Birth Story

Here perhaps is one clue to the conundrum of why maternal mortality in the United States is relatively high for an industrialized nation, 12.7 deaths per 100,000 births in 2007: Two thirds of the women who died giving birth in New York State between 2003 to 2005 were obese, the New York Times reported on Sunday. The Safe Motherhood Initiative provided the figure.

Obese women are more likely to hemorrhage, have high blood pressure, diabetes, anesthesia complications, blood clots and strokes during pregnancy and childbirth.

Not only that, but very obese women, defined as having a body mass index (BMI) of 35 or higher, are three to four times more likely to experience a Caesarean section with their first baby than other as first-time mothers are, Anemona Hartocollis reports in the NYT story.

Obesity is not only hard on mothers, but it may also pose problems for their infants. Babies born to obese women are almost three times as likely to die within their first month of life than those born to women with BMIs within the normal range. Obese women are also nearly twice as likely to have a stillborn baby, Hartocollis reports.

About one in five women are obese when they become pregnant, according to data from the Centers for Disease Control in Atlanta, Ga. Obesity is gauged by a BMI of at least 30. A woman who stands five-foot-seven inches tall and weighs about 195 pounds has a BMI of 30.

We're in the thick of the 50th anniversary rumination on "the Pill," which has been blamed for precipitating "the sexual revolution" -- it was hardly the only impetus -- and has probably played a role in lowering maternal mortality as well. In May 1960, the U.S. Food and Drug Adminstration began the process of allowing the pharmaceutical maker G.D. Searle & Company to market its drug Enovid as the first oral contraceptive.

A hundred million women worldwide use oral contraceptives now; where the average American women had 3.6 children in 1960, she now has 2. That's an important figure for our maternal mortality statistics, as the more children a woman has, the more likely she is to die in childbirth.

Margaret Sanger, who coined the term "birth control," was driven first to become a nurse and then to make disseminating birth-control information her life's work after watching her mother's 18 pregnancies contribute to her death at age 50.

When Sanger began her crusade, the Comstock Law of 1873, an anti-obscenity measure, made it illegal to publish information about birth control, and she was arrested more than once.

In 1936, ruling in U.S. vs. One Package of Japanese Pessaries, Judge Augustus Hand of the U.S. District Court of Appeals in New York exempted birth control devices from restriction under the Comstock Law, which had been absorbed into the Tariff Act of 1930. This was the first step toward making birth control legal. The case came out of Sanger's importation of a shipment of "pessaries," in this case essentially a diaphragm, for distribution through the birth control clinics she had fielded since 1916.

Working with the wealthy philanthropist Katharine Dexter McCormick, Sanger formed the organization that would become the Planned Parenthood Federation of America. (In the spring of 1960, Sanger was 80 and McCormick was 84.)

The researchers John Rock and Gregory Pincus, working first independently and then together, developed an oral contraceptive that they tested in Puerto Rico to get around laws that persisted against birth control on the American mainland.

There have been some great recent stories about the Pill at 50 in the press. I thought Time magazine did a nice job of summing up the pre-Pill atmosphere, the history and today's landscape, and PBS has a useful timeline on birth control from "The American Experience" on its website.

Flashing back to a time when people were arrested for sharing information on birth control is pretty chilling, especially given the fact that it wasn't very long ago.

As Sanger put it, “No woman can call herself free who does not own and control her own body.”

Image from Wikimedia Commons  http://creativecommons.org

Pregnant women were more likely to die in last year’s outbreak of the so-called swine flu than other people were, the Journal of the American Medical Association reports in the issue published today.

Pregnant women represent only about 1 percent of the population of the United States, yet they accounted for 5 percent of deaths from the H1N1 flu between April and August of 2009, according to an analysis of data from the Centers of Disease Control in Atlanta, Georgia, by Alicia M. Siston, Ph.D., of the CDC, and colleagues.

Taking antiviral drugs soon after they became ill greatly helped pregnant women who were hospitalized.

Of 788 pregnant women who were reported to the CDC to have become ill with H1N1 virus between April and August, 30 died. That was 5 percent of all swine flu deaths for the period. Of 509 women who were hospitalized, 115 were so sick they were admitted to intensive care units.

If they had waited four days after the onset of symptoms to go to a doctor, pregnant women were six times more likely to wind up in an ICU than if they sought treatment after only two days.

Pregnant women should be vaccinated against H1N1, and should be treated quickly with antiviral drugs if they do become sick, the authors recommended.

Two-thirds of the women who died in the final tally for the year were in their final trimester of pregnancy. “Changes in the immune, cardiac, and respiratory systems are likely reasons that pregnant women are at increased risk for severe illness with influenza,” the authors wrote.

