More Pregnancy-Related Deaths in California Than in Bosnia or Kuwait: Report

... Continued...

Part Two...

Obesity as well as the tripling of the maternal death rate directly from complications of pregnancy is nationwide. It's not only in California or in Sacramento.

You can check out the site for the Joint Commission, the leading health care standards group in the United States. Read the "Sentinel Event Alert" sent to hospitals Jan. 26, stating, "Current trends and evidence suggest that maternal mortality rates may be increasing."

The alert asked doctors to consider morbid obesity, high blood pressure and diabetes, along with hemorrhaging from C-sections, as contributing factors.

Other sites you can check out for information include the US Centers for Disease Control and Prevention. Check out their figures for maternal mortality rates. You can look up the statistics for the American College of Obstetricians and Gynecologists. Is the tripling related to more careful counting of deaths? Or is the tripling related to obesity, which in turn goes back to nutrition during pregnancy (and before)?

Nutritionists can check with California's Dept. of Public Health. But you'd have to review every maternal death in California. For that type of check, you'd need researchers to check the changes in populations, the age of the mother, her obesity, diet, fertility treatments, but do all these factors account for the tripling of maternal deaths since the year 2000? All the factors don't add up. So are scientists going to look at obesity and nutrition during pregnancy and the age of the mother, or could it be nutrition before the pregnancy as well?

What about environmental pollution? One of the ways maternal deaths might happen is when amniotic fluid gets into the blood stream and quickly kills the mother and baby. This could happen during severe contractions. Or it could be an adverse reaction to the anesthesia. Or a lot of other factors unpredictable. But why is it happening now? What are doctors doing now that they didn't do a decade ago?

Obesity increased, but at the same time C-sections increased 50 percent in the same years that maternal mortality tripled. There is a task force looking into why changes in clinical practice could prevent a significant number of these deaths. But for the majority of women, pregnancy is still safe.

What are the statistics in California? According to the Sacramento Bee article, 95 women died from causes directly related to being pregnant, out of half a million live births where the mother and baby survived.

The U.S. Dept of Health and Human Services wants California to bring down its mortality rate for pregnant mothers. In numerous other countries, it's lower. The rate has to be brought down to 28 deaths related to pregnancy instead of 95. But why do women have to die from pregnancy at all?

If nutrition is a factor, statistics point to African American mothers being three to four times more likely to die from pregnancy-related causes. It's not from being paid less money for work. High income Black women also are at greater risk. Is it diet or genetics?

And can those little epigenetic tags on geness be switched on or off by a change in nutrition? The only problem is that the task force found a more dramatic increase in deaths among white, non-Hispanic mothers and not among Black or Asian mothers.

Maybe it's time for a change in nutrition before and during pregnancy to find out what can be done to reduce complications from pregnancy that lead to so many material (and baby) deaths during pregnancy. If obesity is a factor, so is later age of pregnancies. Should women count on a change in nutrition? Or should age be a factor in deciding whether to take a risk and get pregnant? Or is it about doctors performing too many C-sections? What changes are responsible in the environment, the person and her weight, nutrition, or in medical practices?

END

http://www.examiner.com/x-7160-Sacramento-Nutrition-Examiner~y2010m2d3-Is-there-...

Is there a nutritional basis to why pregnancy mortalities in Sacramento have tripled in 10 years?

February 3, 1:29 PMSacramento Nutrition ExaminerAnne Hart

Part One...

Could obesity in pregnant women be a factor in why the mortality rate in pregnant women has tripled in the past decade? Why are more women in Sacramento, and particularly in California dying from causes related to pregnancy? Could it have a nutritional basis? Or might it be as a result of too many C-sections? The fact is in California, the mortality rate has tripled in the past decade. Doctors are worrying about the dangers of obesity that occurs while the woman is pregnant. Is the obesity linked to the complications of C-sections?

Could the problem be related to eating too much processed foods during pregnancy, a copper deficiency that disturbs the balance of zinc, selenium, and copper, or other nutrition-based upsets? Or is the real problem more like a huge group of women having their labors induced? This process is called 'inductions.' Having an induction doubles the chances of a C-section, according to the Sacramento Bee article.

Let's follow the money. When hospitals do less inductions, there are less c-sections, fewer hemorrhages, and fewer hysterectomies after recent childbirth. But at the same time, hospitals lose money. As procedures are reduced, so does the amount of money coming into hospitals. C-sections bring in about twice the revenue of vaginal births. How many C-sections are performed?

