Childbirth: There’s got to be a better way (E19)
Childbirth has been a constant in human history. Unfortunately, death among mothers was far from rare. We discuss how dangerous it was and how far we have left to go.
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Today’s topic is:
Childbirth: There’s got to be a better way
As most of you could guess, the only direct experience I’ve
had with childbirth is being born and those memories are a bit fuzzy. I have four kids and so I’ve had plenty of
experience on the Dad side, but doesn’t really count. Not too long ago, we were in the hospital
with our daughter, welcoming our first grandchild into the world. As I watched her struggle to bring my
grandson into the world, I thought “this has to be one of the most dangerous
things ever.” This episode goes out to
my daughter and my wife.
Today’s podcast is going to look at how dangerous childbirth
is for the mother. Making it to 5 years
old is a big gamble for the baby and is a topic for another podcast.
US Childbirth deaths
In the US, about 700 women a year die due to complications
with pregnancy. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htm
For a country with the population of the
US, this is a pretty low rate. Other
causes of death with similar rates are slipping and tripping falls, falls from
ladders, drowning in swimming pools, and freezing to death. https://injuryfacts.nsc.org/all-injuries/preventable-death-overview/odds-of-dying/data-details/
As we will discuss in a minute, it has taken a lot of hard
work to get to this place. The leading
causes of maternal death are cardiovascular conditions, hemorrhage, infection,
embolism, cardiomyopathy, mental health conditions, and
preeclampsia/eclampsia. Interestingly,
the death rates were very similar for black and white women, except that deaths
due to mental health conditions were noticeably absent among black women.
Of these fatalities, a quarter occurred during pregnancy,
15% on the day of delivery, 18% 1-6 days postpartum, another 18% 7-42 days
postpartum, and the remaining quarter 43-365 days postpartum.
The fatalities can be categorized as preventable, and
non-preventable. Hispanics had the
lowest rate of preventable deaths at 62%, blacks at 63%, and white at 68%. I found it interesting that of the maternal
deaths in this CDC study, over 65% were still preventable. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/mmr-data-brief.html
Childbirth in Africa and South Asia
So that is in the US, but how about the rest of the
world? In 2015, over 300,000 women died
from pregnancy-related causes. Of those,
the US contributed about 700 with Europe, the Middle East, and Latin America
all having similar contributions. The
vast amount of pregnancy-related deaths come from South Asia and Sub-Saharan
Africa. Since 1990, South Asian deaths
have shrunk from 200,000 per year to about 100,000. However, Sub-Saharan Africa has held steady
at about 200,000 deaths per year.
Clearly, Africa has some problems.
Historic childbirth deaths
Surprisingly, it could be much worse. If we use the 1800 Sweden/Finland mortality
rate of roughly 1% ( 900 deaths per 100,000 live births), the expected
mortality would be about 1.25 million per year.
If we use the current European Union mortality rates of 0.01% ( 8 deaths
per 100,000), the worldwide mortality would only be 11,000 deaths per year.
The mortality rate for Sweden/Finland remained fairly steady
for most of the 19th century.
There aren’t very good records before this, but those rates are probably
a good indication of childbirth risk through much of human history.
An early 1980’s study of a large sect in Indiana that lived
modern lifestyles except that they would not use medical technology examined
maternal mortality. Mortality was very
consistent with 1800s Sweden at 872/100,000 births even though the rest of
Indiana averaged only 9 per 100,000. https://academic.oup.com/ajcn/article/72/1/241S/4729611
In the hand washing episode, we talked about Ignaz Semmelweis’s discovery of the importance of handwashing. The Vienna maternity hospital had two wards. One ward run by midwives had a mortality rate of 1 in 25 or shocking 4%( 4,000 per 100,000) while the other wing run by medical students had a mortality rate of 1 in 10 ( or a 10,000 per 100,000 death rate). That is almost the mortality rate of Russian Roulette! Once Semmelweis implemented handwashing procedures, the rates became similar. This happened in 1846, but in the Western world, the mortality rates didn’t start to drop until 1900. That is a long 50 years with no improvement. https://ourworldindata.org/maternal-mortality
So, let’s go over this again. Currently, in the EU the mother dies in 8 out of every 100,000 live births. In 1800’s Sweden/Finland 800 women died per 100,000 live births. In the 1850 Vienna hospitals, 4-10,000 mothers died for every 100,000 births. That is just mind-blowing to me. In the 19th century, childbirth had to be one of the riskiest things around.
