Birth Story

It isn't that childbirth is more inherently dangerous in countries where many women die in childbirth than in those where relatively few die. The women who survive, statistically speaking, are getting appropriate help from trained attendants.

"...The main complications that lead to death during pregnancy or childbirth are fairly common among all women, regardless of where they live," write the authors of an article titled "Are We Making Progress in Maternal Mortality?" in the May 26 issue of the New England Journal of Medicine.

Hemorrhage, which most often occurs right after birth, is the leading cause of pregnancy-related deaths globally, accounting for 35 percent of all deaths in childbirth, according to the World Health Organization. And in fact, hemorrhage was the second most common complication seen in pregnancies in the United States in 2000.

However, most U.S. women who suffered hemorrhage were treated quickly, and survived, say the article's authors, Anne Paxton and Tessa Wardlaw.

WHO identified the second most common cause of maternal death as hypertensive disorders — pre-eclampsia/eclampsia, for example. Again, these disorders are a common problem all over the world, but women with access to good medical care have a good chance of surviving them.

The countries that are most dangerous for pregnant women are those suffering through wars, or burdened with a large population with HIV/AIDS, the authors write.

In general, poor women die in childbirth more often than affluent ones, rural women more often than urban ones. These populations are more vulnerable because they often deliver their babies without the benefit of skilled birth attendants, and lack access to obstetrical services like surgery by Cesarean section.

Sub-Saharan Africa, with widespread political unrest and HIV/AIDS infection, "has the greatest burden of maternal mortality," even though most countries there are seeing "small but promising" decreases in pregnancy-related deaths.

Worldwide, there is considerable cause for hope, Paxton and Wardlaw write. Maternal mortality has decreased globally by more than one-third since 1990, according to United Nations estimates.

"Dramatic improvements in China and other Asian countries...are associated with economic improvement, decreasing fertility rates and strengthening of health systems...," the authors write.

"The overall rate of decline in global maternal mortality, 2.3 percent, is lower than the 5.5 percent MDG target but is heartening nonetheless," they write.

Image: "Pregnant Graffiti" by Petteri Sulonen

The Washington Post is carrying a remarkable birth story today by Ian Shapira, called "A Facebook story: A mother's joy and a family's sorrow."

Shapira has shaped the story using the Facebook postings of Shana Greatman Swers, a 35-year-old Gaithersburg, Md., consultant who died just weeks after the birth of her son, Isaac Lawrence Swers, on Sept. 23 of this year.

Within days of Isaac's birth, Swers was diagnosed with peripartum cardiomyopathy, a rare, grave heart disease associated with childbirth.

In a "Story Lab" blog post, and in a live Q&A chat, Shapira describes how he came to write about a colleague of his wife's, a woman who, he writes, not only died from "unusual pregnancy complications," but also "had been remarkably public about her ordeal" in her Facebook postings, some of them sent from her iPhone at the hospital.

Shapira determined to tell Swers' story through selected postings from her Facebook page, beginning with her proud announcement of her pregnancy on March 10, and continuing until her death.

What emerges is a picture of a first-time mom reveling in impending motherhood, then reacting with concern and frustration at the unexpected medical problems, responding to friends' good wishes and offers of food and other help.

At one point, her husband, Jeffrey, asked friends to "post a memory or funny story that lets her know why she is special to you," and began himself with the story of their first Fourth of July together.

It seems impossible to believe, reading the posts, that Swers' condition would not improve, that the last post in the story, from Nov. 3, would be her husband's anguished cry: "I love you wifey wife, I love you, I love you, a million times over I love you!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"

Shapira's story, and the Facebook page itself, are compelling artifacts of our times.

From the issue of The Lancet published today:

There is little hope of obtaining precise estimates of maternal mortality rates, as we do for under-5 mortality, for instance. The sources of data are heterogeneous, data quality varies substantially, and the issue of death after induced abortion remains important in countries where it is illegal. It seems a better strategy to separate estimates of obstetric deaths for countries with vital registration, and pregnancy-related deaths for countries that rely on surveys, to increase internal consistency and produce more reliable trends.

Maternal deaths and pregnancy-related deaths are not necessarily the same thing, the article states. A maternal death is one that "could have been prevented by proper antenatal and obstetric care," while a pregnancy-related death "can include infectious, non-communicable, and external causes."

The article's authors, Michel Garenne and Robert McCaa, also say that "one could note a decline in maternal deaths despite an increase in pregnancy-related deaths when confounding with other causes is very strong, as is the case in countries with increasing death rates from HIV, tuberculosis, accidents, and violence."

I would say two things about this article's thesis. First, in a country ravaged by HIV/AIDS and war, some women who are stricken with illness or murdered will be pregnant, but how those deaths are pregnancy-related is a mystery to me. A pregnancy-related death to me would be a woman murdered by her husband for being pregnant, or a woman whose pregnancy contributed to her death from swine flu, for example.