It's the single most common surgical procedure in the nation. Again, the problem might be traced by following the money. But getting back to nutrition, is it possible the C-section epidemic in the USA might have a root cause--poor nutrition such as too much processed food, sugary foods, and too much soda pop? Or obesity, type 2 diabetes, gestational diabetes, hypertension during pregnancy, and other issues that are affecting pregnant women?

The mortality rate of women in California. According to the February 3, 2010 Sacramento Bee article, "Pregnancy-related deaths rise in California: Rise Seen Over a Decade; Report not Released," by Nathanael Johnson ,California Watch, the State Department of Public Health has declined to release a report outlining the trend. According to the Sacramento Bee article, "Investigators who wrote the report, however, confirmed it shows the most significant spike in pregnancy-related deaths since the 1930s."

For further information, check out the site of the California Maternal Quality Care Collaborative, the public-private task force investigating the problem for the state.

...Continued...

http://www.californiahealthline.org/articles/2010/2/3/maternal-mortality-rates-o...

Wednesday, February 03, 2010
Maternal Mortality Rates on the Rise in California, According to State Data

California's maternal mortality rates have nearly tripled during the past decade, according to an unreleased report from the state Department of Public Health, the Sacramento Bee reports.

California Watch, a project of the Center for Investigative Reporting, conducted the investigation into the state's pregnancy-related deaths.

California Rates on the Rise

In 1996, California's pregnancy-related mortality rate was 5.6 per 100,000 live births, slightly more than the national goal of 4.3 per 100,000.

After the World Health Organization revised its coding system, California's rate increased to 6.7 in 1998 and 7.7 in 1999.

California changed its coding system once more in 2003, and maternal mortality rates jumped to 14.6. In 2006, California's rate reached 16.9, compared with the national average of 13.3.

Investigators estimate that reporting system changes account for less than 30% of the increase in maternal mortality rates.

Nationwide Trend?

California might be mirroring the rest of the country with its rise in pregnancy-related deaths, according to a recent "Sentinel Event Alert" from the Joint Commission, a hospital accreditation organization.

On Jan. 26, the commission sent a notice informing hospitals that maternal mortality rates appear to be increasing nationwide.

Possible Contributing Factors

The Joint Commission suggested that diabetes, high blood pressure, hemorrhaging from caesarean sections and obesity could account for some of the increase in maternal mortality rates.

Elliott Main, principal investigator for California's report, said the rise cannot be fully explained by population changes such as fertility treatments, obesity and older mothers.

Main noted that c-sections also increased by 50% during the same decade that pregnancy-related deaths went up.

Currently, c-sections are the most common surgical procedure in the U.S. For hospitals, the surgery also brings in about twice the revenue of a vaginal birth.

Efforts to Reverse the Trend

In response to the rise in maternal mortality, California officials are starting work on pilot programs designed to:

* Improve hospital responses to hemorrhages;
* Reduce the incidence of induced births; and
* Strengthen tracking systems for women's medical conditions (Johnson, Sacramento Bee, 2/3).

Broadcast Coverage

On Wednesday, KQED's "The California Report" is scheduled to include a segment on the rise in pregnancy-related deaths (Montgomery, "The California Report," KQED, 2/3).

... Continued...

Part Five...

Inducing labor before term more common

In 2002, Dr. David Lagrew, the medical director of the Women’s Hospital at Saddleback Memorial Medical Center in Orange County, noticed that a lot of women were having their labor induced before term without a medical reason. And he knew that having an induction doubled the chances of a C-section.

So he set a rule: no elective inductions before 41 weeks of pregnancy, with only a few exceptions. As a result, Lagrew said, the operating room schedules opened up, and the hospital saw fewer babies admitted to the neonatal intensive care unit, fewer hemorrhages and fewer hysterectomies.

All this, however, came at a cost: The hospital had to take a cut in revenue for reducing the procedures it performed. Lagrew doubts that any hospital has increased its C-section rate in pursuit of profit, but he does note that the first hospitals to adopt controls on early elective inductions have been nonprofits.

According to a report issued by the advocacy group Childbirth Connection, “Six of the 10 most common procedures billed to Medicaid and to private insurers in 2005 were maternity related.” On average, a C-section brings in twice the revenue of a vaginal birth. Today, the C-section is the single most common surgical procedure performed in the United States.

“If all these guys were losing money on every C-section, well, what’s the old saying? Whenever they tell you it’s not about the money, it’s about the money,” Lagrew said.

The California task force isn’t waiting to determine the ultimate cause of these deaths. It has started pilot projects to improve the way hospitals respond to hemorrhages, to better track women’s medical conditions and to reduce inductions – as Lagrew did at Memorial Care.

