The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Notes from Marsden Wagner on Maternal Mortality

Some thoughts on maternal mortality (MM) The reason the maternal mortality fell this century had to do with antibiotics and blood transfusion more than anything else. It did not have to do with hospital birth. As long as there is a system in place to transport women in labour to a facility where there is antibiotics, blood transfusion and C section capacity, there should be very little MM.

MM is quite different from perinatal and infant mortality. The latter two are much influenced by socioeconomic factors while MM is much more directly a function of the quality of the health care available. If midwives (traditional, direct entry, CNM) are trained to know the signs of serious complications and have the means to transport, there is no need for a doctor at the site of primary care of pregnant and birthing women who have had no complications. But at the site of the place where the woman is transported, there is need for a doctor who has surgical skills and, ideally, obstetrical skills to manage the complication.

There are at least two reasons why the US is 16th in the world in MM and both reasons have to do with access to quality care. First, the large numbers of women without health insurance have to jump thru so many hoops to get care that there is likely to be delays in receiving the care and this can be a disaster. The women receiving public funded care go to hospitals which are overcrowded and with overworked doctors without sufficient training (ie interns and residents) The result of the delays and crowding and lack of skill of doctors all can lead to MM. The second reason the US does poorly in MM is, to me, a huge irony. US doctors scream that women need to be in hospital at the time of birth and yet the doctors who need to treat them are NOT in the hospital but in their offices doing prenatals and postnatals on healthy women. So when the woman who is in the hospital (or transported to the hospital) needs urgent attention for developing complications, the obstetrician is not there and must be called and he may come too late. In every industrialized country outside of North America, obstetricians are hospital based specialists who remain in the hospital and are there to jump in and treat the complications. Meanwhile it is the midwives who are out in the community giving the prenatals and postnatals to women without complications. I cannot overemphasize that this lack of access of women to immediate obstetrical attention (for whatever reason) is the fundamental difference between maternity care in the US and the rest of the world and is the reason for the poor US MM. Put differently, the countries which do better than the US in MM all have universal health care coverage for pregnant and birthing women and all have hospital based obstetricians ready to care for these women. Midwives are critical to these systems in other countries by being alert for the early signs of maternal complications, referring them quickly and continuing to provide support to these women even when they are receiving treatments from the obstetricians. MM is NOT higher in those places where there is planned home birth with an experienced midwife because there is a system in place to manage complications.

In every State in the US where I have seen the data, the MM is at least 4 times higher for African Americans. This is because this group has more uninsured, more staying in hospitals with desperate situations of understaffing and care from as yet not fully trained staff--in other words, these women have less access to quality care. And this situation will not be solved by simply putting African American women into private care systems or managed care systems because the latter systems are doctor centered, not midwife centered, and doctors do not know how to communicate with these women and the result is little prenatal care, poor access to all maternity care due to poor communication. And of course there is then victim blaming, saying it is the stupid woman's fault when it is the system's fault.