Maternal Mortality – U.S. Has The Worst Rate Of Maternal Deaths (Rich)
by RV/Vijay ·
The story of Lauren Bloomstein illustrates a disparity in our nation’s health care system, where primary focus is given to newborn babies, but often ignores the mothers.
NPR and ProPublica teamed up for a six-month long investigation on maternal mortality in the U.S. Among our key findings:
- More American women are dying of pregnancy-related complications than any other developed country. Only in the U.S. has the rate of women who die been rising.
- There’s a hodgepodge of hospital protocols for dealing with potentially fatal complications, allowing for treatable complications to become lethal.
- Hospitals — including those with intensive care units for newborns — can be woefully unprepared for a maternal emergency.
- Federal and state funding show only 6 percent of block grants for “maternal and child health” actually go to the health of mothers.
- In the U.S, some doctors entering the growing specialty of maternal-fetal medicine were able to complete that training without ever spending time in a labor-delivery unit.
Maternal Mortality Is Rising in the U.S. As It Declines Elsewhere
Deaths per 100,000 live births
“Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015,” The Lancet. Only data for 1990, 2000 and 2015 was made available in the journal.
Source: The Lancet
Credit: Rob Weychert/ProPublica
Ms Lauren Bloomstein
As a neonatal intensive care nurse, Lauren Bloomstein had been taking care of other people’s babies for years. Finally, at 33, she was expecting one of her own. The prospect of becoming a mother made her giddy, her husband, Larry, recalled recently— “the happiest and most alive I’d ever seen her.”
When Lauren was 13, her own mother had died of a massive heart attack. Lauren had lived with her older brother for a while, then with a neighbor in Hazlet, N.J., who was like a surrogate mom, but in important ways she’d grown up mostly alone. The chance to create her own family, to be the mother she didn’t have, touched a place deep inside her.
“All she wanted to do was be loved,” said Frankie Hedges, who took Lauren in as a teenager and thought of her as her daughter. “I think everybody loved her, but nobody loved her the way she wanted to be loved.”
Other than some nausea in her first trimester, the pregnancy went smoothly. Lauren was “tired in the beginning, achy in the end,” said Jackie Ennis, her best friend since high school, who talked to her at least once a day. “She gained what she’s supposed to. She looked great, she felt good, she worked as much as she could” — at least three, 12-hour shifts a week until late into her ninth month. Larry, a doctor, helped monitor her blood pressure at home, and all was normal.
On her days off she got organized, picking out strollers and car seats, stocking up on diapers and onesies. After one last pre-baby vacation to the Caribbean, she and Larry went hunting for their forever home, settling on a brick colonial with black shutters and a big yard in Moorestown, N.J., not far from his new job as an orthopedic trauma surgeon in Camden. Lauren wanted the baby’s gender to be a surprise, so when she set up the nursery she left the walls unpainted — she figured she’d have plenty of time to choose colors later. Despite all she knew about what could go wrong, she seemed untroubled by the normal expectant-mom anxieties. Her only real worry was going into labor prematurely. “You have to stay in there at least until 32 weeks,” she would tell her belly. “I see how the babies do before 32. Just don’t come out too soon.”
When she reached 39 weeks and six days — Friday, Sept. 30, 2011 — Larry and Lauren drove to Monmouth Medical Center in Long Branch, the hospital where the two of them had met in 2004 and where she’d spent virtually her entire career. If anyone would watch out for her and her baby, Lauren figured, it would be the doctors and nurses she worked with on a daily basis. She was especially fond of her obstetrician/gynecologist, who had trained as a resident at Monmouth at the same time as Larry. Lauren wasn’t having contractions, but she and the ob/gyn agreed to schedule an induction of labor — he was on call that weekend and would be sure to handle the delivery himself.
Inductions often go slowly, and Lauren’s labor stretched well into the next day. Ennis talked to her on the phone several times: “She said she was feeling OK, she was just really uncomfortable.” At one point, Lauren was overcome by a sudden, sharp pain in her back near her kidneys or liver, but the nurses bumped up her epidural and the stabbing stopped.
