Readers React

Continuing the fight from deep in the trenches

Thank you, Dr. Lockwood, for your commitment to reducing maternal mortality! It is simply shameful that women, particularly women of color, are dying at such an alarming rate in 2018. As a OB hospitalist in Chicago’s underserved Englewood neighborhood, I am deep in the trenches of maternal obesity, hypertension, diabetes, substance abuse, mental illness, homelessness, domestic abuse, etc. The stories I could tell! Despite the constant threat of malpractice, the fear of traveling in and out of a very dangerous neighborhood, the burnout from a tight work schedule, I press on because I know that I have been blessed with a unique skill set. I can save lives and I must. Therefore, I am as committed as you are to saving the lives of the mothers in my care. It is our duty as well as our gift.

Joy West MD, FACOG

Chicago, Illinois

In Reply:

God bless you Dr. West. You are battling on the front lines of this important struggle. You are also addressing a particularly important component of the challenge of maternal mortality: racial disparities! Dr. Martin Luther King, Jr. said at the Second National Convention of the Medical Committee for Human Rights, “of all the forms of inequality, injustice in health is the most shocking and inhumane.” Now, more than 50 years later, is the time to finally address and eliminate disparities in access and delivery of care and in outcomes.   Thanks for all you do.    

Charles J. Lockwood, MD, MHCM

NEXT: No need to politicize the issue

No need to politicize the issue

The problem of maternal mortality is clearly one without match.  In demeaning a slogan chosen by the President and supported by about half the population of our great nation, you demean the very topic that you choose to uplift into our consciousness. “A call to arms” was a great title and you could have stuck with that and not “gone cheap” with the MAGA reference. It was completely unnecessary, and belittles those that believe that lowering taxes, bringing back foreign jobs and manufacturing to our own country, enhancing US security and border control, enforcing existing immigration laws, seriously confronting terrorism threats, declaring a nationwide public health emergency to attack the opioid epidemic, and renegotiating trade agreements to be more favorable for US taxpayers are critical issues for our nation’s future. I respectfully suggest that your readership is best served when we stick to the medicine and leave out the politics where it serves no purpose but to demean, divide or belittle others of an opposing view; even in a “tongue in cheek” manner.

With respect to maternal mortality, I applaud your efforts and those of your contributors. I would estimate the average BMI of patients presenting to the office I staffed this week to be > 50. Certainly, we have seen a parallel risk in Class III obesity (not to mention extreme advanced maternal age and repetitive cesarean sections), along with the risk in maternal mortality. Educational efforts aimed at increasing awareness of the pregnancy-specific health risks of obesity are needed. In my experience, most of our super-obese patients are unaware that their condition impacts the likelihood for optimal perinatal outcome.  

I look forward to learning from the experts you’ve assembled to provide us with much-needed information on approaches to reducing maternal mortality.

Jordan Perlow, MD

Banner University MedicalCenter - Phoenix

Phoenix, Arizona

In Reply:

Jordan thank you for your kind words and your “political” advisement. While physicians may have diverse political opinions, we should all be committed to evidence-based medicine and many of the issues you raise are major public health problems in need of being addressed. All the best,

Charles J. Lockwood, MD, MHCM

NEXT: Time to reduce cesarean deliveries rates

Time to reduce cesarean deliveries rates

Dear Dr. Lockwood,

Your statistics [on maternal mortality] are correct but, like most members of ACOG, you ignore the iatrogenic nature of the US maternal mortality crisis and blame the patients themselves-obesity, medical conditions, drugs, etc. How can Canada, 15 minutes from where I live and practice in Buffalo, NY, have a maternal mortality rate one-quarter to one-third of the United States? You cannot say their mothers are so much younger, slimmer, have fewer preexisting conditions than ours, or that they live in a world without guns, cars and drugs. Their care is different. They are more often cared for by midwives and, whether cared for by obs or midwives, are subjected to fewer inductions and fewer cesarean sections.

Cesarean sections carry a four-fold risk of death when compared to vaginal birth. The World Health Organization states that the correct cesarean section rate is between 10% and 15% but ours in the United State is 38% to 40%. We know the risks of cesareans, we know the high rate has not helped babies. Why can’t ACOG or Contemporary OB/GYN take a leadership role to decrease cesareans? Forty years of the continuous electronic fetal monitor has shown, through multiple peer-reviewed studies/articles, that it has not helped babies but increased cesarean sections. Why can’t ACOG or your publication take a stance to eliminate this device from Labor and Delivery rooms? Two exhaustive studies by NIH have shown that VBAC is less likely to cause a mother’s death than elective repeat cesarean section. Why can’t ACOG or Contemporary OB/GYN come out against those hospitals that forbid VBAC? 

Until your publication, and ACOG for that matter, comes out squarely against those practices which are actually contributing to mothers’ deaths, devoting 2018 to the subject of maternal mortality will not save a single woman.

Katharine Morrison, MD, FACOG

The Birthing Center of Buffalo

Buffalo, New York

In Reply:

Dear Dr. Morrison,

The high US cesarean delivery rate has many causes including the virtual abandonment of mid-forceps deliveries and cesarean deliveries for breech presentations, ironically after publication of the work of a Canadian author. While less measurable, I am sure a fear of lawsuits has led to excess cesarean deliveries when there is equivocal evidence of fetal distress. Another cause is the reduction in trials of labor to achieve VBAC due to fear of uterine rupture.

But by far the primary driver of high US cesarean delivery rates is the occurrence of dystocia in first pregnancies which, in turn, can be directly linked to larger infants and rising maternal obesity rates. And while our high rate of repeat cesareans has led to an increase in mortality accruing morbidly adherent placentas, this represents a small fraction of the excess American maternal mortality rates. Indeed, the leading cause of current maternal deaths in the United States is heart disease including cardiomyopathies. Ironically again obesity, coupled with older parturients, chronic hypertension and successful correction of congenital heart disease are the likely culprits for this epidemic of maternal cardiac pathology - not rising cesarean delivery rates. Indeed, maternal deaths from hemorrhage, infection and venous thromboembolism-which can be linked to cesarean deliveries-continue to decline as relative causes of the death of American mothers. So, while I agree we should strive to reduce primary cesarean deliveries, it is unlikely that such success will have a major impact on US maternal mortality rates. Thank you for your heartfelt comments.

Charles J. Lockwood, MD, MHCM and Carolyn Zelop, MD

Disclosures The editors reserve the right to shorten or edit letters and comments.