Watching the Clock
A Mother’s Hope for a Natural Birth in a Cesarean Culture
A physician and mother on giving birth in a culture that increasingly pushes women toward cesarean sections.
Carla Keirns
I had been at the hospital for two days in induced labor, unable to get out of bed or eat, almost 24 hours on an oxytocin drip. Doctors and nurses shuffled in and out of my room, many wearing worried expressions. They wanted to start magnesium for suspected preeclampsia, a potentially life-threatening complication of pregnancy, but couldn’t prove whether I had the condition because the baby’s head was causing bleeding from my bladder. The doctors started to talk about stalled labor, a stuck baby, and going to the operating room. I had assisted at dozens of cesareans when I was a medical student, but I didn’t think we were there yet. More time. I just need more time, I thought, as I started flipping through numbers on my mobile phone, looking for friends from medical school who were obstetricians and pediatricians now. I needed another opinion.
As a physician, clinical ethicist, teacher, and health policy researcher, I thought I understood health care in the United States. But nothing in my education or training prepared me for the experience of delivering a baby in the US health care system. As a mother-to-be, I felt what all mothers feel: responsible for the life I was bringing into the world and willing to do anything to increase the chances that I would have a healthy baby. I knew vividly from my time on Philadelphia’s busiest maternity ward during medical school that childbirth is an awe-inspiring process when all goes well but can be terrifying if it does not.
I became pregnant with my first child at the age of 40. My pregnancy was complicated by diabetes, and dietary changes and exercise proved inadequate to keep my glucose levels optimal for the baby. In my first trimester, I started taking insulin and made an appointment with a maternal-fetal medicine (MFM) specialist, someone who specializes in high-risk obstetrics. When I met the MFM team, I was impressed with their command of the recent literature, their thoughtful rather than reflexive use of technology, and their willingness to admit uncertainty.
Labor is an intricate dance of hormones, muscles, and emotions, usually triggered by the baby when he or she is ready to breathe outside the womb. A few months into my pregnancy, a friend warned me that some obstetricians induce labor in all diabetic mothers early, at 38 weeks’ gestation. When I asked one of my doctors about this during an early clinic visit, she assured me that they wouldn’t do that.
There was no more mention of induction or the circumstances of my delivery until I came to the clinic for a routine visit at 36 weeks. By then I was coming in once a week to have vital signs and ultrasounds taken. With swollen feet and a round belly, I got up on the exam table. This appointment was with a doctor I had never met before—a middle-aged woman, the fourth member of the MFM group. It was a busy day at the clinic, and she was absentmindedly flipping through my chart as she walked in. She furrowed her brow, looked me up and down, and asked if I had met with the anesthesiologist yet. No, I hadn’t been referred. She looked down again and fretted about my sugars and blood pressure, surprised when she saw they were normal. “I hope you go into labor on your own,” she said, “because if we induce, the chance of a c-section is 50 percent.” I thought of a close physician colleague of mine who, at 42 weeks’ gestation, had a cesarean delivery after three days of labor induction. After the visit with the new doctor, I was deeply unsettled, worried that she was already planning my cesarean, the one I didn’t want to have unless my baby needed it. A week later I saw the senior obstetrician, who had been managing my pregnancy since the ninth week, and he was much more reassuring.
On a stifling Monday morning in July, when I was 39 weeks and five days into my pregnancy, my husband drove me to the hospital with a couple of changes of clothes, books to read, and my laptop to watch movies or surf the Web. The doctors were going to induce labor. All of my testing had been normal. But my obstetricians explained to me that the risk of stillbirth increases after 40 weeks, diabetic mothers are at higher-than-average risk, and none of our screening technologies allow us to assess or intervene to prevent it. So almost 40 weeks was their compromise, allowing my baby’s body to mature to term but reducing the risk of a catastrophic loss at the end of pregnancy. My sister would be with me at the hospital, updating our parents by phone. They were anxious and excited; this would be their first grandchild.
The induction protocol was a standard strategy of administering two hormones in tandem: prostaglandin to soften or “ripen” the cervix and synthetic oxytocin to trigger or augment uterine contractions. When I arrived at the hospital, I was only one centimeter dilated. The goal for delivery was 10.
Monitors were strapped to my abdomen to assess my baby’s heart rate and the strength of uterine contractions. These monitoring devices became available in the 1950s, and by the 1970s and 1980s had become routine in obstetric practice in the United States, often replacing intermittent auscultation, a technique where a clinician listens to fetal heart tones with a fetoscope or a handheld ultrasound. The monitoring helps determine whether the fetus can handle the stress of labor. Research has shown that compared to intermittent auscultation, the use of electronic fetal monitoring allows early intervention when the fetus is in distress, decreasing the rate of seizures from low oxygen and high acid levels in babies, but it does not change infant mortality or cerebral palsy rates. What’s more, monitoring increases the rates of cesarean and instrumented deliveries because “nonreassuring” or ambiguous readings lead doctors to intervene to speed delivery. My baby kept moving, and it was difficult to get a consistent reading of the heart rate. The nurses would rush into the room in a panic and say, “We’ve lost the baby!” My sister found this hilarious, and when they left she would say to me, “I know where the baby is,” pointing to my gravid abdomen.
In the first 12 hours after labor was induced, I progressed to three centimeters dilated. I was transferred to labor and delivery for an intravenous oxytocin drip to strengthen the contractions. By morning, my obstetrician measured my cervix at six centimeters using the tips of his index and middle fingers as a guide. He suggested we break the amniotic sac to speed the progress of labor. We both knew that infection rates increase in mothers and babies if delivery does not occur within 24 hours after the amniotic sac is ruptured, but at least I didn’t carry Group B strep bacteria, another factor that could have increased the risk of infection in a prolonged labor. When he evaluated me at one o’clock in the afternoon, I was eight centimeters dilated during contractions, and he was optimistic that I would deliver later that day.
When my obstetrician’s partner, along with a resident physician, saw me at five o’clock that evening, they found my cervix only four to five centimeters dilated. They suggested that perhaps labor had stalled or regressed. Obstetric textbooks from the nineteenth century discussed regression of cervical dilatation in mothers who are scared or threatened or whose modesty is compromised, but I’d never heard of this in modern obstetrics. I wondered about the accuracy of both of their measurements. It’s not as if they used a ruler.