Second, just as a note, it's pretty grandiose to say that "proper antenatal and obstetric care" can head off every true pregnancy-related disaster, like amniotic fluid embolism, for example. Sometimes, in spite of the best efforts, women die.

Oh, well, the authors' point is a good one: Precise estimates of maternal mortality are hard to come by.

The African nation of Malawi will take a new tack in its campaign to improve its maternal-mortality statistics.

Almost immediately after his return from the United Nations meeting in New York on the Millennium Development Goals, President Bingu wa Mutharika lifted a ban on traditional birth attendants.

The fifth MDG is to cut the number of women who die in childbirth worldwide by 75 percent by the year 2015. Malawi, along with a number of other countries, has experienced disappointing progress on Goal 5.

Malawi shares Africa's dismal statistics on maternal mortality; a mother's lifetime chance of dying in childbirth there is 1 in 36, according to the latest figures from the World Health Organization. (HIV/AIDS is a major factor in Malawi.) Not only that, but decreases in the rate of deaths, presently 510 per 100,000 births, have only been running about 3 percent per year since 1990.

Banning TBAs was part of an earlier effort to get more women to deliver their babies with assistants trained in modern medical techniques, who would be able to recognize and respond to emergencies. Only 54 percent of Malawi women delivered their babies in a health-care facility in 2005.

However, one result of the ban has been that more women have delivered their babies without any kind of real birth attendant, traditional or modern, or with TBAs working under the threat of fines.

Dorothy Ngoma, executive director of the National Organization of Nurses and Midwives in Malawi, told The Nation, a daily newspaper in Malawi, "They [TBAs] never really stopped.... What happened is that they went underground."

It appears that President Mutharika decided after the UN summit that training TBAs to be part of the solution made more sense. The president married Callista Chimombo last spring, and the new first lady appears to be taking an active role in addressing the country's poverty.

The Nation reported that her Safe Motherhood Foundation will train 20 TBAs from the countryside next year in modern birth methods. They will then return to serve their communities as midwives.

Healthcare facilities tend to be concentrated in Malawi's cities, while 70 percent of the nation's 15 million people live in rural areas. There are reportedly two doctors for every 100,000 Malawians.

"We should not abandon TBAs, as they are very important to our program of safe motherhood," President Mutharika was quoted as saying in The Nation.

"There is not a corner in Britain where this formidable disease has not made many mourners,”  John Mackintosh, an Edinburgh, Scotland "man-midwife" wrote of puerperal or "childbed" fever in the 1820s.

This bacterial disease of the upper genital tract typically began within the first three days after childbirth with abdominal pain, fever and respiratory difficulty, and very often ended with the new mother's death.

Medical writers had been remarking on childbed fever at least since Hippocrates, but in the early modern era, it began to attract attention for a number of reasons. For one, it began to appear in epidemics, with very high mortality rates. For another, accounts of outbreaks were written about and published. And at least some of the new, scientific man-midwives themselves were spreading the disease by going straight from autopsies to the birth chambers of homes and especially of hospitals, without cleaning up at all in between.

There were terrible epidemics of puerperal fever in the German city of Leipzig  in 1652 and 1665, at the Hôtel Dieu in Paris, France, in 1745 and 1746, and at the British Lying-In Hospital in London, England, in 1760. It is possible that these were the first ever epidemics of childbed fever.

Every ninety seconds, somewhere in the world, a mother dies in childbirth. For three days this week, in Times Square in New York City, Amnesty International, a global human rights group, placed a "maternal death clock" to note each minute-and-a-half marker.

The clock was hung in conjunction with the big meeting the United Nations was hosting, the subject of which was how the nations of the world are doing on eliminating poverty and other ills, including infant and maternal mortality.

So far, Goal 5 (of the eight Millennium Development Goals), cutting maternal mortality by 75 percent by 2015, is lagging the rest.

All told, nearly 1,000 women die in childbirth every day, according to estimates by the U.N. and the World Bank.

“It’s such a clear example of people dying who don’t need to,” Larry Cox, the executive director of Amnesty International USA. told the New York Times' Clyde Haberman this week.

World leaders gathered in New York this week for the so-called September Summit to beat the drums for the Millennium Development Goals of the United Nations, one of which is slashing the rate of maternal mortality in the developing world.

The official name of the meeting is "The High-Level Plenary Session of the General Assembly." This year, the spotlight is on the MDG. Only five years remain until the 2015 deadline for meeting the eight goals; however, only a couple of them are likely to be met by then.

Barring a breakthrough, Goal 5, reducing maternal deaths by 75 percent, will not be one of the successes.

The World Health Organization, an agency of the United Nations, recently issued an update on Goal 5. The goals were set in 1990. The update looked at the most recent figures, which are from 2008.

