The State of Our Health - Women's Health: Death In Childbirth

The spectacular drop in maternal deaths since the 1930s to the 1980s, of which the portion from 1950 onward is shown in the graphic, is one of the more laudable achievements of 20^th-century medical practice. The persistently higher maternal death rate of African American women is a continuing source of concern. The graphic shows deaths per 100,000 live births in an age-adjusted fashion, meaning that data from year to year are comparable despite changes in the age composition of the population. Age-adjustment is important to see the age stratification of women dying of this condition. Typically, women 35 years old and older have the highest maternal mortality rate.

In 1950, 2,960 women died in childbirth. In 1998, 281. In 1999, maternal deaths began to be classified under the International Classification of Diseases 10 (ICD-10) which caused more women to be classified as having died because of "complications of pregnancy, childbirth, and the puerperium [the period during and just after labor]" in 1999. Under the previous ICD classification, the number would have been lower than in 1998.

First, why has maternal mortality dropped so dramatically? The process began in 1933 when a report, issued by a White House conference, stimulated changes. Cited as causes for high mortality rates were poorly trained medical practitioners, unsanitary deliveries at home, excessive surgical and obstetric interventions (induced labor, use of forceps, episiotomy [incision to enlarge the vagina during delivery], and cesarean deliveries). Forty percent of deaths were due to infections of the bloodstream caused by unsanitary interventions (sepsis); of these, half occurred after illegal abortions. The rest of the deaths were caused by hemorrhage and pregnancy-related hypertension (toxemia), which occurs in about 8% of all pregnancies.

Dramatic results were achieved as hospital-delivery of babies became more and more prevalent, as certification procedures for practitioners improved, as antibiotics came into use, better drugs were found to induce labor (oxytocin, a contraction-inducing hormone), better methods to provide blood transfusion became established, and improved techniques for managing pregnancy-induced high blood pressure took hold. Septic death from illegal abortions dropped dramatically when induced abortions were legalized in the 1960s.

Rates of maternal mortality have been more or less level since the 1980s. There are still too many. The Centers for Disease Control estimates that more than half could be prevented using accepted interventions. Twenty countries have lower maternal mortality rates than the United States. Leading causes are hemorrhage caused by ectopic pregnancy (the egg is implanted outside the uterus, usually in the Fallopian tubes), other severe bleeding, high blood pressure (toxemia), and pulmonary embolism (clotting — blood fails to reach the lungs).

The other question that needs to be addressed is the persistently higher maternal mortality rate of black women. Black women begin with a disadvantage. Nonwhite women have a 1.6 times higher risk of maternal complication than white women. Risks are associated with physical condition that may, in turn, be linked to socioeconomic factors — nutrition, the prevalence of diabetes, bacterial vaginosis (an infection of the vagina in nubile women-23% of pregnant blacks suffer from it, 9% of whites), high blood pressure, and other factors. Blacks have a higher risk factor before childbirth (almost twice the risk of whites). But they are four times as likely to die in childbirth as whites. The Centers for Disease Control concludes: "This suggests that access to and use of health-care services for early diagnosis and effective treatment, if complications develop, may be a factor." Indeed, it might. One is tempted to put it more bluntly: Black women are just are not getting the proper care, for whatever reason. It may be economic, cultural, or societal in nature. The gap between whites and blacks is narrowing, but it is happening very slowly.

Source: U.S. Department of Health and Human Services. Health, United States, 2001. Online. Available: http://www.cdc.gov/nchs/products/pubs/pubd/hus/tables/2001/01hus044.pdf. History: "Achievements in Public Health, 1900-1999: Healthier Mothers and Babies." MMWR Weekly. Centers for Disease Control. 1 October 1999.