They left me to continue their rounds and returned later with a third doctor, the general obstetrician on call for the night. They said they’d give me a couple more hours. If my cervix was not dilating more quickly, the on-call obstetrician said, “We’re going to talk about a cesarean. When things stop, there’s usually a reason.” They’d said “a couple hours” so casually. I didn’t remember until later that active labor is technically not considered “arrested” until there has been no cervical change for two hours during adequately strong contractions, after the cervix is four centimeters dilated.
After they left, I got a visit from a friend, an obstetric anesthesiologist who was on call that night. She asked how I was doing and promised to check on me later. Before she left to see other patients, she looked straight at me and said, “They’re looking at the clock. They’re not looking at you.”
Suddenly I realized I might lose any say in what was happening. Was I at the mercy of doctors who didn’t know me and had already made up their minds? I didn’t see a compelling medical reason for a cesarean, at least not yet. I thought, “This is what my natural childbirth friends were talking about,” when they said women got rushed into surgery they often didn’t need.
At that point, I called three friends from medical school—a pediatrician, a family-practice physician who delivers babies, and an MFM specialist. I reviewed the situation with them as I lay in the delivery room, with an intravenous oxytocin drip running into one arm, magnesium into the other, an epidural infusing anesthetic around my spinal nerves, an intrauterine pressure catheter monitoring the strength of my uterine contractions, and a fetal scalp electrode monitoring my baby’s heart rate. We all agreed that there didn’t seem to be an urgent clinical reason for cesarean. My baby’s heart rate tracings were described by the labor and delivery team as “beautiful,” and I was tolerating labor fine. My friends counseled patience and advised me to point to the objective data. I resolved to push for more time. My sister watched me open-mouthed. She was shocked by the debate. When I got off the phone with my friends, she said, “I wouldn’t know that was a debatable point.”
I learned the rest of the story later. At this hospital, the obstetricians, anesthesiologists, neonatologists, and nurses on the labor and delivery team meet twice a day to review the status of each patient in labor. Neonatologists learn when they may be needed at a patient’s delivery, anesthesiologists review pain management strategies, and obstetricians and nurses review patients’ progress in labor. It was at one of these meetings that I became the subject of intense debate. The MFM physician reviewed the status of my labor and the team’s management plan. The intrauterine pressure catheter revealed that although I had been receiving oxytocin for almost 24 hours, my dose had been adequate only for the last two hours. I needed more time. The consensus of the other physicians present—none of whom had actually evaluated me—however, was that I should have a cesarean delivery as soon as possible. The MFM physician later called one of his colleagues at home, lamenting, “Everyone wants to section her!”
Two hours passed, but the physicians did not return to my room. After six hours, I asked my nurse what the plan was, and she offered to get the doctor. I didn’t need the doctor, I told her; I just wanted to know what was happening. She said she had been asked to monitor me while they waited to see if I either progressed or developed complications. When she offered again to get the chief resident, I asked her not to.
“If they forget I’m here,” I said, “by the time they come back, I’ll be ready.”
She smiled and left. The labor and delivery unit was busy that night—the doctors were tied up with several cesarean deliveries and an ectopic pregnancy in the emergency department, and I had apparently dropped to a lower priority status.
At six the next morning, the chief resident returned and said, “It’s now or never.” It had been 21 hours since the amniotic sac was broken. If I wasn’t closer to delivery than I had been the night before, it really was time to consider cesarean delivery. She found that my cervix was now more than nine centimeters dilated. I relaxed almost involuntarily when she announced it. It would still be a few hours to full dilation, but labor was certainly not “arrested.”
But when the attending obstetrician on call that day visited a few hours later, my heart sank. This was the one I had met at 36 weeks and had hoped not to see again. She announced that I was only four to five centimeters dilated and said we were going to have to talk about a cesarean. I guess she didn’t get the report from the chief resident and was still going off the physician’s notes from the night before. I said that before we discussed a cesarean, she should confirm the cervical findings for herself. She found that my cervix was more than nine centimeters open. She told me to call when I was ready to have the baby.
I called the team at 11:30 a.m. My cervix was completely open, but I was told not to start pushing until they “got some things ready.” I called them back 30 minutes later; I didn’t think I could wait much longer. The nurse coached me for the next hour and a half as the baby descended steadily. It was hard going, and I was exhausted. When the nurse saw that my baby’s head was visible, she went to get the obstetrician. The obstetrician did not even stop to examine me before she said, “If you haven’t delivered by two thirty, we’ll have to go to the OR.”
“The hell with that,” I thought. And in seven minutes, she had the baby in her hands.
But after all that, the medical team wasn’t ready. The instrument tray was still in the hallway outside my room. The neonatology team should have been called for my delivery but wasn’t. My baby was blue and not breathing. As I lay there, feeling the warm blood flow down my legs, I blocked out all the rest of the sounds in the room, listening for crying. I didn’t hear any crying. I barely heard the doctors say it was a boy.
As the neonatal intensive care unit team was summoned to attend to my son, and my placenta was removed manually to slow the hemorrhaging, I was horrified that my physicians had been so unprepared for the delivery. None of the delivery problems should have been unanticipated. Perhaps they really had already earmarked me for cesarean, and the delivery room simply wasn’t ready for a vaginal birth.
After we were both stabilized, they handed my son to my husband because I was weak, exhausted, and afraid I would drop him.
There are circumstances where surgical births are necessary to protect babies, mothers, or both. Obstetrician Ronald Cyr argued in a 2006 paper in the American Journal of Obstetrics and Gynecology that an “ideal” cesarean-section rate, such as the 10 percent rate proposed by the World Health Organization, is a myth. It depends upon the specific population’s needs and available alternatives. There is, however, broad agreement that the current US rate is too high and not warranted by concerns for fetal or maternal health.
