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More women dying from pregnancy complications; state holds on to report

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.

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.

“The issue is how rapidly this rate has worsened,” said Debra Bingham, executive director of the California Maternal Quality Care Collaborative, the public-private task force investigating the problem for the state. “That’s what’s shocking.”

The problem may be occurring nationwide. The Joint Commission, the leading health care accreditation and standards group in the United States, issued a “Sentinel Event Alert” to hospitals on Jan. 26, stating: “Unfortunately, current trends and evidence suggest that maternal mortality rates may be increasing in the U.S.”  

The alert asked doctors to consider morbid obesity, high blood pressure and diabetes, along with hemorrhaging from C-sections, as contributing factors.

In 2007, the U.S. Centers for Disease Control and Prevention reported that the national maternal mortality rate had risen, but experts such as Dr. Jeffrey C. King, who leads a special inquiry into maternal mortality for the American College of Obstetricians and Gynecologists, chalked up the change to better counting of deaths. His opinion hasn’t changed.

“I would be surprised if there was a significant increase of maternal deaths,” said King, who has not seen the California report.

But Shabbir Ahmad, a scientist in California’s Department of Public Health, decided to look closer. He organized academics, state researchers and hospitals to conduct a systematic review of every maternal death in California. It’s the largest state review ever conducted. The group’s initial findings provide the first strong evidence that there is a true increase in deaths – not just the number of reported deaths.

Changes in the population – obese mothers, older mothers and fertility treatments – cannot completely account for the rise in deaths in California, said Dr. Elliott Main, the principal investigator for the task force.  

“What I call the usual suspects are certainly there,” he said. “However, when we looked at those factors and the data analyzed so far, those only account for a modest amount of the increase.”

Main said scientists have started to ask what doctors are doing differently. And, he added, it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.

One maternity expert who was not involved in the report, Dr. Thomas R. Moore, chair of the Department of Reproductive Medicine at UC San Diego, said about the data: "This could be a sentinel finding, and I could see other states taking a closer look and finding the same thing."

Low numbers, high consequences

Despite the increase in the mortality rate, pregnancy is still safe for the vast majority of women.

In 2006, 95 California women died from causes directly related to their pregnancies – out of more than 500,000 live births. That’s a small number by public health standards. If California had met the goal set by the U.S. Department of Health and Human Services to bring the state’s maternal mortality rate down to a level achieved by other countries, the number of dead would be closer to 28.

It’s not clear who is most at risk, but researchers have long known that African-American mothers are between three and four times more likely to die from pregnancy-related causes than the rest of the population. That racial association is not stratified by socio-economic status: Even high-income black women are at a greater risk.

While the maternal mortality rate among black women is rising, the task force found a more dramatic increase in deaths among white, non-Hispanic mothers. There is not yet enough data to show if the risk of death is associated with poverty.

maternal deaths California WatchTatia Oden French

What’s certain is that each maternal death shatters families. That cold sum – 95 dead – represents 95 stories of people such as Tatia Oden French. In 2001, she was newly wed and had just finished her doctorate in psychology. She was about to have a baby girl she would name Zorah Allie Mae French.

“She’s the type of person that just walked into the room and lit it up,” said her mother, Maddy Oden.

During the labor, Maddy Oden was at home in Oakland, waiting for a call announcing the birth of her granddaughter. Instead, she needed an emergency C-section. “I woke up at 4 in the morning, and I knew that something was wrong,” Oden said.

Then the phone rang. French was in trouble. Powerful contractions had forced amniotic fluid into her bloodstream, stopping her heart and killing the baby. When Oden got to her daughter at an Oakland hospital there was only one thing she could do: “We said a prayer,” Oden said, “and I closed her eyes.”  

Oden lost the subsequent lawsuit: The doctor had not deviated from the standard of care.

Rather than track down the cause of every death and assign blame, the California task force is focused on finding solutions. And Bingham and Main have found that doctors and nurses are eager to help after seeing the numbers.

In 1996, the maternal death rate in California was 5.6 per 100,000 live births, not far from the national goal of 4.3 per 100,000. Between 1998 and 1999, the World Health Organization changed its coding system, which may have increased reporting of deaths. The California rate was 6.7 in 1998 and 7.7 in 1999. Because the number of mothers who die is small, the rate tends to fluctuate from year to year.   

