Research the incentives of those involved; but is it enough to protect yourself?

8 Aug

Why are so many American women dying from childbirth?
Aug 6th 2015, 13:40 BY E.B. | NEW YORK

CHILDBIRTH was once a reliably dangerous experience. As late as the 1930s, one out of every 100 live births in America cost a woman her life; similar rates were seen around the world. But the 20th century brought tremendous advances in obstetric medicine and widened access to decent care. The maternal-mortality rate plummeted in rich countries by as much as 99%, and now poor countries are starting to catch up. But in America something odd is happening: over the past quarter of a century, the maternal-mortality rate (which counts deaths within 42 days after delivery) has been creeping back up. In 2013 more than 18 women died for every 100,000 live births. America is one of only eight countries, including Afghanistan and South Sudan, where these numbers are moving in the wrong direction. What is going on?
The shortest answer is that no one really knows. Some speculate that it has to do with the fact that American women tend to be both fatter and older when they become pregnant these days. Indeed the risks associated with childbirth rise in tandem with weight and age. But these trends can be seen in plenty of countries where the death rates are still coming down. Others suggest optimistically that America is simply more rigorous about counting these deaths. The problem with this theory is that the system for collecting these records hasn’t changed much over the past decade, while the rate has continued to rise.

Death from childbirth is unusually common in America
The most compelling explanation is that more women are in poorer health when they get pregnant, and then failing to get proper care. Chronic health problems, such as obesity, hypertension, diabetes and heart disease, are increasingly common among pregnant American women, and each of them makes delivery more dangerous. Indeed the traditional causes of pregnancy-related deaths, such as haemorrhage, venous thromboembolism and hypertensive disorders, have been declining in recent years, whereas deaths from cardiovascular conditions and other chronic problems have been on the rise. These conditions are more common among African-American women, which partly explains why they are nearly four times more likely to die from pregnancy-related complications than white women. Poverty is also closely correlated with worse health outcomes, as poor women are less likely to have access to proper health care, including contraception and prenatal care. (Women who become pregnant accidentally are less likely to seek timely prenatal care, which raises the risks of death.) Because African-Americans are more than twice as likely as their non-black peers to live below the poverty line, this also helps to explain the grim racial disparity in maternal mortality rates.

Prenatal health and life outcomes
What is the solution? Many hope the Affordable Care Act (ACA), otherwise known as Obamacare, will widen access to health care, which would ensure that more women are in better shape when they become pregnant. In the 31 states plus Washington, DC, that expanded Medicaid under the ACA, poorer women will have access to contraception and better care before and after childbirth, which should reduce their mortality risks. (After-care is seen as essential for both managing potentially critical problems and putting women back on track for a healthy lifestyle.) Studies of obstetric emergencies have also shown that at least 40% of fatalities are completely avoidable in the moment. Once doctors are trained to spot the signs of haemorrhage, severe hypertension and venous thromboembolism when they arise, they can move more swiftly to protect their patients’ lives. Federal, state and professional organisations, including the Centres for Disease Control and the American College of Obstetricians and Gynaecologists, are working together to make sure that hospitals and childbirth centres know how to handle these emergencies. Hospitals in California—where one in eight American births take place—have put these protocols in place already, and the state has managed to bring its maternal-mortality rate down. The hope is to see a similar transformation on a national scale.
PreviousThe Economist explains: How India tried to ban porn and failed Next

Submit to reddit
inShare
18
View all comments (17)Add your comment
More from the Economist

Egypt: A bigger, better Suez Canal

The Republican debate: The candidates offer quite a show

Post-post-nationalist Germany: Strict order
Innovation: Time to fix patents
Polish politics: The German test
Bagehot: Jeremy Corbyn: closet conservative
The Republican race: Who were the debate’s winners and losers?
In graphics: Singapore: Singapore at 50
China’s leaders: Party on the beach
Readers’ comments
The Economist welcomes your views. Please stay on topic and be respectful of other readers. Review our comments policy.