Most commonly used criteria for assessing labor progress in the United States were derived from observations of women in labor in the 1950s. But these observations have come under intense scrutiny recently, in part because of changes in the ages and medical histories of expectant mothers today, as well as changing obstetrical practices. The Consortium on Safe Labor in 2010 published a retrospective study of 62,415 women who delivered a healthy infant vaginally, and it found that the cervical dilatation rate was about half as fast as seen in the 1950s studies. This means that we risk labeling normal labors as slow or abnormal and intervening unnecessarily.
According to a 2011 study in the journal Obstetrics and Gynecology, the most common reason for a first or “primary” cesarean in the United States is “failure to progress.” A primary cesarean usually means that a woman’s subsequent children will be delivered surgically as well. But judgments on what constitutes a slow or stalled labor are often subjective. For instance, a 2012 expert panel of the National Institute of Child Health and Human Development, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine proposed that physicians should wait 24 hours after administering oxytocin and rupturing the amniotic sac before considering an induced labor “failed,” and the clock doesn’t start until cervical ripening is completed. The first mention of “failed induction” in my chart was only six hours after the amniotic sac was broken. In March 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine proposed new standards for deciding when labor is too slow or has stopped, suggesting that laboring women should be given more time.
When I talked over what happened later with clinical colleagues, the consensus was, “If you weren’t a doctor, you would have been sectioned on Wednesday.” Instead, I delivered vaginally on Thursday afternoon. I was lucky to have well-informed physician friends to review the “case” with me in real time.
The principles of “shared decision-making” seemed highly theoretical from the hospital bed. If I hadn’t known that more than half of cesareans are for that most elusive of indications, failure to progress, I would have been less hesitant when it was proposed. Besides that, I was naked and uncomfortable, had invasive lines in place, and hadn’t slept or eaten in three days. If a doctor I trusted, instead of one I didn’t know, had suggested a cesarean 48 hours into my labor induction, I might have agreed. If they had told me that my baby’s life or health was in jeopardy, I would have consented to anything. The vision of the empowered consumer, or even the autonomous patient, is laughable under these circumstances.
Much has been said, written, and done to influence cesarean delivery rates. We should recognize first that if we’ve been lamenting the increasing rate of cesarean sections since the 1970s, and they only keep rising, then cesareans must be solving some problem. As W. Edwards Deming, an American engineer and business consultant, famously said, “Your system is perfectly designed to give you the results you’re getting.” Physician Atul Gawande argued in a 2006 New Yorker article that cesarean deliveries are versatile in solving a variety of problems that physicians encounter during deliveries, are easier to teach and learn than forceps deliveries, and can be safely mastered by almost any doctor.
Though many groups have called for more use of midwives for low-risk deliveries, this solution doesn’t address the growing number of women like me, who are considered “high risk” for complications and, therefore, beyond a midwife’s scope of practice.
Some have advocated that obstetricians should be required to get a second opinion from another obstetrician before performing a cesarean, to ensure that the indications for cesarean deliveries are justified. I’m not optimistic that this would help. Few hospitals are likely to have a second obstetrician in-house in the middle of the night, so in practice this would likely devolve into a perfunctory review by telephone. Additionally, physicians who frequently work together may be reluctant to oppose their colleagues’ decisions, at least openly.
We’ve also tried empowering patients with data. The State of New York publishes hospital-level data on a range of obstetrical interventions, based on the premise that data will make for informed consumers. But even if patients are aware of and able to find, review, and understand the data, factors such as geographic access to appropriate alternatives—as in my case—or limited insurance networks of providers may limit patients’ use of the data.
In my work as a clinical ethicist and palliative care doctor, I’ve seen mothers who have lost their babies and fathers who have lost their wives as a result of complications of pregnancy. As a doctor, I don’t discount any of the problems my doctors were worried about. I know that our obstetric colleagues are working in territory that is fraught with risk, uncertainty, and liability.
If policy makers hope to change the rate of obstetric interventions—or any other medical tests or treatments—we’re going to have to change the culture of medical practice. As expectant mothers become older, with more preexisting medical conditions, guidelines need to evolve beyond those for the low-risk mother in her 20s, and recommendations to avoid cesareans must evolve beyond “choose a midwife instead of an obstetrician.”
I already knew, at least in theory, what the risks were when I was wheeled into the delivery room. If we couldn’t have an honest discussion about the physicians’ fears about my delivery, what hope do we have for shared decision-making with other women? In the end, my son is healthy, I’m fine, and we had the vaginal delivery that epidemiological data suggest was safest for both of us and for any future siblings. Maybe that’s enough—it’s everything to me and my son—but I think we can do better.
Volume 34, Number 1. January 2015.
In the “Gray Zone,” a Doctor Faces Tough Decisions on Infant Resuscitation
A neonatologist must decide whether to revive a premature baby on the borderline of viability.
Gautham K. Suresh
The newborn resuscitation room was getting uncomfortably hot. The thermostat was set high to prevent a naked, wet, just-born baby’s body temperature from dropping rapidly. On this afternoon in May 2004, the neonatology team—the nurse practitioner; nurse; and me, the neonatologist—was finishing up the unavoidable paperwork on a baby we had just resuscitated and stabilized after birth. We were about to leave when a nurse from obstetrics popped her head in, looking flustered. “Don’t leave yet,” she said. “A twenty-three-weeker just rolled in; she might deliver soon!” With that, she rushed away.
Ron, the neonatal nurse practitioner in the resuscitation room with me, groaned. There was no need for him to say anything. All of us in the room felt exactly the same. A baby born before 37 weeks of pregnancy is considered premature. In general, premature babies have higher rates of complications and death than full-term babies born between 37 and 41 weeks, yet most do well after a few days or weeks of hospital care. But a baby born at only 23 weeks’ gestation has a high risk of dying even with the most advanced life-support techniques. Of the few very premature babies who survive, many end up with severe handicaps, including mental retardation, cerebral palsy, blindness, and deafness. Because of this bleak prognosis, we—the neonatologists, neonatal nurse practitioners, nurses, and other neonatal intensive care unit (NICU) staff who care for extremely premature babies—often face impossible decisions: to provide intensive care to such babies or step back and not intervene.