In 2003, when California revised its death certificate, the rate jumped to 14.6. And in 2006, the last year for which data is available, the rate stood at 16.9.  

The best estimates show that less than 30 percent of the increase is attributable to better reporting on death certificates. Even accounting for these reporting and classification changes, the maternal death rate between 1996 and 2006 has more than doubled, Main said.

Not yet public

When researchers unveiled their initial findings to a conference of the American College of Obstetricians and Gynecologists in 2007, there were gasps from the audience, according to participants at the San Diego event. The idea that California was moving backward even in an era of high-tech birthing was implausible to some. Confirmation of the trend was noted in the 2008 report written by 27 doctors and researchers. The report was described in detail to California Watch.

The state of California has yet to share the report with the public. Researchers say that, after reviewing the report in 2008, officials in the Department of Public Health asked for technical clarifications. Revisions were complete and approved in the first half of 2009, according to Ahmad.  

Al Lundeen, the department’s director of public affairs said, “There was no effort to hold that report back. It just needed some more revisions.”

Researchers say that it is important for the public to be aware now that these trends are worsening. Diane Ashton, the deputy medical director for the March of Dimes, has seen the numbers. She says they demand a concerted response.  

“Even though they tend to be small numbers in terms of maternal mortality, it is important – it’s very important – that these trends be looked at,” she said. “And efforts need to be made to try and reverse them when they are going in the wrong direction.”

Rising C-section birth rate

Nearly one in three babies is now born by C-section. Many scientists have acknowledged that at some point, as the number of surgeries spiral upward, the risks will outweigh the benefits. But the C-section remains a useful tool, and in the middle of labor, doctors say, it’s hard to balance the potential long-term harm against immediate crisis.

Today, doctors face a condition called placenta accreta, where the placenta grows into the scar left by a previous C-section. In surgery, doctors must find and suture a web of twisted placental vessels snaking into the patient’s abdomen, which can hemorrhage alarming amounts of blood. Often, doctors must remove the uterus.

Main said this complication from C-sections has increased eight-to-10 fold in the past decade. Nonetheless, most women survive the ordeal. The point, says Catherine Camacho, deputy director of the state’s Center for Family Health, is that the rise in deaths is indicative of a larger problem.  

“For every maternal death, there are 10 near misses; for every near miss, there are 10 severe morbidity cases (such as hysterectomy, hemorrhage, or infection), and for every severe morbidity case, there is another 10 morbidity cases related to childbirth,” Camacho wrote in an e-mail.  

Other factors are contributing to the rise in deaths, but the researchers in California are most interested in the areas where they have control, such as the high C-section birth rate: It’s easier for doctors to improve medical care than to fix more intractable problems like poverty and obesity.

Inducing labor before term more common

In 2002, Dr. David Lagrew, the medical director of the Women’s Hospital at Saddleback Memorial Medical Center in Orange County, noticed that a lot of women were having their labor induced before term without a medical reason. And he knew that having an induction doubled the chances of a C-section.

So he set a rule: no elective inductions before 41 weeks of pregnancy, with only a few exceptions. As a result, Lagrew said, the operating room schedules opened up, and the hospital saw fewer babies admitted to the neonatal intensive care unit, fewer hemorrhages and fewer hysterectomies.  

All this, however, came at a cost: The hospital had to take a cut in revenue for reducing the procedures it performed. Lagrew doubts that any hospital has increased its C-section rate in pursuit of profit, but he does note that the first hospitals to adopt controls on early elective inductions have been nonprofits.  

According to a report issued by the advocacy group Childbirth Connection, “Six of the 10 most common procedures billed to Medicaid and to private insurers in 2005 were maternity related.” On average, a C-section brings in twice the revenue of a vaginal birth. Today, the C-section is the single most common surgical procedure performed in the United States.

“If all these guys were losing money on every C-section, well, what’s the old saying? Whenever they tell you it’s not about the money, it’s about the money,” Lagrew said.

The California task force isn’t waiting to determine the ultimate cause of these deaths. It has started pilot projects to improve the way hospitals respond to hemorrhages, to better track women’s medical conditions and to reduce inductions – as Lagrew did at Memorial Care.

Although the state hasn’t released the task force’s report, the researchers and doctors involved forwarded data to the national Joint Commission, which issued incentives for hospitals to reduce inductions and fight what it called “the cesarean section epidemic.”  

