Is maternal mortality/morbidity being forgotten about in the mad obstetric rush to control womens bodies?
We can see from the links below (Many thanks to Janet Fraser
for letting me use her hard work) that mental health issues are one of the leading causes of death for women. Why? The intricate exchange of hormones that take place immediately after the baby is born sets up our relationship with what is happening, our mothering ability is charged by these hormones. In the first moments of life, when the baby is not put straight onto the chest but removed and touched,treated and manhandled, our hormones are not balanced. In nature the mother would reject an over handled young. With every act of butchery done to women and our inability to allow women the privacy to be with the baby in those first vital minutes we are setting up a pattern leading to long term health issues for our society. It is not good enough to say. Your baby is alive you should be grateful. How long after this will YOU live?
Monitoring maternal mortality and morbidity in Australia
Note that psychiatric conditions are the second leading cause of maternal deaths in Australia and it is possible that there may be under-reporting of these occurrences. It is worthwhile noting that there were no deaths in this triennium from termination of pregnancy procedures.
For the first time, the national report for the triennium 2003-2005 did not include any clinical commentary or practice recommendations. It was considered, by the Australian Commission on Quality and Safety, (rightly, in my view) that because of inconsistencies and quality in the reporting from individual States and Territories, no meaningful conclusions or recommendations could or should be made. Until there is a uniform, consistent approach by a single central, properly authorised confidential committee, no valid clinical conclusions or recommendations are possible, which puts Australia far behind the process undertaken by the UK Confidential Enquiry into Maternal and Child Health.
However, isn’t this good news, that the numbers in Australia are very small and appear to be declining? Well, surely that is so, but as is so often the case, a superficial look at the data doesn’t tell you the whole story, and there are several reasons to be concerned about maternal mortality and morbidity in Australia.
We need first to ask, how good are the data? There is a concern about under-ascertainment. As distinct from a stillbirth or a neonatal death, there is no mandatory notification of maternal mortality, although some States and Territories have a ‘tick box’ for notification that the deceased has been pregnant within the preceding 12 months. It is generally held that in the absence of coordinated efforts to maximise ascertainment, maternal deaths are underestimated by as much as 30 per cent. Some States undertake such efforts, but as is so often the case in public health surveys in Australia, there is variation between States and Territories in the approach to ascertainment. Failure to notify might be more likely for deaths in early pregnancy and when the death occurs remotely in time and/or place from the birth or termination of the pregnancy.
There is also variation and inconsistency in the way in which maternal mortality committees function in Australia, with respect to consideration, classification and reporting of maternal deaths. For example, in the compilation of the most recent report on maternal deaths in Australia, it appeared that there was no functioning maternal mortality committee in Queensland, which was the State with the highest MMR in Australia (over the previous twelve years).Only some States consider and report on preventability. Other States refrain because of privacy or other concerns. There are also variations in referrals of these deaths for coronial investigation. From 2003 to 2005, only 47 of 65 deaths were reported to the coroner, and only 19 of the 29 direct deaths were referred to the coroner.
There are also concerns about the quality of data indicating Indigenous status. In the 2003 to 2005 report, data on Indigenous status was missing in eight per cent of maternal deaths. This deficiency is of special importance because the MMR for Indigenous women was 21.5, compared with 7.9 per 100,000 for non-Indigenous women, reflecting their health disadvantage, in pregnancy and childbirth, as it is in all areas of health of Indigenous groups.
It is estimated that for every maternal death, there are approximately 80 instances of severe maternal morbidity, in which the woman experiences a life-threatening complication from which she survives (completely, or sometimes with residual injury).
A concerning aspect of maternal mortality monitoring in Australia is the lack of recurrent funding or a permanent auspicing agency. The last national maternal mortality report carried a foreword signed by the Director of the Australian Institute of Health and Welfare (AIHW), which auspiced and authorised the report that contained this statement:
‘..the (Australian) Commission (on Safety and Quality in Health Care)
is not able to provide ongoing funding (for regular reporting of
maternal deaths in Australia) and it is concerning that no resources
have been identified to sustain and improve this reporting in the future.’
An options paper to obtain a firm footing for the national maternal mortality survey has been prepared by the AIHW and submitted to the Commission on Safety and Quality in Health Care, but no response had been received at the time of preparing this article.
Maternal deaths in Australia, 2003-2005.
Maternal mortality in Australia, 1973–1996
Maternal mortality in Australia 1964-72
Maternal deaths in Australia 1997-1999
International figures on maternal mortality
Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting
Abstract
- * Maternal mortality associated with psychiatric illness in the perinatal period (pregnancy to the end of the first year postpartum) has until recently been under-reported in Australia due to limitations in the scope of the data collection and methods of detection.