The nurse was already on the phone to the NICU asking for additional staff to help us in the resuscitation room. Ron stripped off his latex-free gloves and left to go find out more details about the new mother in labor. I had an ominous feeling. Events were unfolding too rapidly. Under ideal circumstances, the obstetricians would use medications called tocolytics to try to stop preterm uterine contractions. This would give me, the neonatologist, time to talk to the woman in labor and her husband or partner and explain the risks, complications, and treatment choices for a preterm baby. I would try to allay the anxiety and shock that almost all of them felt. With babies born at 23 weeks, because of the high mortality risk—even with intensive care—and potentially poor quality of life, I also would offer the parents the option of “comfort care only.” If they chose this option, we would only warm, dry, and wrap the baby and let the parents hold her as long as she was alive. Right after the birth, we would arrange for a baptism or any other religious or cultural ritual the parents desired. The baby usually passed away quickly.
When a pregnant woman arrived at the hospital in advanced labor and about to deliver, however, we didn’t have the luxury of time to discuss those options. As I prepared, Ron returned to the resuscitation room, looking tense. Behind him came Mary, an experienced NICU nurse.
“They’re not sure of the dates,” Ron said. “From the ultrasound, they’re saying she could be twenty-three or even twenty-two weeks. She’s already six centimeters dilated. Baby’s going to pop out soon.”
“OK, let’s set up, make sure everything is ready,” I said, initiating a process that I have learned and honed over nearly 20 years of performing emergency resuscitations. “I’ll go talk to the parents; let’s see what they say.”
I walked into the room next door to meet the expectant mother. The baby would be delivered here and then taken to the resuscitation room where I and our neonatology team waited. There was an atmosphere of controlled urgency in the large, well-lit delivery room—the obstetric doctors and nurses attending to the patient with efficient, practiced movements. She was a black girl no older than 14. Standing next to her was a middle-aged woman, her mother.
This would have been an uncommon scene in my previous job in a NICU in Burlington, Vermont, where the patients were predominantly from a white, middle- or upper-class background. I had recently moved south to Charleston, South Carolina, where most of the patients in our inner-city hospital were black, poor, and socially disadvantaged. I was reminded daily of the huge disparities in pregnancy care and pregnancy outcomes in the United States, where black mothers experience much higher rates of premature birth and black infants die at higher rates than their white counterparts.
The pregnant teenager moaned in pain, an expression of fear in her eyes. It would be nearly hopeless to try to talk to her now. The obstetric resident was performing a vaginal exam to assess how much the labor had progressed and how far the baby had descended. The attending obstetrician—a short, stocky, white-haired man in his 60s named Dr. Carver—hovered near the bed, talking in turn to the patient, the resident, and the two nurses in the room.
I maneuvered past the nurses to the bedside, introduced myself to the girl and her mother, and asked whether they had any questions. The girl’s mother shook her head, her face set in a grim expression of pain and confusion. As I walked out of the room to go back to the resuscitation room, Dr. Carver followed me out, closing the door behind him. “She says she didn’t know she was pregnant till this morning,” he said. The girl had gone to the doctor’s office for abdominal pain, discovered she was pregnant and in labor, and was then rushed here to deliver.
I was surprised. Although it was common for women who delivered at our hospital to have received little or no prenatal care, they usually knew they were pregnant. Dr. Carver continued: “The ultrasound from the office this morning says she’s twenty-three weeks. We just repeated an ultrasound, and she could actually be more like twenty-two weeks. Anyway, I told the family that you guys will look at the baby when it’s born and figure out if it’s viable or not.”
I dreaded the prospect of having to immediately determine without any reliable medical criteria whether a baby was viable or not. Until a couple of decades ago, physicians commonly used criteria such as whether the newborn’s eyelids were fused to decide. At the time, if the baby’s eyelids were fused shut and couldn’t open on their own, doctors thought the baby wouldn’t make it. Research later showed that this test was flawed. Nowadays, the best predictor is a precise estimate of the duration of pregnancy (the gestational age), which is most accurate if the mother reliably knows the date of her last menstrual period, had an ultrasound early in her pregnancy (later ultrasounds are less reliable), or had in vitro fertilization. Unfortunately, many lower-income women don’t have access to, or use, prenatal care. For my patient on this day, we had no accurate estimate of the baby’s gestation.
Back in the resuscitation room, we began to prepare for the baby’s arrival. I sensed disapproval from Ron and Mary, whose expressions, tone, and behavior suggested that they felt we shouldn’t be resuscitating 23-weekers whose prospects were so grim. I agreed, but it wasn’t up to us. It was for the parents of such babies to decide, armed with the information and advice we provided. So we moved forward. In preparation, the nurse set up a suction catheter to clear the baby’s nose and mouth, a face mask attached to an inflating bag to give positive pressure breaths, and a thin plastic tube (an endotracheal tube) to pass into her windpipe to connect her to a ventilator. A medication called surfactant was prepared, which would be instilled through her windpipe into her lungs to help them function better.
By now the respiratory therapist had also arrived on the scene to hook up the breathing equipment. With the whole team assembled, I explained that if the mother wasn’t sure of her “dates,” 23 weeks was just a guess. We could always withdraw life support after we initiated it, but it would be a catastrophic mistake to let a baby die on a mistaken assumption of her gestational age.
My team did not seem convinced. I knew they felt that they were being forced to do something that they did not agree with. They knew my experience in my previous hospital had been with a quite different patient population. “You know, black patients almost never agree to withdraw life support,” Ron told me. Mary agreed—both of them warning that if we resuscitated this baby, we were committed to treating it until the very end, whatever complex form that treatment might take.
From that moment on, things happened fast. The nurse called us back to the delivery room next door. “Baby’s coming,” she said. We stood next to the mother’s bed, waiting for the obstetric resident to deliver the baby. Normally, watching a birth invokes a sense of wonder. To see a new life emerge, to hear the baby’s loud cries of protest, to see the vigorous kicking of his limbs and the dawning pink color of his skin as the oxygen floods his body—these moments fill me with a sense of awe, even after witnessing them time after time for nearly 20 years.
An extremely preterm baby is different, however. Most of these babies are born limp and silent as death. Their skin has an unhealthy dark color and is often covered with purple bruises from the delivery. They are so tiny and fragile looking.