It is interesting to me that now we think of hospitals as
the safe place to have a child, but in the 19th century, having a
child in the hospital was the last thing you wanted to do. In 1927 only 15% of children were born in
hospitals, 1946 saw 54%, 1970 was over ¾ but it wasn’t until 1980 that nearly
all children were born in hospitals in the US.
So, what accounted for this enormous mortality? For most of the 1800s, the delivery
techniques of formalized medicine may have been partly to blame. Generally, you would see higher death rates
among the working class than the ruling classes, but even as late as 1930 the
working class had significantly lower death rates than the wealthier classes.
Does poverty cause maternal mortality?
Poverty and social condition are often blamed for poor maternal outcomes, but the story of Rochdale England indicates that proper medical care and hygiene has more of an impact that poverty or social conditions. In early 1930 it had the highest childbirth mortality in all of England. The appointment of an exceptional medical officer of health saw the rate drop from 900 per 100,000 births to 170 deaths even though all of England averaged 4-500 deaths per 100,000. Even though the community remained poor and malnourished, focused attention on medical and public health practices led to sustained and marked improvement.
All throughout the Western world, about 1937 there was a
sudden and precipitous drop in maternal mortality. There were likely many factors, but no doubt
antibiotics, better treatment for hemorrhage, blood transfusions and
improvements in medical education all played a role in this exceptional
reduction. https://academic.oup.com/ajcn/article/72/1/241S/4729611
The effect of multiple births on mortality
The next
question I had was whether the first birth was the dangerous one, or if the
risk continued to increase with each pregnancy?
I know that for my wife, each pregnancy was different, but didn’t know
what the overall statistics had to say about it.
A study of
Tanzanian women who had delivered more than 5 children found that these women
had a higher risk for maternal and neonatal complications. These later children scored lower on most
tests of newborn wellbeing. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3878019/
Another study
compared women with 2-5 deliveries and those with greater numbers. The mothers with more pregnancies had a
higher incidence of postpartum hemorrhage, maternal anemia as well as prolonged
labors, cesarean delivery, birth defects, and child mortality. https://www.ncbi.nlm.nih.gov/pubmed/20402567
A separate
study found that having >10 children increase the risk of hemorrhagic stroke
fourfold. These mothers also had a 50%
higher rate of obesity compared to mothers with 2-4 children. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2465489/
A final study
looked at adolescents with 1 or 2 births.
This study looked more at the outcome of the infant rather than the
mother, but in young women, the infants did significantly better if their
mothers had delivered a previous child.
Interestingly, second time mothers were more likely to deliver a
pre-term infant. https://www.ajog.org/article/S0002-9378(18)31348-6/fulltext
Out of hospital births
The
long-established mistrust of hospitals and labor is evident by the multiple
articles comparing hospital births to home births. Keep in mind that the statistics will be
somewhat skewed as high-risk pregnancies are more likely to occur in hospitals
rather than at home so the figures aren’t completely apples to apples.
A sampling of
the studies found that home deliveries with trained midwives were less likely
to have tearing or postpartum hemorrhage.
Those women delivering at home were also much less likely to have a
cesarean delivery. Consistent across
studies was that first-time deliveries tended to have more complications,
particularly those births out of a hospital.
Some studies found a slightly elevated risk to the child in home
deliveries, while others