By Ina May Gaskin, CPM, MA
Originally published by Journal of Perinatal Education, 2008-03-04
Jasmine E. Gant, an honor student and promising athlete, entered St. Mary’s Medical Center in Madison, Wisconsin on July 5, 2006, in labor. A nurse mistakenly gave her a dose of epidural medication in an intravenous line, instead of the intended penicillin that had been prescribed to treat a strep infection in labor. The epidural medication caused cardiac arrest, and Jasmine died within a few hours. Her 8-pound baby son survived.
Valerie Scythes and Melissa Farah, special education teachers at the same elementary school in Woodbury, New Jersey, had their babies at Underwood Memorial Hospital and died within two weeks of each other in spring, 2007. Both were healthy young first-time mothers, both had cesareans and died shortly after giving birth. The second woman’s death was particularly eerie for her co-workers, as she was reported to have said, on hearing about her colleague’s death, “I wonder if that’s going to happen to me.” Despite the national publicity that followed, Underwood Memorial Hospital was one of just seven hospitals in the country to receive Johnson and Johnson’s childbirth nursing award at the end of 2007.
Angela Wilburn was the first member of her family to graduate from high school. She was 28 years old and pregnant with her 8th and 9th babies at the time. Her nine children were born in eleven years. At more than 41 weeks gestation, her labor was induced with pitocin and artificial rupture of membranes. With her doula at her side, she labored easily with light contractions for about two hours and dilated quickly in about half an hour. Her son Rodney was soon born, weighing 6 pounds, 10 ounces. Before her second son was born, his amniotic sac broke, prolapsing his umbilical cord. The doctor called for a cesarean, and seven minutes later, Randle was born, weighing 7 pounds 13 ounces. Angela, however, bled profusely from the surgery, and a hysterectomy was performed to try to save her life. A Jehovah’s Witness, she refused a blood transfusion and died August 10, 2005, in Coon Rapids, Minnesota. Her estranged husband is in prison. Angela’s grandparents are raising eight of her nine children.
At least two of the deaths mentioned above could have been prevented. The medication mistake which killed Jasmine Gant was made by a very experienced nurse, who surely knew better. Was she taking care of too many patients at once? Did Angela Wilburn’s doctor decide on the cesarean instead of a breech extraction because he or she had never been taught breech skills? That would have been the recommended step a generation ago. Was anything learned by careful review and analysis of what went wrong in the care of these two women who should be alive today?
It can take a long time, I’ve learned, to retire a long-held public myth—especially when it is one that is particularly cherished. The myth I’m thinking of is the one that holds that the United States is one of the safest nations in the world for women giving birth. I’m sure that everyone in our country would like to believe this. Like most people raised here, I accepted without question the story that modern medical advances have brought the maternal death ratio (the number of deaths directly related to pregnancy or birth per 100,000 live births) to such a low point that problem of preventable maternal death could be considered to have been solved. Only after I had been a midwife for more than 25 years, was I finally shocked out of my own complacency about the safety of becoming a mother in my country compared with others. For me, the triggering event was a hospital insider telling me that several women within the previous few weeks had died from complications during or following a cesarean at the hospital where he worked. With no mention of any of these cases having appeared in the media in that city, that surprising disclosure forced me to realize that maternal deaths which occur in hospitals aren’t usually reported by the media. It was only later that I found out that they might not even be reported as maternal deaths to a government agency—whether at the state level or nationally.
Let’s be clear at the beginning that not every maternal death can be prevented. Still, almost all maternal deaths are preventable. The U. S. Department of Health and Human Services (2000) set our national goal for a maternal death ratio to be no higher than 3.3 deaths per 100,000 live births by 2010. Unfortunately, we are far from achieving that goal—in fact, we are moving in the wrong direction.
Currently, according to the World Health Organization and several United Nations agencies, the United States ranks behind no fewer than forty other nations in preventing maternal deaths (based upon the official but unreliable number*). (2 Hill et al., 2007) In 1982, the U.S. ratio was 7.5 deaths per 100,000 births. In 2004, it was 13.2 deaths per 100,000. In 2005, the last year for which we have figures, the maternal death ratio was 15.1 deaths per 100,000 births. For African-American women, the ratio was an outrageous 34.5 deaths per 100,000 births. (Kung, Hoyert, Xu, & Murphy, 2008) In other words, for all U.S. women the maternal death ratio is almost 5 times as high as it should be, and for African-American women, it is more than 10 times what it should be.
The Centers for Disease Control (CDC) reported in 1998 that more than half of these deaths could have been prevented (Johnson & Rutledge, 1998) —surely, a conservative estimate. In that same publication, the CDC admitted that in 1996 that not only had there been no improvement in the maternal death ratio since 1982 but that the officially reported ratio was a substantial underestimate because there are so many classification errors in the system. A recent article in a major obstetrical journal revealed a 93% underreporting rate of maternal death in Massachusetts. (Deneux-Tharaux et al., 2005) It is very likely that a similar rate of error could be found in the other 49 states. Not only do we have a comparatively high death rate for women from causes directly related to pregnancy or birth, we are almost certainly failing to gather most of the data. Because of this, we literally have no idea how many U.S. women die from pregnant or birth-related causes every year. The CDC’s most recent guess is that they could be missing as much as 2/3 of the maternal deaths. (Johnson & Rutledge, 1998) How can we prevent those deaths that are preventable when we don’t really know why all of these women are dying?
In case you are curious about how such an error rate can be perpetuated year after year in data-gathering in our country, you should know that unlike neonatal and infant mortality, maternal mortality is far from easy to count accurately and completely. Women of childbearing age die of a variety of causes that may or may not have any direct link to a pregnancy or birth. Car accidents, domestic violence, and illness all take a toll. There has to be a way to distinguish these deaths from those, which were actually directly caused by the pregnancy, birth, or its aftermath and the care that the woman received (or failed to receive).