The baby emerged quickly, her body slick, covered with amniotic fluid and blood. The obstetric resident lifted the newborn’s limp body into the sterile blue towels on Mary’s outstretched arms, and we followed her into the resuscitation room, where she placed the baby on the chest-high warm resuscitation bed.
After Ron and Mary dried the baby, I took a closer look at her thin, almost transparent skin, the bruising on her trunk, and her immobile limbs. She looked very premature indeed, possibly even 22 weeks. I quickly estimated her weight as somewhere around 450 grams, about the weight of a 16-ounce cup of soda. Generally, babies weighing less than 500 grams have a really bad prognosis. The outcome wasn’t looking favorable for our newborn.
“Start bagging,” I said. Ron looked unhappy as he placed the mask over the baby’s face and started positive pressure ventilation. Mary reached out to feel the baby’s umbilical cord.
“Heart rate less than sixty,” she announced after a few seconds.
“The chest’s not rising,” I observed.
Ron adjusted the position of the mask and tightened the seal of the mask rim, and he was able to get the chest to expand with each positive pressure breath he delivered. The baby was still immobile and blue.
“Heart rate still less than sixty,” Mary stated.
“Ron, get ready to intubate,” I said. I told the respiratory therapist to take over the bagging.
As Ron prepared to intubate the baby—passing an endotracheal tube into her windpipe to deliver positive pressure breaths—the obstetric resident walked into the room. Clasping her gloved hands together to avoid touching anything unsterile, she craned her neck to look at the baby over our shoulders. “You know, the family does not want any heroic measures for the baby,” she told me. “If the baby’s going to suffer, they’d rather let her go.” It sounded like the obstetric team had more time to talk to the mother about the baby’s treatment after she delivered.
“OK, thanks,” I replied. “I’ll come over to talk to them in a few minutes.” I asked Ron to proceed. He slid the thin endotracheal tube into the baby’s trachea, and the respiratory therapist gave positive pressure breaths through this tube. The baby’s skin, previously a dark shade, was slowly turning pink.
“Heart rate over one hundred,” Mary announced.
Dr. Carver checked in on us. “Gosh, she does look like a twenty-three-weeker, doesn’t she?” he said, peering at the baby. “Are her eyelids fused?” As if on cue, the baby slowly opened her eyes, drew up her legs, and stretched her arms. The respiratory therapist continued to deliver positive pressure breaths. The baby’s skin began to turn a healthy shade of pink, and she was vigorously moving her limbs.
“Wow, she’s a fighter,” Mary said.
I suggested we perform a Ballard exam, a structured examination of a premature baby after birth in which the baby’s muscle tone, skin, ears, and other physical signs of maturity are scored numerically to estimate the gestational age. To our surprise, the exam estimated the baby’s gestation to be around 25 or 26 weeks.
The baby weighed 650 grams, much more than any of us had expected. We double-checked and got the same number again. My visual estimate had been wildly inaccurate, and I was glad I had not used it or any other immediate impression to make a snap decision about resuscitation. As the team prepared to move the baby to the NICU for further care, I went to talk to the baby’s mother and grandmother. I congratulated them on the birth of the baby girl and explained that she was stable after our resuscitation. We would bring the baby to the mother so she could see her before transferring her to the NICU. The teenager seemed tired, and she did not reply, turning her face away from me. Her mother thanked me but did not smile. Her face was impassive.
The next day I met Dr. Carver in the cafeteria. “How’s that kid from yesterday doing?” he asked. She was improving and being weaned off her ventilator support, I reported. He nodded. “I wouldn’t have thought she’d make it, at twenty-three weeks, but I guess she turned out to be older,” he said.
The baby we resuscitated was one of 15 million premature babies born each year worldwide; that’s 1 in every 10 babies born. And one million of these premature babies die each year. A recent report from the March of Dimes ranked the United States (with a 12 percent prematurity rate) 131st among other countries in the world, almost tied with Somalia, Turkey, and Thailand. In the United States, prematurity contributes directly or indirectly to more than one-third of all deaths in infants less than a year old. More than half of these deaths occur in babies born earlier than 32 weeks’ gestation, although such babies account for only 2 percent of all births. The estimated cost of prematurity in the United States each year is $26 billion (in 2005 dollars), which includes not just intensive care at the hospital but also ongoing care for long-term problems such as cerebral palsy; mental retardation; visual and hearing impairments; behavioral, social, and emotional issues; learning difficulties; lung problems; and poor health and growth.
So why are so many babies premature? In some cases, babies are intentionally delivered early by doctors to protect the mothers—for instance, if continuing the pregnancy poses a medical risk to a mother with uncontrolled high blood pressure. In our case, the cause was uncertain. No single factor has been pinpointed as the cause of spontaneous premature birth, but many associations have been suggested. Many of these risk factors are social and economic, predating the pregnancy. Rates of prematurity are higher in teenage mothers and twice as high in black women as white women. Maternal smoking, alcohol consumption, low maternal body mass index, age greater than 35, and a short interval between pregnancies are also associated with unplanned premature birth. Women who deliver prematurely are also more likely to be poor and unmarried, with limited education and inadequate prenatal care.
At our Charleston, South Carolina, safety-net hospital, the majority of our deliveries featured more than one risk factor: mothers and their babies with the deck stacked against them socially, demographically, and economically.
Babies born at extremely low gestations are in a special category of their own. Their care raises a host of ethical, moral, medical, and economic questions. Extremely preterm babies strain the limits of neonatal intensive care both technologically and morally.
If you talk to senior NICU nurses and neonatologists, many of them will tell you that 30 or 40 years ago it was common to not resuscitate babies born at 28 or even 30 weeks. Yet over time, neonatal intensive care technology and knowledge improved, and intensive care is now offered at increasingly lower gestational ages.
But with improved ability to save babies, the cutoff point became blurred. Today premature babies around 25 weeks are routinely provided with intensive care because their prognosis is considered good. Babies whose gestation is 22 weeks or less are routinely not offered resuscitation in most hospitals because their outcomes are dismal even with intensive care. Babies in between these thresholds are considered to be in the “gray zone.” For them, intensive care is considered to be optional, to be decided upon by the parents after discussions with neonatologists.