Sort:Newest firstOldest firstReaders’ most recommended
SheSheAug 8th, 12:54
Poll this: In every poll taken when it come to any type of whose most likely to be affected by a disorder,disease and or death African Americans are always at the top of the poll.
Recommend
1
ReportPermalinkReply
karanti_mariaAug 8th, 10:20
Many of those competent, diligent, efficient, well-educated, high performing Obstetricians and Gynecologists from Europe and Latin America would be eager to immigrate and work in remote areas of the United States, saving women’s lives and ensuring healthy neonates.
Strict exhausting unrealistic long term bureaucratic selection procedures are imposed to “maintain quality”, or better seclude the profession and maintain high wages.
Funny thing is that those who examine for high quality foreign colleagues are the same poorly performing dangerous US Obstetricians!
The only hope for US women is that the forthcoming EU-USA Treaty liberalizes professional services and abolishes seclusion processes and bureaucratic procedures…
Recommend
3
ReportPermalinkReply
kongxiangfei2014@outlook.comAug 8th, 08:56
the article really shocks me a lot….
Recommend
1
ReportPermalinkReply
guest-onosnaeAug 7th, 19:47
If unhealthy = greater chance of death during childbirth (seems reasonable), then would be good to look at different proxies for unhealthy vs healthy (e.g. age, income, geography, etc.) and determine if the birthrate for the unhealthy is growing faster than the healthy. Has to be something like this. Seems like a simple way to test the above hypothesis, no?
Recommend
3
ReportPermalinkReply
eKK25iuTRTAug 7th, 06:47
I was in Silicon Valley and I thought I was getting the most natural and “alternative” birthing experience I could at a hospital. My midwife encouraged me to write a birth plan and hire a doula, so I did. So alternative, so natural! I was warned multiple times about the dangers of epidurals and interventions that quickly spiral into a C-section, which is risky, major surgery. But when the big day arrived, my midwife was too busy to see me. I had a horrible nurse that hounded me every 5 minutes to take an epidural even though I said “No!” several times. My birth plan stated that nobody was to offer me an epidural, but I’m fairly certain she didn’t read it. The only doctor available was a complete stranger, not my regular ob/gyn. I refused to have pitocin but they hounded my doula until I agreed to a tiny dosage which “would not do anything”. Turns out it’s impossible to say no with any authority when you are having contractions every few minutes. Between contractions, I realized I was sold a false bill of goods, so in desperation I locked the bathroom door and allowed them to knock and bang on the door repeatedly. I gave birth on the bathroom floor alone without their “help”. If I hadn’t done so, I’m fairly certain I would have had a C-section and the medical team would have received a nice chunk of cash from my insurance company. When I emerged from the bathroom a new mother, my midwife eventually showed up and had the nerve to be angry with me. I had no idea why she would be upset, but I found out later that whoever “catches” the baby receives extra cash. Moral of the story: the incentive structure ($$) sets up American women for unnecessary major surgery.
Recommend
24
ReportPermalinkReply
umghhhin reply to eKK25iuTRTAug 7th, 07:50
Nice chunk of cash for a routine op is a driving force for apparent increase of C-section. Doctors know it, hospitals know it and mothers to be should know it too.
It is all about not harming the patient while digging a pile of cash.
Recommend
9
ReportPermalinkReply
New Freetraderin reply to eKK25iuTRTAug 8th, 01:39
Well, it is of course your choice to refuse an epidural. Most women prefer to have one – my wife arrived at the hospital for our second in plenty time but by the time the Midnight Shift RNs finished their coffee it was ‘too late’. So she ended up going without.
Recommend
1
ReportPermalinkReply
CA-OxonianAug 7th, 04:16
Data suggests that the “natural” rate of C-sections is about one in a thousand. In the USA approximately one third of all births are by C-section. American women want to be gassed into unconsciousness and wake up only after it’s all over; American doctors want to be able to schedule their golf games without risk of disruption so they regularly induce with oxytocin, leading to complications, leading to an “emergency” C-section. In consequence, a large number of overly-large women undergo invasive surgery that is wholly unnecessary and which puts their lives at risk. But that’s the American Way.
When my two children were born we agreed in advance with the attending physician that short of a real medical emergency they would be natural births. The physician agreed, but when the time came he was unable to contain his urge to use all manner of unnecessary procedures and it was only by threatening actual force that I was able to dissuade him. Our two children were born without complications, while three of the other women on the ward were induced, had C-sections, and so enjoyed the Full American Experience.
