As I visited with a recent patient who is entering her last few months of pregnancy, I realized that I was much more nervous about her upcoming delivery than she was. She is age 39, pregnant for the 7th time and with twins. She has chronic hypertension, gestational diabetes and weighs just over 300 lbs. Her risk factors check every box for maternal hemorrhage, stroke and a cardiac event. This was an unplanned pregnancy and she does not have the support of a partner, meaning her risk of postpartum depression after delivery is greatly increased. She is concerned about how soon she can return to work and finding childcare. I am concerned about keeping her alive to be a mother to her 8 children.
Multiple news articles have appeared recently lamenting the rising maternal mortality in this country. Statistics demonstrate that our maternal mortality rate of 26.4/10,000 women is more than double the rate in other developed countries. None of this information comes as a surprise for those of us who have been taking care of pregnant patients for more than 10–15 years. As patients problem lists become longer, their risk of complications during pregnancy and childbirth dramatically increase. Some days I am amazed that worse outcomes are not more common.
There are multiple reasons for the increase in maternal mortality. The top three causes are cardiac, hemorrhage, and hypertension. As our population has become more obese, we see more women entering pregnancy with a pre-pregnancy diagnosis of chronic hypertension and adult onset diabetes. These diagnoses put a strain on the heart that is exacerbated by the doubling of blood volume and cardiac output needed to sustain a pregnancy. As women delay pregnancy into their later 30’s and early 40’s, these factors can take an even larger toll. One of our patients died after suffering cardiac collapse while hospitalized for pre-eclampsia and refusing induction. She was in her early 40’s, had pre-existing HTN and developed diabetes during pregnancy. She received immediate resuscitation efforts and delivered a healthy infant via emergent cesarean but was not able to be resuscitated a few hours later when she suffered another cardiac episode.
Not only do these diagnosis increase maternal mortality, but they also drive up the cost of prenatal care. Patients undergo weekly visits and fetal monitoring during the third trimester and are often induced early requiring greater use of hospital resources. The cesarean rate of morbidly obese patients is approximately 50%, double the national average and also contributing to greater cost of care.
When you consider that 50% of pregnancies are unplanned, it should not be surprising that many women haven’t modified their lifestyle in anticipation of a healthy pregnancy. They are still smoking cigarettes or marijuana, haven’t started a folate supplement, have poor control of their diabetes, are sedentary, and eat an unhealthy diet. Nausea and fatigue in the first trimester make it difficult to discuss changing unhealthy behaviors when a patient is just starting to accept that she is dealing with an unplanned pregnancy.
Black women have an even greater risk of maternal mortality with statistics showing a 20% increase since 2000 and overall 3–4 times as high as their Caucasian counterparts. The higher rate of obesity, HTN, and diabetes among black women is part of the cause but other causes include the lack of quality prenatal care in underserved urban areas and availability of contraception to prevent unwanted pregnancies.
I have also seen a growing trend of women who consider pregnancy naturaland that “my body will know what to do without outside intervention.” These are the women who refuse the recommended flu or pertussis vaccines, decline testing for gestational diabetes, and don’t recognize that obesity is a risk factor. When their bodies don’t cooperate during labor and give them their expected ideal birth plan outcome, it often is blamed on the provider or hospital.
For any of us who have experienced childbirth, myself included, the postpartum period is a time of raging hormones, new aches and pains beyond what we experienced during pregnancy, constant demands on our time and sleep deprivation. At the same time that we are becoming accustomed to this new person in our life, we are often planning our re-entry back to work. None of this resembles what we see in magazines or on TV — the bliss of the new mom as she eats organic food, takes selfies with her newborn, and gazes lovingly into her partners eyes as the baby sleeps peacefully. Suicides, homicides, and deaths due to drug use account for almost 50% of deaths in the postpartum period. We need to recognize that support of women extends beyond childbirth and implement policies that can assist women after their child is born.
Some causes of maternal mortality are not preventable. I have been witness to two episodes of women experiencing amniotic fluid embolus shortly after delivery. Despite receiving prompt medical attention, both women died within a few hours. A co-worker died in the weeks after her child was born after an uncomplicated pregnancy due to a cardiac arrhythmia. Pregnancy is not risk free, despite the many advantages that medical care has made. But we should be able to cut our rate in half to match that of other developed nations by increasing public awareness of the importance of pre-pregnancy health, increasing availability of free contraception and support of women in the months after pregnancy.
Dr. Leslee Jaeger is an ob/gyn and a 2018–2019 Doximity Author. She is also a mom to 3 bio and 2 adopted children, advocate for women’s health domestically and internationally, and loves good food and good books. She currently blogs about her family and work at jaegerleslee.wordpress.com