Many babies born in the gray zone die within a few days of birth despite maximal intensive care. Survivors usually have long NICU stays with multiple medical problems that often require invasive and painful treatments. After hospital discharge, many have neurologic or pulmonary impairment that affects their long-term quality of life. Caring for such babies engenders much debate and emotional and ethical dilemmas among NICU health professionals, who want neither to provide futile care to nonviable babies nor to sustain significantly premature babies destined for a painful life of extreme disability. In addition, we are aware that NICU care for gray-zone babies who survive but face long hospital stays is costly. Even though we’re not supposed to think about “rationing,” the burden of the high costs weighs on our minds.
Since the day I started training in neonatology more than 20 years ago, decision-making about extremely premature infants has troubled and fascinated me. Thinking about the baby we resuscitated that particular day, I am reminded of and humbled by how easy it is for doctors to make mistakes when they try to decide which baby lives or dies based on a last-minute ultrasound or how the baby looks in the delivery room. According to a web-based estimator provided by the National Institute of Child Health and Human Development, if the baby girl we cared for had indeed been at 23 weeks’ gestation and weighed 450 grams, the probability of her survival without significant disabilities (what we call “intact survival” in our business) would have been around 7 percent. In reality, at 26 weeks’ gestation and a birth weight of 650 grams, she had around a 35 percent chance of surviving without significant disabilities. Still a discouraging prognosis, but also a dramatic improvement.
In an ideal world, decisions about the care of these borderline babies should follow the principles of shared decision-making based on in-depth, compassionate discussions between the parents and health professionals before the baby is born. Health professionals should provide information and ensure that the patient understands what is at stake. We must identify the expectant parents’ values and preferences; make recommendations if the parents desire; and ultimately help them make choices about when to initiate, continue, or withdraw intensive care.
In the real world, however, expectant parents frequently receive poor prenatal counseling and are not adequately involved in decision-making. Preterm labor usually develops unexpectedly, so patients are frequently admitted emergently under time pressure, when they are sleep deprived, medicated, and anxious. These conditions do not create the optimal setting for conversations about imminent life-and-death decisions.
There is also an issue of health professional bias against extremely premature babies. Multiple studies—including one that I coauthored—have shown that health professionals are overly pessimistic about the outcomes of such infants, overestimating their mortality and underestimating the rates of survival without handicaps.
Neonatologists, obstetricians, and others counseling parents may overtly or implicitly (and often unconsciously) slant their counseling toward nonintervention. Or they may decide whether or not to pursue resuscitation only after they have seen “how the baby looks” in the delivery room. Such practices are not supported by the evidence, but they are common. To help clinicians manage extremely preterm infants, the American Academy of Pediatrics issued a clinical consensus-based report in 2009, which recommends a comprehensive and consistent approach to preterm infants in each hospital, accurate prognostic data for parents, and resuscitation decisions based on the probability of good outcomes with treatment. But there has been no systematic attempt to monitor on a national level how these recommendations are being carried out.
The best solution may lie in preventing premature births and avoiding these tricky ethical situations in the first place. Between 1990 and 2006, despite millions of dollars spent on research to identify preventive measures, the prematurity rate in the United States rose by 20 percent. It reached 12.8 percent in 2006.
Yet recent developments give me hope. The March of Dimes launched a campaign in 2003 to prevent prematurity by raising awareness of the problem, disseminating evidence-based practices and assigning prematurity rate “report cards” to states. The campaign also aimed to improve women’s access to medical care during and between pregnancies and sponsored research on prematurity prevention. In 2008, the March of Dimes extended the campaign until 2020 while also expanding the effort globally, with activities in 62 countries by 2012.
By 2011, the prematurity rate in the United States had declined to 11.7 percent.
In addition, the Centers for Medicare and Medicaid Services launched a national initiative in 2012 called Strong Start, testing whether enhanced prenatal care for women enrolled in Medicaid or the Children’s Health Insurance Program can reduce premature births. Healthy Start, a program from the Health Resources and Services Administration, funds efforts to reduce the infant mortality rates and improve perinatal outcomes in the areas of highest need. The program has shown promising improvements.
It is my hope that these kinds of programs will ultimately reduce premature births and the number of gray-zone babies who are born. As a result, neonatologists will face fewer snap decisions such as the one I had to make in the delivery room that day, and babies, their families, and society will benefit.
Volume 32, Number 10. October 2013.
Editor’s Note: The names of the people described in this article have been changed to protect their identities.
Reversing the Rise in Maternal Mortality
A mother’s death in the 1950s tears a family apart; 60 years later, maternal mortality is on the rise again.
Katy B. Kozhimannil
In the fall of 1997, I drove an hour from my college to the small rural town in central Minnesota where my grandmothers lived to pay them what I thought would be a routine visit. The first stop was at my Grandma Lorraine’s. She’d left necessities out on a table for me: a $20 bill, a martini, and a note inviting me to join her at the casino. I decided instead to walk the six blocks to my Grandma Rita’s house.
Grandma Rita lived in a one-story two-bedroom yellow ranch house on a corner, less than a mile from where she was born. Next to the home’s garage was a vegetable garden with half of a bathtub painted blue inside and set up as a grotto for a two-foot statute of the Virgin Mary.
It was my first time sleeping over at my grandparents’ house as an adult, without my siblings, parents, or cousins. My grandpa had gone to the basement to do a puzzle, and I recall the warmth of the kitchen light as my grandma and I sat around her small, round kitchen table that night. The table was covered with a plastic gingham tablecloth, and on it sat the usual: two stacked plastic containers of cookies, the top one filled with homemade ginger cookies and the bottom with store-bought sandwich cookies. The walls were decorated with “fancy” plates that my grandparents had mounted—gifts from friends or relatives who had gone to far-off places like Niagara Falls. In that cozy, familiar kitchen I heard a haunting story. I knew that my grandma’s sister had died young and unexpectedly, but that evening as darkness fell, I heard the whole story of how maternal morbidity and mortality had shaped our family.
