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Thursday, January 3, 2019

A soaring maternal mortality rate: What does it mean for you?

A new guideline from the World Health Organization (WHO) aims to help reduce steadily rising rates of caesarean sections around the globe. While crucial at times for medical reasons, caesarean births are associated with short-term and long-risks health risks for women and babies that may extend for years.

In June 2018, Serena Williams told Vanity Fair about her journey to motherhood, including the story of how she nearly died a few days after giving birth. In September, Beyoncé punctuated her Vogue cover with the story of how she developed a life-threatening pregnancy condition called preeclampsia, which can lead to seizures and stroke. Throughout the summer, headlines like “Dying to Deliver” and “Deadly Deliveries” and “Maternal Mortality: An American Crisis” popped up on newsfeeds and streamed on screens across America.

As a professor who studies safety in pregnancy, I was quoted in many articles and media features. I explained what the harrowing stories indicate about our health systems, our public policies, our society at large. But as an obstetrician, I’ve been puzzling over how to explain to my patients what this means for them individually. And my pregnant wife, who is due any day, has been noticing the headlines too.
What is maternal mortality?

Typically, deaths that occur due to complications of pregnancy or childbirth, or within six weeks after giving birth, are recorded as maternal mortality.
What do the statistics tell us?

In 1990, about 17 maternal deaths were recorded for every 100,000 pregnant women in the United States. While relatively rare, this number has risen steadily over the last 25 years, indicating a worsening safety problem. In 2015, more than 26 deaths were recorded per 100,000 pregnant women. This means that compared with their own mothers, American women today are 50% more likely to die in childbirth. And the risk is consistently three to four times higher for black women than white women, irrespective of income or education.

Additionally, for every death, pregnancy-related conditions, such as high blood pressure or blood clotting disorders, result in up to 100 severe injuries. For every severe injury, tens of thousands of women suffer from inadequately treated physical or mental illnesses, as well as the broader disempowerment mothers face in the absence of paid parental leave policies and other social support.
Are the statistics misleading?

The root cause of these startling statistics is often misunderstood. The public image of maternal death is a woman who has a medical emergency like a hemorrhage while in labor. However, very few deaths counted in maternal mortality statistics occur during childbirth. Rather, four out of five of these deaths happen in the weeks and months before or after birth. So, they occur not in the hospital, but in our communities. And they represent many failures — not just unsafe medical care, but also eroding social support necessary for women to recognize medical warning signs, like abnormal bleeding or hopelessness about the future, and to seek timely care.

A few days after having a baby, American women are sent home from the hospital, infant in hand. More often than not, mother and family are left on their own until a cursory 15-minute visit with a healthcare provider several weeks later. During long gaps between checkups, mothers experience deep worry for their infants. They struggle with rapidly accelerated responsibilities, extreme sleep deprivation, and relentless pressure to return to work. And all while recovering from pregnancy and adjusting to parenthood — a transition that marks one of life’s greatest physiological endurance tests. Too often, this experience is isolating, disempowering, and mortally dangerous.  And over time, these risks are getting increasingly severe.
What can we do to help?

Undoubtedly, clinicians and hospitals can do more to ensure the safety of women giving birth. For example, they can issue health guidelines and run simulations to better prepare to handle emergencies. Policymakers can do more, too, including tracking maternal mortality so that failures like delays in lifesaving care can be identified and fixed.

In some cases, moms can do more to take care of themselves, including by eating well and exercising to stay healthy. The challenge, of course, is that most new moms are exhausted because motherhood is exhausting. And in general, society expects moms to put themselves last in order to put their families first.

So, I would say a major responsibility to address the well-being of mothers actually lies with the rest of us. If rising maternal mortality is fundamentally a failure of social support, we all need to step up: birth partners, grandparents, friends, neighbors, professional colleagues — all of us. All people are vulnerable during the period surrounding the birth of their child. But in the United States, we forget to advocate for ourselves and for each other. We need to listen to moms. And we need to support them. After distilling all the data, and reading all the headlines, I believe saving their lives is as simple as that. While we know that breastfeeding has many health benefits for mothers and babies, the studies have been a bit fuzzy when it comes to the link between breastfeeding and preventing obesity in children. Some studies show a clear link, but in others that link is less clear. A new study published in the journal Pediatrics may help explain the fuzziness. It showed that what really helped prevent obesity was getting breast milk directly from the breast.

That’s not to say that drinking expressed breast milk from a bottle isn’t healthy. After all, it’s the food that was explicitly designed for infants — and in the study, babies that got breast milk from a bottle did have lower rates of obesity at 12 months. Some of that benefit is thought to be related to the microbiome that breast milk helps create. Babies who drink breast milk are more likely to have certain bacteria in their digestive tracts that help prevent obesity.

But the babies that had the lowest risk of obesity in the study were those that got only breast milk directly from the breast for the first three months of life. Why would that be?

To be able to breastfeed directly from the breast for three months, you have to be able to be with your baby constantly for three months. Mothers who can do that either have access to paid maternity leave or have enough resources to take an unpaid leave — or to stay at home with their babies and not work outside the home at all. Studies have shown that mothers who breastfeed longer are more likely to have higher incomes, more education, and private insurance.

These, then, are mothers who are also more likely to have access to and be able to afford healthy foods, to live in areas where there are safe places to exercise — and to be able to pay for sports and other forms of exercise as their children grow. It’s not just about how these babies are fed, but also about the context in which they are born and raised.

The way in which they are fed, though, is important. Babies who feed directly from the breast are less likely to be overfed. When they are full, they stop sucking, or switch to a “comfort” kind of sucking that doesn’t produce milk. When babies are fed from bottles, parents and caregivers are more likely to push them to finish the bottle; feeding becomes a bit less about appetite and more about volume and schedule.

Learning to eat only when you are hungry and stop when you are full is a really good skill when it comes to preventing obesity. That’s why the American Academy of Pediatrics has encouraged parents to learn and use “responsive feeding,” that is, responding to the cues of babies and children of both hunger and being full. The motto is, “You provide, your child decides.”

What this study helps us see is that the link between breastfeeding and obesity prevention is part of a bigger picture we need to pay attention to if we want to fight the obesity epidemic. It shows us that we need to:

    Do everything we can to help mothers stay at home with their babies for at least three months, which will require paid maternity leaves. The United States is way behind the rest of the world in this.
    Help all parents, regardless of how they feed their infants, learn about responsive feeding, and thus help their babies learn to eat when they are hungry and stop when they are full.
    Understand obesity risk as part of a bigger societal issue — truly, as a social justice issue. All children need — and deserve — access to healthy foods and exercise, and there is more we can do to make this happen.

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