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.
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