Why are so many new and expectant mothers dying in the US?

The Finnish baby box system has received a lot of press in the US. Americans think, oh, safe sleep, it'll reduce SIDS/SUID. While that may be true, the whole scam in Finland (since 1949) was that you only got a box if you went to your new free prenatal appointments! Can you imagine the US saying, hey, we'll give all moms & babies cute free stuff if you take advantage of prenatal care! The current situation is rather different.

http://www.econtalk.org/archives/2014/11/emily_oster_on.html

> Russ: ... So, we started off by saying on the surface, the United States despite its relative wealth is something like Croatia--it's 51st in the world in infant mortality. Which is somewhat appalling. And we're double the countries in the world that are doing the best at keeping infants alive. Which is Finland. Given what you've looked at now, how would you summarize what we know about that picture?

> Guest: I think that what I would say is that what we get out of our data is a recognition that the issues that the United States is having are not issues about the kind of medical technology part of this, and I think that's--in some ways surprising that [?] I think [?] we think of infant mortality as kind of being special and about things that are happening in hospitals and [?] and how we're doing with very small babies and it's true that that is an important part of infant mortality, but it's not a place that the United States is falling down. Instead the place that the United States seems to be doing worse is in the more mundane issues of what is happening before birth, most of which is going to be about things that are happening in people's households. And then what's happening after people are home with their infants. And both of these are not unrelated to broader issues in the United States, like we in general have a higher mortality rate among children, among adults, than most other places, and sort of thinking about this a little wholistically and thinking about how we can support women with infants when they are at home, if they do something that might be of some significant policy value.

A scary quote: "So, for example, among, like, black women with less than a high school education in Cook County--which would basically be the South Side of Chicago--the infant mortality rate in this period is about 16 per 1000."

Note that due to differences in reporting, these numbers may not be comparable across countries; while the WHO recommendation is that all children who show signs of life should be recorded as live births, in many countries this standard is not followed, artificially lowering their infant mortality rates relative to countries which follow those standards.

-So, how does the US record live births? Does the US count a 22 week old premature birth as a live birth? Does the EU? If it is different, I wonder if it would account for a lot of the difference.

- US health care is shit overall (people are less healthy as a baseline)

- Sexism in various ways: "Whether they are pregnant or not, women are second-class citizens when it comes to health care" - vs. men, and vs. their fetuses or babies when pregnant; maternal care not being prioritized in health care

- Excessively invasive/interventionist healthcare practices

- "With its uniquely fragmented health system, straddling states and federal government in a complex web of public and private, for-profit and nonprofit, it is nearly impossible to effectively tackle complex issues."

Very high C-section rates, born out of OB/GYN training that concentrates on the abnormal and generally emphasizes an interventionist approach, shift mortality burden to mothers from children.

Lack of standardization of care means OB/GYNs follow idiosyncratic rather than evidence-based protocols. This is particularly striking when it comes to maternal death from pre-eclampsia or HELLP. These are complications that are easy to treat in an algorithmic fashion if you care to bother. Anti-coagulants after C-section -- another boring, algorithmic treatment that would decrease mortality a bunch.

Moms are getting a older and less healthy. This is also true in other countries and they do a lot better, because other countries make it a priority to deliver low-cost prenatal and maternal care. US emphasis on personal responsibility leads to an attitude that moms should treat themselves/advocate for themselves/blah blah. Prenatal care is not as easy to access as it should be, postnatal care is almost nonexistent (both medical and mental health).

Inequality in the US, ranging from economic to straightforwardly racial, leads to poorer outcomes for many groups.

>> Overall summary (last paragraph before the first subtitle)

Through the course of reporting this story, it quickly became apparent that there is no single reason, but instead a complex brew of factors that, together, point to deep-rooted, systemic problems that run through the entire social and health care system of the country. Gender, class, race—and across all, a fragmented, mainly private health system—conspire to work against maternal health.

>> Older, fatter, sicker: The fault of the mothers (first subtitle)

In certain parts of the world—Scandinavia and Western Europe, in particular—a focus on more dedicated care, before, during, and after birth leads to dramatically different results.

Instead, we need to understand why American women are fatter and sicker in the first place, and why manageable conditions end in women dying.

>> Priority matters (second subtitle)

When it comes to pregnant women, this manifests itself in a focus on the child, at the cost of a focus on the mother, as highlighted in a recent investigation by NPR and ProPublica into the issue.

American women typically have three to five ultrasounds of their fetus, for instance, compared to the two or three British (and most other European) women have.

Many other countries (including the UK) provide support from nurses and doulas after a woman has left the hospital, while that’s rarer in the US. Meanwhile, the US is the only rich country that doesn’t mandate maternity leave.

This marked a big step forward given that suicide is the second leading cause of death among postpartum mothers. But a pregnant or postpartum woman who finds herself in need of mental health support still has to navigate a complex process of getting treatment, including waiting lists and screenings, said Joy Burkhard, who leads 2020 Mom, an organization focused on improving maternal mental health care in the US.

