June 14, 2009
Mothers' death rates under scrutiny
Analysis of mortality report shows possible links to surgery
By Mary Beth Pfeiffer
Poughkeepsie Journal
Seventy percent of
women who died from pregnancy-related causes in New York state
underwent cesarean-section births, more than twice the rate at which
cesareans are performed in the state. The
findings come from a report on maternal mortality obtained under the
Freedom of Information Law from the state Health Department, which
sponsored the study. The research was performed by the New York chapter
of the American College of Obstetricians and Gynecologists. The
study, which was not dated, analyzed case files of 33 of the 141 women
who died as a result of pregnancy and childbirth from 2003 to 2005.
There were two deaths among Ulster County women in that time, and none
in Dutchess, but it is not known if they were part of the study. The
Poughkeepsie Journal reported in March that the rate of cesarean
sections soared 42 percent in New York state from 1999 to 2007; one in
three babies was delivered surgically in 2007, many for nonmedical
reasons such as mothers' concerns over labor and physicians' liability
fears or time constraints. At the same time, the rate of maternal
mortality in the state is rising; it went up 70 percent from 1997 to
2007, the Journal found. The
maternal-death report does not suggest the cesareans caused the deaths,
noting 43 percent of the women had high-risk complications or
conditions. But nor did it discuss the potential role of the surgery
itself in driving maternal mortality, particularly among women who may
have had cesareans for convenience or simply because they had had
previous cesarean sections. Some experts saw this as a major flaw in
the data. "It's
troubling that the new mortality review does not discuss implications
for maternal death of rising record-level cesarean rates," said Dr.
Carol Sakala, program director for the research and advocacy group
Childbirth Connection, based in New York City. "We need to know whether
women are dying needlessly because of these disturbing trends." Assemblywoman
Amy Paulin, a Democrat from Scarsdale in Westchester County who has
sponsored legislation to inform women on birthing choices, said the
oversight was "stunning." "There
was no effort to address - there was almost an acknowledgement that an
elective (cesarean) is OK even though it can lead to a death," Paulin
said. "Clearly it was acknowledged in the report as a circumstance. If
it was a circumstance, the first thing you can do is address
eliminating elective C-section." New report under way
Dr. Cynthia Chazotte, a Bronx
obstetrician and co-chairwoman of the project that produced the report,
acknowledged it did not explore the link between cesarean section and
mortality and said the next report, now in preparation, would attempt
to "tease that out." "What
is the contribution of the surgery itself?" asked Chazotte, vice
chairwoman of obstetrics at Albert Einstein College of
Medicine/Montefiore Medical Center. "That's a question we don't have a
good answer for." The
study is part of a state effort called the Safe Motherhood Initiative,
which aims to reduce maternal death to 3.3 deaths per 100,000 live
births; in 2007, it was nearly five times that, at 15.3 deaths. The
research was not posted on the Health Department's Web site because,
state officials explained, it was available on the Web site of the
obstetricians' group. However, it had not been seen by Paulin and
others active on the issue of cesarean birth until copies were provided
by the Journal. An effort will be made to disseminate the next report
more broadly, Chazotte said, adding the current report had been sent to
obstetricians. The study found: •
Eight women died from pregnancy-induced high blood pressure and eight
from an embolism, or blood clot. Five each died from hemorrhage and
infection. Two died of heart disease, and five others were not
specified. • Half the women had no documented prenatal care in their first trimester. • Half had chronic diseases such as hypertension, diabetes, ovarian cysts and sickle cell anemia. • Twelve of the 33 deceased women, who ranged in age from 17 to 42, were obese and four more were overweight. Pregnancy-related
death is a rare event and is suspected to be linked, at least in part,
to such things as a lack of prenatal care, poor health and obesity. Dr.
Ira Jaffe, a Rhinebeck obstetrician, said the report's association
between cesarean section and maternal death "almost certainly has to do
with the high and very high-risk patients who are the ones most likely
to die and most likely to need" a cesarean. The question for those concerned with rising cesarean rates is how and whether they are contributing to mortality. Christie
Craigie-Carter, Hudson Valley coordinator of the International Cesarean
Awareness Network, or ICAN, said the report gives tacit approval to
unnecessary cesareans in suggesting physicians pay special attention to
hydrating "women undergoing elective cesarean section with
uncomplicated pregnancy and no other risk factors." "I
have to ask why women with no other risk factors are having cesareans,"
said Craigie-Carter, who underwent two cesareans followed by a vaginal
birth. "Understandably, sometimes things happen in labor that
necessitate a cesarean, even in low-risk women, but this should be the
rare event." Complications on rise
As cesarean rates have soared
nationwide, so have serious obstetrical complications such as renal
failure, pulmonary blood clots, shock, blood transfusion and
ventilation, according to a 2008 report in the American Journal of
Obstetrics and Gynecology. Researchers suspect a link. Surgery is
widely acknowledged to carry increased risk of blood clot, hemorrhage
and infection, which were responsible for 18 deaths in the study,
including 13 among women who had undergone cesareans. "It
is possible that the eight women with embolism would not have died if
they had had a vaginal birth," wrote Dr. Mary Barger, an associate
professor of maternal and child health at Boston University School of
Public Health, in an e-mail message. But she added it was difficult to
know if the deaths were unavoidable. "We do not know why they had a
cesarean." "I do
not think the report pays attention to the reasons for the C-sections -
other than the usual, blame the mother for being overweight or
otherwise high-risk - and notably absent is discussion about how
cesareans could have been avoided," ICAN's Craigie-Carter said. "If we
didn't do so many cesareans, the incidence of embolism would go down." A
Health Department spokeswoman, Beth Goldberg, agreed in a statement in
response to Journal questions that "there are always risks associated
with any type of surgery" that should be considered when deciding to
operate. But she
defended the report against critics who said it failed to address the
role of cesareans, and especially repeat cesareans, in the deaths. "As
the study showed, these women were at higher risk because of various
conditions, and it was found that cesarean section was warranted in
these cases," the statement said. Citing
the need to maintain confidentiality at several points, the report
avoids discussing individual cases and describes only three in a few
sentences each. One involved a woman with a congenital heart defect who
had been counseled not to become pregnant; she delivered vaginally. A
second woman died of a brain hemorrhage and a third of an infection and
enlarged heart, both after cesareans. The
report includes recommendations to avoid maternal deaths through better
assessment of risk, clearer guidelines for the use of anticoagulants
and antibiotics, better response to obstetric emergencies and improved
response to excessive blood loss. "Any
pregnancy-related death is one too many," it quotes a former secretary
of the U.S. Department of Health and Human Services, Tommy G. Thompson,
as saying.
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