Birth Story

For every step forward the United States takes toward improving women's health, the country appears to be taking one back — or more.

The overall picture is so bad that the nation got a big, black "Unsatisfactory" grade on a report card issued recently by the National Women's Law Center, in conjunction with Oregon Health & Science University.

We are doing all right in some areas. Women are smoking less. The percentage of women getting regular mammograms, annual dental checkups and colorectal screenings has held steady since 2007. In only one area, cholesterol screenings, have we actually improved.

On the negative side, more women are binge drinking, and fewer are getting Pap screening tests for cervical cancer. More women are obese, diabetic and hypertensive, too. More are turning up with chlamydia, a sexually transmitted disease.

Not a single state got a "Satisfactory" mark this year; in 2007, three states made the grade. Massachusetts and Vermont have the best scores, a limp S (for satisfactory) -minus.

Many of the goals have to do with things people can conceivably control themselves, like quitting smoking, and drinking only moderately.

However, nearly 20 percent of women ages 18 to 64 have no health insurance. The disparities are troubling: 38 percent of Hispanic women, 32 percent of Native American women, 23 percent of African-American women — but only 14 percent of Caucasian women — lack health coverage.

And only seven states now require comprehensive maternity care — prenatal care, childbirth and postpartum care — be included in all individual and group health plans.

Most of the goals the report card addresses come from the Healthy People 2010 campaign of the U.S. Dept. of Health and Human Services. On its website, Healthy People is already hoping for better results in 2020, its new goal year.

"The Favorite" by Leon-Francois Comerre, courtesy of Wikimedia Commons

Well, this is discouraging. Two recent studies indicate that, after a decade-long, nationwide campaign to make hospitals safer for patients, essentially no progress has been made.

A patient checking into a hospital today appears to face at least a one-in-four chance of coming to some degree of harm there.

A study published this week in the New England Journal of Medicine looked at the records of 2,341 patients discharged from 10 randomly selected hospitals in North Carolina, which was chosen because of that state's "high level of engagement in efforts to improve patient safety."

The study took place between January 2002 and December 2007. What it found was, in short, that "harm to patients resulting from medical care was common in North Carolina, and the rate of harm did not appear to decrease significantly during a 6-year period ending in December 2007, despite substantial national attention and allocation of resources to improve the safety of care," the report stated.

A total of 588 patients were injured — 25.1 percent of study subjects. Harm was caused by, in declining numbers, procedures, drugs, hospital-based infections, other therapies, tests, falls and other causes, the study found. Sixty-three percent of these injuries were deemed to have been preventable. Nine preventable errors resulted in death, and 13 in permanent damage.

In addition, a report from the U.S. Dept. of Health and Human Services released earlier this month documented the experiences of 780 randomly selected Medicare patients discharged from various hospitals in October of 2008.

About one in seven of these patients experienced "adverse events" — serious harm that comes to a patient as a result of medical care.

A second group of about the same size in the HHS study suffered "temporary harm," a transient injury like bedsores (here called "pressure ulcers") for example, or hypoglycemia. Twenty-seven percent of temporary harm events were caused by drugs.

Twenty-eight percent of patients who experienced more serious "adverse events" also suffered some temporary harm during the same hospital stay.

About 44 percent of all these events — adverse events and temporary harm — in the HHS study were deemed preventable — the result of errors, substandard care, or insufficient monitoring.

In 1999, the independent, not-for-profit Institute of Medicine published a report on hospital safety, "To Err is Human," which caused a sensation and produced a massive effort to improve protocols at hospitals across the country. The goal was to decrease errors by 50 percent over a five-year period.

"To Err is Human" asserted that as many as 98,000 patients die in hospitals each year because of medical error.

Commenting on the two discouraging new studies, the authors of the NEJM report on patient safety in North Carolina write, "All the findings about extent of harm should increase our commitment to prevent it."

President Franklin Roosevelt founded the forerunner of the March of Dimes, the National Foundation for Infantile Paralysis, in 1938, to raise money for research to find a cure for poliomyelitis, and to care for victims of the disease.

Roosevelt himself was paralyzed after being stricken by "polio," also called infantile paralysis, in 1921. The NFIP itself was an expansion of Roosevelt's Warm Springs Foundation, which sponsored a rehabilitation center for polio victims in Warm Springs, Ga.

