By Ingrid Skop, M.D., F.A.C.O.G.
The U.S.’ abysmal maternal mortality rates are horrifying to those of us who love women and provide their medical care in pregnancy. What could be more devastating than for a child to lose his mother at birth? For a husband to lose his wife or family members and friends to lose a loved one at what should be one of life’s happiest occasions, the birth of a child? How can we who provide obstetric care impact this devastating problem?
It appears the U.S. leads the developed world in maternal mortality despite our affluence and medical advances. This paradox is a frequently discussed, though often politicized, topic of conversation. But what does this really signify? How is maternal mortality detected, defined and measured? What events are leading to the deaths of women in proximity to childbirth, and most importantly, how can we impact this crisis?
To begin to unpack this complex topic, we must understand the terms used to describe these deaths. There is no standard definition of “maternal mortality.” Definitions differ depending on the organization compiling the data, how the deaths are investigated (whether relying upon death certificate coding or in-depth analysis of a woman’s medical record) and the length of time (six weeks vs one year) after the end of pregnancy. The death of a woman while pregnant or within a given time frame after the end of pregnancy from any cause (even if unrelated to pregnancy) is called a “pregnancy-associated death.” When the death has been determined to be caused by an obstetric complication of pregnancy (direct death), or preexisting disease that was aggravated by the effects of pregnancy or disease that developed during pregnancy (indirect death), it is called a “pregnancy-related death.” Maternal mortality review committees (MMRCs) will then make an additional determination, whether the death was “preventable” or might have been avoided with one or more reasonable changes to patient, community, provider, facility or systems, and the MMRCs will then provide recommendations on how deaths might be avoided in the future.
The U.S. Centers for Disease Control and Prevention (CDC) oversees maternal mortality data collection, but it relies primarily upon death certificate documentation to identify deaths related to pregnancy for analysis. Unfortunately, many maternal deaths are not documented on death certificates, causing many of these deaths to remain unknown and unexamined. This is especially true for deaths related to early pregnancy events such as induced abortion or miscarriage, for which linkage of death certificates in reproductive-aged women with birth certificates (assigned after 20 weeks’ gestation) can’t be performed. Due to numerous data deficiencies related to induced abortion in the U.S., a direct comparison cannot be made of the likelihood of death resulting from childbirth compared to death from induced abortion, although ideologically motivated abortion advocates advance this false proposition, eugenically promoting abortion to high-risk women as a way to protect themselves from maternal mortality.
While it may be commonly assumed that maternal mortality usually occurs due to catastrophic events at childbirth, the good news is that direct obstetric deaths from hemorrhage, sepsis, embolism, and hypertensive crises are decreasing, now accounting for only ¼-1/3 of maternal deaths. Most hospitals employ safety-bundle protocols and emergency drills to improve the physicians’ and staff’s detection and response to obstetric emergencies. All of us should willingly engage in these quality improvement initiatives to provide the best possible obstetric care.
Unfortunately, there is a rising incidence of deaths related to chronic medical conditions such as obesity, diabetes, hypertension, reflecting the poor preconceptual health and advanced maternal age of many American mothers. Additionally, mental health conditions leading to “deaths of despair” from suicide, substance overdose and intimate partner homicide are adding to the toll, causing almost ¼ of maternal deaths. Indirect contributions from “upstream determinants of health” also impact maternal mortality, including factors such as single motherhood, poor family and community support, poverty, rural location or difficulties in accessing quality obstetric care.
Although induced abortion is sometimes promoted as a solution to this heartbreaking problem, as Hippocratic medical practitioners we know that ending the life of our fetal patients is not the solution to the crises affecting our maternal patients. Both of our patients deserve our best care and advocacy. Very few abortions occur in response to medical factors. In fact, > 96% of U.S. abortions are justified due to social, economic or other elective reasons. Abortion is not health care!
With these facts in mind, we recognize that far from being a solution, abortion may be contributing to the problem of maternal mortality for many reasons. Although abortion advocates have falsely implied that obstetricians cannot provide quality care for obstetric emergencies in states with abortion restrictions, the reality is that every state allows an exception in the exceedingly rare situation that a life-threatening complication requires ending a pregnancy. Contrary to the narrative that abortion is safer than childbirth, records-linkage studies demonstrate a woman is much more likely to be alive a year following childbirth than following abortion. Notably, the racial population most affected by maternal mortality, Black women, is also the population with the highest rates of abortion.
Limitations on abortion will prevent later abortions which are more likely to result in a mother’s death. The CDC documents a 38% increase in maternal mortality for each week beyond eight weeks that an abortion is performed, with a 76-fold increase when an abortion is performed after viability. Other high-risk abortions may be prevented, such as those that are coerced or unwanted by the woman, multiple repeat abortions, and abortions in women with preexisting mental health disorders, all subgroups of women who are at higher risk of mental health complications following abortion, possibly leading to “deaths of despair”. Hopefully, the lack of easy access to abortion as a “back-up” if contraception is not used or fails will encourage couples to safeguard their sexuality and avoid promiscuous behavior. Modifying sexual behavior and encouraging healthy relationships may eventually lead to fewer single mothers and healthier families, something that we all should applaud for the good of society.
On a final note, surveys indicate the majority of women with a history of abortion would have preferred to give birth if they only had more relationship, material, or financial support. Thus, through the work of AAPLOG members as medical directors of many of this country’s almost three thousand pregnancy centers, we are uniquely positioned to impact the heartbreaking problem of maternal mortality by protecting women from the mental health harms of unwanted abortions and helping mothers to access the support they really need in order to give birth to their children.
Ingrid Skop, M.D., F.A.C.O.G. has been a practicing board-certified obstetrician-gynecologist in San Antonio, Texas for over 30 years. Dr. Skop is a Fellow of the American College of Obstetrics and Gynecology and a board member of the American Association of Pro-Life Obstetricians and Gynecologists. She currently practices with OB Hospitalist Group and is Vice President and Director of Medical Affairs for the Charlotte Lozier Institute. She is a member of the Texas Maternal Morbidity and Mortality Review Committee (MMRC). Her views herein do not necessarily represent the views of the MMRC.
