(continued from Part II)
By Ina May Gaskin, CPM, MA
Originally published by Mothering, No. 147, 2008-03-04
Incidentally, the US autopsy rate, which was about 50 percent in 1960, has dropped to less than 5 percent. (23) In large part, this development has taken place for economic reasons. Autopsies, although they are necessary for medical research, medical education, and quality control, do not generate profit for hospitals. Numerous studies have shown that in between 25 and 40 percent of cases, autopsy reveals a different cause of death than what had previously been diagnosed. (24) For this reason, a law in Austria requires that all hospital deaths must be followed with an autopsy. (25)
Whenever a maternal death occurs in the UK, CEMACH is automatically notified, and a multidisciplinary team made up of individuals who do not work at the hospital where the death occurred are dispatched to review all of the woman’s records. In sharp contrast, when a maternal death takes place in the US, there is usually no review of the case external to the hospital in question, and all employees with knowledge of the event are warned to keep silence about it.
My own informal survey and research reveal that fewer than half of the states still have mortality and morbidity review committees but the findings of these committees are (e.g., Alaska, Colorado, Florida, Georgia, and Maryland (26) are examples of those which do) are only beginning to be made available to the public. Some states, including my own, Tennessee, have never bothered to conduct maternal mortality and morbidity reviews to clarify the causes of preventable deaths. However, almost every state has statutes that protect a review committee’s reports, proceedings, and findings from legal discovery. (28)
With only an honor system to encourage accurate reporting within a profit-based health industry, should we be surprised that so many deaths are missed in the count? All of the incentives pressure hospitals to underreport. There are no penalties for misclassification, and national audits are not possible. (The states report to the CDC only crude numbers, with no names nor records attached, so there is no way to find out whether a given woman’s death is included. Can we imagine banks and other financial institutions being trusted to function according to such an honor system?
The CDC did make another very important statement in its1998 report, one that it has had no reason to change since: there has been no improvement in the maternal death rate since 1982, when it was reported to be 7.5 maternal deaths per 100,000 births. (29) Our current maternal death rate is four times has high as it should be, and this statement, remember, is based upon our underreported figure. According to the Department of Health and Human Services, the rate should not exceed 3.3 deaths per 100,000 live births, whereas the rate in 2004 was more than 13 per 100,000 births and the rate in 2005 more than 15 per 100,000 births. (30)
In February 2007, the CDC issued a report predicting that maternal death rates in the future will likely rise—not because of actual increases in maternal mortality, but because more states may add to their death certificates the important question about whether or not a deceased woman had been pregnant within the year before her death. What evidence, I wonder, does the CDC have that would allow it to say that it is unlikely there will be an actual increase in maternal mortality rates? Yes, it’s possible that some of the rise in maternal mortality can be attributed to better reporting, but comparatively little has changed when we consider the many flaws in our chaotic methods of maternal death ascertainment. We still have the honor system, no penalties for misclassification or false reporting, little or no training for those who fill out death certificates, and very few autopsies. In addition, most states lack maternal mortality and morbidity review committees, and almost none has the power to look at medical records, or a way to audit the data.
Another vital point: We have a US Standard Certificate of Death In 1979 and 1989, it was proposed that this certificate should include a question asking if the deceased had been pregnant in the year previous to death. Inclusion of this question has been shown to significantly increase the count of maternal deaths.
Amazingly, this question was not adopted in the US Standard Certificate until 2003. However—and this is a big however—the federal government does not require that the states use the US Standard Certificate, and most still don’t! From 1996 to 1998, 16 states included a question related to pregnancy status, and by 2003, 21 states had such a question. But, according to the CDC, “in 2003, only four states could capture information consistent with the standard. (36) The UK has no problem with this kind of craziness. All four countries of the UK use the same forms while, when lives are literally at stake, we can’t get more than a handful of states to cooperate in this gathering of important public health information. What is wrong with us?
Here’s another shock: The rate of maternal death for black women in the US for 2005 was 36.5 deaths per 100,000 (37) Most countries with rates that high are seeking help from international agencies. In fact, according to the World Health Organization, at least 40 other countries have maternal death rates lower than we do in the US. (38) But even that ranking is based on our officially published rate, which is, by the CDC’s own admission, very much underreported.
