Birth Story

"Women have long delivered for society, and, slowly, society is at last delivering for women. This is a moment to celebrate—and accelerate," The Lancet editor-in-chief Richard Horton wrote in a commentary that accompanied the publication of a new survey on global maternal mortality the British journal published on Monday.

Four factors associated with maternal mortality are moving in a good direction in many areas of the world, according to the study published this week, which was discussed in the previous post here on Birth Story.

First, the global total fertility rate (TFR), which reflects births per woman, has come down considerably, from 3.7 children in 1980, to 2.6 in 2008. That is a good thing, as the TFR is closely associated with maternal mortality.

Secondly, per capita income is also up, especially in Asia and Latin America. When families have more money, women get more nourishing food, and are more likely to get access to medical care.

Women are also more likely to get some education than they were 30 years ago, which bodes well for a society in which mothers can give birth in a safe environment. Women 25 to 44 years of age in sub-Saharan Africa had 1.5 years of school in 1980, but now have 4.4 years of school on average.

And lastly, women are more likely to have skilled birth attendants in 2008 than they were thirty years ago. "Some large countries such as India have witnessed quite rapid increases in skilled birth attendance in recent years," the study reports.

Scratch that last post.

It appears that societies around the world are working to improve the survival rate for mothers in birth after all -- and that their efforts are working.

Even as I was tapping out Monday's post, The Lancet was publishing a new study online that shows that maternal mortality has actually been dropping dramatically in many countries.

"The overall message, for the first time in a generation, is one of persistent and welcome progress," Lancet editor-in-chief Richard Horton wrote in a commentary that accompanied the study.

The number of maternal deaths per year worldwide has been tallied at 500,000+ in 2005, based on United Nations survey published in 2007. However, the new study, which was conducted by researchers at the University of Washington and the University of Queensland in Brisbane, Australia, and funded by the Bill and Melinda Gates Foundation, shows deaths to have fallen from 526,300 in 1980 to 342 ,900 in 2008. That's good news.

Not only that, but taking out deaths from HIV/AIDS, which has emerged as a major factor in global maternal mortality, the figure would have been 281,500 in 2008.

More than half of maternal deaths are concentrated in six countries-- India, Nigeria, Pakistan, Ethiopia, the Democratic Republic of Congo, and Afghanistan, which has the highest maternal mortality rate in the world, this survey states. (Italy has the lowest rate, according to this report.)

The United States, Canada, Denmark and Norway are among the prosperous nations that are experiencing increases in maternal mortality (less than 1 percent for the U.S.). More comprehensive reporting could account for the increase, the researchers noted.

Not everyone is excited by the new survey's findings, Horton wrote in his commentary.

"Even before the paper ... was submitted to us, we were invited to “delay” or “hold” publication," by some members of  what Horton calls the "global health community" who fret that the relatively rosy picture the new study paints will lead to a flagging interest in working to make birth safer around the world.

Horton dismisses those worries, but expresses concern that the figures in the new report are so different from those in the 2007 UN survey.

"A process needs to be put in place urgently to discuss these figures, their implications, and the actions, global and in country, that should follow," he writes.

So it appears that MDG5, the Millennium Development Goal that has to do with improving birth safety for moms is, after all, alive and well.

"This new evidence suggests there is a much greater reason for optimism than has been generally perceived, and that substantial decreases in the (maternal mortality rate) are possible over a fairly short time," the report states.

Image by Petteri Sulonen

The Chicago River, ready for the parade

From Chicago on St. Patrick's Day, here is our famous green river, dyed last Saturday for the big downtown parade, captured by my friend Bill Linden.

What does this have to do with the birth story? Well, nothing, but we of Irish descent just get the one day to celebrate, you know? Or, counting parade day and the festivities on the South Side on Sunday, three days, tops.

And Ireland does have the lowest maternal mortality rate in the world at last tally, with just one mother dying per 100,000 births in 2005.

That certainly is something to celebrate, and to remark upon.

Happy St. Patrick's Day!

The World Health Organization estimates that the "natural" maternal mortality rate, which women with no access to health care could be expected to suffer, is between 1,000 and 1,500 per 100,000 births.

In Ireland, which has the world's lowest rate of maternal mortality, one woman dies per 100,000 births, so attention to laboring mothers makes a difference. In 2005, the worldwide maternal mortality rate was 402 deaths per 100,000 births.

The highest rates occur in politically unstable parts of Africa and Asia, notably Sierra Leone (2,000 deaths) and Afghanistan (1,900). The rate in the United States is 13, up from 12 the previous year. (All figures are from 2005.)

WHO defines maternal mortality as the death of a woman while pregnant or within 42 days of termination of pregnancy, regardless of the duration or site of the pregnancy, as long as the cause of death is related to or aggravated by the pregnancy or its management, and not from accidental or incidental causes.

Birth was already arduous in Haiti before the earthquakes hit.

The poor Caribbean nation has the Western Hemisphere's highest rates of maternal and infant mortality.

Of 100,000 Haitian women who gave birth in 2005, 670 died, compared with 11 in the United States and 1 in Ireland, which has the world's lowest rate of maternal mortality. Fifty-seven Haitian infants died out of every thousand born in 2007, compared with seven in the United States and two in Singapore, which has the lowest rate of infant mortality.