Until doctors are not remunerated for creating unnecessary surgeries and until women accept that a certain amount of pain is part of childbirth, the horrific level of unnecessary death will remain a fact of American life.
Recommend
20
ReportPermalinkReply
guest-ljnoawlin reply to CA-OxonianAug 7th, 06:34
All of which misses the article’s main point – that maternal death rates are rising in the US and falling everywhere else. Unnecessary C-sections could theoretically explain the comparative LEVELS of maternal deaths (though I deeply doubt it – else why do black women die so much more than white ones?), but unless these have become far more common in the US and/or far less common in other countries (neither of which are remotely true) then it cannot explain the comparative TRENDS.
A far more likely cause is the intersection of the US’ inefficient and unfair health system with increasing inequality. That explains that white/black differential.
Recommend
15
ReportPermalinkReply
New Freetraderin reply to CA-OxonianAug 8th, 01:42
C sections are not part of the issue; or at least, there is no indication that they are. C sections are used often because doctors (and more frequently – the patients) want to schedule the birth as if it were any other ‘elective’ medical procedure. I’m not sure I have any right to judge anyone who chooses for convenience to have a C section – why the Hell not if that’s what they want – but having one’s abdomen cut open unnecessarily seems like a bad idea to me.
Recommend
2
ReportPermalinkReply
guest-onoiimlAug 7th, 03:07
Why is this a mystery? American Maternity care involves much more “interventions” than all comparable countries. Scheduled c-sections, avoidable c-sections, pitocin and other medical inducements, and an over-use of epidurals. All of these things (when not absolutely necessary) increase the risk for harm of mother and baby.
Just look at the c-section rates in the US compared to European nations. The answer is right there.
Recommend
17
ReportPermalinkReply
A. AndrosAug 7th, 01:46
“These conditions are more common among African-American women, which partly explains why they are nearly four times more likely to die from pregnancy-related complications than white women.”
And,once we control for that there really is no story.
Black women, as observed, live in less prosperous circumstances and more than two-thirds of the time lack a husband or reliable male partner.
They far more likely to drop out of high-school.
As a hypothesis, one can postulate that lack of spousal assistance, little attention at home to prenatal care as a result of limited education and economic distress are the culprits.
Regardless, it is worth any amount of money to mitigate this situation. I do not know the relevant provisions of ACA — at our age my wife is unlikely to become pregnant and if she does we aren’t likely to name the kid after me — but a national health plan that does not contain free and easily obtained care for expectant mothers is a failure.
Visiting nurses . . . visiting dieticians . . neighborhood walk-in maternity clinics in each locale with an above-average loss of mothers and or child. . . well-baby care at community centers . . . extensive daycare for newborns so that an exhausted post-delivery mom can recoup her strength . . . amplified WIC provisions so that formula and diapers are free . . . week-long stays for new, young single-mothers in maternity and recovery wards that not only assist in bonding but give mothers confidence and acquired skills . . . these are a few positive things, some of which may already be in place, but there must be others readers can imagine.
Also . . . kick the ass of every insurance company in America until they stop hassling people with chicken-shit objections and questions to routine claims in the hope they can stiff the consumer. Maternity should be safe, comfortable and without unnecessary stress.
Cost is not a consideration.
Recommend
12
ReportPermalinkReply
BrownPelicanAug 7th, 01:39
They flat out don’t give a shit, as indicated by the continued rise in obesity.
Recommend
7
ReportPermalinkReply
Connect The DotsAug 7th, 00:05
“Indeed the traditional causes of pregnancy-related deaths, such as haemorrhage, venous thromboembolism and hypertensive disorders…These conditions are more common among African-American women, which partly explains why they are nearly four times more likely to die from pregnancy-related complications than white women.”
===
Ideally White American Women should be subsegmented and compared to White Europeans for health outcomes.
And Black American Women should be subsegmented and compared to Black Africans for health outcomes.
In both cases, American health outcomes are either on par or excel.