* The recent United Kingdom report Why mothers die 2000–2002 identified psychiatric illness as the leading cause of maternal death in the UK.
* Findings from the last three reports on maternal deaths in Australia (covering the period 1994–2002) suggest that maternal psychiatric illness is one of the leading causes of maternal death, with the majority of suicides occurring by violent means.
* Such findings strengthen the case for routine perinatal psychosocial screening programs, with clear referral guidelines and assertive perinatal treatment of significant maternal psychiatric morbidity.
* Data linkage studies are needed to measure the full extent of maternal mortality associated with psychiatric illness in Australia
Issue 44, January 26, 2010
Preventing Maternal Death
Attempts to identify preventable deaths and understand how to prevent them has yielded varying results; several studies (6,7,8) determined that from 28 to 50 percent of maternal deaths were preventable. In 2008, Hospital Corporation of America (HCA) looked at individual causes of maternal deaths among 1.5 million births within 124 hospitals in the previous six years. (6) The study concluded that the majority of maternal deaths are not preventable and that while some deaths can be prevented by better individual care, precise figures indicating the frequency of preventable deaths should be examined carefully and with caution. According to the HCA study, the most common preventable errors are:
- * Failure to adequately diagnose and treat pulmonary edema in women with pre-eclampsia
- * Failure to pay attention to vital signs following Cesarean section
- * Hemorrhage following Cesarean section
- * Failure to adequately control blood pressure in hypertensive women
Doubling of maternal deaths in U.S. ‘scandalous,’ rights group says
Deaths from pregnancy and childbirth in the United States have doubled in the past 20 years, a development that a human rights group called “scandalous and disgraceful” Friday.
In addition, the rights group said, about 1.7 million women a year, one-third of pregnant women in the United States, suffer from pregnancy-related complications.
Most of the deaths and complications occur among minorities and women living in poverty, it noted.
Amnesty International issued a report Friday that calls on President Obama to take action.
“This country’s extraordinary record of medical advancement makes its haphazard approach to maternal care all the more scandalous and disgraceful,” said Larry Cox, executive director of Amnesty International USA.
Wagner Says WHO Research on Cesarean Rates is Current
Dr. Marsden Wagner, former Director of Women’s and Children’s Health for the World Health Organization, stated via e-mail that the WHO’s 1985 recommendation that cesarean rates by country should not fall below 10% or above 15% remains “absolutely valid and not out-of-date.”
Additionally, Wagner reported that the WHO published a new study in 2007 supporting its original findings that as a country’s cesarean section rate rises above 15%, the maternal mortality too rises. According to Wagner, “[The] unnecessary c-section kills women.”WHO researchers analyzed nationally representative data available from surveys or vital registration systems on the proportion of births by cesarean section. Their analysis suggests a strong inverse association between caesarean section rates and maternal, infant and neonatal mortality in countries with high mortality levels. There is also some suggestion of a direct association at lower levels of mortality.
Said Wagner, “In the past twenty years in the U.S., the maternal mortality rate keeps rising and rising while the rate of c-section continues to rise. It can now be reliably calculated that [the] c-section is the number one cause of maternal mortality in the U.S.–at least 45% of all maternal death is associated with a c-section.”
According to the CDC’s National Center for Health Statistics, the U.S. maternal mortality rate rose to 13 deaths per 100,000 live births in 2004 for a total of 540. This amounts to 45 more maternal deaths than were reported in 2003 and for the first time since 1977, the maternal death rate rose above 10 per 100,000 live births.
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You’re welcome.
This is an interesting article too which rather goes along with the RANZCOG article that suggests there are 80 life threatening scenarios for every maternal death. It’s six years old and there haven’t been any policy changes to prevent IOL on dates or to make vbac the norm so I have no reason to suppose the rates have changed very much. Anyone seen something recent?
http://www.theage.com.au/articles/2004/03/28/1080412235095.html The Age 2004
Warning on Caesareans
An alarming rise in the number of emergency hysterectomies performed on Victorian women after childbirth has prompted an obstetrics expert to warn doctors against performing elective caesareans without medical cause.
The warning follows a report commissioned by the Department of Human Services to investigate claims of an increase in hysterectomies to stem severe bleeding in new mothers. The report found that, although still rare, the incidence had risen from 20 post-partum hysterectomies in the state in 1999 to 48 in 2002. Over the same period, caesarean rates rose from 22.8 per cent of births to 27.4 per cent. The report’s author, obstetric epidemiologist James King, said it was likely there was a causal link between the two.
Read the rest at the link.
importance of this subject has been brought to light in the USA by Ina May Gaskin. Her Maternal Mortality Quilt has travelled far and wide, bringing the names and stories of women who have died during and after childbirth to public notice.