Inductions have been associated with higher cesarean-section rates, but Lauren progressed well enough to deliver vaginally. On Saturday, Oct. 1, at 6:49 p.m., 23 hours after she checked into the hospital, Hailey Anne Bloomstein was born, weighing 5 pounds, 12 ounces. Larry and Lauren’s family had been camped out in the waiting room; now they swarmed into the delivery area to ooh and aah, marveling at how Lauren seemed to glow.
Larry floated around on his own cloud of euphoria, phone camera in hand. In one 35-second video, Lauren holds their daughter on her chest, stroking her cheek with a practiced touch. Hailey is bundled in hospital-issued pastels and flannel, unusually alert for a newborn; she studies her mother’s face as if trying to make sense of a mystery that will never be solved. The delivery room staff bustles in the background in the low-key way of people who believe everything has gone exactly as it’s supposed to.
Then Lauren looks directly at the camera, her eyes brimming.
Twenty hours later, she was dead.
“We don’t pay enough attention”
The ability to protect the health of mothers and babies in childbirth is a basic measure of a society’s development. Yet every year in the U.S., 700 to 900 women die from pregnancy or childbirth-related causes, and some 65,000 nearly die — by many measures, the worst record in the developed world.
American women are more than three times as likely as Canadian women to die in the maternal period (defined by the Centers for Disease Control as the start of pregnancy to one year after delivery or termination), six times as likely to die as Scandinavians. In every other wealthy country, and many less affluent ones, maternal mortality rates have been falling; in Great Britain, the journal Lancet recently noted, the rate has declined so dramatically that “a man is more likely to die while his partner is pregnant than she is.” But in the U.S., maternal deaths increased from 2000 to 2014. In a recent analysis by the CDC Foundation, nearly 60 percent of such deaths are preventable.
While maternal mortality is significantly more common among African-Americans, low-income women and in rural areas, pregnancy and childbirth complications kill women of every race and ethnicity, education and income level, in every part of the U.S. ProPublica and NPR spent the last several months scouring social media and other sources, ultimately identifying more than 450 expectant and new mothers who have died since 2011.
The list includes teachers, insurance brokers, homeless women, journalists, a spokeswoman for Yellowstone National Park, a co-founder of the YouTube channel WhatsUpMoms, and more than a dozen doctors and nurses like Lauren Bloomstein. They died from cardiomyopathy and other heart problems, massive hemorrhage, blood clots, infections and pregnancy-induced hypertension (preeclampsia) as well as rarer causes. Many died days or weeks after leaving the hospital. Maternal mortality is commonplace enough that three new mothers who died, including Lauren, were cared for by the same ob/gyn.
The reasons for higher maternal mortality in the U.S. are manifold. New mothers are older than they used to be, with more complex medical histories. Half of pregnancies in the U.S. are unplanned, so many women don’t address chronic health issues beforehand. Greater prevalence of C-sections leads to more life-threatening complications. The fragmented health system makes it harder for new mothers, especially those without good insurance, to get the care they need. Confusion about how to recognize worrisome symptoms and treat obstetric emergencies makes caregivers more prone to error.
Yet the worsening U.S. maternal mortality numbers contrast sharply with the impressive progress in saving babies’ lives. Infant mortality has fallen to its lowest point in history, the CDC reports, reflecting 50 years of efforts by the public health community to prevent birth defects, reduce preterm birth, and improve outcomes for very premature infants. The number of babies who die annually in the U.S. — about 23,000 in 2014 — still greatly exceeds the number of expectant and new mothers who die, but the ratio is narrowing.
The divergent trends for mothers and babies highlight a theme that has emerged repeatedly in ProPublica‘s and NPR’s reporting. In recent decades, under the assumption that it had conquered maternal mortality, the American medical system has focused more on fetal and infant safety and survival than on the mother’s health and well-being.
