US Maternal Mortality Rate Exemplifies Moral Bankruptcy of Our Health System

My friend, Dr. Don Frey, recently published America’s DWP Crisis: Dying While Pregnant (DWP) on his blog, “A Family Doctor Looks at the World”. It leads with shocking and distressing statistics about the US maternal mortality rate, which has long been the highest in the “developed world” and has been steadily increasing. Citing a recent article in JAMA, Trends in State-Level Maternal Mortality by Racial and Ethnic Group in the United States (LG Fleszar, AG Bryant, CO Johnson, July 3, 2023), he  points out that in the 20 years from 1999 to 2019 US maternal mortality more than doubled (it actually went up 2.5 times):

In every corner of the country, for every ethnic group, outcomes worsened.  By 2019, deaths per 100,000 pregnancies (the benchmark measure) had increased from 12.7 to 32.2.  For Black and American Indian women, the picture was much worse.  Their mortality skyrocketed to 55.4 and 49.2, respectively.

And this doesn’t even include deaths from accidents and homicide – the latter being the #1 cause of death for pregnant women in the US!

Let’s stop and think about that. In the rest of the OECD (Organization for Economic Cooperation and Development, = wealthy) countries maternal mortality is going down. For the most recent reported years, it ranges from about 1.6 to 8.8, with most below 5. When we were at 12.7 we were way out of the picture. Now we are at 32.2! And our rates for minority women are like poor countries! Even though the maternal mortality rate is high and rising for all races and ethnicities, it is made even higher by the ridiculously high rates for some populations. In what conceivable way could this be compatible with the US having “the best healthcare in the world”, or anything approaching it? Only if you accept the definition of “well, the best healthcare is available for some people, who can afford it, but not even for most Americans”.

Dr. Frey points to several reasons why our “DWP” (and our dying-while-recently-pregnant, ie, post-partum) rate is so high, and they are valid, and addressing them would certainly significantly lower it. The major one is what we often refer to as “the social determinants of health”. This is a fine term, except it has almost become routine to cite them while we, as a country, continue to do little or nothing to address them. People are much more likely to have poor health status if they are financially poor, poorly nourished, poorly housed, poorly educated and live with ongoing danger and the fear that comes from it. And when those bad things happen in childhood, their risk continues higher for the rest of their lives. We call this “ACEs”, Adverse Childhood Events, and the higher number and degree of ACEs, the worse the outcome for not only those children but for the adults that they will become. Thus a person who grew up poor is likely to have worse health status as an adult than a neighbor who did not grow up poor, even if they end up with similar incomes and lifestyles. In addition to the ACEs that have their origin in poverty, there are others, ranging from growing up in a family with adults who abuse alcohol and other drugs, to parents’ divorce, to death of a parent, to physical and sexual abuse, that can occur in any socioeconomic group.

Dr. Frey also cites the number of states that have passed – and implemented – “anti-woman” laws, usually under the guise of being “anti-abortion”. While the legislators who propose and vote for them, and the state governments implementing them, would deny that they are anti-woman, the facts speak otherwise. A good example that Dr. Frey discusses, is

Last year in Missouri, for example, the legislature debated whether to outlaw surgery for ectopic pregnancies (an embryo that implants in the fallopian tube instead of the uterus), even though such pregnancies are 100% non-viable.  Apparently, the near-certainty of a mother’s tubal rupture, internal bleeding, sepsis, and death, wasn’t particularly important.

That law has not passed (so far) but many others have so limited access to abortion that women have to travel very far, have waiting periods, get illegal abortions, and otherwise risk their lives. Despite the ostensible justification for anti-abortion laws is to protect the “unborn”, the result is to increase the risk to fetuses, newborns, and their mothers. Dramatically.

There are also medical and healthcare factors that contribute to the maternal mortality rate in this country. As much as the social determinants of health, and anti-abortion anti-woman laws, contribute to the problem, medical care can make a difference. But too many women are not able to access good medical care for their pregnancies and births, in the prenatal and especially in the post-partum period. Among the important factors are the number and type of providers, geographic distribution of those providers, preference of providers for the kind of care that they want to do (or not do), and the ownership of practices and hospital by corporations that are interested mainly in money-making.