Ina May has a campaign to get standardized reporting done in each and every state because, right now, it is very disjointed in the U.S., too. A comprehensive reporting form was developed by the National Institute of Health but it is not universally used by each state.
Pushing for comprehensive and standardized data collection is very important.
Thanks for this post, Lisa. Gloria
Hi Lisa,
I might have mentioned it before, but I am the perinatal and infant mental health nurse on our team, and this year I have had 2 mum’s I’ve “case managed” with PPD – one of them chronically suicidal – both caesars. A huge part of my work with them has been to work through their births. Both were totally accepting that their caesars were both ok seeing they had live babies (one was a repeat caesar for no other indication other than her first was a caesar, the second was a failed augmentation after SROM at term without rushes, which ended in the typical foetal distress-caesar cascade!). But after therapy both realised the impact their births had on their mental state. It also affected their ability to BF. I also care for women with psychotic disorders (such as schizophrenia) and bipolar illnesses, which by the nature of these illnesses leaves them vulnerable to relapse intrapartum. To be honest, I have come across nothing but judgement toward our mums who become mentally unwell – some of the horror stories I could tell would make your blood run cold.
I am seeing more and more women as well with post-traumatic stress disorders following what are usually traumatic hospital births, the more intervention rates rise, seriously, the more woman I am seeing damaged or scarred from what should be empowering and strengthening births!
Its criminal really what they do to women!
It’s pretty sad, and kinda telling, that this entry on dead women gets so few comments in comparison with other posts.
You’d think at least Dr Amy would want to come along and splain how we’re imagining all the dead and injured women.
We so often allow the obstetric discourse to dominate birth and yet when faced with the reality of what obstetrics does to women, we fall silent, not wanting to be seen to be uppity or agitating selfishly on our own behalf.
If HIV/AIDS activists hadn’t started off that struggle on their own, who else would have done it for them? The devastation done to women, families, communities and our babies isn’t being protested by any of those doing the damage.
We need to stand up and start challenging those dominant voices every time they tell those lies about neonatal mortality and homebirth with the totally obvious and demonstrable facts about maternal injury and death. Their own work shows that maternal mortality is under reported, so what are they doing about it?
Obstetrics doesn’t like scrutiny because they’re not fact based, they’re driven by a misogynist ideology and a race for the dollar. They like using women from developing countries to berate those in developed countries but they don’t really like addressing this reality we in developed countries experience at their hands.
Enough is enough, people.
Janet you have a way with words, I also noticed that facebook shares were much less than normal. Dead women are just not trendy.
Thank you so much for posting this information.
Although not having birthed/been pregnant yet myself, I have been supporting my cousin through her second pregnancy and your website is a fantastic resource. After a ‘post-date’>’macrosomia’>induction>ARoM>augmentation>’failure to progress’>c-section for baby no. 1, B was really traumatised and couldn’t talk about the birth let alone countenance another pregnancy for a long time.
Talking about ppd and the psychological trauma of birth is incredibly important. We were lucky that in a family with a history of bipolar and depression we recognised the signs that something was wrong and B was able to get the support she needed.
After three years of other family member’s pressure (you’re all better now, when’s S getting a brother/sister?) B became pregnant with no. 2 and was quickly overwhelmed again by the fears – the powerlessness, the pain, the feelings of failure. B started on the hospital vbac route and when she came home from her first hospital midwife appointment they had given her a booklet about vbac and caesareans and the risks therein.
I live round the corner now (to offer support and be a part of her ‘village’) and she asked me to come over to go through the information with her.
From a layperson’s perspective I said I thought it was quite fair (almost pro-vbac really) in its representation of risky outcomes of vbac vs repeat-c … so far as it went. But I was furious for B that her very real, actually life-threatening outcome was minimised/omitted.
They had all the stats on uterine rupture, hysterectomy, infection, blood loss, cuts to baby, respiratory distress … but nothing about the psychological damage from a highly interventionist/medically managed birth. I was so angry for B and for all those other women whose emotional scars are very real but whose experiences are discounted as their own “failure”/”flawed psychology” and “nothing to do with the birth” (quotes from in-laws/’friends’).
This omission has plagued me for weeks and I keep thinking why doesn’t B’s story count? Is it really so difficult to identify, to quantify, to count, to tabulate and present this data? Or, is it just because it doesn’t serve the purposes of the medicalised model of birth? “This woman is just weak, a freak, a nutcase, was always going to have a breakdown, none of the scary things I said and did, none of the invasive/too frequent examinations and none of my abuses of power at a time of critical vulnerability caused this outcome.” An outcome with life-threatening risks that is all too eagerly laid at the feet of the woman as her fault entirely is an outcome that is too frequently dismissed.
