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.

Booties on the ground

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.

Pushing back against home-birth critics

British and Australian midwives are pushing back against a recent editorial in The Lancet, a British medical journal, which builds on a study released last month that appears to show that home births are less safe than those that occur in a hospital.

"Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk," stated the unsigned editorial from July 31.Pregnant Graffiti

In an interview today with the Guardian, a British newsaper, Cathy Warwick, the general secretary of the Royal College of Midwives, said that midwives believe home birth is "being unfairly pilloried by some sectors of the global medical maternity establishment."

Hannah Dahlen, the president of the Australian College of Midwives, weighed in as well. "Intense medical lobbying and strategically released journal articles" had put midwifery in her country "in the hands of the medical profession," she said.

Warwick said, "What shocked us about The Lancet editorial was its language and tone and how it pumped the hype about the dangers of home birth, and made sweeping and misogynistic statements."

"The Lancet said it stood by its editorial," wrote Randeep Ramesh in the Guardian article.

The impetus for the piece in The Lancet was a meta-analysis scheduled for release next month in the American Journal of Obstetrics and Gynecology, a peer-reviewed journal published jointly by a number of organizations that includes the Society for Maternal-Fetal Medicine. The meta-analysis was presented at the SMFM meeting in Chicago in February.

The article, published on-line last month, "provides the strongest evidence so far that home birth can, after all, be harmful to newborn babies," according to The Lancet editorial.

Home births account for about 3 percent of births in the United Kingdom, according to the article in The Lancet; in the United States, the figure is about 1 percent.

American midwifery groups and out-of-hospital birth advocates like The Big Push for Midwives have already questioned the findings of the AJOG article.

The Coalition for Improving Maternity Services called the report a "poorly designed and methodologically unsound study," expressed itself "outraged" that AJOG accepted it for publication, and suggested the report was rushed on-line as a ploy to stop legislation then pending (since signed into law) in New York that will make the practice of midwifery easier in that state.

"Pregnant Graffiti" by Petteri Sulonen

Ultimately, all bets are off

There is no arguing with death, except through art.

Here is a poem I found through an Art of Medicine essay by physician-writer Caroline Wellbery MD in the Lancet. She uses it to talk about the value of medical uncertainty.

Dr. Wellbery's article is worth reading, and so is the commentary that went with it in the May 15, 2010 issue.

My Father's Autopsy
by David Gewanter

The one he did, that is, and took me to
when I was 13. I turned as white as
the old woman lying naked there;

but as he clanked out tools I inspected her
quickly, the dead cinder of her nipples,
the stiff tuft at her crotch (“Still black?

Wouldn't it turn gray?”). Dad took stock
of her length, weight, muscle tone, telling me
or the microphone how she lived,

what made her sick. “Like being a detective,”
he said, “except I answer my own questions.
Here; touch this.” But I wouldn't, and

I wanted her body to resist interrogation,
prayed weirdly she never said “aah” for a doctor.
Then he slit and sawed her down the middle –

she opened as easily as a yam, or a duffel
bag; dipping delicately in, Dad scooped
out a handful of stuff, all jumbly

like underwear from Mom's dresser. He
read her guts like a priest: proving
the tubes, slicing wafers from her heart,

so thin they would glow under lens-light –
at last she yielded him a brown pebble
which I felt between his finger and thumb;

then he put it back. Death's story, deduced from
facts hard as bone – as he talked me through it,
I could hear the joyful lift in his voice….

He had little patience for his house,
its prattling unready anatomies,
his wife's “incompetent housekeeping”;

at night he sat over journals and drinks,
compact, severe, inward as a microscope.
Now he's home all day waiting for the mail,

hasn't cut a corpse for years. He calls
every weekend, his news familiar
as a backache, and we talk without fear.

Once I thought my pen would open him here
like the corpse on its single pan of judgment;
but as I cover this pan with pages

he is alive on another one.

David Gewanter, In the Belly, University of Chicago Press.

Surprises in a new study of maternal deaths

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.Pregnant Graffiti

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