By Nathanael Johnson
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 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, it's more dangerous to give birth in California than it is 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. "That's what's shocking."
The problem may be occurring nationwide. The Joint Commission, the leading health care accreditation and standards group in the United States, issued a "Sentinel Event Alert" to hospitals on Jan. 26, stating: "Unfortunately, current trends and evidence suggest that maternal mortality rates may be increasing in the U.S."
The alert asked doctors to consider morbid obesity, high blood pressure and diabetes, along with hemorrhaging from C-sections, as contributing factors.
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. He organized academics, state researchers and hospitals to conduct a systematic review of every maternal death in California. 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."
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.
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.
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."
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.
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.