Although the state hasn’t released the task force’s report, the researchers and doctors involved forwarded data to the national Joint Commission, which issued incentives for hospitals to reduce inductions and fight what it called “the cesarean section epidemic.”

“You don’t have to be a public health whiz to know that we are facing a big problem here,” Bingham said.

END

... Continued...

Part Four...

Rising C-section birth rate

Nearly one in three babies is now born by C-section. Many scientists have acknowledged that at some point, as the number of surgeries spiral upward, the risks will outweigh the benefits. But the C-section remains a useful tool, and in the middle of labor, doctors say, it’s hard to balance the potential long-term harm against immediate crisis.

Today, doctors face a condition called placenta accreta, where the placenta grows into the scar left by a previous C-section. In surgery, doctors must find and suture a web of twisted placental vessels snaking into the patient’s abdomen, which can hemorrhage alarming amounts of blood. Often, doctors must remove the uterus.

Main said this complication from C-sections has increased eight-to-10 fold in the past decade. Nonetheless, most women survive the ordeal. The point, says Catherine Camacho, deputy director of the state’s Center for Family Health, is that the rise in deaths is indicative of a larger problem.

“For every maternal death, there are 10 near misses; for every near miss, there are 10 severe morbidity cases (such as hysterectomy, hemorrhage, or infection), and for every severe morbidity case, there is another 10 morbidity cases related to childbirth,” Camacho wrote in an e-mail.

Other factors are contributing to the rise in deaths, but the researchers in California are most interested in the areas where they have control, such as the high C-section birth rate: It’s easier for doctors to improve medical care than to fix more intractable problems like poverty and obesity.

... Continued...

... Continued...

Part Three...

Rather than track down the cause of every death and assign blame, the California task force is focused on finding solutions. And Bingham and Main have found that doctors and nurses are eager to help after seeing the numbers.

In 1996, the maternal death rate in California was 5.6 per 100,000 live births, not far from the national goal of 4.3 per 100,000. Between 1998 and 1999, the World Health Organization changed its coding system, which may have increased reporting of deaths. The California rate was 6.7 in 1998 and 7.7 in 1999. Because the number of mothers who die is small, the rate tends to fluctuate from year to year.

In 2003, when California revised its death certificate, the rate jumped to 14.6. And in 2006, the last year for which data is available, the rate stood at 16.9.

The best estimates show that less than 30 percent of the increase is attributable to better reporting on death certificates. Even accounting for these reporting and classification changes, the maternal death rate between 1996 and 2006 has more than doubled, Main said.

Not yet public

When researchers unveiled their initial findings to a conference of the American College of Obstetricians and Gynecologists in 2007, there were gasps from the audience, according to participants at the San Diego event. The idea that California was moving backward even in an era of high-tech birthing was implausible to some. Confirmation of the trend was noted in the 2008 report written by 27 doctors and researchers. The report was described in detail to California Watch.

The state of California has yet to share the report with the public. Researchers say that, after reviewing the report in 2008, officials in the Department of Public Health asked for technical clarifications. Revisions were complete and approved in the first half of 2009, according to Ahmad.

Al Lundeen, the department’s director of public affairs said, “There was no effort to hold that report back. It just needed some more revisions.”

Researchers say that it is important for the public to be aware now that these trends are worsening. Diane Ashton, the deputy medical director for the March of Dimes, has seen the numbers. She says they demand a concerted response.

“Even though they tend to be small numbers in terms of maternal mortality, it is important – it’s very important – that these trends be looked at,” she said. “And efforts need to be made to try and reverse them when they are going in the wrong direction.”

...Continued...

... Continued...

Part Two...

Changes in the population – obese mothers, older mothers and fertility treatments – cannot completely account for the rise in deaths in California, said Dr. Elliott Main, the principal investigator for the task force.

“What I call the usual suspects are certainly there,” he said. “However, when we looked at those factors and the data analyzed so far, those only account for a modest amount of the increase.”

Main said scientists have started to ask what doctors are doing differently. And, he added, it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.

One maternity expert who was not involved in the report, Dr. Thomas R. Moore, chair of the Department of Reproductive Medicine at UC San Diego, said about the data: "This could be a sentinel finding, and I could see other states taking a closer look and finding the same thing."

Low numbers, high consequences

Despite the increase in the mortality rate, pregnancy is still safe for the vast majority of women.

