By Leslie Loftis
Tuesday, July 11, 2017
According to recent reports, the American maternal mortality rate is shockingly high for the developed world and rising. This is obviously due to poor delivery, pre- and post-natal care for mothers in a land lacking health coverage and strong communities. The medical establishment does not properly prepare women or care for them in their early maternity, and the medical and general community care more for children than their mothers, hence our high rising maternal mortality rate.
But before accepting this conventional wisdom and seeking to make the government both medical enforcer and the village stand-in, a closer examination of the issue is in order. The coverage of U.S. maternal death has been a grand exercise in confirmation bias from all sides, leading us to look for solutions to problems we either do not have or are already effectively solving simply because we do not want to see—we will not accept—the problem that actually exists.
The Difficulties of Worldwide Data Comparisons
The alarming rank of the American maternal mortality rate (MMR) comes out of a project undertaken by the Bill and Melinda Gates Foundation, “Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.” In conjunction with researchers, international organizations, governments, and medical groups, The Gates Foundation has been gathering data on various ailments from 1990 to 2015 and has set target goals, Millennium Development Goals, and forward-looking Sustainable Development Goals for improvement. For maternal mortality, or pregnancy related death, one of the subsets of data it used was the World Health Organization (WHO) study, “Trends in Maternal Mortality: 1990-2015.”
Both the WHO study and the Gates Foundation report have made the rounds while the U.S. Senate debates healthcare because they both show a rising MMR for the U.S. that is higher than other developed countries, which fits the preferred narrative—on all sides—of cold and terrible maternity care in the U.S.
Both the WHO and Gates reports also present the same limitation, however, one that has caused a problem in the past, and which they each tried to remedy. Alas, the finding of terrible American maternity care was too desirable to debunk.
The U.S. Defines Maternal Mortality Differently
The WHO collects MMR’s from assorted countries and ranks them. It all seems rather simple, but the U.S. often uses different standards than other countries. This shouldn’t be difficult to believe of the country that still refuses to adopt the metric system. Different definitions caused a problem with infant mortality rate rankings. We have a broader definition of neonatal death and have more accurately recorded it. That resulted in higher infant mortality rate rankings that made headlines. The pattern is the same for maternal death data.
For instance, in the well circulated NPR/ProPublica report on the rising MMR within the U.S. , one can find the U.S. Center for Disease Control’s definition for maternal death: a pregnancy-related death from the start of pregnancy though one year after end of pregnancy. The WHO definition, or the one most countries seem to use: start of pregnancy to 42 days after end of pregnancy. Therefore, unless the WHO has filtered the U.S. data for the deaths that occurred in the first 1/8th-ish of the WHO term, such a large range difference likely skews the rate and bumps the U.S. rank.
Based upon the U.S. report charts in the WHO study, they did not filter the U.S. data until 2011, when it seems the U.S. started tracking “late maternal death,” 42 to 365 days postpartum, for the Gates initiative. Prior to 2011, late maternal death was included in the total.
Other Countries Don’t Report MMR Properly
Aware of this problem of differing definitions, The Gates Foundation sought to normalize the data. They could not, and cautioned anyone reading the report. From a pink pull-quote box on page two of the Gates report in The Lancet, “Research in Context”:
In their latest iteration, the WHO methods have also now adopted a single model for all countries and computed statistical uncertainty intervals. Important differences remain, however, that at times paint divergent pictures of levels and trends in maternal mortality globally and in many countries.
Later, in the body of this report—upon which Vox and other media sources rely in their effort to induce panic about US maternal mortality rates—we find details that do not at all fit the conventional wisdom: (footnotes omitted)
Late maternal death statistics need to be improved. Maternal mortality surveillance studies such as confidential enquiry have showed that late maternal death is non-trivial in even low-resource settings and can account for up to 40% of maternal deaths in high-income settings. A contemporary linkage study in Mexico found that 18% of maternal deaths are missed when the definition is truncated at 42 days’ post partum. As immediate mortality continues to decrease as a result of improved antenatal, bobstetric, and post-partum care, it is therefore increasingly likely that the proportion of late maternal deaths will continue to increase. Despite knowledge of its importance, only a few countries using ICD-10 reliably code late maternal deaths. This is especially egregious because many of the same countries who have completed multiple confidential enquiries also have not recorded a single late maternal death in their official statistics. Denmark, Ireland, Finland, and the UK all fall into this category. Australia, France, and South Africa likewise completed multiple confidential enquiries and have recorded a total of eight maternal deaths combined in the entirety of their official statistics. This is the exact inverse of the USA where no nationally comprehensive confidential enquiries have been completed (although some states have established maternal mortality review boards). The USA has high MMR for a high-SDI country—and is one of the few where it is increasing—but following the lead of Mexico and much of Latin America, it is also one of the only countries that has proactively improved its civil registration system with addition of a pregnancy checkbox on the standard death certificate, so it is possible that at least a portion of the increase is related to enhanced case ascertainment.
In other words: the U.S. accurately reports its late maternal deaths, while it seems that Australia, France, South Africa, Denmark, Ireland, Finland, and the UK, and perhaps others, do not. This can account not only for some of the rise in the U.S. rate, as the report mentions, but also for the international rank of the U.S. that has shocked the public.
There Are Still Problems We Need To Address
True, the U.S. still has a rising MMR—which I will address in a continuing article. But what we will leave here is the notion that the public healthcare systems of nations abroad hold solutions for us. Those supposedly better public healthcare systems the media and the left keep telling us we should emulate might only appear better because they are bad at tracking their outcomes.
The Gates report and U.S. research present a picture more grave than the definition problem stated in the quote. Rising maternal mortality in the developed world is changing, generally shifting from early bleeding deaths to later cardiac deaths, precisely the kind the U.S. is tracking and for which it is adapting responses, while others countries haven’t even registered the shift.
In contrast to the picture presented by incomplete data, our rising maternal mortality is a problem our medical community is rising to research and address. It will remain a problem, however, because its root is a cultural belief we do not want to confront and that we prefer to keep hidden behind conveniently incomplete data.