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


A dangerous remedy

One physician's exploration of possible remedies for deadly hemorrhages that occurred during and after birth led to a renewed interest in blood transfusion in the 19th century, and to the first human-to-human transfusion.

James Blundell, who like many physicians and researchers of the time also delivered babies, studied the short, disastrous history of transfusions and came to two far-reaching decisions — that only human blood should be used, and that it should be used for one purpose only, to replace blood. No curing mental illness, no altering personalities.

Blundell performed the first human-to-human transfusion in 1818, and went on to transfuse 10 patients over the next several years, half of whom died. Even with that dubious track record, transfusion took on new life, because Blundell's results weren't that bad, given the mortality picture of the time, according to Douglas Starr, author of Blood: An Epic History of Medicine and Commerce.

In 1873, Franz Gesellius, a Polish doctor, studied the records of all the transfusions he could find and determined that 56 percent  of the subjects had died. Critics began to attack transfusion as an attention-grabbing gimmick, and an dangerous one at that.

At the end of the 19th century, transfusion appeared to be headed the way of bloodletting and other quackery.

Amniotic fluid embolism

Amniotic fluid embolism was first identified in 1926, but it still isn't fully understood today.

AFE is rare, unpredictable and unpreventable, accounting for between 5 and 10 percent of maternal mortality in the United States, and is likely triggered when amniotic fluid enters the bloodstream. However, by no means every woman who gets amniotic fluid in her bloodstream suffers an AFE.

Some estimates have AFE occurring anywhere from 1 birth in 8,000 to 1 in 30,000, with mortality running as high as 80 percent. Many women who survive AFE suffer life-altering brain damage.

A study published in the American Journal of Obstetrics & Gynecology in 2008 found AFE occuring in about 7.7 of every 100,000 births -- that's about 1 in 13,000 births, which makes it a rare event -- and still killing more than one in five mothers it strikes.

The authors of the AJOG article found associations between AFE and mothers older than 35, Caesarean births and "placental pathologies" like placenta previa, in which the placenta attaches low in the uterus, where it can cause hemorrhaging and other complications during a pregnancy.

However, the study did not find an association with artificial induction -- the use of drugs like Pitocin to start or hurry up labor.

AFE displays a cascade of symptoms that can include cardiac arrest and disseminated intravascular coagulation, or DIC for short. During a DIC, a person's clotting factor is deployed all at once, after which hemorrhage can ensue. A mother can die from these events and so can a baby who is still in the womb -- the saddest birth story of all.