In 2006, 95 California women died from causes directly related to their pregnancies – out of more than 500,000 live births. That’s a small number by public health standards. If California had met the goal set by the U.S. Department of Health and Human Services to bring the state’s maternal mortality rate down to a level achieved by other countries, the number of dead would be closer to 28.

It’s not clear who is most at risk, but researchers have long known that African-American mothers are between three and four times more likely to die from pregnancy-related causes than the rest of the population. That racial association is not stratified by socio-economic status: Even high-income black women are at a greater risk.

While the maternal mortality rate among black women is rising, the task force found a more dramatic increase in deaths among white, non-Hispanic mothers. There is not yet enough data to show if the risk of death is associated with poverty.

maternal deaths California WatchTatia Oden French

What’s certain is that each maternal death shatters families. That cold sum – 95 dead – represents 95 stories of people such as Tatia Oden French. In 2001, she was newly wed and had just finished her doctorate in psychology. She was about to have a baby girl she would name Zorah Allie Mae French.

“She’s the type of person that just walked into the room and lit it up,” said her mother, Maddy Oden.

During the labor, Maddy Oden was at home in Oakland, waiting for a call announcing the birth of her granddaughter. Instead, she needed an emergency C-section. “I woke up at 4 in the morning, and I knew that something was wrong,” Oden said.

Then the phone rang. French was in trouble. Powerful contractions had forced amniotic fluid into her bloodstream, stopping her heart and killing the baby. When Oden got to her daughter at an Oakland hospital there was only one thing she could do: “We said a prayer,” Oden said, “and I closed her eyes.”

The subsequent lawsuit was dismissed: The doctor had not deviated from the standard of care.

... Continued...

... Continued...

Taking action

The California task force isn't waiting to determine the ultimate cause of these deaths. It has started pilot projects to improve the way hospitals respond to hemorrhages, to better track women's medical conditions and to reduce inductions.

Dr. David Lagrew, meanwhile, thinks he may have arrived at an answer. In 2002, Lagrew, the medical director of the Women's Hospital at Saddleback Memorial Medical Center in Orange County, noticed that many women were having their labor induced before term without a medical reason. He knew that having an induction doubled the chances of a C-section.

So he set a rule: no elective inductions before 41 weeks of pregnancy, with only a few exceptions. As a result, Lagrew said, the operating room schedules opened up, and the hospital saw fewer babies admitted to the neonatal intensive care unit, fewer hemorrhages and fewer hysterectomies.

All this, however, came at a cost: The hospital had to take a cut in revenue for reducing the procedures it performed. Lagrew doubts that any hospital has increased its C-section rate in pursuit of profit, but he adds that the first hospitals to adopt controls on early elective inductions have been nonprofits.

On average, a C-section brings in twice the revenue of a vaginal birth. Today, the C-section is the single most common surgical procedure performed in the United States.

Although the state hasn't released the task force's report, the researchers and doctors involved forwarded data to the national Joint Commission, which issued incentives for hospitals to reduce inductions and fight what it called "the cesarean section epidemic."

"You don't have to be a public health whiz to know that we are facing a big problem here," said Bingham, the executive director of the task force.

Online resources: To read more about maternal mortality rates and pregnancy-related deaths, go to californiawatch.org.

California Watch is a project of the Center for Investigative Reporting with offices in the Bay Area and Sacramento.

... Continued...

Finding ways to help

Rather than track down the cause of every death and assign blame, the California task force is focused on finding solutions. Bingham and Main have found that doctors and nurses are eager to help after seeing the numbers.

In 1996, the maternal death rate in California was 5.6 per 100,000 live births, not far from the national goal of 4.3 per 100,000. Between 1998 and 1999, the World Health Organization changed its coding system to include definitions of obstetric death, which may have increased reporting of deaths. The California rate was 6.7 in 1998 and 7.7 in 1999.

Because the number of mothers who die is small, the rate tends to fluctuate from year to year.

In 2003, when California put a new checkbox on death certificates asking if the deceased was pregnant within one year of death, the rate jumped to 14.6. And in 2006, the last year for which data is available, the rate stood at 16.9. The national rate was 13.3 per 100,000 live births.

The best estimates show that less than 30 percent of the increase is attributable to better reporting on death certificates. Even after adjusting the numbers to reflect better reporting, the maternal death rate between 1996 and 2006 has more than doubled, Main said.

When researchers unveiled their initial findings to a conference of the American College of Obstetricians and Gynecologists in 2007, there were gasps from the audience, according to participants attending the San Diego event.

The idea that California was moving backward even in an era of high-tech birthing was implausible to some. Confirmation of the trend was noted in a 2008 report written by 27 doctors and researchers. The report was described in detail to California Watch.

