Birth Story

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.

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

Following one topic, childbirth, for an entire year has given me an unusual perspective on what is happening on that front, both here in the United States and also globally.

If you ask me, the newly apparent muscle of the holistic birth community was the most important “birth story” of 2010. One sign of this was the passage of the so-called Midwifery Modernization Act in New York, which eliminated a requirement that midwives obtain a written practice agreement from a physician or hospital to practice in New York State.

Also, as we just discovered from a new report from the Centers for Disease Control, released last week, birth by Cesarean section reached a new high, 32.9 percent of births in 2009, up from 32.3 in 2008. The steadily rising rate — up every year since 1996, when the rate was 20.7 — has been a major story all year.

That CDC report also showed the birth rate for U.S. teen-agers hit its lowest level last year since records began to be kept seventy years ago — 39.1 births per 1,000 teens, down from 41.5 per 1,000 in 2008. The record low held true for all racial and ethnic groups.

A couple of other big birth stories of 2010, sadly, revolved around the fact that too many mothers are still dying in childbirth.

In March, Amnesty International called out the American childbirth establishment on a rising rate of maternal mortality in a report called “Deadly Delivery: The Maternal Health Care Crisis in the USA.” The human-rights advocacy organization pointed out that while the United States spends more on health care than any other country in the world, “maternal mortality ratios have increased from 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006.”

Many other groups joined in that call for changes to improve birth safety in this country.

Meanwhile, in the developing world, the United Nations’ Millennium Goal 5, which aims to bring down rates of maternal mortality by three-quarters in places like sub-Saharan Africa and Southern Asia, is the subject of much scrutiny, with a major push in some places creating bright spots in what appears to be a generally gloomy picture with just five years to go.

Pregnant Graffiti by Petteri Sulonen / Wikimedia Commons

The Washington Post is carrying a remarkable birth story today by Ian Shapira, called "A Facebook story: A mother's joy and a family's sorrow."

Shapira has shaped the story using the Facebook postings of Shana Greatman Swers, a 35-year-old Gaithersburg, Md., consultant who died just weeks after the birth of her son, Isaac Lawrence Swers, on Sept. 23 of this year.

Within days of Isaac's birth, Swers was diagnosed with peripartum cardiomyopathy, a rare, grave heart disease associated with childbirth.

In a "Story Lab" blog post, and in a live Q&A chat, Shapira describes how he came to write about a colleague of his wife's, a woman who, he writes, not only died from "unusual pregnancy complications," but also "had been remarkably public about her ordeal" in her Facebook postings, some of them sent from her iPhone at the hospital.

Shapira determined to tell Swers' story through selected postings from her Facebook page, beginning with her proud announcement of her pregnancy on March 10, and continuing until her death.

What emerges is a picture of a first-time mom reveling in impending motherhood, then reacting with concern and frustration at the unexpected medical problems, responding to friends' good wishes and offers of food and other help.

At one point, her husband, Jeffrey, asked friends to "post a memory or funny story that lets her know why she is special to you," and began himself with the story of their first Fourth of July together.

It seems impossible to believe, reading the posts, that Swers' condition would not improve, that the last post in the story, from Nov. 3, would be her husband's anguished cry: "I love you wifey wife, I love you, I love you, a million times over I love you!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"

Shapira's story, and the Facebook page itself, are compelling artifacts of our times.

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.

"There is not a corner in Britain where this formidable disease has not made many mourners,”  John Mackintosh, an Edinburgh, Scotland "man-midwife" wrote of puerperal or "childbed" fever in the 1820s.

This bacterial disease of the upper genital tract typically began within the first three days after childbirth with abdominal pain, fever and respiratory difficulty, and very often ended with the new mother's death.

Medical writers had been remarking on childbed fever at least since Hippocrates, but in the early modern era, it began to attract attention for a number of reasons. For one, it began to appear in epidemics, with very high mortality rates. For another, accounts of outbreaks were written about and published. And at least some of the new, scientific man-midwives themselves were spreading the disease by going straight from autopsies to the birth chambers of homes and especially of hospitals, without cleaning up at all in between.

There were terrible epidemics of puerperal fever in the German city of Leipzig  in 1652 and 1665, at the Hôtel Dieu in Paris, France, in 1745 and 1746, and at the British Lying-In Hospital in London, England, in 1760. It is possible that these were the first ever epidemics of childbed fever.

