Last year, ProPublica, in association with NPR, published Why
Giving Birth Is Safer in Britain Than in the U.S. In typical journalistic
style, it starts by grabbing your attention with a case report of a woman in
England who almost died of post-partum hemorrhage, but did not. The lesson is
presumably that she did not because the physicians, midwives, and others
attending her followed a rigorous set of established protocols for addressing
post-partum hemorrhage that are implemented nationally in the UK.
Of course, there is a possibility that this individual woman
could have died, or had to undergo more invasive surgical procedures further
down the protocol’s algorithm, but the real point is that, overall, the system
is working. The evidence is in that the maternal mortality rate (deaths/100,000 women delivering) is 8.9 in Britain, while in the US the rate in 2015 was 25.1,
three times that of the UK! What makes this more dramatic is that the disparity
has developed only since 1990; until then the maternal mortality rates in the
US and UK had been declining in parallel since the 1950s.
The article cites several reasons for this difference. One,
a very important one, is that the UK collects data on maternal mortality
nationally and develops guidelines based upon this data which are implemented
nationally. In contrast, the US collects data at best by state, or even by
hospital, and
There
is no federal-level scrutiny of maternal deaths, and only 26 states have an
established committee (of varying methodology and rigor) to review them. Nor do
all U.S. hospitals routinely examine whether a death could have been avoided.
Procedures for treating complications such as preeclampsia, and for responding
to emergencies such as hemorrhage, vary from one doctor, hospital and state to
the next.
This is true despite the fact that the methods used by the
British to collect and analyze this data were developed in the US. While there
has been a well-documented 30-year effort to improve quality and to reduce
preventable deaths (a category into which most maternal mortality falls) in the
US, led by such organizations as the Institute for Healthcare Improvement (IHI)
and embraced by such other organizations as the American Hospital Association
(AHA), National Center for Quality Assurance (NCQA), the Joint Commission for
the Accreditation of Healthcare Organizations (TJC), the National Academy of
Medicine, and on and on, no compulsory national approach to this problem has
developed. This reflects a common, and often knee-jerk, opposition to centralized
approaches to almost everything, even when they have been determined to have an
important effect on reducing death. It is actually parallel to efforts within
hospitals to standardize care, to require, for example, all surgeries to go
through a series of prescribed steps (“timeouts”) before operating, or limiting
the number of different devices implanted to those needed by different types of
patients rather than by the preference of the individual surgeon (for an
interesting discussion, see A. Gawande, “Big
Med”, New Yorker, August 13, 2012).
That is, it is effective where it has been done, but it is not mandated to be
done everywhere and comprehensive national data is not even collected.
Another big part of the successful UK approach to the
reduction of maternal mortality has been collecting detail on what happened and
why; this goes beyond “there was a death”, or “there was a death from
hemorrhage”, or “there was a death from sepsis”, to identifying why it
happened, particularly if the reason was something that is relatively easily
addressed. Marian Knight, head of MBRRACE-UK, the group that collects the data
and makes the guidelines, says
It’s
all very well to know a woman died of sepsis, but to know that she died of
sepsis because nobody measured her temperature, as they had no thermometers on
the postnatal ward, that’s where the instruction Put a thermometer on your
postnatal ward might make a difference.
It’s not just the what, it’s the why.
Can you believe that there might be post-partum units where
there is no thermometer? Apparently it has happened. And having a rule that it
must be present is a way of preventing it from happening again.
There are at least three other important dimensions. One is
that, as the report states, “These U.S. deaths are not spread equally. Women
who are poor, African American or live in a rural area are more likely to die
during and after pregnancy.” This is not
a big surprise. Poor women, minority
women, rural women, and uninsured women do much worse, and are much more likely
to die from complications of delivery. It is the familiar song in the US, as in
so many areas, of health and of every aspect of society. Is it not true in
Britain? The article goes on to say
In
the U.K., while inequalities persist when it comes to serious complications,
according to 2012-2014 data, there is no statistically significant difference
in mortality rates between women in the highest and lowest socioeconomic
groups. All British women have equal access to public medical services,
including free care and prescriptions from pregnancy through the postpartum
period.
This also has two components; the greater equity of the
quality of healthcare delivered to all segments of the population, a result of
having a national health care system, and less disparity in the “social
determinants of health”, the actual quality of the lives of people (women, in
this case) before they access care. Especially for rural women, some of the
problem the lack of an adequate number of health professionals. Over 20 years
ago, family medicine residencies in Texas were surveyed and only a small
percent of residents were interested in providing rural obstetric care, but no
OB/Gyn residents were! This has not improved; while a recent study published by
Tong, et al., in Family Medicine (Characteristics
of Graduating Family Medicine Residents Who Intend to Practice Maternity Care)
found that 22% of FM residents planned to deliver babies, they cite his 2012 study that showed
that only 9.1% of FM residency graduates were delivering babies 1-10 years out
into practice despite an intention to do so of 24%, comparable to the current study.
Another dimension is that the difference in maternal
mortality reflects a greater focus on the health – and life -- of the pregnant
woman in Britain, while in the US the focus is more on the health of the fetus
and the newborn. This goes far beyond the issue of abortion, although the focus
on children rather than women is one that is also characteristic of the anti-choice
movement in the US. It is so deeply ingrained in our culture that even many
health professionals (including midwives, doctors, and nurses) who see
themselves as “pro-choice” and would never want to see a maternal mortality,
are still more focused on the fetus and baby. It results in a practice, if not
a belief, that considers the woman but a vehicle for producing a child.
Finally, there is cost, ironically but again unsurprisingly
much higher in the US. Much higher. The total cost for a normal vaginal
delivery in the US is about $30,000, and about $50,000 for a Caesarean section.
In Britain, the cost for a normal vaginal delivery or planned Caesarean is
about $2500, or less than 1/10th the cost in the US, perhaps rising
to $3400 for complicated cases (such as the one that leads off the article).
Thus, the US charges far more, but has much worse outcomes for maternal
mortality (as for many other conditions). This is not a side note; it is not
just an interesting contradiction that our care costs more but has worse outcomes. And it is not by any means limited to pregnancy care or maternal mortality, but is
present in our healthcare system at almost all levels and for most conditions. What
ties these two components, cost and quality, tightly and inversely together, is
that our “healthcare system” is only secondarily about delivering quality
healthcare, and primarily about being a profit-making business.
So, that is the bottom line. The US has three times the
maternal mortality rate of the UK despite charging ten times as much for
delivery. The reasons are the absence of a national strategy to identify and
remedy the causes of maternal mortality and the lack of a national healthcare
system to provide the access necessary for women at risk. It causes the
suffering and death to disproportionately affect those women who are already at
greatest risk: the poor, minority, rural, and uninsured. The root cause is that
our healthcare system is composed of poorly interconnected components, most of
which are run as businesses to make money.
It is inequitable, and it is irrational from a health
perspective if not from a business one. It causes unnecessary death and
excessive cost, and seems to not be improving. It is not acceptable. We need to
change it.