On December 28, 1947, Grandma had traveled 30 miles from her home in the countryside to give birth at a regional hospital in the largest city in Stearns County: St. Cloud, Minnesota. Her baby was stuck, and she spent four days in hard labor. Then she endured nearly a day of pushing, pain, and bleeding before she lost consciousness. My Uncle Tom was finally born on New Year’s Day, 1948, and both of them were hospitalized for two weeks after the birth.
“I don’t remember anything from that time in the hospital,” Grandma whispered, eyes downcast. Still, she said, she was grateful that the hospital had the capacity to care for her and her baby. It could have been worse.
After Tom came, my Aunt Becky, and then her third pregnancy, which ended in a miscarriage. Her third child, my mother, was born in 1952.
Three years later, in 1955, Grandma’s younger sister Beatrice, whom she called “Beattie,” headed from a stint as an army nurse to a job in a Choctaw tribal jurisdictional area in Oklahoma. She got pregnant shortly thereafter with her fifth child, a daughter who would be named Jeannie. When she went into labor, she traveled off the reservation to give birth because there was no local hospital with maternity services. Beattie never left the hospital after giving birth to Jeannie. She died within days, from what was likely a pulmonary embolism—a blood clot in her lungs.
Beattie was 29 when she died, leaving her five children behind. Her husband was unable to care for them but wanted the children to stay together. Grandma Rita, with three small children of her own, could not adopt all five, but she wanted to adopt the girls. Her other sister, Millie, offered to adopt the boys. That way, at least the children would be raised in the family. Still, Beattie’s husband insisted the children should stay together, and someone outside our family eventually adopted them in a closed process.
“Back in those days I thought about Beattie’s babies every day … every day,” Grandma told me. “When I fed my kids, I wondered who was feeding my nieces and nephews. I wondered if they were hungry. I also wondered if they knew about their mother.”
In the early 1970s, our family finally reunited with Beattie’s five children, after the oldest child successfully searched for us. They had been raised by a family in northern Minnesota, not 200 miles from their aunts, uncles, and cousins. Putting the pieces of our family back together was emotional for everyone, punctuated by joy at what we had regained and sadness about what had been lost forever. It feels like a small miracle that I now see one or two of Beattie’s children at family reunions, but the pain of the earlier separation never fully abated.
That night back in 1997, I lay awake in Grandma’s guest bedroom. The last photo taken of Beattie sat on the nightstand: a professional photograph of my great-aunt in her army nurse uniform and matching white hat, her dark hair carefully arranged in curls, her gaze slightly to the right of the camera. Looking at her gentle smile, I replayed the horror again and again. I was grateful that Grandma Rita had trusted me to hear this. I would not discuss Beattie’s death and her children’s separation from the family with Grandma Rita again in depth until days before her death, but the family silence had been broken.
Beattie was one of about 1,800 women who died giving birth in the United States in 1955, when the maternal mortality rate was approximately 47.0 deaths per 100,000 live births, according to historical vital statistics records. During the 1960s and 1970s, access to health care and the quality of health services improved, and maternal mortality decreased. In addition, family planning improved dramatically as birth control became widely available and abortion became legal. Medicaid was established in 1965, and in an effort to improve birth outcomes, a separate eligibility category for pregnant women was added in 1984. Clinical innovations such as the development of safe surgical birth by cesarean further improved health outcomes for mothers in the United States. More hospitals were built, and perinatal care was regionalized. These factors all contributed to massive improvements in maternal health. By 1978, the year my mom gave birth to me, the maternal mortality rate had dropped to 9.6 deaths per 100,000 live births. Maternal mortality in the United States reached its lowest point in history in 1987, when 6.6 women died per 100,000 live births, according to the Centers for Disease Control and Prevention. That year about 250 US mothers died giving birth.
When Grandma opened up to me about our family’s trauma, she had reason to hope that the darkest days for new mothers were in the past. Birth was safer for her daughters than it had been for her. So why, by the time I was giving birth to my own children, did that change? Since the conversation with my grandma in which I truly understood, for the first time, how maternal mortality had shattered the lives of those I loved, I focused my professional work on maternal health.
In the 1990s, the maternal mortality rate in the United States began to increase. Between 1987 and 2010 it more than doubled, reaching 16.0 deaths per 100,000 live births. But as the rate ticked upward, the trend was not making headlines. In graduate school in the 2000s, I learned that childbirth was the most common and costly reason for hospitalization, yet it was not routinely studied. Shockingly little was known about safety and the quality of care in childbirth, and shockingly little attention was paid to the women who died, or nearly died, giving birth.
Blame for the recent rise in maternal mortality falls upon the policies and systems that do not support the health of women before they become pregnant, during pregnancy, at the time of childbirth, and postpartum.
Notably, some of the trends that accompanied the prior decline in maternal mortality have begun to reverse course. From the late 1980s through 2009, the percentage of reproductive-age women who reported being uninsured at some point during the prior year increased substantially. Even for those with health insurance, maternity care became more costly, especially with the rise of high-deductible health plans, and many women experienced gaps in health insurance coverage during the postpartum period. Access to reproductive health services has declined—a trend that is associated with more restrictive laws and policies enacted in the 1990s and 2000s. Hospitals and clinics have closed or consolidated services, and shortages in the maternity clinician workforce have affected access to care, practice arrangements, and relationships between patients and their care teams. Additionally, fee-for-service payment models have incentivized procedures over physiological processes in childbirth, and some of the medical procedures that were developed to support safe childbirth—such as labor induction and cesarean delivery—became overused when not medically necessary.
By 2010, when I gave birth to my daughter, the US maternal mortality rate was worse than that in 56 other countries. I would have been statistically safer giving birth in Egypt, Iraq, Latvia, Mongolia, or Uruguay than here. That year, the US maternal mortality rate was the highest it had been in decades. Nearly 1,000 women died giving birth, and more than 60 percent of these deaths were likely preventable, according to a 2018 analysis by nine state maternal mortality committees. In the United States, no group bears this burden more heavily than black mothers, who are more than three times as likely as white women to die giving birth and—if they survive—more than twice as likely as white women to bury their babies before their first birthday. In addition, rural mothers are more likely than urban mothers to lose their babies to infant mortality. They have to travel farther to receive care during pregnancy and childbirth, putting both them and their babies at risk. The perspectives of the people, families, and communities who have endured the greatest losses should guide policy responses to maternal mortality in the United States.