The premise is an apples to oranges comparisons, when it should be apples to apples.
Recommend
7
ReportPermalinkReply
Mike Hoyin reply to Connect The DotsAug 7th, 00:21
A less ridiculous comparison would be the pregnancy-related death rates of white and black American women with their white and black European counterparts.
Recommend
16
ReportPermalinkReply
umghhhin reply to Mike HoyAug 7th, 07:58
Actually that would be a nice comparison and I would urge TE to do so. Do a comparative study in which poverty is controlled for so that we can extract that as a factor – I have this hunch that while you take care of poverty in US by giving a chance to rise out of it, the racism apparent from any statistics on social malaise in US will wither enough not to be considered systemic anymore.
Recommend
6
ReportPermalinkReply
Expand 1 more reply
Comment (17)
Timekeeper reading list
E-mail
Reprints & permissions
Print
About The Economist explains
On this blog, our correspondents explain subjects both topical and timeless, profound and peculiar, with The Economist’s trademark clarity and brevity
RSS feed

Follow The Economist
Facebook
Twitter
Linked in
Google plus
Tumblr
Instagram
YouTube
RSS
Newsletters
Latest updates »

The Republican race: Who were the debate’s winners and losers?
Democracy in America | Aug 7th, 21:38

Mozambique: A tuna scandal strikes
Middle East and Africa | Aug 7th, 20:03

Islam and Northern Ireland: The right to rancour
Erasmus | Aug 7th, 18:38

August 7th 2015 edition: Pick of our week, in audio
International | Aug 7th, 17:11

American jobs: Disappointing figures probably won’t put off the Fed’s rate…
Free exchange | Aug 7th, 14:48

Doping in sport: All that glisters
Game theory | Aug 7th, 14:20

Life in the universe: The cosmic haystack
Science and technology | Aug 7th, 14:01

More latest updates »
Most commented
1
Mass shootings
God, good guys and guns
2Russia and the world: Making waves, if not ruling them
3Polish politics: The German test
4The Republican debate: The candidates offer quite a show
5Lexington: Living with inequality
More articles from GE Look ahead
No longer a pipe dream
The extreme world of ultra-deep-water oil and gas exploration.
The Industrial Internet supercharges oil and gas
Big gains can be realized by making oil and gas exploration and development more efficient.
Future Scope: Angela Belcher, MIT
Belcher speaks on pioneering ways to harness nature’s own processes in order to design advanced materials and devices for energy, the environment and medicine.
Economist blogs
Buttonwood’s notebook | Financial markets
Democracy in America | American politics
Erasmus | Religion and public policy
Free exchange | Economics
Game theory | Sports
Graphic detail | Charts, maps and infographics
Gulliver | Business travel
Prospero | Books, arts and culture
The Economist explains | Explaining the world, daily
Products and events
Test your EQ
Take our weekly news quiz to stay on top of the headlines
Want more from The Economist?
Visit The Economist e-store and you’ll find a range of carefully selected products for business and pleasure, Economist books and diaries, and much more
Classified ads

Contact us
Help
My account
Subscribe
Print edition
Digital editions
Events
Jobs.Economist.com
Timekeeper saved articles
Sections
United States
Britain
Europe
China
Asia
Americas
Middle East & Africa
International
Business & finance
Economics
Markets & data
Science & technology
Special reports
Culture
Multimedia library
Debate and discussion
The Economist debates
Letters to the editor
The Economist Quiz
Blogs
Buttonwood’s notebook
Democracy in America
Erasmus
Free exchange
Game theory
Graphic detail
Gulliver
Prospero
The Economist explains
Research and insights
Topics
Economics A-Z
Style guide
The World in 2015
Which MBA?
MBA Services
The Economist GMAT Tutor
Executive Education Navigator
Reprints and permissions
The Economist Group »
The Economist Intelligence Unit
The Economist Intelligence Unit Store
The Economist Corporate Network
Ideas People Media
Intelligent Life
Roll Call
CQ
EuroFinance
The Economist Store
View complete site index »
Contact usHelpAbout usAdvertise with usEditorial StaffStaff BooksCareersSite index
Copyright © The Economist Newspaper Limited 2015. All rights reserved.AccessibilityPrivacy policyCookies infoTerms of use

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: