Why are so many new mothers in California dying?
What's going on in California? Why has the maternal mortality rate risen so sharply?
Nathanael Johnson, of California Watch, broke the story yesterday:
The mortality rate of California women who die from causes directly related to pregnancy has nearly tripled in the past decade, prompting doctors to worry about the dangers of obesity in expectant mothers and about medical complications of cesarean sections.Unfortunately, it is impossible to figure out what is going on because the state of California is withholding information on the deaths. We don't know the causes of death, the demographics of the mothers, or the level of care they received.
For the past seven months, the state Department of Public Health declined to release a report outlining the trend.
California Watch spoke with investigators who wrote the report and they confirmed the most significant spike in pregnancy-related deaths since the 1930s. Although the number of deaths is relatively small, it's more dangerous to give birth in California than it is in Kuwait or Bosnia.
Although the state of California refuses to release the case by case accounting of the deaths, we can find some information. The California Maternal Mortality Care Collaborative (the same entity that is withholding the complete report) has some startling graphs on its website.
The graph above reveals several interesting findings. First, the maternal mortality rates have been rising in the US as a whole, but have been rising faster in California. Second, the large increase after 2002 reflects the change in the way that maternal mortality is reported. It had been suspected for some time that maternal mortality in the US was being substantially underestimated. New data collection forms confirmed this undercounting; hence part of the rise in maternal mortality reflects better data gathering. Third, rates of maternal mortality are so low that a few deaths can dramatically change the rates, hence the sawtooth nature of the graphs. Fourth, although the rates fluctuate from year to year, the overall trend is upwards.
The graph displaying racial differences in California maternal mortality is truly mind boggling.
Maternal mortality among Asian and Hispanic women is lower than or equal to the rates for white women. The maternal mortality rate for black women is astoundingly high, topping out at an extraordinary 54.9/100,000. That number is more than triple the rate for women of other races, and is consistent with overall US data from 2006 (white maternal mortality of 9.5/100,000 compared to black maternal mortality of 32.7/100,000). African Americans make up only 6% of the population of California, less than half the nationwide percentage, so the high rate of black maternal mortality cannot be blamed for the increase in California maternal mortality.
What is the reason for the high and rising rate of maternal mortality in California? Without patient level data, it is impossible to know. However, there are three possibilities: changing characteristics of pregnant women, changing level of care provided, and change in the type of care, specifically the rising C-section rate.
The mortality rate of California women who die from causes directly related to pregnancy has nearly tripled in the past decade, prompting doctors to worry about the dangers of obesity in expectant mothers and about medical complications of cesarean sections.Does the increase in maternal mortality reflect an increase in obesity, age or fertility treatment in pregnant women? We don't have access to the data that will tell us. Is the increase in maternal mortality related to California's worsening fiscal status and associated cutbacks in services? We don't know that either. We do know that the C-section rate has been rising dramatically all across the US. The C-section rate in California in 2006 was 31.3% almost exactly the same as the overall US rate. This is an increase from the US rate in 2003 of 27.5%, representing an increase of 13.8%.
For the past seven months, the state Department of Public Health declined to release a report outlining the trend.
California Watch spoke with investigators who wrote the report and they confirmed the most significant spike in pregnancy-related deaths since the 1930s. Although the number of deaths is relatively small, it's more dangerous to give birth in California than it is in Kuwait or Bosnia.
Is the rising C-section rate responsible for the rising maternal mortality rate? Without patient level data we cannot know, but it certainly is a possibility. I have written in the past about the diminishing returns of an ever increasing C-section rate and predicted that there would be a point at which the risks to mothers would outweigh the benefits to infants. I await the release of the California report to find out if we have reached that point.
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Comments
I am concerned because I feel like there is a lot of guessing going on and not a lot of good old fashioned root cause analysis. The article I read in my local paper made sounds like they were going to go after C-sections as just sorta a knee-jerk reaction.
"Dr. Amy, do you know what the leading causes of maternal mortality are for black women?"
Studies that have looked at maternal mortality in black women have found that the incidence of specific complications is the same as for other races, but the mortality for each complication is dramatically higher. So it does not appear that black women face special complications or higher numbers of complications.
There is much interest in your findings here and look forward to hearing more from your medical perspective and experience.