“You don’t have to be a public health whiz to know that we are facing a big problem here,” Bingham said.

 

This story was edited by Robert Salladay and Mark Katches. It was copy edited by William Cooley.

Comments

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Anonymous's picture
It seems like the main cause is inducing labor early and performing a C-section and I wish you would have gotten to that sooner in the story, since that's the most interesting part. But very good story overall.
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Anonymous's picture
Agree with Anonymous. A follow-up story might focus on whether medical professionals are learning how to perform C-sections so that the danger of complications in subsequent pregnancies are reduced. Excellent piece.
Anonymous's picture
The vast majority of c-sections in this country are done the safest way possible for moms in subsequent pregnancy s. However there is no c-section that does not leave scar tissue in the uterine wall to cause placenta acreta. Not doing unnecessary c-sections is the only way to reduce that risk.
Anonymous's picture
In my experience as a nurse there is a culture of wanting to produce babies on a schedule that leads to induction when it really isn't necessary. Until there is a shift in attitude by doctors and patients to allow birth to take a more natural course I don't see anything changing.
Anonymous's picture
I think that's the biggest thing IMO...People have become more and more lazy. Doctors and Patients alike.
Anonymous's picture
I just love educated American journalists. Why is exactly Kuwait and Bosnia mentioned here? Kuwait as 11th wealthiest country in the world and yes, war in Bosnia ended 15 years ago. Bravo!
Anonymous's picture
That would be because, believe it or not, they keep track of the number of maternal mortality rates in different countries (like Kuwait and Bosnia, crazy huh?) and the United States is ranked near the bottom of all developed countries.
Anonymous's picture
The headline is a bit of a misnomer- the real problem is not complications from pregnancy, but complications from an increase in medical interventions (c-sections) that are based on convenience, not necessity. Great article.
Anonymous's picture
Watch the documentary called 'The Business of Being Born' for more insight into this topic. Wonderful article -- thank you!
Anonymous's picture
When will we learn that unnecessary inductions and c sections harm babies and mothers? We need to ban non medical inductions and really cut down the rate of primary c sections.
Anonymous's picture
Maybe it's not what we think. Maybe it's GMO corn that's doing it, which if you research it you'll find out is a foreign toxin (pesticide) in the bloodstream. Or something else we haven't thought of. s
Anonymous's picture
How many more women and babies have to die or suffer outrageous, needless, complications before we practice according to the research that tells us that most expectant women should be attended by general practitioners and midwives - not surgeons.
Anonymous's picture
It's also very important to note that in the US - Maternal mortality is voluntary. Check out the Safe Motherhood Quilt Project for more info. I believe that it is mostly the unnecessary c-sections, and interventions leading to the rise, not just the under-reporting.
Highland Midwife's picture
This rise in maternal deaths is NOT occurring with licensed home birth midwives. For a great analysis, go to www.highlandmidwife.com/HomeBirth.html, and scroll down to the link "Medscape 2010", which will take you to an excellent article recently posted by WebMD on Medscape.
poetra's picture
One of the supporting factors of dying from pregnancy is the factor which is currently food contain many chemicals, so dangerous for the health of children conceived by its mother. Including high levels of pollution.
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diziizle's picture
When it really isn't necessary. Until there is a shift in attitude by doctors and patients to dizi izle allow birth to take a more natural course I don't see anything changing.
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juliajin's picture
The mortality rate of Illinois females who die from causes directly related to pregnancy \. For the past three months, the state Department of Public Health has declined to release a document outlining the trend. \. mothers are two to three times more likely to die from pregnancy-related causes. ...Naruto Shippuden
adamwestrop's picture
You would think that in todays day and age, that deaths in pregnancy would start to take a massive u-turn downwards, however instead the same complications are arising, or new complications are arising. I think there needs to be a significant independent authority to deal with pregnancy related issues and to regulate practices etc. Pregnancy is such an important time which touches a lot of individuals lifes directly or indirectly and thus needs a lot of attention. Portable dvd player Ipad covers Transportable homes
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It is really truth that pregnancy may lead to death but still it is life we should take it as it is. glutamine
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nicoduca's picture
In 2002, Dr. David Lagrew "set a rule: no elective inductions before 41 weeks of pregnancy, with only a few exceptions." Lagrew admits that "operating room schedules opened up, and the hospital saw fewer babies admitted to the neonatal intensive care unit, fewer hemorrhages and fewer hysterectomies." But hospital revenues declined. Connection? Duh. But here's the real Duh Moment: Lagrew "doubts that any hospital has increased its C-section rate in pursuit of profit, but he does note that the first hospitals to adopt controls on early elective inductions have been nonprofits." One would have to wonder whether this man was actually smart enough to graduate from medical school, except that, clearly, he was. So what's going on here? Oh, right. He is afraid of being politically incorrect in the current climate of teabaggers bashing the rest of us with their cockamamie ideas, and possibly afraid of the pharmaceutical companies (they do manufacture anesthetics, after all, not to mention other drugs used before, during, and after c-sections) and the insurance companies. I mean, if Americans actually understood that health care was better without the profit motive skewing the medical dictum "First, do no harm," people would want far more than the pitiful, drug-company engineered excuse for universal health Congress is maybesortakindasoonwehope considering. Submited by : Parto
stevengerad's picture
There is a culture of wanting to produce babies on a schedule that leads to induction when it really isn't necessary. Until there is a shift in attitude by doctors and patients to allow birth to take a more natural course I don't see anything changing.
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kahfy's picture
Very Glad that you shared this to us. One factor that die in support of the pregnancy is the factor that is found in many foodstuffs, chemicals are so dangerous to the health of children conceived by his mother. Including high levels of pollution. It's some pretty great info, I'm sure some people will really like this information.
narutohits's picture
as an ob/gyn, i can't express enough how much obesity plays into inferior health care. providing any sort of medical service is more difficult, and more dangerous, in an obese patients - pelvic exams, delivery, fetal monitoring, pregnancy complications, c-sections, post-operative complications... the list goes on and on.disability insurance
timothgreg's picture
In delivery, the moms are often told to lie back then often the baby is forcibly pulled out by the head and neck , and then the doctor often puts traction on the cord to speed along delivery of the very vascular placenta (this saves at most 20 minutes typically). The last is how my cousin hemorrhaged. She would’ve been fine if the doc would’ve been willing to give the blood vessels time to clamp down and the placenta to come on its own. So much of the complications come from the interventions (was shocked by the number of articles describing such cases i found by torrent SE ). In the U.S. our maternal death and infant death rates put us WAY down on the list of industrialized nations, and yet we have the “best” health care. And NO, those can’t be explained by higher rish pregnancies.
rian's picture
This post is different from what I read on most blog. Other factors are contributing to the rise in deaths, including high levels of pollution, chemicals in food ingredients and others. And it have so many valuable things to learn. Thank you for sharing this article. Nice post.
emperot's picture
I've done some researches according to this theme, so the article is quite helpful. Californian mothers should stop stop eating fast food.