“We worry a lot about vulnerable little babies,” said Barbara Levy, vice president for health policy/advocacy at the American Congress of Obstetricians and Gynecologists (ACOG) and a member of the Council on Patient Safety in Women’s Health Care. Meanwhile, “we don’t pay enough attention to those things that can be catastrophic for women.”
At the federally funded Maternal-Fetal Medicine Units Network, the preeminent obstetric research collaborative in the U.S., only four of the 34 initiatives listed in its online database primarily target mothers, versus 24 aimed at improving outcomes for infants (the remainder address both).
Under the Title V federal-state program supporting maternal and child health, states devoted about 6 percent of block grants in 2016 to programs for mothers, compared to 78 percent for infants and special-needs children. The notion that babies deserve more care than mothers is similarly enshrined in the Medicaid program, which pays for about 45 percent of births. In many states, the program covers moms for 60 days postpartum, their infants for a full year. The bill to replace the Affordable Care Act, adopted by the U.S. House of Representatives earlier this month, could gut Medicaid for mothers and babies alike.
At the provider level, advances in technology have widened the gap between maternal and fetal and infant care. “People became really enchanted with the ability to do ultrasound, and then high-resolution ultrasound, to do invasive procedures, to stick needles in the amniotic cavity,” said William Callaghan chief of the CDC’s Maternal and Infant Health Branch.
The growing specialty of maternal-fetal medicine drifted so far toward care of the fetus that as recently as 2012, young doctors who wanted to work in the field didn’t have to spend time learning to care for birthing mothers. “The training was quite variable across the U.S.,” said Mary D’Alton, chair of ob/gyn at Columbia University Medical Center and author of papers on disparities in care for mothers and infants. “There were some fellows that could finish their maternal-fetal medicine training without ever being in a labor and delivery unit.”
In the last decade or so, at least 20 hospitals have established multidisciplinary fetal care centers for babies at high risk for a variety of problems. So far, only one hospital in the U.S. — NewYork-Presbyterian/Columbia — has a similar program for high-risk moms-to-be.
In regular maternity wards, too, babies are monitored more closely than mothers during and after birth, maternal health advocates told ProPublica and NPR. Newborns in the slightest danger are whisked off to neonatal intensive care units like the one Lauren Bloomstein worked at, staffed by highly trained specialists ready for the worst, while their mothers are tended by nurses and doctors who expect things to be fine and are often unprepared when they aren’t.
When women are discharged, they routinely receive information about how to breast-feed and what to do if their newborn is sick but not necessarily how to tell if they need medical attention themselves. “It was only when I had my own child that I realized, ‘Oh my goodness. That was completely insufficient information,'” said Elizabeth Howell, professor of obstetrics and gynecology at the Icahn School of Medicine at Mount Sinai Hospital in New York City.
“The way that we’ve been trained, we do not give women enough information for them to manage their health postpartum. The focus had always been on babies and not on mothers.”
In 2009, the Joint Commission, which accredits 21,000 health care facilities in the U.S., adopted a series of perinatal “core measures” — national standards that have been shown to reduce complications and improve patient outcomes. Four of the measures are aimed at making sure the baby is healthy. One — bringing down the C-section rate — addresses maternal health.
Meanwhile, life-saving practices that have become widely accepted in other affluent countries — and in a few states, notably California — have yet to take hold in many American hospitals. Take the example of preeclampsia, a type of high blood pressure that occurs only in pregnancy or the postpartum period, and can lead to seizures and strokes. Around the world, it kills an estimated five women an hour. But in developed countries, it is highly treatable. The key is to act quickly.
By standardizing its approach, Britain has reduced preeclampsia deaths to one in a million — a total of two deaths from 2012 to 2014. In the U.S., on the other hand, preeclampsia still accounts for about 8 percent of maternal deaths— 50 to 70 women a year. Including Lauren Bloomstein.