In 1938, during a radio fund-raising campaign for the NFIP, the entertainer Eddie Cantor coined the term "The March of Dimes" as he urged listeners to contribute their spare change to defeat polio. The term, as Cantor used it, was a play on the popular newsreel series "The March of Time."

The campaign against polio is one of the great medical success stories. The March of Dimes provided the money for the development of two effective vaccines, by Jonas Salk and Albert Sabin. Within little more than a decade, polio was reduced from one of the scourges of the 20th century to a footnote in the 21st.

A global effort to eradicate polio altogether by the year 2000 fell short; the latest target date for eradication, in parts of Africa and Asia, is 2013.

In 1958, with polio under control in the United States, the March of Dimes re-directed its efforts toward a new campaign, to eliminate birth defects. The following year, Dr. Virginia Apgar, who in 1953 had devised a scoring system for the well being of newborns, joined the organization that was then still headed by President Roosevelt's former law partner, Basil O'Connor.

For the past half-century, the March of Dimes has been involved in virtually every effort undertaken to improve the health of babies in this country and, more recently, around the world.

The March of Dimes supported research that showed that a pregnant woman's consumption of alcohol could cause birth defects, as well as the development of surfactant therapy for premature babies with respiratory distress, to name a couple.

Image from Wikimedia Commons

The Black Death came to Europe in the 14th century, probably mostly aboard merchant ships from the Crimean peninsula in the Black Sea, though soldiers returning from late, intermittent Crusade-type forays likely contributed to the pandemic as well.

One early episode in this notorious outbreak of plague demonstrates that its victims had the misfortune to learn firsthand that the disease could be transmitted from person to person.

In 1346, a Tartar army laid seige to Caffa, a port in Crimea, now an autonomous republic just south of Ukraine. Caffa, now called Feodosija, was then held by Genoa, a mighty Italian city-state and commercial power. The seige lasted three years, and the residents and refugees in Caffa were in a bad way by the end. But then the Tartars began to die in great numbers from a horrific disease, and the tide appeared to be turning.

The remaining Tartars got the idea of catapulting the rotting corpses of their plague victims into the walled city of Caffa. Apparently, the Tartars' hope was that the "intolerable stench would kill everyone inside," according to an account by the Italian notary and writer Gabriele de’ Mussi. At the time, "miasmas," or noxious airs from rotting organic matter, were thought to be one source of disease.

Soon, even though the cadavers were dumped into the sea, people began to die in the besieged city. And then, the survivors began to flee.

De' Mussi writes:

Among those who escaped from Caffa by boat were a few sailors who had been infected with the poisonous disease. Some boats were bound for Genoa, others went to Venice and to other Christian areas. When the sailors reached these places and mixed with the people there, it was as if they had brought evil spirits with them: every city, every settlement, every place was poisoned by the contagious pestilence, and their inhabitants, both men and women, died suddenly. And when one person had contracted the illness, he poisoned his whole family even as he fell and died, so that those preparing to bury his body were seized by death in the same way.

De' Mussi was not an eye-witness to the events in Caffa. However, his account preserved not only the details of what has been remarked upon as an early instance of biological warfare, but also what the survivors learned about how diseases can be transmitted.

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.

The "humoral theory" of disease, which originated with Hippocrates (who lived from about 460 to about 370 B.C.) and lasted until the early 20th century, held that a balance had to be maintained among four humors or liquid substances in the human body. If that balance got out of whack, the thinking was, people got sick.

The four humors were black bile, red or yellow bile, blood and phlegm. The ancients believed that these substances ruled our personalities as well as our bodies. They divided all the possible character types into these four — melancholic, choleric, sanguine and phlegmatic — depending on which substance dominated that particular person.

Treatments for disease were designed to restore the balance among the humors, but what worked for one person might not work for another, which helped let practitioners off the hook if a "cure" didn't work. Purges like enemas and emetics were popular, and physicians often advised changes to a patient's diet or routine. Blood-letting was an especially durable cure for just about anything.

During labor, for example, "some women were bled to unconsciousness to counter delivery pains" or any other complications large or small, according to Peter Conrad's The Sociology of Health and Illness.

The acceptance of the germ theory finally put an end to humoral theory in mainstream medical thought.