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imobiliare's picture
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normally As per system at delivery, the moms are often told to lie back. when you feel that your life is likely to be at greater risk over a short period of time for some reason.A follow-up story might focus on whether medical professionals are learning how to perform C-sections so that the danger of complications in subsequent pregnancies are reduced. I enjoyed reading your articles. Bridal Makeup
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Beverley Walker's picture
I am an eminent midwife having been a midwife since 1962. I finished my professional career as a Senior Lecturer in Midwifery and co-ordinator of a midwifery course. I completed a Masters in Bioethics and spoke at a 1995 Bioethics Conference at Georgetown University in Washington DC. I visited the University of North Carolina and Duke University hospitals where practice was worse than Australian hospitals at the time. The reasons I undertook this degree was because most of the students I taught were hanging from the ceiling with stress. Like me they were disturbed by the way women were being given induction chemicals and restricted to lying on their backs to labour. I have always been an activist but more in the last year I have been very busy. In Australian hospitals 1 in 3 women are having caesarian (major abdominal surgery) births. Medical and surgical inductions are in part leading to this high rate. I term this unlawful assault and battery due to lack of informed consent. There is a global witch hunt world wide against midwives who are acting to normalise birth. Australian women are currently fighting against the restrictive legislation brought about by high profile obstetricians for the sole purpose of preventing midwives influencing women to birth out of hospital and disallow midwives to trade as private practitioners.
Nubby's picture
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It is crazy to think that because of insurance issues that expectant mothers are not able to get the proper care that they need coupled with the fact that many types of insurance in CA provide less than adequate coverage. Baby Cribs
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One of the supporting factors of dying from pregnancy is the factor which is currently food contain many chemicals, so dangerous for the health of children conceived by its mother. Including high levels of pollution. Alex - Narconon Specialist
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It is amazing that California with all of its supposed high quality doctors and nurses would be going backwards in terms of the rankings. Just another sign the budget and economy have had in California that shows no signs of improving in the near future. If you are close to birth, you might want to consider having it done out of state. Garage Storage
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I wonder what is going on if the mortality rate is increasing??? Maybe it would help if people used more pure maple syrup instead of raw, white sugar. dark maple syrup is quite good for health too. Lots of vitamins and minerals.
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I'm glad I've had all my children, this is pretty scary. I had 4 children and had to have them all by C-section since I was told I couldn't have children naturally. So many people have C-sections these days and the doctors brush it off as acceptable, my doctor told me it was safer have a C-section than natural birth. bassinet
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"its more dangerous to give birth in california"??God,that is too bad.i wish this situation will change. help for single mothers free child care
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It is a blatant post. It is true that mostly woman's are die at the delivery time. Their are so many cause, such as always and every place have not a good delivery instrument, some time for their careless and most visited cause is obesity at the pregnancy time. But at current time the death rate of this cause going dawn by their awareness and suitable arrangement for delivery. Embroidered shirts
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It is very alarming information that 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. More tangible action needs be taken urgently to arrest the deteriorating health care services. thanks. Acai Max Cleanse
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This is alarming really with today's understanding of pregnancy. The fact that it's tripled is even more astonishing. I would think these types of numbers would be going down not up. guitar lessons dvd
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Wow! This should serve as a big warning to women who are obese. I also saw a study that said obesity can be passed on to the baby causing the child to have a higher chance of being obese as well. People need to get off the couch and start moving around and take care of their health before this country suffers from an epidemic.
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How many more women and babies have to die or suffer outrageous, needless, complications before we practice according to the research that tells us that most expectant women should be attended by general practitioners and midwives. I dread to imagine what happens in developing countries

