By Hani K. Atrash, MD, MPH; Sophie Alexander, MD, and Cynthia Berg, MD, MPH
Originally published by Obstetrics and Gynecology, 1993-02-05
How is maternal mortality counted in various wealthy countries? The authors’ objective in this article was to answer this question and, at the same time, to review the information that is needed to understand the events leading to death and to assess how much underreporting of maternal deaths has been reduced by recent strategies to increase accuracy.
Since the maternal mortality rates among various countries are often compared, it is relevant to ask how much agreement there is among countries on how they define maternal deaths. A partial answer to this question is that the United States has defined itself into a category of one, making it difficult to compare our maternal death rate with those of other countries. Here’s the situation. In 1992, recognizing the need for clearer definitions of maternal death, the Tenth International Classification of Disease developed a new, different terminology. According to this system of classification, if a woman dies during pregnancy or within 42 days of pregnancy outcome, whatever the cause, her death is defined as pregnancy-related. However, the American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control (CDC) have not accepted this definition for the United States. Here, such a death would be defined as pregnancy-associated, rather than as pregnancy-related. Pregnancy-associated deaths would include those from homicide, suicide, road accidents, and human immunodeficiency virus (HIV). Why did ACOG and CDC decline to accept the definition used by several other developed countries? No answers to this question are given in this article, but perhaps ACOG and CDC made their decision on the basis that homicide rates in the United States are so high that they would make the maternal death rate climb to levels far above those of other developed countries. This would cast a poor light upon U.S. maternity care.
The authors state, “The actual numbers and rates of maternal death in the United States are not known.” They continue that when various states use new strategies to find more pregnancy-associated and pregnancy-related deaths, the results have frequently been dramatic. For instance, when a check-box on the death certificate in Puerto Rico was introduced, there was a 69 percent increase in the reported maternal mortality ratio. In some states the increase has been as high as 150 percent.
Of all the maternal death reporting systems in the developed countries, the one “believed to obtain as close to complete ascertainment of maternal deaths as is possible, while guaranteeing utmost confidentiality,” is the Confidential Enquiry into Maternal Deaths (CEMD) in the U.K. This system has functioned since 1952 and exists in similar form in the former Commonwealth countries of Australia, New Zealand, and Singapore.
The authors note that one of the greatest weaknesses of the reporting of maternal deaths in the United States lies in the deaths that occur in early pregnancy, such as those associated with induced or spontaneous abortion or ectopic pregnancy. Interestingly, Austria and Bavaria have systems that produce more valid maternal mortality ratios because of an old law that makes a coroner’s autopsy compulsory for all hospital deaths. This means that the Austrian hospital autopsy rate is greater than 95 percent, in contrast with rates in the United States, which have dropped drastically since the 1960s to approximately 9 percent.
The authors make a strong case for adding detailed information to understand the relationship between ethnic origin and maternal death. Why? Because the risk of maternal death among black women in the United States is about four times higher than among white women. This higher risk applies to black women in higher socio-economic levels as well as those in lower levels.
The authors conclude in their final paragraph: “The magnitude of the pregnancy-related mortality problem is grossly understated.” Amen! The question before us now is what are we going to do about it? Evidence-based Medicine: Keeping Your Practice from Getting Stale By David A. Grimes Contemporary Ob/Gyn January, 1999 David Grimes frequently writes about evidence-based medicine, especially as it applies to obstetrics, since he is an obstetrician. Clinical competence declines with age, he believes, not because of the aging process but because of remoteness from formal training. He lists the following powerful forces that keep many obstetricians from up-dating their practices or from practicing in a way that is evidence-based.
- Reluctance to question authority (bloodletting was practiced for centuries for this reason)
- The lure of technology (the widespread acceptance of routine electronic fetal monitoring, despite the evidence weighing against it)
- Medical inertia (routine episiotomy and nonstress testing are given as examples of this)
- The last disastrous result
The conventional wisdom among obstetricians holds that academic leaders and seasoned physicians are the best sources of information. Not so, says Grimes, citing the case of a landmark study from the field of cardiology, which demonstrated that a treatment was available that provided statistically significant benefit. However, because the cardiology authorities who wrote the textbooks were unaware of the study, they gave recommendations in their texts for more than ten years that were dangerously obsolete.
Grimes takes to task home uterine-activity monitoring, a treatment shown by randomized controlled trials to be ineffective in improving outcomes in preterm labor. Small randomized trials have shown that the terbutaline pump is not helpful in stopping preterm labor as well, but the device is still used – even though at least one woman has died from its use (a different woman than the one mentioned in the study in Abstracts, page X).
Grimes’ guidelines for evidence-based practice are the following:
- Learn how to practice evidence-based medicine
- Use evidence-based summaries produced by others. (Here, he suggests A Guide to Effective Care in Pregnancy and Childbirth: 2nd ed., by Enkin, Keirse, Renfrew and Chalmers, Oxford University Press, 1995, which he promises will be an epiphany for many U.S. obstetricians.
- Incorporate into your practice evidence-based medicine guidelines generated by others. Here, he suggests the use of the U.S. Preventive Services Task Force guidelines for women of different ages.
U.S. obstetricians in training spend too much time memorizing and too little time learning how to think critically, writes Grimes. “Clearly, we are failing our medical students and residents miserably when three quarters of physicians in practice admit that they cannot decipher the medical literature intelligently,” he concludes.
Only 15 U.S. Hospitals Designated “Baby-Friendly” By Mike Bykowski, Senior Writer Ob.Gyn News, February 1, 1999 This short article gives us some idea of how well U.S. hospitals are complying with world standards about the facilitation of breastfeeding. In a couple of words, we suck. Check this out. More than 13,000 hospitals worldwide have won the Baby-Friendly Hospital Award. Only 15 are in the United States. The Baby-Friendly Hospital Initiative is sponsored by the World Health Organization and the United Nations Children’s Fund to encourage and recognize facilities that provide an optimal level of lactation care. As of January 1999, 68 hospitals and birthing centers had signed certificates of intent to take steps to receive the award, said Dr. Karin Cadwell, coordinator of Baby-Friendly USA, the organization that implements the Baby-Friendly Hospital Initiative in the United States. She added that getting more hospitals to receive the award is a sure way to increase the initiation and duration of breast-feeding in the United States To receive the award, hospitals and maternity centers must implement these 10 steps:
- Maintain a written breast-feeding policy that is routinely communicated to all health care staff.
- Train all health care staff in all the skills that are necessary to implement this policy.
- Inform all women who are pregnant about the benefits and management of breast-feeding.
- Help mothers initiate breast-feeding within 1 hour of birth (or within 1 hour of mother’s recovery if she delivered by cesarean).
- Show mothers how to breast-feed and how to maintain lactation, even if they are separated from their infants.
- Give infants no food or drink other than breast milk, unless it’s medically indicated.
- Practice “rooming in,” that is, allowing mothers and infants to remain together 24 hours a day.
- Encourage unrestricted breast-feeding.
- Give no pacifiers or artificial nipples to breast-feeding infants.
- Foster the establishment of breast-feeding groups and refer mothers to them on discharge from the hospital or clinic.
Birth Gazette volume 15, no. 3