Birth is the most common reason for a person to be hospitalized in the United States, a major point of intersection for a healthy population with the health-care system.

But while birth may be common, it isn't cheap. The average cost of maternity care in the United States in 2004 was $8,800, according to a report by the March of Dimes, and that figure can take off for the stratosphere — into the tens and even hundreds of thousands of dollars — in the event of complications.

With the national mid-term elections just a few weeks away, many politicians are drumming up votes by weighing in on the health-care reform legislation Congress passed earlier this year, and on government programs that subsidize health-care services like maternity care for low-income people.

Rand Paul, an ophthamologist who is the Republican candidate for the Senate in Kentucky, remarked last week that half the state's 57,000 yearly births are paid for by Medicaid. “Half of the people in Kentucky are not poor. We’ve made it too easy,” Paul said.

You could say Paul is right. A woman doesn't have to be officially poor in Kentucky to have her baby's birth paid for by Medicaid.  Kentucky allows Medicaid coverage for a woman whose income is 185 percent of the official federal poverty level of $18,310 for a family of three. That is, her family of three can make just under $34,000 and still qualify.

But remember, the average birth experience will cost her almost $9,000.

The March of Dimes analysis found that consumer costs for a birth averaged just under $500, but that pre-supposes that the mother has health insurance that covers childbirth and maternity care.

Analysts for The Guttmacher Institute, which concerns itself with sexual and reproductive health both in the United States and globally, working with recent figures from the U.S. Census Bureau, figure that 2.3 million women of reproductive age lost health insurance in the year between 2008 and 2009 alone.

The National Women's Law Center has found that individual insurance plans, which are exempt from the Pregnancy Discrimination Act of 1978, tend not to offer maternity care. The NWLC found that just 12 percent of the plans it examined offered maternity care, and that the provisions they offered were often limited.

"That’s why having insurance coverage is so critical. Employer-based group plans usually have good maternity care coverage, but most low-income women don’t get insurance through the workplace," the Guttmacher Institute states on its website today.

So looked at from that aspect, Paul is wrong. We're not making things too easy at all. The way thing are set up now, we're making it too hard for women to obtain coverage for maternity care.

Pregnant Graffiti by Petteri Sulonen, courtesy of Wikimedia Commons

In his excellent review of Annie Murphy Paul's new book, Origins: How the Nine Months Before Birth Shape the Rest of Our Lives in the New York Times Book Review on Sunday, physician/author Dr. Jerome Groopman wrote:

Of necessity, research on fetal development involves observing pregnant women in their daily lives; no one would purposefully have one group eat in a possibly risky way or be exposed to a potentially dangerous substance, and compare outcomes with an unperturbed control group. We have, at best, only correlations between a mother’s lifestyle and her child’s future health, not clear causation.

And, in "The Case Against Breast-Feeding," Hanna Rosin's 2009 article in The Atlantic, she wrote, "An ideal study would randomly divide a group of mothers, tell one half to breast-feed and the other not to, and then measure the outcomes. But researchers cannot ethically tell mothers what to feed their babies."

Really? Why not? Both Groopman and Rosin are writing about how vulnerable observational studies are to being tainted by hidden variables. Controlled trials are a better system for testing what works and what doesn't.

But if I am reading their statements correctly, Groopman and Rosin are saying that we cannot even think about practicing actual, rigorous science if babies and fetuses are involved.

Building up a body of "evidence-based medicine" around a segment of the population that is exempted from clinical trials — depending entirely on observational research, that is — seems unwise to me. We don't need to wonder what a worst-case scenario involving babies would look like;  we have the 50-year-old thalidomide catastrophe as a demonstration. Thousands of children around the world were born with deformed limbs after their mothers took the drug.

Subjecting drugs and behaviors that can affect unborn children to standard scientific trials that include pregnant women might save the population from potentially massive damage from those behaviors, and from the drugs once they are put on the market. This is especially true now that we suspect the experience in the womb has a huge influence on the course of an individual's life — the subject of Paul's book, Origins.

Now I understand why the medical ethicist Ruth Macklin, writing in The Lancet last winter, called for the inclusion of pregnant women in drug trials, and retaining women who get pregnant in such trials. Conventional wisdom seems to have rendered the concept so unthinkable that a call for change is necessary.

What do you think about including pregnant women in clinical trials? I would love to read your comments.

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.