IOM recommends women’s services, for free

The Institute of Medicine issued a report this week that added eight preventive services for women to the provisions that will be provided free of charge under the Patient Protection and Affordable Care Act.

One noteworthy recommendation calls for free contraception and counseling on how to prevent unintended pregnancy.

In addition, pregnant women would be screened for gestational diabetes and new mothers would receive counseling and equipment to support them in efforts to breastfeed their babies.

The report "provides a road map for improving the health and well-being of women," said committee chair Linda Rosenstock, dean of the School of Public Health at the University of California at Los Angeles.  Each of the eight services "stands on a foundation of evidence supporting its effectiveness," she said.

The recommendations would fill "gaps" in care that bedevil women in the present system, the report said.

The seven additional recommendations are these:

  • contraceptive methods and counseling to prevent unintended pregnancies
  • screening for gestational diabetes
  • cervical cancer screening, including human papillomavirus testing, for women over 30
  • counseling on sexually transmitted infections
  • counseling and screening for HIVAIDS
  • lactation counseling and equipment to promote breast-feeding
  • screening and counseling to detect and prevent interpersonal and domestic violence
  • yearly well-woman preventive care visits to obtain recommended preventive services

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


Keeping track of maternal mortality

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.

Malawi eases rule on birth attendants

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.

Fascinated with blood

I'm embarking on a series of posts about blood. I can't help it. I'm fascinated with blood.

The final classic symptom of amniotic fluid embolism is disseminated intravascular coagulation (DIC). When I suffered an AFE during the birth of my younger daughter, I was nothing but classic.

Edward Cullen
Also fascinated by blood

I hemorrhaged to the point where all the blood ran out of my body three times over. I didn't die from this event because I received a total of 87 units of blood and blood products — whole blood, plasma, cryoprecipitate and extra clotting factor.

I am alive to tell our birth story because thoughtful strangers had donated their blood, a large stockpile of blood was five minutes away when I needed it, and because a whole raft of people had done the work over centuries to figure out how to make someone else's blood work in my body.

And, by 1997, the blood supply had been made safe again, after a horrific tainting with the HIV/AIDS virus.

The bill for my daughter's birth, including two surgeries (a Caesarean section and separate hysterectomy performed to stop the bleeding), a stint for the baby in the high-risk nursery, a night for me in the intensive-care unit and an additional four days in the hospital, was $100,000 all those years ago.

Blood accounted for $13,000, more than 10 percent of the total.

Blood was a major factor in giving our birth story a happy ending. Fascinating!