repeat caesareans carry even greater risks.
Placenta accreta is one of them. The placenta embeds into the uterine scar from a previous surgery, causing a catastrophic hemorrhage at the time of delivery. Most women with placenta accreta lose their uteri; as many as 1 in 15 bleed to death. In 1970, accretas were so rare that most obstetricians never encountered one in their career. Today, according to a University of Chicago study, the incidence may be as high as 1 in 500 births. And that is all because of caesareans and repeat caesareans.
Obesity plays a part as well because obese women are more likely to have health problems that make a caesarean more likely, and more likely to suffer surgical complications. Still, it all comes back to the "C," which could easily stand for "culprit."
According to a sweeping 2006 study by the World Health Organization, published last year in the medical journal Lancet, a hospital's caesarean rate should not exceed 15%. When it does, women suffer more infections, hemorrhages and deaths, and babies are more likely to be born prematurely or die.
Too many caesareans are literally medical overkill. Yet some U.S. hospitals are now delivering half of all babies surgically. Across the nation, 1 in 4 low-risk first-time mothers will give birth via caesarean, and if they have more children, 95% will be born by repeat surgery. In many cases, women have no choice in the matter. Though vaginal birth after caesarean is a low-risk event, hundreds of institutions have banned it, and many doctors will no longer attend it because of malpractice liability.
American maternity wards are fast becoming surgical suites. We've become dangerously cavalier about it, but the caesarean rate should be a major public health concern. Universal care alone won't solve the problem; what pregnant women need is entirely different care. They need doctors and hospitals that promote normal labor and delivery. Of course, reducing obesity belongs on the healthcare agenda, and so does curtailing the scalpel.