The latest figures on global maternal mortality, which I've written about in the last two posts here on Birth Story, are encouraging. But are they correct?

The new figures, in a study funded by the Bill and Melinda Gates Foundation, are much more positive than the ones the World Health Organization came up with in 2006. Advocate groups fear that the brighter statistics will slow down progress on making birth safe for women in developing countries.

The New York Times columnist Nicholas Kristof, who has made a specialty of chronicling the dire state of women in the world's least prosperous areas, wrote in his blog "On the Ground" on April 16 that "when women die in childbirth in poor countries, nobody keeps track, and so all these figures are very rough estimates."

Imagine that. A mother dies, and nobody even writes it down.

I am a regular reader of Kristof's column, as he consistently mines the rich vein of human interest stories about indigent women.

Kristof has done some great video work on "On the Ground."  Video gives a face -- and a voice -- to the actual women who are living the difficult lives he writes about.

I would recommend taking a look at Kristof's videos from eastern Congo, although some of them are terribly upsetting, as many of these women have been brutalized in the political unrest there.

Here is one video that is simply illuminating, "What Are You Carrying?"

"Women have long delivered for society, and, slowly, society is at last delivering for women. This is a moment to celebrate—and accelerate," The Lancet editor-in-chief Richard Horton wrote in a commentary that accompanied the publication of a new survey on global maternal mortality the British journal published on Monday.

Four factors associated with maternal mortality are moving in a good direction in many areas of the world, according to the study published this week, which was discussed in the previous post here on Birth Story.

First, the global total fertility rate (TFR), which reflects births per woman, has come down considerably, from 3.7 children in 1980, to 2.6 in 2008. That is a good thing, as the TFR is closely associated with maternal mortality.

Secondly, per capita income is also up, especially in Asia and Latin America. When families have more money, women get more nourishing food, and are more likely to get access to medical care.

Women are also more likely to get some education than they were 30 years ago, which bodes well for a society in which mothers can give birth in a safe environment. Women 25 to 44 years of age in sub-Saharan Africa had 1.5 years of school in 1980, but now have 4.4 years of school on average.

And lastly, women are more likely to have skilled birth attendants in 2008 than they were thirty years ago. "Some large countries such as India have witnessed quite rapid increases in skilled birth attendance in recent years," the study reports.

Scratch that last post.

It appears that societies around the world are working to improve the survival rate for mothers in birth after all -- and that their efforts are working.

Even as I was tapping out Monday's post, The Lancet was publishing a new study online that shows that maternal mortality has actually been dropping dramatically in many countries.

"The overall message, for the first time in a generation, is one of persistent and welcome progress," Lancet editor-in-chief Richard Horton wrote in a commentary that accompanied the study.

The number of maternal deaths per year worldwide has been tallied at 500,000+ in 2005, based on United Nations survey published in 2007. However, the new study, which was conducted by researchers at the University of Washington and the University of Queensland in Brisbane, Australia, and funded by the Bill and Melinda Gates Foundation, shows deaths to have fallen from 526,300 in 1980 to 342 ,900 in 2008. That's good news.

Not only that, but taking out deaths from HIV/AIDS, which has emerged as a major factor in global maternal mortality, the figure would have been 281,500 in 2008.

More than half of maternal deaths are concentrated in six countries-- India, Nigeria, Pakistan, Ethiopia, the Democratic Republic of Congo, and Afghanistan, which has the highest maternal mortality rate in the world, this survey states. (Italy has the lowest rate, according to this report.)

The United States, Canada, Denmark and Norway are among the prosperous nations that are experiencing increases in maternal mortality (less than 1 percent for the U.S.). More comprehensive reporting could account for the increase, the researchers noted.

Not everyone is excited by the new survey's findings, Horton wrote in his commentary.

"Even before the paper ... was submitted to us, we were invited to “delay” or “hold” publication," by some members of  what Horton calls the "global health community" who fret that the relatively rosy picture the new study paints will lead to a flagging interest in working to make birth safer around the world.

Horton dismisses those worries, but expresses concern that the figures in the new report are so different from those in the 2007 UN survey.

"A process needs to be put in place urgently to discuss these figures, their implications, and the actions, global and in country, that should follow," he writes.

So it appears that MDG5, the Millennium Development Goal that has to do with improving birth safety for moms is, after all, alive and well.

"This new evidence suggests there is a much greater reason for optimism than has been generally perceived, and that substantial decreases in the (maternal mortality rate) are possible over a fairly short time," the report states.