The United Nations estimates that 63,000 women in the earthquake-ravaged areas of Haiti are pregnant, according to a story in the New York Times.

The rule of thumb is that as many as one in five of those births will have some complications, and the NYT story reports that facilities that have been thrown up in the shambles of the capital and other hard-hit areas are being strained to the limits. Some Haitian birth attendants were still looking for their own family members, the story reports.

Dr. Howard A. Kelly

In 1888, nine years after Robert Felkin brought back his amazing story from Uganda, Dr. Howard A. Kelly of Philadelphia, a brilliant young obstetrician who would go on to help found the medical school at Johns Hopkins University in Baltimore, announced at a convention of the fledgling American Gynecological Society that he had performed the first successful Caesarean section in Philadelphia in 51 years—that is, the mother had survived the operation.

Very few members of the audience he was addressing that day had ever attempted even one Caesarean section because, at the time, the procedure virtually always ended in the mother's death.

What do women need when birth becomes difficult? The Averting Maternal Death and Disability program has identified a handful of intervention capabilities that should be in place for emergencies wherever babies are born.

These "signal functions" include having personnel on hand who are trained to administer drugs by injection -- antibiotics, anticonvulsants and "oxytocics," which can start or speed labor -- manually remove the placenta and other "products of conception" not leaving the body spontaneously, and perform assisted vaginal delivery -- with forceps, for example.

AMDD, a major initiative of the Mailman School of Public Health at Columbia University in New York City,  has worked with UNICEF and other partners for 20 years to bring down maternal-mortality rates in the developing world.

Its directive, issued in 1997, cites two additional interventions that might be necessary to save lives -- Caesarean section and blood tranfusion. These two go beyond the basics of a birth center -- in some parts of the world they are strictly wish-list items -- but they can often make the difference between life and death, as they did in our case.

AMDD doesn't include anesthesiology in its signal functions, although surgery is difficult without it.

We in the United States might view these interventions as humdrum, or even as irksome or worse if they become part of our own birth story, but behind the development of each one of them are amazing tales.

One big surprise of the WHO survey of Asian births was that "operative vaginal delivery" -- the use of forceps or vacuum -- had the highest death rate for mothers of any method.

Ninety-seven women died during the 108,000 surveyed births. Of those, 53 died during spontaneous vaginal births, as would be expected, given that those were the majority of births (75,000 deliveries), for a rate of less than .1 percent.

However, of 3,465 OVD births, nine mothers died, a rate of nearly .3 percent. In a commentary that accompanied the WHO report in the medical journal The Lancet, the editors called the figures "a sobering reminder of the dangers of operative deliveries," although they noted that most OVDs are "high-risk situations that cannot be easily avoided."

Twenty-three of the 16,500 mothers having Caesaean sections "with indications" during labor died (more than .1 percent), and one woman died of the 554 having elective C-sections during labor (a rate of nearly .2 percent).

The report also found that women undergoing elective Caesarean section were  far more likely to spend time after the birth in intensive care than women whose births were spontaneous.

The irony is that while many unnecessary C-sections are being performed in some areas, women in other areas who desperately need them are not able to get them, the WHO report notes.

Robbie and Susan Goodrich had been married three years when she died of an amniotic fluid embolism during the birth of her son Charles Moses last year.

The couple had been full of plans. Robbie would ramp up his career so that Susan could scale hers back to spend more time with the children. Now he's going back to work after a year's leave of absence, as a single father.

Moses Goodrich

During a phone interview, Goodrich said, "I'm throwing myself into my work, so I can go home and be with the kids."

Goodrich said, "I have to re-invent myself as a widower, with two kids in diapers. I'll do what has to be done to put bread on the table, but it's just me now.

"I know that the process isn't over. I have to do everything that has to be done emotionally to deal with the loss of Susan. I have to accept that it won't be the same me or the same life," he said.

On Dec. 6, Moses took his first steps.

On Dec. 10, the family celebrated Susan's birthday the way they usually had. They cut down a tree for Christmas, went snowshoeing, made Susan's favorite tapas.

"We celebrate her birthday. Her death day coincides with Moses' birthday but we celebrate Moses and the life that she gave on that day.  We celebrate who she was and how she lived and not the accident of her death," Goodrich said. "Though that's easier to say than to do."

Photo courtesy of Robbie Goodrich

Jane Seymour, the third wife of King Henry VIII of England, was hardly the first woman to die in childbirth. However, her status as the mother of Henry's only son made her death in 1537, probably from puerperal fever, an outsize event at the time. Although she was never crowned Queen of England -- Henry perhaps withheld that honor until after she had borne him an heir -- Jane was the only one of Henry's six wives to receive a queen's funeral.

Jane Seymour

Jane died about two weeks after the long, difficult birth at Hampton Court Palace of her son, Edward, who would briefly reign as King Edward VI. She was mourned by all of England, and by Henry to a singular degree. He wore black for a year, refrained from marrying again for more than two years, and was buried next to Jane -- and Jane alone -- in St. George's Chapel at Windsor Castle when he died in 1547 at the age of 55.

Even though her importance to the country derived wholly from her status as wife and queen of one of the world's most powerful men, Jane's death in childbirth would reverberate through history.