While 10 of the 87 countries targeted in the program have brought down their rates of maternal mortality by 5.5 percent, 30  other countries have made little or no progress.

Ninety-nine percent of maternal deaths in 2008 occurred in the developing world.

We're in the thick of the 50th anniversary rumination on "the Pill," which has been blamed for precipitating "the sexual revolution" -- it was hardly the only impetus -- and has probably played a role in lowering maternal mortality as well. In May 1960, the U.S. Food and Drug Adminstration began the process of allowing the pharmaceutical maker G.D. Searle & Company to market its drug Enovid as the first oral contraceptive.

A hundred million women worldwide use oral contraceptives now; where the average American women had 3.6 children in 1960, she now has 2. That's an important figure for our maternal mortality statistics, as the more children a woman has, the more likely she is to die in childbirth.

Margaret Sanger, who coined the term "birth control," was driven first to become a nurse and then to make disseminating birth-control information her life's work after watching her mother's 18 pregnancies contribute to her death at age 50.

When Sanger began her crusade, the Comstock Law of 1873, an anti-obscenity measure, made it illegal to publish information about birth control, and she was arrested more than once.

In 1936, ruling in U.S. vs. One Package of Japanese Pessaries, Judge Augustus Hand of the U.S. District Court of Appeals in New York exempted birth control devices from restriction under the Comstock Law, which had been absorbed into the Tariff Act of 1930. This was the first step toward making birth control legal. The case came out of Sanger's importation of a shipment of "pessaries," in this case essentially a diaphragm, for distribution through the birth control clinics she had fielded since 1916.

Working with the wealthy philanthropist Katharine Dexter McCormick, Sanger formed the organization that would become the Planned Parenthood Federation of America. (In the spring of 1960, Sanger was 80 and McCormick was 84.)

The researchers John Rock and Gregory Pincus, working first independently and then together, developed an oral contraceptive that they tested in Puerto Rico to get around laws that persisted against birth control on the American mainland.

There have been some great recent stories about the Pill at 50 in the press. I thought Time magazine did a nice job of summing up the pre-Pill atmosphere, the history and today's landscape, and PBS has a useful timeline on birth control from "The American Experience" on its website.

Flashing back to a time when people were arrested for sharing information on birth control is pretty chilling, especially given the fact that it wasn't very long ago.

As Sanger put it, “No woman can call herself free who does not own and control her own body.”

Image from Wikimedia Commons  http://creativecommons.org

Pregnant women were more likely to die in last year’s outbreak of the so-called swine flu than other people were, the Journal of the American Medical Association reports in the issue published today.

Pregnant women represent only about 1 percent of the population of the United States, yet they accounted for 5 percent of deaths from the H1N1 flu between April and August of 2009, according to an analysis of data from the Centers of Disease Control in Atlanta, Georgia, by Alicia M. Siston, Ph.D., of the CDC, and colleagues.

Taking antiviral drugs soon after they became ill greatly helped pregnant women who were hospitalized.

Of 788 pregnant women who were reported to the CDC to have become ill with H1N1 virus between April and August, 30 died. That was 5 percent of all swine flu deaths for the period. Of 509 women who were hospitalized, 115 were so sick they were admitted to intensive care units.

If they had waited four days after the onset of symptoms to go to a doctor, pregnant women were six times more likely to wind up in an ICU than if they sought treatment after only two days.

Pregnant women should be vaccinated against H1N1, and should be treated quickly with antiviral drugs if they do become sick, the authors recommended.

Two-thirds of the women who died in the final tally for the year were in their final trimester of pregnancy. “Changes in the immune, cardiac, and respiratory systems are likely reasons that pregnant women are at increased risk for severe illness with influenza,” the authors wrote.

The latest figures on global maternal mortality, which I've written about in the last two posts here on Birth Story, are encouraging. But are they correct?

The new figures, in a study funded by the Bill and Melinda Gates Foundation, are much more positive than the ones the World Health Organization came up with in 2006. Advocate groups fear that the brighter statistics will slow down progress on making birth safe for women in developing countries.

The New York Times columnist Nicholas Kristof, who has made a specialty of chronicling the dire state of women in the world's least prosperous areas, wrote in his blog "On the Ground" on April 16 that "when women die in childbirth in poor countries, nobody keeps track, and so all these figures are very rough estimates."

Imagine that. A mother dies, and nobody even writes it down.

I am a regular reader of Kristof's column, as he consistently mines the rich vein of human interest stories about indigent women.

Kristof has done some great video work on "On the Ground."  Video gives a face -- and a voice -- to the actual women who are living the difficult lives he writes about.

I would recommend taking a look at Kristof's videos from eastern Congo, although some of them are terribly upsetting, as many of these women have been brutalized in the political unrest there.

Here is one video that is simply illuminating, "What Are You Carrying?"