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Dr. David Lagrew should be applauded for his efforts.. its just too bad that hospitals do put "profit" before anything else. you can't tell me that there is no connection to the "C" section being the single most common surgical procedure AND the fact its double the profit for the hospitals? cmon... maybe they should do an investigative report and arm a reporter with some type of spy phone software so they can record the conversation with the docs and try to get them to admit why they choose the "C" section route.. buying mobile phone spyware is easy.. so perhaps a reporter should give it a shot and bring down these crooks who put profit ahead of the well being of the mother and child.
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Interesting article and it's shocking to know how rapidly this rate has worsened. Dying is a major issue, Women dying from pregnancy is much worsen now
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Everything is going down. We are not in touch with our nature any more. Women give birth after 30 now, before they gave birth at 20. We will see less and less humans being born. But humans will adapt (like all creatures).
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These are truly frightening statistics. The only time we ever here about these complications are usually from undeveloped countries and we never expect to see or hear it happen in our own back yard.
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A follow-up story might focus on whether medical professionals are learning how to perform C-sections so that the danger of complications in subsequent pregnancies are reduced. Excellent piece.
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Very sad news, but isn't it common sense that by having an a problem with obesity, could actually lead to complications.
mikerussal's picture
Well women are dying due to the pregnancy complications and this problem is spreading quickly. Now government should have to take some serious steps for the betterment of Gynecologist profession. Anyways life is very important and we should have to love each other.
zhapkiel's picture
Interesting article and it's shocking to know how rapidly this rate has worsened. Dying is a major issue, Women dying from pregnancy is much worsen now
word templates's picture
Well, we must encourage such articles that are meant for someone's benefits. We all know that women are dying each day due to pregnancy complications. Education is yet a vital factor that cannot easily be offset but by providing healthy and useful information, we can help such womens. If our article saves one life then it means we have saved whole humanity.
kaseymacleod's picture
Nice post. I'm very glad that you shared this to us. Until there is a shift in attitude by doctors and patients to allow birth to take a more natural course. Also on fertility is influenced by other factors. This is the factor that is found in many foodstuffs, chemicals are so dangerous to the health of children conceived by his mother. Including high levels of pollution. I don't see anything changing.

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