Here's an interesting article about how maternal mortality statistics can increase through better tracking:
"Active Surveillance of Maternal Mortality in New York City"
"Results: Active surveillance revealed 14 new maternal deaths not previously reported, an 88% increase. Nine of these deaths were found through the hospital discharge database search, 1 was found through the autopsy record search, and 4 were found in both searches. Overall maternal mortality ratios associated with active surveillance and routine surveillance were 24.3 and 13.0 deaths per 100 000 live births, respectively."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447237/
Concerning the racial differences, you'd see the same kind of graph if you were looking at infant mortality or low birthweight babies -- even though black women tend to have higher rates of adequate prenatal care than do hispanic women. (At least that was the case back when I was in the medical data analysis business.)
Just out of curiosity, I did a little research and found that while California's infant mortality rate is really low, the infant mortality rate for African-American babies, again, is nearly 3x the rate for other groups.
Mortality rate is probably due to the fact the OBs are more worried about making their 2:30 tee time, than attending to their patients. If the mom's labor isn't progressing on the doctor's schedule, go ahead and give her some pitocin to speed things along. And when labor starts progressing before she's built up the endorphins to deal with the pain and her tissues have had a chance out stretch out naturally, and she can't deal with the pain anymore... just slice her open! Hell, if she hasn't gone into labor by her due date (because by God, little baby, we've got a SCHEDULE to keep! God forbid we let nature run it's course a little) lets slice Mom open!
I realize that my (admittedly flip) statement is a bit over generalized, but not by all that much. I was horrified by the stories my peer mommies have told about being induced because they didn't start labor on day 7 of the 40th week, and then hearing the story of the domino effect the induction caused. The poor moms always say, "thank God I was in a hospital!" I have to bite my tongue to keep from saying, "did you ever think that the hospital CAUSED the problems you needed to be there for?"
I had two healthy babies... **steeling myself for slings and arrows** ... at home. There I said it. Both of my guys were born 10 days after their supposed due date. Both labors took more than 12 hours. I didn't need a SINGLE STITCH and (I am not exaggerating, I have witnesses) I was out doing yard work THE NEXT DAY.
I understand that not every woman is the baby-having machine I turned out to be, and I understand that there are often complications where being able to get to a hospital is a 100% blessing. But why do we have to assume that just the state of BEING pregnant is a complication and automatically start intervening medically? I think your post backs up my claim, actually. More cesareans = more mommy mortality. I mean, duh?
So while the high-intervention culture is suspect, as far as I can tell amongst my mom-peers, this attitude hasn't really changed signficantly in the last decade. If anything, I sort of feel like doctors are moving back towards more mom-centered less-intervention heavy births. But, perhaps I am mistaking a very loud and vocal minority for an actual (yet slight) cultural shift here. Also I live in the midwest, and not California. I have no idea what the hospital birth culture might be like there. It sounds like c-section rates are soaring, so I know that is much more telling of the culture of intervention than my guesstimation based on my local experiences.
I tend to agree with the above poster that these perceived increases in mortality could be due to changes in data collection. But it is impossible to know without more information. We can speculate a million reasons for this shift, but we can't know for sure without more info. Why would they be withholding data anyway?
That's what I would expect, although it is possible that the increased interventions have played a part. It is interesting to note that California has a low neonatal mortality rate comparatively, and it raises the possibility that low neonatal mortality was achieved by putting mothers at increased risk.
I don't understand the motivation in withholding the report. That type of behavior usually signals that there is something to hide, but what would the state of California feel a need to hide in connection with maternal mortality?
Why would a baby 2 weeks overdue seem so apparently "not done with the oven" and look like he was not late? I was pretty sure about his date of conception and the U/S's seemed to confirm it, but I've wondered ever since about whether there isn't something doctors can and should be doing to prevent inducing babies who really need a few more days to get ready to join the outside world.
My second son came 4 days after his due date, naturally, and was born in a very quiet, dark birthing room with just a midwife and my husband present. He was an easy, happy kid. I know, data set of 2 - but I can't help but wonder if their entrances into the world made their baby year so different.
I suspect the high rate of death among African-American mothers may have a lot to do with racism, along with inadequate nutrition and inadequate insurance. Non-paying patients (read uninsured) just don't get the needed attention. Small detail, but WHERE ARE THE BABIES IN ALL THIS? How can the two be separated? Typical cold scientific manner. How many motherless babes does this leave?