A mother’s death is a searing, unimaginable tragedy, the effects of which last for decades. In this country we cannot turn our backs on our mothers. The United States must take action to prevent needless deaths among women who have just given birth. To do so, I believe, will require drastic improvements in five areas: data on maternal deaths and near misses, access to care, birth equity, accountability, and—most importantly—listening to the mothers who were nearly lost and the families left behind by maternal death.
The first step toward making childbirth safer again is the establishment of a national maternal mortality review committee and support structure for consistent data collection within and across states so that we can understand how each maternal death fits into broader patterns of risk. Other countries do this and are able to respond quickly to emerging crises in maternal health. Only about half of all US states have maternal mortality review committees. I’ve served on Minnesota’s committee since 2012. Every six months we meet to discuss maternal deaths in the state, reviewing every bit of evidence available (from clinical records and autopsy reports to obituaries) to determine whether the death was preventable and to try to draw broader lessons from patterns that emerge across stories. To my knowledge, the data from our work in Minnesota have never been publicly released, and our numbers are too small for meaningful statistical estimates. It’s heartbreaking to know that our work has little influence on the rising tide of maternal mortality. This should change.
Second, access to care must improve. Health insurance coverage before, during, and after pregnancy helps women afford the care they need. Recent efforts to repeal portions of the Affordable Care Act that require health plans to cover maternity care as an essential benefit threaten financial access to care during pregnancy, and Medicaid eligibility policies that drop pregnancy-related coverage 60 days after childbirth contribute to health insurance “churning” in the postpartum period. Also, women need access to care in their own communities whenever possible. To keep maternity units open, policy efforts to address workforce shortages and the financial challenges of low-volume obstetrics are needed. More than half of rural counties currently have no hospital that provides maternity care, and in those communities there is a need for housing and transportation support for mothers who travel to give birth in distant communities—as well as for emergency response support locally.
Third, we must directly confront the unconscionable racial disparities in maternal death. To do so requires a recognition of the role of racism—at an interpersonal level and at a structural level—in creating or denying opportunities for health, including the chance to flourish during pregnancy, childbirth, and early parenting. Key to this work are efforts aimed at improving workforce diversity and addressing unconscious bias among clinicians and within health care institutions. A recently published Council on Patient Safety care bundle provides concrete guidance on steps that clinicians and health systems can take to reduce racial disparities in care during pregnancy and childbirth. But the work of improving racial equity in childbirth extends well beyond the health care system to encompass the social determinants of health, including employment, housing, education, food access, environmental health, and criminal justice—all of which require policy-level action.
Fourth, in childbirth, it is essential to hold health plans, health care delivery systems, and clinicians accountable for what matters and to make it easy to do the right thing. The development and use of evidence-based tool kits and protocols can improve the safety of clinical care for every birth. California provides an instructive example through the efforts led by the California Maternal Quality Care Collaborative, which has successfully deployed care protocols that have led to demonstrable reductions in maternal morbidity and mortality. Additionally, payment reform that prioritizes outcomes over procedure use holds potential for reducing the financial incentive to overuse services.
Finally, and most importantly, reversing the rise in maternal mortality requires listening to mothers. It is not sufficient for mothers to be present: they need to be front and center in the decision-making in each of the areas described above. Women’s questions and concerns about their health and safety during pregnancy, labor, delivery, and postpartum must be heard. The onus is on health care delivery systems and those individuals who are clinically responsible for care during childbirth and afterward to find ways to heed every warning.
Reversing the rise in maternal mortality is possible, and California has the track record to prove it. From 2006 to 2013, California bucked the national trend, and maternal mortality declined by 57 percent, from 16.9 deaths to 7.3 deaths per 100,000 live births. Many of the ideas outlined above come from California’s experience, and that state gives me great hope. At the same time, potential policy decisions on the horizon could pose a threat to maternal health. Efforts to roll back the Affordable Care Act threaten to dramatically reshape and scale back state Medicaid programs, which finance nearly half of all births nationally. Furthermore, court decisions and policies restricting access to family planning and abortion services threaten women’s health and disproportionately affect women who are medically underserved, including those in rural, low-income, or black communities.
In 2017, Grandma Rita was 94 years old and living in a nursing home, where she was receiving hospice care. Twenty years had passed since she’d told me about Beattie. On her bedside table, she kept an article cut from a newspaper: a Washington Post op-ed I’d written with a colleague about the challenges rural women face to give birth.
I was proud of the article, which had been picked up on social media by members of Congress, but I was prouder still of the attention it garnered at the nursing home in rural central Minnesota where my grandmother lived. She showed it to every nurse, doctor, personal care attendant, food service staff member, clergy, family member, and volunteer who walked through the door of her room.
On a cold day in mid-December 2017, I drove across the windswept prairies to visit Grandma, bringing my own daughter with me. It would be the last time I spoke with her. On her windowsill, not one foot away from the tattered copy of the op-ed I’d written, was the last picture taken of Beattie, in her nurse’s uniform. It was the same photo that I remembered from that evening two decades ago in Grandma’s old home. Grandma looked at the picture and said, “You know … my sister Beattie … I miss her every day. I think about her every day.” She touched the well-worn piece of newspaper lightly and said, “It is important that moms get the care they need. I am so surprised about how many places have no hospitals. It’s a shame what is happening to our moms. I could have died if I had not been able to get to a hospital when I gave birth.”
Grandma Rita died four days after my visit.
I have Grandma Rita’s nose, her love of books, and her pathological sense of responsibility. On June 20, 2010, exactly 61 years after she gave birth to her second child, I gave birth to mine, also a daughter. I named her Rita.
The stories I tell my daughter Rita about her great-grandmother reveal the fragility of life and the depth of women’s strength. If we can turn the pain of maternal death into righteous indignation about the loss of something so precious, we can take action to ensure that for our daughters and granddaughters every birth is sacred and safe.
Volume 37, Number 11. November 2018.