Let’s look at providers. Usually we think of obstetricians (OB-GYNs) as the people who deliver babies. And they do. Or at least many of them do. Actually, a minority, decreasing in % as they age. Doing gynecologic surgery is much more lucrative, and doesn’t require getting up at all hours to do deliveries. Plus, like most specialists, they are concentrated in urban (but not poor or inner-city) and suburban areas. So access to them is limited, especially geographically and financially. Certified Nurse-Midwives (CNMs) and family physicians also deliver babies, but often have the same “lifestyle” disincentives. Nurse-midwives are by definition about delivering (or “catching”) babies but usually are subservient to the dictates of the OB-GYN community. OBs probably do not mind if CNMs -- or family physicians -- deliver babies where the OBs do not want to be (rural and inner-city areas) but training programs may not have enough deliveries to allow them to learn. While nurse-midwives are a separate profession, their training may not strongly encourage them to assert themselves in practice.

And there is huge gap is in post-partum care. It is not uncommon for OBs (and, perhaps, others) to believe their job is done when the baby emerges, or at least when the woman is discharged. But as Dr. Frey’s piece points out, a very large number of maternal deaths take place in the post-partum period, up to 6 weeks after delivery, from bleeding, infection, and other causes that could be identified with the kind of close follow-up that too frequently does not occur. Not to mention identifying the risks for homicide (and suicide) in the situation in which the women lives.

Finally, but far from least important, is the structure of the medical care system. I have written extensively in previous blog posts about how hospitals and medical practices are run as businesses, to make money, rather than as facilities dedicated to improving the health of communities and the people in them. Birth, and the accompanying circumstances including maternal mortality, make a particular case. The businesses, as well as the physicians who work for them, are interested mainly in providing care when and where it is relatively easy and most profitable. This is understandable, but it is unacceptable. It is, at bottom, the cause of all the other problems. Receiving care for childbirth –including the prenatal and postpartum periods, as with all necessary medical services, should not be treated as luxury goods.

It may be OK that some people have a Lexus or Tesla, others a Toyota or Chevy, and still others an old clunker, while many have to walk or ride the bus. But it is not ok for healthcare, and specifically not childbirth. Women need to have access to excellent care no matter how much money they have or where they live.

That they do not is yet another indictment of a system built on profit rather than health.

"People will believe anything": Snake oil salesmen and bad health advice

The other day, I took a nephew to see the new Spider Man movie, “Far from home”. No review here; just to say that a big part of the plot revolves around the bad guy using a high-tech virtual reality system to project fake images that everyone takes to be real. Several times in the film he and his henchmen say “people will believe anything”. The parallels to the daily reality of our times, to “fake news” and distrust of science, are too obvious to be coincidental. Of course, in the movie the bad guy loses and the good guy (Spider Man) wins.

It is still far from clear if the “good guys” (and here I speak not of specific individuals, but of those who advocate for truth, a real reality, and science) are going to win in the actual world. The forces of darkness and reaction, wearing the face of Donald Trump and facilitated by the Republican Party, but actually representing and funded by the corporate elite – gangster capitalists – may not wear capes and fly around or use astral projection, but they have enormous resources to control the dialogue, provide misinformation, and serve themselves. They are resilient not only because of their wealth and power, but, sadly, because so many people are happy to try to deal with their own oppression by hating, oppressing, and believing bad things of others.

Health and medicine are clearly not immune from the reach of “fake news” and false beliefs and those willing to exploit our willingness to believe what we want to be true rather than what is. This is often a result of also a logical fallacy, wishful thinking (which is only a fallacy when it is expressed as true; not when it is expressed as a hope or wish) but may be more appropriately called “magical thinking”, a developmentally appropriate stage for young children that is always pathological in adults. Those who promulgate false scientific, medical and health theories and advice can be doing so to make money, to exert power and control, because it derives from a pre-existing belief (sometimes but not always religious). Sometimes it is also self-delusional, especially when the proposed solution is easier, more palatable, less painful, and requires less discipline than the medical alternative (take these simple pills – or snake oil -- and you won’t have to diet/exercise/stop smoking or drinking/have radiation or chemotherapy or surgery and you can be more youthful or beautiful or sexual). I once wrote about a patient who was obsessed with getting mammograms for breast cancer, a condition for which she was not at elevated risk and was far too young for routine screening, but was uninterested in addressing her actual risks resulting from heavy smoking, uncontrolled high blood pressure, and unprotected sex with multiple partners (Healthful Behaviors: Why do people adopt them? Or not?, October 8, 2011). Because, I inferred, it was easier, and would require no real effort or difficulty on her part. This is why it is an attractive option. But it is not a good idea.

