Making a difference in maternal mortality

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.Pregnant Graffiti

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


ACOG: Still down on home births

The American College of Obstetricians and Gynecologists came out once again this week cautioning against home births.

Hospitals and birthing centers are the safest place for labor and delivery, the speciality organization of obstetricians stated in a committee opinion on Thursday.

A prior Cesarean delivery "is an absolute contraindication to planning a home birth due to the risks, including uterine rupture," the statement said. Twins, breech babies and pregnancies that have gone beond 42 weeks are not good candidates either — too risky for the babies, ACOG said.

"Home births don't always go well, and the risk is higher if they are attended by inadequately trained attendants or in poorly selected patients with serious high-risk medical conditions such as hypertension, breech presentation, or prior Cesarean deliveries," said Richard N. Waldman MD, ACOG's president.

This is the latest in a long line of statements the group has made cautioning against the less than 1 percent of  American births that take place at home.

Even so, ACOG does want women to know that if they decide to deliver their babies at home, they should get the "standard components of prenatal care, including Group B strep screening and treatment, genetic screening, and HIV screening."

And, they should work with a birth attendant who is part of "an integrated and regulated health system, have ready access to consultation, and have a plan for safe and quick transportation to a nearby hospital in the event of an emergency," the statement said.

A perfect baby every time

Every pregnancy begins with a 3 percent chance that the resulting baby will have birth defects, and that is before individual genetic and environmental histories come into play. Some birth defects cannot be prevented or fixed. Medicine cannot work miracles.

That's the message in "The perils of the imperfect expectation of the perfect baby," an article in this month's American Journal of Obstetrics and Gynecology. Prospective parents need to understand that "perfection in pregnancy is not attainable now or even in the foreseeable future," according to the article's authors.

Doctors too can get drawn into "expecting more from medicine than its limited diagnostic and therapeutic capacities justify," say the article's authors, led by Frank A. Chervenak MD. Not only that, but "many pregnant patients are optimistic about the advances in medicine and are confident that their physicians will solve all problems that could occur with their pregnancy."

In fact, everyone needs to get in touch with "the inherent errors of human reproduction, the highly variable clinical outcomes of these errors, the limited capacity of medicine to detect these errors, and the even more limited capacity to correct them," the article states.

The expectation that a perfect baby can eventually be taken away from every pregnancy "assumes powers of medicine to control human reproduction that medicine does not possess," the article states.

William Harvey

In the early 17th century, before the scientific method began its ascendancy in the Western world, the Englishman William Harvey described how the blood circulates through the human body, solving a mystery that had stumped scientists for centuries.

Some other scientists — Galen, the ancient Greek; Ibn al-Nafis, who worked in Egypt in the 13th century; and Michael Servetus, a 16th-century Spaniard — had got a chunk of the story right.

William Harvey

William Harvey

Only Harvey, who assiduously tested his theories on living animals, figured out that blood circulates throughout the entire body.

He published his thesis in 1628, as On the Motion of the Heart and Blood in Animals. His discovery is considered one of the most important achievements in medical history.

Harvey introduced the "experimental and observational approach" to scientific inquiry, the British medical historian P.M. Dunn writes in an article for the Archives of Disease in Childhood.

In addition to his revolutionary work on blood, Harvey also advanced our understanding of human reproduction. His practice extended to obstetrics, and he was interested in and knowledgeable about birth.

Harvey's 1651 book On the Generation of Animals, published with the stunning essay "On Parturition," debunked the idea that embryos were fully formed at conception, and advanced the theory of epigenesis, which held correctly that a chick, for example, grew all its various parts from a single cell.

Harvey also addressed labor, advising birth attendants to let nature take its course rather than to intervene unnecessarily. Harvey's tract was the first original work on obstetrics written by an Englishman. Aside from these famous works, the rest of his prodigious writing has been lost.

What remains is "truly remarkable when judged against the ignorance of the times and the prevalent reliance on ancient authority," Dunn writes of Harvey.