By Ina May Gaskin, CPM, MA
Originally published by Mothering, No. 147, 2008-03-04
Twenty-two-year-old Army Specialist Tameka McFarquhar had no family members nearby to help her when she was released from Samaritan Medical Center in Watertown, New York, a day after giving birth to her first child on December 14, 2004. A single mother, the Jamaican-born office clerk had been transferred stateside from Army duty in South Korea after becoming pregnant with her daughter, Danasia Elizabeth. She never revealed her child’s father’s name.
On the night of December 19, McFarquhar spoke with her mother mother in Jamaica and told her that she had a headache. Worried about her, her mother advised her to drink some warm milk and keep herself warm.
That phone call was the last time that any family member or friend heard McFarquhar’s voice. No one could get her to answer her phone or her apartment door. A concerned friend notified the Watertown police, who found no probable cause to break into the apartment. Finally, on Christmas morning, McFarquhar’s friend again contacted the police, who this time went to McFarquhar’s apartment, only to find a horrifying scene. McFarquhar had bled to death several days earlier, and baby Danasia had died of dehydration and starvation.
According to the Watertown Daily Times, the Jefferson County medical examiner said the cause of McFarquhar’s death was placenta increta, a rare complication in which the placenta cannot be released in the normal way because it had burrowed itself into the uterine muscle instead of attaching only to the uterine lining which is shed just after birth. (1) But could it really have been an increta? Placentae increta must be removed surgically with the patient under deep anesthesia, so if McFarquhar had indeed had this complication, she must have been discharged from the hospital with the placenta still inside her uterus. Who could believe that really happened?
One possibility is that a very small bit of placenta or membrane was left inside McFarquhar’s uterus, a much more common occurrence that can indeed cause a late postpartum hemorrhage such as that she suffered. Because it sometimes takes a few days for soreness and infection to develop, this complication could more easily have been missed than a placenta increta in any examination that took place during the 24 hours McFarquhar was still in the hospital following birth.
It’s not just single first-time mothers who can die from lack of post-birth follow-up care. The same complication is likely to be what happened to Galit Schiller, a San Anselmo, California, mother of three, who three days after giving birth in a hospital in June 2007, died in her husband’s arms of a massive post-birth hemorrhage. (2)
Maternity care systems in countries with low maternal death rates (unfortunately, the US is not among these) plan for the certainty that some percentage of previously healthy women will be in danger of a late postpartum hemorrhage, uterine or perineal infection, breastfeeding problem, postpartum depression or some other post-birth complication requiring special attention. These countries— Australia, England, the Netherlands, New Zealand, Norway, Wales, Scotland, Sweden, and Northern Ireland, just to name a few (3)—send specially trained nurses to make home visits for new mothers during the first ten days or so following birth. Had McFarquhar had such a visit, her death and that of her baby could almost certainly have been prevented, as incomplete expulsion of the placenta and membranes can rather easily be diagnosed by a trained professional before a life-threatening hemorrhage occurs.
Inexcusably, such home visits during the postpartum week or ten days are rare in the US, even though most women here are discharged from hospital too early for some problems to be detected. The exceptions to this rule are those mothers who had planned homebirths, since post-birth visits are considered necessary by the attending midwives. But for women giving birth in hospitals, it seems fair to ask why most US maternity services fail to recognize that postpartum home visits by midwives, nurses, or physicians are not luxuries, but necessities for every new mother. Making post-birth home visits part of the standard maternity care package in the US is only one of the steps that our country should take to reduce the maternal death rate.
Every three years, the British Royal College of Obstetricians and Gynaecologists publishes a book titled Saving Mothers’ Lives (formerly Why Mothers Die). Anyone in Wales, Scotland, England, and Northern Ireland can walk into a bookstore and buy the 400-page book, which is a sort of report card on the results of the combined maternity services of the four countries. (4) As the public outreach component of the UK’s respected Confidential Enquiries into Maternal and Child Health (CEMACH), each edition of the book is based upon data drawn from every maternal death in the UK from causes stemming from pregnancy or birth during the preceding three years of available data. Each of the main causes of maternal deaths—hypertension, thromboembolism, hemorrhage, amniotic fluid embolism, infection, anesthesia problems, and injuries to the cervix, perineum, or vagina—gets its own chapter and includes at least one narrative of a case of such a death.
The UK claims a high degree (97 percent) (5) of accuracy in determining how many maternal deaths occur each year: the triennial Saving Mothers’ Lives report is actually considered the “gold standard” in professional self-audit. Sometimes cases involving substandard care are described in Saving Mothers’ Lives, but the names of hospitals or cities are never mentioned. Because the purpose of the CEMACH program (a rough equivalent to our own Centers for Disease Control) is to get at the truth, names and places are kept confidential so that results of the enquiries can’t be used in malpractice lawsuits. Saving Mothers’ Lives not only provides detailed, accurate numbers of deaths for each category of death but also makes recommendations about what steps should be taken to ensure that the number of deaths will be reduced in the next three-year period. As of 1999, building upon the excellent feedback provided by CEMACH, the UK maternity system has been able to reduce the number of maternal deaths each triennium. (6) There was a slight, but statistically insignificant, rise in the death rate in the 2002 edition of Why Mothers Die. (7)
What a different situation we have in the US. Here, while we take it for granted that everything possible is done to prevent maternal death, most of us haven’t a clue about what this effort requires. We don’t read much about maternal death in the news media or on the internet, so we assume that women rarely die from pregnancy or birth. What we don’t realize is how infrequently the deaths of mothers that do occur are mentioned in the news. Tameka McFarquhar’s death, for instance, was mentioned only in the Watertown paper and a newspaper in Kingston, Jamaica—never nationally. More recently, Caroline Still Wiren’s death from hemorrhage after her first birth in a Florida hospital in spring 2007, made the news most likely because of her husband, Nyle Wiren’s, fame as a long-time football player for Tampa Bay. (8) In early spring 2007, when two teachers from the same small-town New Jersey elementary school died within 15 days of each other after the cesarean births of their first babies, local news coverage of the story prompted national coverage on network television. (9) But when a third New Jersey mother died after the cesarean birth of her twins two months later, we were back to the norm of no news coverage at all. (10)
