International Cesarean Awareness Network

A number of days ago, a resolution was passed by the American Medical Association (AMA), as put forward by the American College of Obstetricians and Gynecologists (ACOG) that proposed an organized effort to make planned homebirth illegal (I’d assume they wouldn’t be prosecuting women who really did have a oops homebirth.  Then again, I might be giving them too much credit for compassion or even just rational thinking).  ICAN responded to that statement, as did a number of other maternity and women’s health care concerned organizations.  And the process of doing that has led me to consider the meaning of the numbers we throw around when we describe maternal/infant health and how to measure it.

When the initial draft of the statement was presented to the Board of Directors for editing and approval, we immediately noticed these statements:  “Approximately 95 percent of women in the U.S. give birth under the care of an obstetrician in the hospital and with this care, the U.S. has the second worst newborn death rate in the world[ii], and ranks 41^st in maternal deaths among all nations [iii]”.  At that time, there were no footnotes attached to them and our reaction was pretty much that of many of the people who’ve commented on our statement – whoa, those numbers are WAY too awful – we know it’s bad but it isn’t that bad.  After all, we are fairly conversant with this sort of data and we know the usual numbers that are bandied about.  The author of the statement defended the numbers.  So, in the final tweaking I was doing on the statement, before I changed the numbers I figured I’d go looking.  So, in my best post-modern fashion, I plugged “maternal mortality United States” into my google search engine.  And was very surprised by the results.  On the first page of links, every link for 2007 gave a variation on the “40 other nations with better maternal mortality rates” statement.  There was one paper that referenced 2004 and gave a ranking of 21^st amongst developed nations.  All the others referenced rates for the 1990’s or earlier.  And when I looked to see who did this study, I was again surprised – this was done by some heavy hitters…. World Health Organization, the United Nations Population Fund, the U.N. Children’s Fund, the U.N. Population Division & The World Bank….well, I guess we rank “better” when we don’t include developing nations.  Yikes.  So I made the decision to leave the statement as it was, but put in an end-note explaining where it came from (I wasn’t naive enough to think people wouldn’t notice, and comment, nor would I want people to accept it unquestioned).

So then there was left the “newborn death rate”…also a rather more dire statement than we are used to seeing.  So I did the same thing – googled “infant mortality rate United States” and bingo – the second link is to an article by CNN (more on that in a moment) that contains this very statement (the first link was to a research article about the role of bacterial infections in infant mortality, followed by links about breast feeding reducing infant mortality, etc).  Farther down on the page, I find today (as I check myself) a paper I missed the first time – again making the statement “second highest Infant Mortality Rate among all economically advanced nations”, and the reference here is to UNICEF’s Innocenti Research Center.  Wow.  I’ll admit that citing Save the Children (the reference given by the CNN article and several others I found) didn’t have the same cachet as someone like WHO or the UN….but there it is – UNICEF.

Now you say – come on, this is the internet, you can’t believe everything you find on the internet.  Well, of course.  But, I’d argue, when you find the same set of “facts” repeated widely, sometimes in articles from news organizations who are fairly likely to do their background work (like CNN), when you find references to well-known international organizations…it’s hard to completely discount that data.  And let’s be honest – the numbers we are more comfortable with – that the U.S. ranks somewhere between 21 and 24 in infant mortality (developed nations) and about 12^th in maternal mortality (developed nations) also come from various internet searches to find the data and then reference it as concrete numbers.

But, you say, its apples and oranges!  There are all sorts of reasons why these numbers aren’t accurate and why our ranking isn’t as low as it looks.  And I will be the first to acknowledge that this is probably true, our rates probably aren’t as abysmal as they might seem.  Infant mortality is quite tricky to get a comparison handle on – the U.S. counts very premature babies in our numbers, most other countries don’t.   The rate includes the first year, so there are likely other factors at work that aren’t directly related to the delivery of that infant (more non-delivery first year problems in the U.S. than elsewhere?  Really?  Or other countries don’t count non-delivery causes of mortality? Hmm…not simple to make us over-reporting and them under-reporting when you stop and think about it).  And there are problems with comparing very divergent populations (more on that in a moment too).  So I will say that I agree – the numbers in and of themselves don’t mean what someone using them might think or even intend.  And it’s important to acknowledge that, so as to not give an advantage to those who would have us completely ignore these numbers “because they are inaccurate”.

One of the biggest reasons given to discount our maternal mortality rate is this – the countries with the best rates have very homogenous populations (i.e. Japan, Iceland).  When you compare white women of higher social status in the U.S. with these populations, the numbers are pretty much the same.  This discrepancy is explained by the persistent lack of prenatal care for women of color and women of low social standing in the U.S.  Well, ok.  I can agree with that but it completely misses the point!  There is no biological reason why a Hispanic or African American woman should have an inherently higher mortality rate!  The difference between Japan and the U.S. isn’t about a homogenous racial mix but rather about access to care and more specifically, access to midwifery model care.  Which explains exactly why we have this shameful maternal mortality rate (which is likely under-reported anyway) and why there is simply no excuse for it – we have more than enough money to provide good (midwifery model) prenatal care for every pregnant woman in this country and we don’t for reasons that have a lot to do with profit margins and protective labor practices (if you don’t believe ACOG is a labor union, you might want to rethink that notion).  It might not be exactly about what happens during the actual delivery of a given woman and her baby but it is definitely about the circumstances that lead up to that delivery – and THAT is something that ICAN is concerned about.  After all, if women in this country were provided with midwifery model care throughout their pregnancies, I’m willing to bet money that the cesarean rate would decline precipitously (as would both profits for some interested parties and overall health care expenditures).

So in the end, what does it mean?  Well, I have no idea (nor does anyone) what the true maternal and infant mortality rates are for any country and how the U.S. actually ranks relative to other countries (developed or not). What I think is incontrovertible is that the numbers are horrible – whether they are 21 or 41, fifth worse or second worse.  There is simply NO GOOD EXCUSE.   Why did I choose to leave the numbers as they were originally presented to the Board?  Because they are numbers that are out there – accurate?  Who knows.  Frivolous?  Not at all.  And we need to talk about this stuff.  (And well, if I’m honest, I do like stirring things up too.)  We need to get over arguing over whether or not a number is “accurate”.  The trend that all these differing numbers and rates represent is the problem.    The fact that they are not getting better, no matter where we start from, is the problem.   The fact that women and babies are dying when they shouldn’t be and no one is doing anything effective about it is the problem.  I easily admit that the numbers (all of the numbers) that we use to represent maternal and infant mortality are not accurate, if what you want is an exact measure.  And because of that, the rankings generated from these rates are also not completely accurate numbers.  But I maintain that the numbers, whatever they are, are still inexcusably bad and no amount of deconstruction on how they were determined will change that.   And so, I stand by the statement we released, because the numbers and rankings we reported say exactly what needs to be said.  And that’s what’s important.

[ii] State of the World’s Mothers: Save the Children.

[iii]  World Health Organization, the United Nations Population Fund, the U.N. Children’s Fund, the U.N. Population Division & The World Bank.