Every ninety seconds, somewhere in the world, a mother dies in childbirth. For three days this week, in Times Square in New York City, Amnesty International, a global human rights group, placed a "maternal death clock" to note each minute-and-a-half marker.

The clock was hung in conjunction with the big meeting the United Nations was hosting, the subject of which was how the nations of the world are doing on eliminating poverty and other ills, including infant and maternal mortality.

So far, Goal 5 (of the eight Millennium Development Goals), cutting maternal mortality by 75 percent by 2015, is lagging the rest.

All told, nearly 1,000 women die in childbirth every day, according to estimates by the U.N. and the World Bank.

“It’s such a clear example of people dying who don’t need to,” Larry Cox, the executive director of Amnesty International USA. told the New York Times' Clyde Haberman this week.

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.

There is more than one way of looking at this, I know, but I believe I cheated death when I survived an amniotic fluid embolism during my younger daughter's birth in 1997. These extra 13 years, and counting, seem like a stupendous lagniappe tacked onto the lifetime I was meant to have.

That might be why, every so often, an event comes along that reduces me to a heap of gratitude for the medical advances, the professional competence, the technology — and the luck — that saved me. My older daughter's college graduation last week was one of those events.

Nora had just turned 10 when Maeve was born. She had not enjoyed being an only child, and was thrilled about the prospect of welcoming a new baby into our family. I had spent 4 1/2 months on bedrest, punctuated by a couple of terrifying bleeding incidents, which Nora had suffered through along with her dad and me. We were all relieved when the pregnancy reached term, and I went into Prentice Women's Hospital for a scheduled induction.

That fall Friday was a holiday from school, and Nora was off picking apples with friends in a far suburb, hoping that when she came home she would meet her new sister or brother.

She came back instead to a phone call from her dad, telling her about Maeve, who by that time was swaddled up in Prentice's high-risk nursery. Nora wanted to talk with me, but her dad said I had had a rough time and couldn't come to the phone. At the time he was talking with her, he still didn't know if I would live or die.

What if I hadn't survived? Both my girls would have been motherless, but Maeve wouldn't have known anything else. Nora would have suffered a devastating loss.

That didn't happen, of course. Because I have been there these 13 years, I know the scrapes Nora has been through, the joys, the disappointments, the accomplishments. Success in school never came easily to her, but last week, she graduated cum laude from DePaul University in Chicago.

I don't want to take credit for Nora's successes, but I do believe that mothers make a difference in their children's lives. I am proud of the wonderful young woman my daughter has become, and I am grateful that I have been there to see it.

The Bill & Melinda Gates Foundation this month committed $1.5 billion over the next five years to support programs that will work to improve maternal and child health, family planning and nutrition in developing countries.

Bill and Melinda Gates

Melinda Gates announced the  plan on Monday at Women Deliver 2010, a gathering of world experts, advocates and policy makers in Washington D.C.

“In poor countries, pregnancy and childbirth often end in tragedy. Our goal must be to build a world where every birth brings joy and hope for the future,” Gates said.

Gates said that the money will be used to support local efforts toward a comprehensive approach to health that will include family planning, prenatal care, nutrition and improving the conditions under which women give birth.

“Every year, millions of newborns die within a matter of days or weeks, and hundreds of thousands of women die in childbirth,” said Gates. “The death toll is so huge, and has persisted for so long, it’s easy to think we’re powerless to do much about it. The truth is, we can prevent most of these deaths – and at a stunningly low cost – if we take action now.”

Gates said, “Most maternal and newborn deaths can be prevented with existing, low-cost solutions – such as basic prenatal care, or educating mothers about the importance of keeping babies warm,” said Gates. “Countries that have made women’s and children’s health a priority – and have invested in proven solutions – are achieving amazing results.”

Researchers at the Institute for Health Metrics and Evaluation at the University of Washington say that maternal mortality has fallen more than 35 percent since 1980, from more than 500,000 maternal deaths to about 343,000 in 2008, according to a press release from the Gates foundation.

Deaths among children younger than 5 are also down dramatically. About 7.7 million children are expected to die this year, down from 11.9 million in 1990, and 16 million in 1970, the release stated.

The Bill & Melinda Gates Foundation, one of the world's largest philanthropic entities, is a "family foundation driven by the interests and passions of the Gates family," according to its stated principles. The foundation seeks to impact a number of major global issues, including health and education.

Bill Gates, founder of the Microsoft computer software giant, co-chairs the foundation with Melinda Gates and his father, William H. Gates Sr.

Photo by Kjetil Ree / www.commons.wikimedia.org