Image by Petteri Sulonen

The world is seeing progress on such worthy goals as ending hunger and extreme poverty, conquering pervasive health menaces like AIDS and malaria, achieving universal primary education and ensuring environmental sustainability.

However, of the eight Millennium Development Goals the United Nations and partner organizations set in 2000 for achievement by 2015, lowering the number of the world's women who die in childbirth is the farthest from being met, according to UN Population Fund Executive Director Thoraya Ahmed Obaid, speaking at a meeting last fall  in Addis Ababa, Ethiopia.

"Women’s lives, dreams and rights have not been given the priority attention they deserve,” Obaid said.

"We know what works and needs to be done," Obaid said -- education, medical supplies and services that include prenatal care, the availability of skilled birth attendants and emergency obstetrical care.

But while funding for other health goals has risen significantly during this period, money tagged to improve reproductive health has remained static, Obaid said. And so the birth story continues to be a tragic one in 500,000 families throughout the world every year.

“It would cost the world $23 billion per year to stop women from having unintended pregnancies and dying in childbirth, and to save millions of newborns. This amounts to less than 10 days of global military spending. Instead, the world loses $15 billion in productivity each year by allowing mothers and newborns to die,” she said.

See more recent post, which contradicts this one!

The Chicago River, ready for the parade

From Chicago on St. Patrick's Day, here is our famous green river, dyed last Saturday for the big downtown parade, captured by my friend Bill Linden.

What does this have to do with the birth story? Well, nothing, but we of Irish descent just get the one day to celebrate, you know? Or, counting parade day and the festivities on the South Side on Sunday, three days, tops.

And Ireland does have the lowest maternal mortality rate in the world at last tally, with just one mother dying per 100,000 births in 2005.

That certainly is something to celebrate, and to remark upon.

Happy St. Patrick's Day!

Mary Breckinridge, a daughter of a prominent Kentucky family that included John C. Breckinridge, James Buchanan’s vice president, suffered the loss of both her children before they reached the age of 5. Instead of allowing these tragedies to ruin her life, she channeled her energy into a passionate campaign to improve the health of the children of Appalachia.

Mary Breckinridge at work

To Breckinridge, a healthy child required a safe birth, a living mother and a healthy family. Making childbirth safe was a primary goal when, in 1925, she founded the Frontier Nursing Service in Leslie County, Ky. The previous year, Breckinridge, 43 and already a nurse, had traveled to England to learn midwifery because she could find no adequate course in the United States. She continued to send FNS nurses to England until the outbreak of World War II.

The FNS deployed the first nurse-midwives to practice in the United States. Breckinridge had encountered nurse-midwives in Europe, and thought that the model was well suited not only for delivering babies but also for providing prenatal care and for assessing and helping to plan for the health needs of the whole family and, indeed, the whole community.

FNS nurses traveled by horseback to attend home births; high-risk patients went to the FNS hospital in Hyden, Ky. Clinics in the community served an average of 250 families. The FNS maternal mortality rate for its first 30 years was about one quarter of the rate for the United States as a whole.

Breckinridge died in 1965. The Frontier Nursing Service, based in Wendover, Ky., is still active, as its midwifery school, which was added in 1939.

Bring on the party hats!

I started my blog on Jan 3, full of trepidation about whether I would be able to keep up with posting three times a week about pregnancy, childbirth, medical history, maternal mortality, etc. After all, I have a job, a family, a dog, and on and on.

But I can do this! And I've learned a lot!

What's next?

My most popular post so far was "Birth in Haiti." You could've knocked me over with a feather.

My own favorites were the two posts I wrote after interviewing Robbie Goodrich, who lost his wife, Susan, last year to amniotic fluid embolism. Robbie was kind enough to talk with me while planning a big birthday celebration for his son, Charles Moses, and honoring Susan's memory on the anniversary of her death.

Career adviser Penelope Trunk tells bloggers not to succumb to the temptation to start that second blog. Penelope, you read my mind! I have been thinking how much fun it would be to lighten up a little, loosen up the voice, write about something else besides the point in childbirth at which bliss and safety concerns intersect.

But you know what? Penelope is right. "Birth Story" is my topic, because for 12 years, since I survived an amniotic fluid embolism during my younger daughter's birth, I have been fascinated with extreme childbirth. So I am going to stay with the difficult stories, the life-saving innovations and all those mixed emotions.

I enjoy the immediacy of blogging, and "meeting" other bloggers, many of whom are moms as well. I've settled into a Monday/Wednesday/Friday publishing schedule. And I'm still finding my voice.

So now we'll embark on the next leg of the journey. Maybe every couple of months I'll drop in a totally irrelevant picture like the one above and celebrate a little, just like today!