pregnant woman

Maternal Mortality and Morbidity

MATERNAL MORTALITY Paraphrasing the World Health Organization’s definition:

“Maternal mortality is the death of a woman while pregnant or within 42 days after being pregnant. How long the pregnancy was (not full term, may be due to miscarriage or termination of pregnancy), or the site of the pregnancy(ectopic pregnancy, fertilized egg implants outside of the uterus) doesn’t change the fact that any cause that is related to, or made worse by the pregnancy or its management is the definition of maternal death.”

MATERNAL MORBIDITY: Paraphrasing WHO definition of Maternal morbidity

Any health condition that has a negative impact on the woman’s well being, caused by and/or made worse by pregnancy and childbirth.”

Friends, I have been working on this post for ages. I’ve lost count of the hours I’ve spent on it, and how many times I’ve edited it. There is no fun or light way to share this information, but if you believe in the power of knowledge, read on.

Maternal mortality and morbidity continue to be a challenge in the USA. The U.S. has the worst rate of maternal deaths in the developed world. Every year in the U.S., 700 to 900 women die from pregnancy or childbirth-related causes. More than 60,000 women almost die (details regarding why this is the case are listed at the end of this post.) About half of all maternal deaths in the USA are preventable.

Every life is precious, and breaking down maternal deaths into cold statistics makes me feel disrespectful somehow; but knowing how anxious we women are when we are pregnant, I think it’s important to put the likelihood of this happening to you, dear reader, in perspective.

There were 3,791,712 births in the US (in 2018). If we look at the number of women who died because of pregnancy-related complications, 700 – 900, statistically the rate is 2 out of 10,000 women (0.02%) The number women who almost died, 60,000 breaks down to 131 women out of 10,000 (1.31%).

Education is just one of the ways to help change these numbers, therefore I am trying to contribute by putting this information out there. Deaths and “near misses” are shamefully common.

I myself had preeclampsia with my first baby. Three family members experienced placental abruptions.

In the course of my 19 years as an RN I have met women who have experienced one or more of the complications listed here. The stories of these women, the trauma and distress that they suffered are forever emblazoned in my mind and on my heart. Too many times their heartbreaking experiences are dismissed (with the best of intentions) by even those closest to them. “Well you’re alright” or “You and your baby survived” or  “I’m sorry for your loss, but you’ll have another baby” (not something to say to a woman who you do not know well, who had to have an emergency hysterectomy to save her life!)

Women who have experienced complications are often left with long-lasting (morbidity) physical and/or mental health illnesses. The stigma and shame associated with suicide, postpartum PTSD , PPD/PPA also have long lasting, devastating affects on society at large, and should be addressed much more openly and vigorously.

Research shows that because many in the medical community mistakenly believe that maternal mortality is no longer an issue, women aren’t always getting the level care that they need. Nor are they being adequately informed and educated about health risks associated with pregnancy. This failure to provide information and education to pregnant and postpartum women can lead to devastating and tragic outcomes.

Amy Bartlett, a mother of two sons, died on May 15, 2006, one week after giving birth to her daughter.

“At 41, Amy was thrilled to finally have a daughter. But a week after going home, while Jerry was putting the boys to bed, Amy suddenly began feeling strange — pain in her neck and jaw, a galloping heartbeat, extremely high blood pressure readings on her home monitor. Her symptoms sounded like a heart attack. She needed to get to the hospital right away.”

They thought it was a false alarm, and because they lived more than an hour away from a medical center, they stayed home. Shortly after her symptoms started, Amy died of spontaneous coronary artery dissection or SCAD. It’s not a preventable condition, but Jerry said if they had ever heard of it they might have been able to save her life. “Neither of us wanted to believe this could be happening to her,” he said.”

From the Propublica article Lost Mothers”

”We worry a lot about vulnerable little babies,” said Barbara Levy, vice president for health policy/advocacy at the American Congress of Obstetricians and Gynecologists (ACOG) and a member of the Council on Patient Safety in Women’s Health Care. Meanwhile, “we don’t pay enough attention to those things that can be catastrophic for women.”