So, a very big thank you Lisa (and Janet) for getting this information out there.
As far as B is concerned we linked up with a brilliant birth trauma group. Through recommendations from that group and her own research and decision making, B is planning a HBAC with an awesomely lovely, supportive and experienced midwife. Home is where B feels safest and feels most secure, home is where B feels most competent and feels most capable of making her own decisions.
Feelings count (and should be counted more).
oh thx janet for writing this. no, maternal mortality – as i have seen – is not a trendy topic. i have thought so much about this esp. in relation to the maternal mortality rates of women of color in the states. these rates are not falling but rising yearly. part of the problem, in terms of visibility of maternal mortality, is the high morbidity rates are held in pockets of the states. another problem is that the emphasis, at least in black communities, is on the infant mortality rates (which is often blamed on lifestyle choices of the mother), rather than the maternal rates.
of course the mortality rates are used as one more reason why women of color must follow the doctor’s orders no matter what in terms of prenatal, birth, and post partum care. this meme filters into our communities as if we of all people cannot afford to do any type of alternative to the obgyn because of the level of ‘risk’ involved. thus black women are even less likely to look outside of the medical system for childbearing health care.
Hi Matilda,
the basic issues are that women with trauma resulting from their careproviders are not acknowledged as even a possibility in obstetrics where the only goal is to remove the foetus from the incubator as fast as possible, leaving both alive. In obstetrics the definition of “healthy” means “not dead”. It doesn’t mean intact, empowered, triumphant, emotionally well, supported or joyful. Women are unimportant in their model of care, we’re just the inconvenient obstacle between them and the baby. I can hear the gasps from here of some people reading this but this is the reality.
I’m very relieved to hear that your cousin has made a choice which will hopefully nurture her and support her in becoming a confident, competent parent of two children as well as a woman who trusts her own decisions and knows her body is hers to own. I hope you’ll update us with how she feels about her care experience postbirth and many blessings to her for a beautiful birth!
Last week I attended a birth at home of a baby whose mother had had previous caesarean surgery. It was a normal, unremarkable, beautiful, everyday miracle of a birth, like most births. The woman worked hard all her pregnancy, and before it, to deal with the issues resulting from being so systematically disempowered and abused with her first child in a UK hospital and birthed triumphantly and magnificently. I was so honoured to attend. She hasn’t stopped smiling in the last 9 days.
As Andrew Pesce said in the paper today, “Most women are fairly happy with the care they receive” in hospitals. Really? Does he ask us? And are “most” and “fairly happy” really how we want to feel after we’ve birthed? I think not. Women are sadly so used to asking for a slice and then being grateful for crumbs. We’ve forgotten that the loaf is ours and no one can really steal it from us but we can sure as hell give it away and regularly do.
mai’a we have similar figures with Aboriginal and Torres Strait Islander women. While the rates of murder by a partner go up exponentially when white women are pregnant, they rise even higher when black women are pregnant. Indigenous women have high stillbirth rates, low birthweights, and very little genuine support. Women from isolated areas are expected to leave their country, family and language and travel to major cities for birth. There is a Birthing On Country movement here thought with indigenous women reclaiming their right to birth on land their grandmothers own. It is moving, profound and beautiful all at once. There is some patronising recognition officially that indigenous women should have cultural birthing practices respected but overall the reality is far from this.
The US health system is even less desirable than ours although perhaps the reforms will see healthcare being delivered to vulnerable members of your society. I hope so.
i keep a page on my blog for Australian hospitals in the media for anyone who’s interested. It gets updated nearly every day… unfortunately.
http://janetfraser.id.au/blog/australian-hospitals-in-the-media/
“In obstetrics the definition of “healthy” means “not dead”.”
Oh wow. What a powerful, and frighteningly true, statement.
An incubator for the baby…that is just how I felt. It was like i was supported so beautifully right until he came out, then suddenly I was unimportant. “Phew”, everyone said, he’s out now our job’s done. suddenly all the love and care was removed and I was forgotten there on the bed while everyone helped themselves to basking in the baby’s glow.
I felt so abandoned unimportant and powerless, my feeble attempts to ask for help were brushed off like it was all too hard to assist me, I was even accused (subtly and not so subtly) of being lazy. Yes, lazy, not totally exhausted, in pain, disoriented and isolated. It’s not just the hospital staff who exhibited this attitude but also a number of people (though thankfully, not all) close to me.
This for me is one place where the status of women is clear, where it’s so bleeding obvious that women are STILL not equal. We are all supposed to somehow just get on and get up like nothing just happened, and to do otherwise is selfish. I would like to see some broader cultural awareness that birth doesn’t end when the baby takes its first breath. I reckon it’s at least a 3-month process: mum needs support for ALL that time.