Rising maternal mortality rate causes alarm, calls for action
After a difficult pregnancy, weeks of bed rest and an emergency cesarean section, Liz Logelin got only a quick peek at her daughter before the newborn, healthy but premature, was whisked away to the neonatal unit.
The next day, a nurse arrived with a wheelchair to take the first-time mother to see her baby. With husband Matt by her side, Logelin rose, took a few steps, said, “I feel light-headed,” and died.
She was 30.
“She never got to hold her baby,” said Matt Logelin, who lives in Los Angeles with the couple’s daughter Madeline, now 2. “That is one of the hardest things for me.”
Each day in the U.S., two women die of problems related to pregnancy or childbirth. The numbers have been rising, for reasons that are not entirely clear. After plunging in the 1900s, maternal mortality rates in California tripled between 1996 and 2006, from 5.6 deaths per 100,000 births to 16.9.
Nationally, the rate, defined as deaths from obstetrical causes within one year of giving birth, rose from 7.6 per 100,000 to 13.3 per 100,000.
For each death, experts estimate, there are about 50 instances of complications related to pregnancy or childbirth that are life-threatening or cause permanent damage. According to a study published last year, such “near misses” — including kidney failure, respiratory distress syndrome, shock and the need for blood transfusions and ventilation —rose 25% from the late 1990s to 2005.
Childbirth-linked deaths are still rare in the U.S., numbering about 90 women a year for California. But health experts believe that at least one-third are preventable.
Furthermore, they add, it is a problem typically associated with poor nations, not a rich, industrial country like the U.S. It is one of the primary indicators of public health that improves dramatically as countries develop and strengthen access to, and quality of, medical care.
Though the U.S. spends more per birth than any other nation, maternal mortality is higher here than in 40 other industrialized countries, including Croatia, Hungary and Macedonia, and is double that of Canada and much of Western Europe.
That the United States is backsliding in this most basic of healthcare measures has triggered attention and alarm in medical circles. In January, the Joint Commission, an independent organization that accredits and certifies healthcare organizations and programs, issued a “sentinel event alert” warning of the rising maternal mortality rates.
In March, the human rights organization Amnesty International released its own report, “Deadly Delivery,” calling for sweeping changes in maternal healthcare in the U.S.
The California Department of Public Health has commissioned a statewide review of medical charts in maternal death cases to identify reasons for the rise and seek ways to improve.
“Mothers shouldn’t die in childbirth,” said Dr. Elliott Main, chief of obstetrics at Sutter Health and director of the ongoing California review. The trend, he said, may signal a much larger problem with U.S. maternal healthcare.
Experts don’t yet know what has caused the increase in deaths, but there are plenty of potential explanations.
A 1999 change in how maternal mortality statistics are calculated is believed to be responsible for about 30% of the bump; that still leaves the bulk unexplained.
Health experts point to a mismatch between the way American medicine delivers babies and the changing profile of the American mother. Traditionally, physicians have viewed pregnant women as both young and healthy. In this country, that is no longer the case for a growing portion of expectant mothers.
More women today are giving birth in their 30s and 40s, when risks of complications during pregnancy and childbirth significantly increase. Almost 25% of women of childbearing age are obese and thus at higher risk for conditions such as diabetes and high blood pressure. Physicians haven’t adapted their approach to childbirth to accommodate these new risks, maternal health experts said.
Some experts implicate the rise in rates of cesarean sections, which account for one-third of all births — up from one-fifth in 1997. Although many are done to save the life of a mother and her baby, perhaps half are elective, meaning the surgery is medically unnecessary. After one C-section, cesareans are typically recommended for subsequent pregnancies.
Yet these are major operations and “should not be taken lightly,” said Dr. Michael Lu, a UCLA associate professor of obstetrics and gynecology. Each additional cesarean increases the risk of placental complications that threaten the lives of mother and baby.
The induction or prompting of labor by medication, which is sometimes medically advisable but more often performed for the doctor’s or patient’s convenience, has climbed so steeply — it now occurs in 22% of births — that the American College of Obstetricians and Gynecologists felt compelled to advise its members last year to avoid inductions before 39 weeks’ gestation.
When labor is induced a week or so before the due date, the uterus may not be ready, leading to prolonged labor. After delivery, the exhausted muscle may not contract properly to stop bleeding. Blood can no longer clot and becomes the consistency of water.
Staffing of maternity wards is also a serious problem, said Nan Strauss, a senior researcher at Amnesty International and a coauthor of the organization’s March report on maternal deaths.
“What we heard over and over is that facilities are underfunded in a lot of areas and providers are stretched thin,” Strauss said. “They can’t provide the best care they want to provide.”
Finally, a mistaken belief that childbirth is no more dangerous than having a tooth pulled may have led to complacency in a field often chosen by doctors and nurses because it is a happy medical specialty. Electronic monitoring, Lu said, may have the unintended consequence of making the monitoring of women during labor so passive that they may be neglected, with warning signs missed.
The death certificates are a litany of awful events.
Thromboembolisms — blood clots that break off and lodge in the heart or lungs — are the leading cause of maternal mortalities, accounting for 20% of cases. Hemorrhage, a profuse loss of blood, causes about 17%. Next, at 16%, is preeclampsia, a condition of high blood pressure and leaky kidneys that can lead to seizure, organ failure and death.
Liz Logelin had a hereditary condition that increased her risk of clots, her husband said. But that didn’t raise much concern for the couple or her doctor, he added. Liz was in great shape. She hiked regularly in Runyon Canyon and worked out with a personal trainer. She didn’t smoke or use drugs.
But the pregnancy was tough. In her sixth month, she was told that she had low levels of amniotic fluid, which can harm the baby. The umbilical cord was wrapped around the baby’s neck.
Two weeks of home bed rest was followed by three weeks of bed rest and monitoring at Huntington Memorial Hospital in Pasadena. When the baby’s heart rate plunged March 24, 2008, a cesarean was ordered.
In the hospital, Liz had worn pneumatic compression stockings to reduce the chance of blood clots in the weeks before delivery. Before her death, she had been bedridden for 27 hours. When she stood, the doctors told her husband, a blood clot dislodged from her leg and traveled to her lungs.
Matt Logelin, disbelieving, stood in the hall outside her hospital room as doctors and nurses worked to revive her.
A state task force on maternal mortality is working to create standards for hospital maternity wards to reduce deaths like these. Lu says 10 inexpensive steps could be enacted, including a protocol to deal with hemorrhaging that obstetrics teams could regularly practice, and routine use of compression stockings for women who have had C-sections. The L.A. Department of Public Health has implemented such a program at the city’s top 10 delivery hospitals.
Another way to reduce maternal deaths would be to strengthen prenatal care for all women, especially women of color and those on public assistance, Strauss said. Black maternal deaths are nearly four times higher than those of whites.
Amnesty International has called on the federal government to create an Office of Maternal Health to improve the quality of maternal healthcare.
There are no federal requirements to report maternal deaths, and there are only six states that mandate such reporting, much less any formal accounting of the financial and psychological costs to widowers and children who will never know their mothers.
Matt Logelin doesn’t blame anyone for his wife’s death.
“It didn’t make sense that this could happen to someone like her, someone who follows every precaution the doctor mentions,” he said. “But I’m not angry. I want to focus on my child.”
A former operations manager at Yahoo, he is writing a memoir about his first year as a young widower. He has started a foundation to assist parents of minor children who have lost a spouse. He and daughter Maddy have traveled to India, Singapore, France — seeing sights he promised Liz that they would one day see together.
“I think of all the things Liz has missed,” Logelin said. “I see Maddy doing amazing things, and I start to cry.”