Could Rising Maternal Death Rates in California Signal a Broader Trend?

This post was orginally published on California Watch, a project of The Center for Investigative Reporting

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

“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

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.

maternal deaths California Watch

Tatia Oden French

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

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

“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.

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  • eternalskeptic

    Excellent piece…and not at all surprising that doctors are jumping to blame the victims, women, for a phenomenon that most of the science is proving to be iatrogenic at its core.

  • invalid-0

    Unfortunately, the rise in obesity and weight gain in the US is undeniable. Only through public education and aggressive implementation of weight loss and weight control will the US population be put back on track to normal health. Until then, every specialty, including Obstetrics, will see rising morbidity in its patient population.

  • crowepps

    By Jennifer Block Friday, Mar. 12, 2010


    Amnesty International may be best known to American audiences for bringing to light horror stories abroad such as the disappearance of political activists in Argentina or the abysmal conditions inside South African prisons under apartheid. But in a new report on pregnancy and childbirth care in the U.S., Amnesty details the maternal-health care crisis in this country as part of a systemic violation of women’s rights.


    The report, titled “Deadly Delivery,” notes that the likelihood of a woman’s dying in childbirth in the U.S. is five times as great as in Greece, four times as great as in Germany and three times as great as in Spain. Every day in the U.S., more than two women die of pregnancy-related causes, with the maternal mortality ratio doubling from 6.6 deaths per 100,000 births in 1987 to 13.3 deaths per 100,000 births in 2006. (And as shocking as these figures are, Amnesty notes that the actual number of maternal deaths in the U.S. may be a lot higher, since there are no federal requirements to report these outcomes and since data collection at the state and local levels needs to be improved.)  “In the U.S., we spend more than any country on health care, yet American women are at greater risk of dying from pregnancy-related causes than in 40 other countries,” says Nan Strauss, the report’s co-author, who spent two years investigating the issue of maternal mortality worldwide. “We thought that was scandalous.”


    According to Amnesty, which gathered data from many sources, including the Centers for Disease Control and Prevention, approximately half of the pregnancy-related deaths in the U.S. are preventable, the result of systemic failures, including barriers to accessing care; inadequate, neglectful or discriminatory care; and overuse of risky interventions like inducing labor and delivering via cesarean section. “Women are not dying from complex, mysterious causes that we don’t know how to treat,” says Strauss. “Women are dying because it’s a fragmented system, and they are not getting the comprehensive services that they need.”


    The report notes that black women in the U.S. are nearly four times as likely as white women to die from pregnancy-related causes, although they are no more likely to experience certain complications like hemorrhage.


    The Amnesty report comes on the heels of an investigation in California that found that maternal deaths have tripled there in recent years, as well as a maternal-mortality alert issued in January by the Joint Commission, a group that accredits hospitals and other medical organizations, which noted that common preventable errors included failure to control blood pressure in hypertensive women and failure to pay attention to vital signs after C-sections. And just this week, a panel of medical experts at a conference held by the National Institutes of Health (NIH) recommended that physicians’ organizations revisit policies that prevent women from having vaginal births after having had a cesarean. Such policies, designed in part to protect against litigation, have contributed to the rise of the U.S. cesarean rate to nearly 32% in 2007, the most recent year for which data are available.


    The Amnesty report spotlights numerous barriers women face in accessing care, even among those who are insured or qualify for Medicaid. Poverty is a major factor, but all women are put at risk by overuse of obstetrical intervention and barriers to access to more woman-centered, physiologic care provided by family-practice physicians and midwives.


    Amnesty is calling on Obama to create an Office of Maternal Health within the Department of Health and Human Services to improve outcomes and reduce disparities, among other recommendations. The report also calls on the government to address the shortage of maternal-care providers.


    “Access is only one factor,” cautions Maureen Corry, executive director of Childbirth Connection, a research and advocacy organization that recently convened more than 100 stakeholders, including members of the American College of Obstetricians & Gynecologists and the NIH, in a large symposium on transforming maternity care. “We need to make sure that we reduce the overuse of interventions that are not always necessary, like C-sections, and increase access to the care that we know is good for mothers and babies, like labor support.”



    Link to Report


  • crowepps

    Each year in the United States, almost 1,000 women die of pregnancy-related complications.1 Although the number of such deaths has decreased dramatically since the late 19th and early 20th centuries, there has been no decrease in the maternal mortality ratio during the last 15 years.2,3 On a population level, this number may appear small; however, on the individual level, each death is a heartbreaking loss.


    Because each pregnancy-related death is a sentinel event, every death counts and every death should be counted. Many of these deaths could have been prevented through changes in the health and behaviors of women before pregnancy, the timing of conception, access to heath care and social services, or the quality of care received. Every death prevented is meaningful. Improved surveillance is needed to help develop interventions to reduce pregnancy-related deaths.


    The major causes of pregnancy-related deaths are the same today as in the past: bleeding, hypertensive disorders of pregnancy, embolism, and infection.1 These can pose a threat to any pregnant woman. Yet not all women with these conditions die. Why do some women survive while others do not? Moreover, some groups of women are at increased risk for pregnancy-related death. For example, although most women who die of pregnancy-related complications are white, black women continue to have a four-times greater risk for pregnancy-related death and Hispanic women a 70% greater risk for death than white women.1,4,5 The risk of pregnancy-related death also dramatically increases with maternal age. Comprehensive, broad-based surveillance is needed to identify the factors, from before pregnancy through the puerperium, that affect a woman’s chance of survival and that place minority and older women at increased risk for pregnancy-related death. With the resources available today, we should be able to eliminate this gap in such an important health outcome.


    Pregnancy-related deaths are the tip-of-the-iceberg with regard to complications of pregnancy. For every woman who dies of a pregnancy-related cause, several thousand suffer morbidity related to pregnancy—before, during, or after delivery. Each year six million women become pregnant, almost four million give birth, and over one million experience pregnancy-related complications. This means that pregnancy-related complications are a significant burden on women, their families, and society in economic, social, and personal terms (Unpublished article: Danel I, Berg CJ, Atrash HK, Johnson CH. The magnitude of maternal morbidity during labor and delivery, United States, 1993-1997.). Public health surveillance—identifying and reviewing pregnancy-related deaths, analyzing the findings, and taking action—should decrease a woman’s risk of mortality due to pregnancy as well as help the many women who suffer pregnancy-related morbidity without dying.