The state of California has yet to share the report with the public. Researchers say that, after reviewing the report in 2008, officials in the Department of Public Health asked for technical clarifications. Revisions were complete and approved in the first half of 2009, according to Ahmad.

Al Lundeen, the department's director of public affairs said, "There was no effort to hold that report back. It just needed some more revisions."

... Continued...

... Continued...

C-sections increase

Main said scientists have started to ask what doctors are doing differently. He added that it is hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased.

The task force has found that changing clinical practice could prevent a significant number of these deaths.

Despite the increase in deaths, pregnancy is still safe for the vast majority of women.

In 2006, 95 California women died from causes directly related to their pregnancies - out of more than 500,000 live births. That's a small number by public health standards. But if California had met the goal set by the U.S. Department of Health and Human Services to bring the state's maternal mortality rate down to a level achieved by other countries, the number of dead would have been closer to 28.

It's not clear which mothers are most at risk, but researchers have long known that African American mothers are three to four times more likely to die from pregnancy-related causes. That racial association is not stratified by socio-economic status: Even high-income black women are at a greater risk.

While the maternal mortality rate among black women is rising, the task force found a more dramatic increase in deaths among white, non-Hispanic mothers.
Real stories

Each maternal death shatters families. That cold sum - 95 dead - represents 95 stories of people such as Tatia Oden French. In 2001, she was newly wed and had just finished her doctorate in psychology. She was about to have a baby girl she would name Zorah Allie Mae French.

"She's the type of person that just walked into the room and lit it up," said her mother, Maddy Oden.

During the labor, Maddy Oden was at home waiting for a call announcing the birth of her granddaughter. Instead, her daughter needed an emergency C-section.

"I woke up at 4 in the morning and I knew that something was wrong," Oden said.

Then the phone rang. French was in trouble. Powerful contractions had forced amniotic fluid into her bloodstream, stopping her heart and killing the baby. When Oden got to her daughter at an Oakland hospital, there was only one thing she could do: "We said a prayer," Oden said, "and I closed her eyes."

The subsequent lawsuit was dismissed: The doctor had not deviated from the standard of care.

... Continued...

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/02/03/MNER1BRFT4.DTL&type=printable

Pregnancy-related death rate on the rise

Nathanael Johnson, California Watch

Wednesday, February 3, 2010

The mortality rate of California women who die from causes directly related to pregnancy has nearly tripled in the past decade, prompting doctors to worry about the dangers of obesity in expectant mothers and about medical complications of cesarean sections.

For the past seven months, the state Department of Public Health has declined to release a report outlining the trend.

California Watch spoke with investigators who wrote the report, and they confirmed the most significant spike in pregnancy-related deaths since the 1930s. Although the number of deaths is relatively small, the rate in California is higher than in Kuwait or Bosnia.

"The issue is how rapidly this rate has worsened," said Debra Bingham, executive director of the California Maternal Quality Care Collaborative, the public-private task force investigating the problem for the state.

The problem may be occurring nationwide. The Joint Commission, the leading health care accreditation and standards group in the United States, issued an alert to hospitals on Jan. 26, stating: "Unfortunately, current trends and evidence suggest that maternal mortality rates may be increasing."

To help improve care, the advisory asked doctors to consider morbid obesity, high blood pressure and diabetes, along with hemorrhaging from C-sections, as contributing factors to deaths.

In 2007, the U.S. Centers for Disease Control and Prevention reported that the national maternal mortality rate had risen. But experts such as Dr. Jeffrey C. King, who leads a special inquiry into maternal mortality for the American College of Obstetricians and Gynecologists, chalked up the change to better counting of deaths. His opinion hasn't changed.

"I would be surprised if there was a significant increase of maternal deaths," said King, who has not seen the California report.

But Shabbir Ahmad, a scientist in California's Department of Public Health, decided to look closer. In 2006, he organized academics, state researchers and hospitals to conduct a systematic review of every maternal death in California from 2002 to 2006. It's the largest state review ever conducted. The group's initial findings provide the first strong evidence that there is a true increase in deaths - not just the number of reported deaths.

Changes in the population - obese mothers, older mothers and fertility treatments - cannot completely account for the rise in deaths in California, said Dr. Elliott Main, the principal investigator for the task force.

"What I call the usual suspects are certainly there," he said. "However, when we looked at those factors and the data analyzed so far, those only account for a modest amount of the increase."

Continued...

http://www.centerforinvestigativereporting.org/blogpost/200908californiawatchlau...

An explanation of California Watch...