Earlier this week, we discussed the media-induced panic about the U.S.’s abnormally rising Maternal Mortality Rate (MMR). In typical Vox-speak: “More and more women are now dying in childbirth, but only in America.” That’s misleading on multiple points, but we exposed the “only in America” claim last time. Other developed countries do not track late maternal deaths, whereas the U.S. not only tracks those deaths, but also has improved its tracking of maternal deaths in general. Therefore, our superior data can account for the U.S. international ranking, and may partially account for the rise of the U.S. MMR rate.
Still, the country’s MMR is rising, and to the public this is almost inconceivable. Childbirth outcomes improved for decades. Maternal death is a thing of the past, of BBC period dramas. If we have such great healthcare, if our medical research and facilities are second to none, if our medical schools and accreditation are the envy of the world, how can our MMR be rising unless something is very, very wrong?
The usual scapegoat for our rising MMR is the cesarean section rate and its underlying causes. American doctors in American hospitals do too many of them unnecessarily, due to our tendency to treat pregnancy as a disease, doctors and/or patients who prefer convenience or vanity to child safety, insurance companies and ambulance-chasing lawyers promoting the “Business of Being Born,” or the whole lot of them quashing the feminine power of the natural birthing experience. If we had more woman-centric, midwife-focused care, the logic goes, new mothers wouldn’t die or be injured by big medicine.
The Problem Is Larger Than Health Care and Big Medicine
But this scapegoating was a much fairer assessment 10 years ago. According to the CDC, the rate of low-risk c-section deliveries has been declining since 2009 due to “new guidelines from the American Congress of Obstetricians and Gynecologists (ACOG), initiatives to improve the quality of perinatal care, changes in hospital policies to disallow elective delivery before 39 weeks, and public education campaigns.” Of course there is still room for improvement. The national trend is positive, but some states have shown no improvement, and three have seen an increase in their low risk rate.
Michigan may want to contact Virginia and ask how they achieved a 15+ percent decline in low risk c-sections. But on the whole, the medical community saw the problem, acted, and has reduced the rate of low risk c-sections without U.S. Congressional action or counterproductive copycatting of public health systems that cannot even get data collection down. These groups should have our congratulations and continued support in their efforts.
But they can’t enjoy either, because the reduced rate of low risk c-sections doesn’t fit the narrative of cold, bad American-style medicine, and the overall c-section rate remains high. The CDC explains why: “[t]he proportion of all cesarean deliveries that are low risk declined from nearly one in three deliveries (32.5%) in 1990 to just over one in four (26.5%) in 2013.” Or stated inversely, the proportion of high-risk c-section deliveries rose. And here, we come closer to the root of rising maternal morality that we simply do not wish to confront.
There are more high-risk births occurring in the U.S. Which leads to the inevitable question: why are there more high-risk births occurring in the U.S.?
The Problem We Are Not Allowed To Name
Popular rationales given for rising MMR are an attempt to get around one elephant in the room data set: rising maternal age. Average maternal age in the U.S. is 26 and rising, but “[f]rom 2000 to 2014, the proportion of first births to women aged 30–34 rose 28% (from 16.5% to 21.1%), and first births to women aged 35 and over rose 23% (from 7.4% to 9.1%).”
The medical textbooks define advanced maternal age as 35, but the assorted heightened risks to the mother—which include gestational diabetes, thyroid dysfunction, high blood pressure, complications resulting in cesarean sections, injuries resulting from vaginal birth, cardiac events, and stroke—begin to rise after 30. They climb steeply after 35. And note, these risks compound. High blood pressure or gestational diabetes each make a c-section more likely, and a c-section for one birth makes a c-section for subsequent births far more likely. But this data gets, at best, a passing mention in popular source discussions of rising MMR or pregnancy in general. (It doesn’t get that much more study in the professional literature, either.)
To speak of these facts is to drag women back to the 1950s, when women were ruled by their biology. Today, we have birth control and in-vitro fertilization. We can choose if, when, and how to have children. Thus spake our Second Wave elders, many of our mothers, our professional mentors, popular magazines, sitcoms, movies, college professors, peers male and female, those new companies advertising egg freezing services… or, from the crunchy perspective—still disapproving of the medical facts, only with a retro-feminine spin—to mention these risks is to engage in fearmongering. The female body is amazing. It is designed to give birth. As long as one remains fit and healthy, age has little effect, and thinking otherwise creates a negative attitude that sets one up for feminine failure.
MMRs Rise As Women Have Children Later In Life
Combined, these cultural perspectives make sure that the risks to mothers of rising maternal age are seldom openly discussed and are denied when attempted.
Counter-examples are easy to find, after all. We the public know about the famous 45-year-olds who have given birth without complication, along with a more personal example or two.
But our topic is the maternal mortality rate. It is the realm of statistics, and in this realm, the Gates Foundation global data set report tells us, repeatedly, “The risk of maternal mortality increases greatly with age…” (pg 1976) “Although the risk of death from all causes increases with age…” (pg 1977) and specifically:
Fourth, the highest SDI geographies [wealthy, medically advanced nations like the US and the UK] are likely also experiencing a confluence of factors leading to higher-risk pregnancies and subsequently higher than expected MMR—namely, delay of fertility to older ages and a corresponding increase in the proportion of pregnant women with non- communicable diseases (NCDs). Other direct maternal disorders are the dominant cause of maternal death in high SDI locations, driven by cardiomyopathy and obstetric embolism, both of which are of higher risk in older women and those with preexisting conditions such as hypertension, obesity, and diabetes. If the trend of increasing NCDs continues and, barring any breakthrough in preventing such complications, we could reasonably expect to see MMR increases begin to emerge in other regions besides those in the highest SDI.
The more high-risk pregnancies a region has, the higher its MMR. Medicine, wealth, and research might slow this trend, but they can’t stop it. Age matters in pregnancy.
We Need To Tell Women About These Risks
In the popular coverage, authorities have dismissed this connection between rising maternal age and rising maternal mortality based upon the U.S. ranking against other developed nations. As the excuse goes, if the higher MMR resulted from higher maternal ages, then other developed countries would also have higher MMRs. They probably do. Vox and others cherry-picked the countries whose MMR didn’t appear to be rising. Since it appears that those countries’ rates are artificially low, the media hampers inquiry. They encourage us to dismiss the connection between maternal age and maternal mortality in a quest for some other, more socially acceptable explanation for women dying from pregnancy-related complications.
Like so many times in the past (birth control trials, anyone?), women’s health data gets used as a political football. Now, in the effort to maintain the illusion that women have complete control over our reproductive life—that we can carry a child whenever we please—we hide knowledge of the physical risks of pregnancy as women age.
More than federal government initiatives and insurance mandates, women need knowledge. In the past, when advocacy groups have tried to level with women about maternity and aging, they met with considerable “feminist” resistance. In fact, this resistance deserves much of the blame for the almost exclusive focus on risks to the infant. The medical community has made the same assessment pro-life groups have. Faced with the taboo topic of dangers of delayed childbearing, they only get to make one argument, so they make it the one they know women will hear: risks to their children. Hence, when one Googles pregnancy over 30, the vast majority of information offered covers getting pregnant, staying pregnant, and chances of genetic issues.
But the risks to women are real. If there is another thing the groups who lowered the low-risk c-section rate could do to help lower the maternal mortality rate, it would be initiatives to inform women of their own risks. Because right now, women really don’t know.