How the Safe Motherhood Quilt Began: Its Purpose

My interest in maternal mortality began when I was still publishing the quarterly magazine Birth Gazette. A nurse-midwife sent in a eulogy that she had written for Nancy Lim, a family nurse practitioner friend of hers. Nancy had died in Oakland, California, a few months earlier of complications that began during the cesarean delivery of her first-born child, son Max. Nancy's death was caused by a small nick of her bowel with the scalpel as her doctor prepared to deliver Max. This bowel nick led to a severe form of peritonitis, requiring a second surgery to remove a gangrenous section of bowel and the installation of a colostomy. Nancy's colostomy was "taken down" after a few weeks-her third surgery within a few months.

Ill or recovering from surgery during the entire first six months of Max's life, Nancy still marshalled the strength to breastfed and continued to express milk for Max during the times when she was hospitalized. One morning when Max was nearly nine months old, as Nancy was beginning to feel the return of reasonably good health, she became very nauseous and experienced sharp abdominal pain. Knowing that these symptoms could signal a bowel obstruction, she mentioned this as a possibility when her husband, Michael Barnes, took her to the emergency room of the hospital where Max had been born. Somehow, her intuition about what was wrong was never picked up in the charting of her case that ensued from that point. The emergency room doctor who was in charge of her case during the night gave her pain medications, on the assumption that her pain was consistent with a tentative diagnosis of gall stones and that she could wait until morning for the arrival of her own physician to undergo further testing. It was a technician who came to draw blood the following morning, who noticed that Nancy Lim was in trouble, even though the emergency room doctor had left Nancy's room only a short time earlier. A code was called because Nancy had stopped breathing and less than an hour later, Nancy was declared dead. An autopsy showed that she had been right about her diagnosis: a bowel obstruction caused by the proliferation of web-like scar tissue after her three surgeries.

In my mind, Nancy Lim's tragedy was compounded was the fact that I had learned (to my amazement) that her death, occurring as it did nearly nine months after the end of her pregnancy, was never figured into the count of U.S. maternal deaths occurring in 1993, since it did not fit the definition of a maternal death. If she had lived in most wealthy nations in the world and had died at the same time of the same complication, her death would have been counted among the list of maternal deaths. The difference? For a maternal death to be recorded as such in our country, it must happen within six weeks of the end of the pregnancy, while most other wealthy countries count all pregnancy-related deaths that occur with in a year of the end of pregnancy. The more restrictive definition used by the Centers for Disease Control and the National Center for Health Statistics in the U. S. makes our maternal death rate appear somewhat lower than it would if we used the definitions standard in most countries. Even so, according to the World Health Organization in 2003, thirty other countries have lower rates of maternal death than we do.

It is not only the maternal deaths that happen between six weeks and a year after the end of pregnancy that may not be counted in our country. Because maternal death reporting is done on the so-called honor system here (not in other countries, where most employ systems that call for auditing maternal deaths), there is no penalty for underreporting of maternal deaths in the U.S. Try to imagine banks and other financial institutions being free to report numbers without threat of audit. To date, no laws have been proposed to address the problem of underreporting.

Currently, it is relatively easy for a woman of childbearing age to die in this country without her death being recorded as a maternal death. A woman may leave the hospital and be readmitted with an infection, be transferred to an intensive care ward and die there, with the connection never being made that her complications began during the care she received while giving birth. Because the data often give only the leading cause of death and not the underlying causes, it is quite possible that the leading cause of death, namely hemorrhage, is, in