Once the baby is born, new mothers in the US generally have to wait six weeks for their first post-delivery obstetrician-gynecologist (OB-GYN) appointment, so even if their doctor is trained to recognize symptoms of depression (which isn’t common) those first symptoms of depression that can follow delivery will be missed entirely. This contributes to a vast underdiagnosis of postpartum depression (only 50% cases are recognized in the US) and undertreatment of the condition (15% receive treatment). Suicide accounts for 20% of postpartum deaths.

According to the CDC, as many as 17% of the pregnancy-related deaths caused by blood clots—like Liz Logelin’s—could be prevented with simple measures such as compression stockings, or anti-coagulants post-surgery. Such precautions are typically employed after other kinds of surgery, yet often aren’t after c-sections. It was only in 2011 that the American College of Obstetricians and Gynecologists (ACOG) postpartum guidelines were updated to recommend anticoagulant therapies following a c-section.

>> Birthing while black (third subtitle)

But 10 days past her due date, even though neither she nor the baby showed any signs of distress, the personnel at the hospital insisted on inducing labor.

Maddy Oden, her mother, remembers her daughter arguing with the staff that she did not want to be induced, but “finally the nurse said ‘well, you don’t want to go home with a dead baby, do you?’” This succeeded in gaining her daughter’s assent.

She said it was only later, after both Tatia and baby Zorah had died during an emergency c-section, that the family was told that the drug, misoprostol, could cause severe side effects, including amniotic fluid embolism, a potentially lethal complication of childbirth that occurs when amniotic fluid enters the bloodstream.

>> A matter of access (fourth subtitle)

“Maternal health doesn’t just begin [and end] at pregnancy,” says Nadia Hussein, an advocate with MomsRising, noting that health care before, in between and after pregnancies is equally important, especially for the 20% of women dependent on Medicaid who suffer from chronic conditions like depression, hypertension, and type 2 diabetes.

For example, of the 3,144 counties that make up the US, more than a third—1,263—don’t have an OB-GYN. By 2020, it is estimated the country will be 8,000 to 9,000 OB-GYNs short, largely because the number of OB-GYNs has remained steady since the 1980s, while the population has continued to grow. Financial pressures are, once again, a major reason why. OB-GYNs pay the second-highest malpractice insurance rates after neurosurgeons, reflecting their exposure to a high risk of claims against them. (78% of ACOG fellows have been sued at least once in their career.)

Crear-Perry describes the hospital birthing practice as a mix of “efficiency and fear of litigation.” There are, she says, certain delivering techniques, for instance how to turn a baby who’s in an inconvenient position for birth, that are no longer taught to OB-GYNs. They are instead trained to turn to surgical intervention whenever the situation isn’t straightforward, or if delivery isn’t happening within a certain timeframe.

>> Too much is not enough (fifth subtitle)

C-sections, after all, are far more convenient for a hospital. They are easier to schedule, quicker, and make a lot more money; a US hospital can, on average, bill 50% more for a c-section than a vaginal delivery.

Jennie Joseph, a British-trained nurse midwife who has been practicing in the US for the past 26 years and runs Commonsense Childbirth, a birth center which offers midwifery prenatal care in Orlando, Florida, sums it all up effectively: “It’s racism, it’s classism, it’s sexism: All of these things are at play and […] the intersection with capitalism and power,” she told Quartz. “[Women] are dying of a system that’s broken.”

>> No country for new mothers (sixth subtitle)

If the US was like other rich countries, a health crisis such as this would be met with a flurry of initiatives, spearheaded and mandated at a federal level, to find out why mothers are dying, and to figure out ways to reverse it. But the US isn’t like other rich countries. With its uniquely fragmented health system, straddling states and federal government in a complex web of public and private, for-profit and nonprofit, it is nearly impossible to effectively tackle complex issues.

For years, 27 state review groups known as maternal mortality review committees (MMRCs)—some which have sprung from public-health initiatives, others via state OB-GYN societies—have tried to look at available data to assess the causes of maternal death, and if and how they were preventable.

Five years ago, the CDC embarked on an effort to coordinate this ad-hoc system of state-by-state analysis of maternal mortality, providing guidance to help individual review committees standardize their findings to make them comparable across states. However, the CDC still isn’t involved directly in the reviews and, so far, the committees continue to operate independently from one another, says Goodman.

It’s a leadership void that in the past few years has been filled in part by a private-sector actor.

Though the program was built for developing countries with maternal mortality outcomes far worse than the US, Naveen Rao, the doctor who leads it, says Merck for Mothers was expanded to include the US in response to the poor state of childbirth outcomes in the country.

>> There is a graph with the title Maternal mortality halved in California while it doubled in the US

I hope that helps.