“The nature of our system is to focus on these women while they’re pregnant,” said Eugene DeClercq, a professor of community health services at Boston University School of Public Health. “And then if there are difficulties later, they get lost to the larger system that doesn’t particularly care about women’s health to a great degree unless they’re pregnant.”

As I was researching complications (morbidity) and maternal death related to pregnancy and postpartum I was surprised to learn that while maternal death due to high blood pressure (preeclampsia) massive hemorrhage, blood clots, and infection still happens, cardiovascular disease is now the leading cause of death in pregnancy and the postpartum period.

You might think “But if there is no history of heart disease…?” There isn’t necessarily such criteria, as evidently even in otherwise healthy women, heart conditions may be triggered by pregnancy hormones.

The second cause of death among pregnant and postpartum women is suicide.

CARDIOVASCULAR DISEASES

PERIPARTUM CARDIOMYOPATHY is a weakness of the heart muscle that begins sometime during the last month of pregnancy, and through about five months after delivery, although it most commonly occurs right after delivery. The symptoms mimic the normal discomforts of pregnancy so they are often ignored.

Signs and symptoms of peripartum cardiomyopathy:

  • Fatigue
  • Feeling of heart racing or skipping beats (palpitations)
  • Increased nighttime urination
  • Shortness of breath with activity and when lying flat
  • Swelling of the ankles
  • Swollen neck veins
  • Low blood pressure or blood pressure may drop when standing up

Another heart condition, known as SPONTANEOUS CORONARY HEART DISSECTION,  or SCAD, can occur late in pregnancy, or in the weeks after having a baby.

Signs and symptoms of SCAD may include:

  • Chest pain.
  • A rapid heartbeat or fluttery feeling in your chest
  • Pain in your arms, shoulders or jaw
  • Shortness of breath
  • Sweating
  • Unusual, extreme tiredness.
  • Nausea
  • Dizziness

SUICIDE: the act of intentionally causing one’s own death. The second cause of maternal mortality.

Warning signs:

  • Excessive sadness or moodiness: Long-lasting sadness, mood swings, and unexpected rage.
  • Hopelessness
  • Sudden calmness
  • Withdrawal
  • Changes in personality and/or appearance: Dangerous or self-harmful behavior
  • Recent trauma or life crisis
  • Making preparations: Putting personal business in order. Writing a note. Buying a firearm or finding some other means to commit suicide.
  • Threatening suicide: Not everyone who is considering suicide will go through with it. 50 – 75% of people considering suicide will give someone (a friend or relative) a warning sign. Every threat of suicide should be taken seriously.

PREECLEMPSIA is high blood pressure that occurs during pregnancy. It can develop without any symptoms (such as sudden weight gain and swelling).

Signs and symptoms of preeclampsia for mom to be aware of: (your doctor will check for other signs)  

  • High blood pressure – greater than 140/90 (BP may rise slowly or may suddenly become high)
  • Sudden weight gain and swelling (edema) particularly in your face and hands
  • Severe headaches
  • Changes in vision, including temporary loss of vision, blurred vision or light sensitivity
  • Abdominal pain, especially on the right side

A blood clot, DEEP VEIN THROMBOSIS (DVT) is a clot that develops in the deep veins of the legs, thigh or in the pelvic area (or rarely in other parts of the body).

It is not common in pregnancy but a pregnant woman is 5 times more likely to develop one, and it can also happen during the postpartum period (up to 6 weeks after birth).

DVT Signs and symptoms

The most common symptom is swelling and heavy pain or extreme tenderness in one of your legs (most likely in left leg)

Other symptoms of DVT include:

  • pain in the leg when standing or moving around
  • pain in the leg that worsens when you bend your foot up toward your knee
  • warm skin in the affected area
  • red skin at the back of the leg, typically below the knee
  • slight to severe swelling

 A DVT can cause a Pulmonary Embolism, PE, caused by a blood clot that travels to the lungs. This is a life-threatening condition that must be treated immediately.

