Curtailing the Scapel: C-Sections and the Rise of Maternal Mortality
By Christine Cupaiuolo — September 26, 2007
In an op-ed in the L.A. Times, Jennifer Block further contextualizes last month’s surprising news that the U.S. maternal mortality rate rose to 13 deaths per 100,000 live births in 2004.
That amounts to the deaths of 540 women in 2004, 45 more than were reported in 2003 when the rate was 12 deaths per 100,000 live births. That also happened to be the first year since 1977 that the maternal death rate rose above 10 per 100,000 live births.
The statistics were released by the CDC’s National Center for Health Statistics (PDF).
Block, the author of “Pushed: The Painful Truth About Childbirth and Modern Maternity Care,” takes a closer look at the numbers:
For a country that considers itself a leader in medical technology, this figure should be a wake-up call. In Scandinavian countries, about 3 per 100,000 women die, which is thought to be the irreducible minimum. The U.S. remains far from that. Even more disturbing is the racial disparity: Black women are nearly four times as likely to die during childbirth than white women, with a staggering rate of 34.7 deaths per 100,000.
These high rates aren’t a surprise to anyone who’s been investigating childbirth deaths. Physician researchers who have conducted local case reviews across the country consistently have found death rates much higher than what the CDC has been reporting. In New York City between 2003 and 2005, researchers found a death rate of 22.9 per 100,000; in Florida between 1999 and 2002, the rate was 17.6. Other reports by CDC epidemiologists have acknowledged that deaths related to childbirth are probably underreported by a factor of two to three.
Caesarean sections, which now account for a staggering almost 30 percent of all births, and increasing maternal obesity, which can lead to more complications, are cited as probable reasons for the increase. Some researchers also point to changes in the way childbirth deaths are reported.
As Block notes, a c-section is major surgery, “and although it saves lives when performed as an emergency intervention, it causes more harm than good when overused. Here’s why: Caesareans are inherently riskier than normal, vaginal birth. They also lead to repeat caesareans. And repeat caesareans carry even greater risks.”
According to a 2006 study by the World Health Organization that was published last year in the medical journal Lancet, a hospital’s caesarean rate should not exceed 15 percent. “When it does, women suffer more infections, hemorrhages and deaths, and babies are more likely to be born prematurely or die,” writes Block, adding that at some U.S. hospitals, nearly half of all births are delivered surgically.
While 1 in 4 low-risk first-time mothers will give birth via caesarean, the vast majority of them — 95 percent — will have another caesarean when they give birth to their next child, writes Block. Vaginal birth after caesarean (VBAC) is a pretty low-risk event, but more medical institutions are banning VBACs, and doctors shy away from it for a variety of reasons, including malpractice liability.
Indeed, last month, Rachel wrote about a Maryland woman whose obstetrician dropped her — via a letter — when she was eight months pregnant because her first birth was by caesarean and she now wanted to attempt a vaginal birth.
“Universal care alone won’t solve the problem; what pregnant women need is entirely different care,” concludes Block. “They need doctors and hospitals that promote normal labor and delivery. Of course, reducing obesity belongs on the healthcare agenda, and so does curtailing the scalpel.”
Plus: Live near Newton, Mass.? Block will be reading from “Pushed” this Sunday, Sept. 30, at Newtonville Books at 2 p.m.
Future event information is available here. And let’s also put in a plug for Block’s excellent blog, Pushed Birth, a new addition to the OBOB blogroll.
I have a 7 year old son and was dropped by my gyn as well. The reason behind what happened to me was that I was giving birth for the first time at 32 and told my GYN upfront that I wanted a home birth or other low-tech option, no drugs or interventions, no tests that were not necessary (for example – did you know that the glucose fasting test basically puts your baby into hypoglycemic shock? What fool would ask a pregnant woman to fast?), no fetal monitoring and would not consent to a c-section for anything less than a life and death situation. She proclaimed me “an accident waiting to happen.”
Bear in mind, this GYN had cared for me since I was 14, had been my mother’s doctor as well and previously praised me on my good physical condition and health (I am a 5K runner and semi-vegitarian). In response, I sought other options and found a midwifery group that delivered my son the way I intended. And no, neither my son nor I suffered any ill effects. In fact, I recovered from delivery much faster than any woman I know…
In my pregnancy research, I found that my two local hospitals had c-section rates of 35% and 51% — which is unacceptable to me. The answer I can offer to my situation as well as the VBAC controversy is “RESEARCH.” Too many women put their minds and decision-making capacities into the hands of doctors who may know as little or less than they do. Or, into the hands of doctors whose minds are more on profit margins and avoiding malpractice than they are on being good providers.
Knowledge is available and free to any woman who can read or use the internet, and it’s a woman’s own fault for a bad/over-medicalized experience if she chooses not to do the research. Henci Goer wrote an excellent book called “The Thinking Woman’s Guide To A Better Birth” that should be required reading for all pregant women. She outlines in plain fact what the risks for all interventions are and also states that VBAC is safer than repeated c-sections…
“Knowledge is available and free to any woman who can read or use the internet, and it’s a woman’s own fault for a bad/over-medicalized experience if she chooses not to do the research.”
Some women can’t choose to do research, due to illiteracy or lack of access to information. Or, they’re on medicaid which only covers hospital birth, so they lack the choice to refuse and risk having their OB “drop” them.
It’s the same struggle for women to control their bodies that has played out for centuries (think about seeking abortion care pre-Roe). Privileged women are more likely to be able to manipulate the system to get the control they have a right to.
The system’s what’s screwed up, and its imperative that birth activists work on changing the system so that it benefits all women, not just women with the privilege and access to challange it individually.
Congratulations, however, for believing in the power of your own body and fighting for the birth you knew you should have.
Melissa, you make a couple of very good points. Even if a woman is not illiterate, it can be difficult to identify reliable health information online, and there is often a barrier between patient-level information and the vast amount of professional-level information that is in medical terms that are less easily understood.
Your points about individuals vs. the system are also well-taken. It’s hard to ask questions and demand accountability if you aren’t in a position to ask for more or don’t know what questions to ask. If you have choices, it seems relatively easy. If you don’t, the system can be very difficult to negotiate.
Many hospitals are closing the maternity wards because they are not profitable. It seems to happening a lot in Philadelphia.
Thanks so much for your insights. I am pregnant with my first child and I am clueless so this is quite helpful. I am visiting a new GYN on Friday since I took an at home pregnancy test. I have never met this doctor but he was recommended to us. I know that I want a vaginal birth but had no idea that this could be an issue.
What are some questions that I should ask this doctor? My husband and I just watched Knocked Up so I told him that if I don’t like this doctor we will just have to keep looking like they did in the movie. My last period was December 25th so I might be a few weeks pregnant. Who knows.
Sorry to miss your initial appointment. Before your next visit, you may want to check out Questions to Consider Asking Midwives and Doctors. There’s also a new article posted on “Models of Maternity Care.” Good luck!