The trend toward getting health and medical advice from those who are not medically trained has always been with us, but the same easy dispersion of information (or misinformation) through the Internet that allows us to hear anything we want and, to a large extent, only what we want, impacts health care as well as politics. The “anti-vax” movement is very popular, and promoted by celebrities. (Why should we not get our health advice from those whose qualification is that they are celebrities?) In addition to being wrong, it is very dangerous to the public health. I say that with absolute certainty. The anti-vaxxers are wrong. Period. There is some risk that individuals will have a reaction, very rarely a serious one, but this impact is totally miniscule compared to the benefit of preventing disease through vaccination. Indeed, vaccination is one of the few areas in which we actually can prevent, and thus not have to treat, diseases!

Some celebrities deserve a special call-out for their comprehensive and ubiquitous denial of fact, reason, and science – amazingly, often in conjunction with a profit motive from the brand of snake oil that they are selling; Gwyneth Paltrow is the exemplar. Of course, Ms. Paltrow deserves some credit for being able to convince people that they should do things that are actually unpleasant and painful for the sake of their health and beauty, like getting stung by bees, even though these are of no actual value to her clients. Obviously, they are of financial value to her. And, while I admire much of what she does in the world, Oprah Winfrey is also a big proponent of false health information.

Sometimes, bad policies are advocated by the self-righteous, as is the case with the current Israeli Education Minister, the most recent bigot coming out for “conversion therapy” for gay people. This is an example of falsely medicalizing a condition by suggesting it requires therapy, something that should not be. Sometimes, as in Paltrow’s case and many others, it is at least in part motivated by the opportunity for profit. Often, and this is sad, it is motivated and believed because people do not trust doctors and other health professionals. One reason it is sad is because people eschew treatments that could be of benefit to them in favor of those that will not help and may even hurt. But another major reason is that many doctors and other health professionals have been themselves guilty of pushing treatments that do not benefit, and may hurt, their patients. They do this for the same set of reasons as those I criticize above: to make money themselves, to make money for drug and device makers who pay them directly or in gifts including drug samples, because they are too lazy (or “too busy”) to actually read and evaluate the evidence and so taking the advice of drug or device salespeople is easier, and because they think that because they are doctors everything they think is right. I wish this were not true, but it often is. Holding physicians to a higher standard than non-medical people is appropriate, but this is not an argument for believing people because they are not doctors, no matter how confident. Iit absolutely in no way justifies listening to the advice of non-medical people who know even less!

It is also the case that some “alternative” suggestions for treatment are helpful, and many others are probably benign (except for the cost), even if the evidence is that they are not helpful; one example is taking vitamin supplements. If you can afford them, and don’t take excessive doses, they probably don’t hurt. It is certainly a better way to waste your money than on cigarettes, but if you can’t afford them, skip them. Other medical interventions can be good, and of benefit, but the benefits are often overstated, or reified as totally important. This is especially true when it is promoted as more “natural”, a word so overused as to have almost no consistently definable meaning. One example might be the use of birth attendants, called doulas. For many people, especially those who do not have a support system such as a spouse or parents or siblings or friends (and, likely for some who do) it is very helpful to have a knowledgeable, supportive person during your labor, focused entirely on you. But they are neither magic nor necessary.

Having someone who can help you deliver your baby, like a midwife or physician, is often necessary. A birth support attendant is a nice addition. Nurse-midwives train as registered nurses then do additional years of midwifery training and attend many births, including many doing deliveries under supervision. They can deliver babies as well as support women in labor.  In contrast, becoming a doula, according to https://www.naturalhealers.com/midwifery/doula requires a total of about 2-3 weeks including the need to attend a few births. So what scientific basis could there be for NY State Gov. Cuomo is advocating the expansion of the use of doulas to decrease maternal mortality, something for which there is not only no evidence, but no rational basis for thinking.

Come on, Governor! Come on, people! Not harmful is good, helpful is even better, not breaking the bank is important, and sometimes natural is nice. But let’s not choose magical thinking over science. That helps no one, except the snake oil vendors.