Signs and symptoms of PE:

  • sudden shortness of breath
  • chest pain or tightness in the chest
  • a cough that produces blood-streaked sputum (mucus)
  • rapid heartbeat

MASSIVE HEMORRHAGE

The list of symptoms is long, I advise visiting the website: https://www.chop.edu/conditions-diseases/postpartum-hemorrhage

There is one particular cause of massive hemorrhage, placental abruption, which is “the early detachment of the placenta from the uterus” that I feel I must specifically mention here. It affects only 1%of pregnant women, so it’s not that common. On the other hand, I have had family members who experienced this, as well as several of my clients, so I think it’s very important to understand placental abruption.

Signs and symptoms of the early detachment of the placenta from the uterus, placental abruption, which can happen any time after 20 weeks.

  • Vaginal bleeding
  • Abdominal pain
  • Back pain
  • Uterine tenderness
  • Uterine contractions, often coming one right after another
  • Firmness in the uterus or abdomen

Back pain and abdominal pain begins suddenly. The amount of vaginal bleeding can vary greatly, and it is possible for the blood to be trapped inside the uterus, so there might not be any visible bleeding.

INFECTIONS

Infections can occur from a c-sections wound, an episiotomy or vaginal tear, or from mastitis (mastitis is an infection of the tissue of the breast) that occurs most frequently during the time of breastfeeding. It can occur when bacteria enter a milk duct through a crack in the nipple.

Symptoms of postpartum infection vary but there’s almost always fever, pain, or tenderness in the infected area, or foul-smelling discharge (from the vagina in the case of uterine infection, or from a wound).

For some women, there is an increased risk for developing some of the complications discussed in this post, based on family history or her own health history. In other instances, complications can occur unexpectedly or inexplicably and knowing signs and symptoms to watch for may help you avoid or minimize the impact of such complications.

Also, when choosing a physician and birth facility do research (some insurance plans have a program set up to help their customers with information about a physician). It may be important to you to have unmediated childbirth, or you may want to find out what they think about inductions, when they think a c-section birth might be the best option, etc. Google questions to ask when choosing OB!

FACTORS CONTRIBUTING TO MATERNAL MORTALITY AND MORBIDITY

  • Pregnancy-related complications are often identified too late; complications that aren’t properly treated can be fatal or have long term health consequences (morbidity)
  • Hospital protocols for dealing with treatable complications may be a confusing mixture, and the lack of clear guidelines on providing proper treatment can lead to death.
  • A hospital may have a NICU – an Intensive Care Unit for Newborns, yet be sadly unprepared for a maternal emergency
  • Of federal and state-funded grants for maternal child health, only 6% are put toward maternal health
  • In the USA, women who lack health insurance are three to four times more likely to die of pregnancy-related complications
  • Some doctors specializing in the growing specialty of maternal-fetal medicine were able to complete their training without ever spending time in a labor and delivery department.

I hope you find this information to be helpful, and I urge you to share it with as many people as you can.

I wish every one of you a safe and healthy birth experience that brings you the magic and delight of holding your precious one in your arms.

~Liz

https://www.who.int/bulletin/volumes/93/3/14-148627/en/

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3397324/

https://www.npr.org/2017/12/22/572298802/nearly-dying-in-childbirth-why-preventable-complications-are-growing-in-u-s

https://www.seleni.org/advice-support/2018/3/16/new-study-reveals-disturbing-ppd-statistics

https://www.heart.org/en/health-topics/cardiomyopathy/what-is-cardiomyopathy-in-adults/peripartum-cardiomyopathy-ppcm

https://www.mayoclinic.org/diseases-conditions/spontaneous-coronary-artery-dissection/symptoms-causes/syc-20353711

https://www.mayoclinic.org/diseases-conditions/preeclampsia/symptoms-causes/syc-20355745

https://www.webmd.com/baby/preeclampsia-eclampsia#2

https://www.healthline.com/health/dvt-in-pregnancy#symptoms

https://www.webmd.com/mental-health/recognizing-suicidal-behavior#1

https://www.medicinenet.com/script/main/art.asp?articlekey=206434

https://www.propublica.org/series/lost-mothers

https://www.whattoexpect.com/first-year/postpartum-health-and-care/postpartum-infection/

Want more interesting and helpful articles? Find more at my Maternology Blog page.

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