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Childbirth in America Becoming More Dangerous for Women

pregnancyBy David A. Grimes, M.D.
One of the world’s most beautiful buildings, the Taj Mahal stands as a monument to maternal mortality. Mumtaz Mahal died in 1631 after giving birth to her 13th or 14th child (accounts differ).  Her grieving husband Shah Jahan built the Taj Mahal as her mausoleum.Despite great progress in obstetrics and midwifery since the 1600s, bearing children remains inherently risky business. Moreover, the risk of injury and death is now increasing in the U.S., a worrisome trend.

From the beginning of pregnancy until several weeks after its conclusion, a pregnant woman has a higher risk of illness and death than do other women.  According to the Centers for Disease Control and Prevention (CDC), about one woman in 10,000 dies from pregnancy, childbirth, or its complications.   More than 500 pregnancy-related deaths occur each year in the U.S.  From 1998 to 2005, 4,693 women were known to have died, for a pregnancy-related mortality rate of 15 per 100,000 live births.  If corrected for under-reporting of deaths, the true figure may be twice as high.

Pregnancy is far more dangerous in developing countries.  Each year, more than 300,000 women die worldwide from pregnancy and childbirth.  In Afghanistan, the Central African Republic, Malawi, Chad, and Sierra Leone, the risk of maternal death exceeds one percent with each pregnancy.  The cumulative risk of dying from pregnancy is astounding: 1 in 7 women in Niger and 1 in 8 in Afghanistan will die from pregnancy and childbirth.

The reported risk of death from pregnancy and childbirth in the U.S. is rising. Whether this is due to better surveillance of deaths, the increasing frequency of cesarean delivery or other factors is unclear.   African-American women are at unique peril: their risk of death is about four times higher than that of white women.  Older age and minority race synergize to increase a woman’s risk of death dramatically.

How pregnancy ends greatly influences a woman’s risk of death.  According to CDC data, the safest conclusion of pregnancy is miscarriage or induced abortion.  These have risks of death around 1 per 100,000 events.  (By comparison, the risk of death from an injection of penicillin is about 2 per 100,000 events).  Continuing the pregnancy to childbirth carries a risk of death 14 times higher than that of abortion.  Far more deadly are the complications of ectopic (tubal) tubal pregnancy or stillbirth.

More than half of all pregnant women suffer one or more complications of pregnancy, childbirth, or the post-partum period.  Landmark studies by the CDC using Kaiser Permanente databases have consistently found the complication rate for pregnancy and childbirth to be about 60 percent.  Among the more common complications are urinary tract infection, anemia, mental health problems, and a tear of the vagina during delivery.  With about 4 million births occur each year in the U.S., this translates into more than 2 million women encountering obstetrical complications, some of which are permanent.

Severe complications — close brushes with death — are also increasing according to the CDC.  These life-threatening events include hemorrhage requiring blood transfusion, a complication requiring hysterectomy as treatment, and eclampsia (toxemia with seizures).  About 20,000 women each year nearly die.

Half a million women are hospitalized each year during pregnancy for a problem unrelated to delivery.  Premature labor, nausea and vomiting, high blood pressure, and urinary tract infection are leading reasons for admission.  In addition, some women are readmitted to the hospital soon after delivery or have a prolonged hospital stay after delivery.  In one report, the frequency was 3 percent after vaginal delivery and 9 percent after cesarean birth.

Today, one in three babies in the U.S. is born by cesarean delivery.  By comparison, in the private sector in Brazil, more than 80 percent of births are cesarean.  The risk of complications, especially infection, is greater after cesarean birth than after vaginal delivery.  Blood loss is greater as well, about a quart on average.  The rising cesarean rate has been accompanied by higher rates of hemorrhage in the U.S.  In 2006, the most recent year available, CDC found that 3 percent of births were complicated by dangerous bleeding.

The burden of suffering from pregnancy and childbirth is massive on a national scale, affecting more than 2 million women each year.  The human and economic costs are staggering.  That state legislatures have shown no interest in mandatory state-scripted counseling about the risks, benefits, and alternatives of childbirth (as many states have done for abortion) remains unexplained.

Former Chief of the Abortion Surveillance Branch at the Centers for Disease Control and Prevention, Dr. Grimes helped to chronicle the public health benefits of legal abortion in the U.S. in the early 1970s, making several discoveries that improved its safety. 

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