Perinatal and maternal mortality in a religious group avoiding obstetric care.
Editor’s Synopsis: This paper focuses on childbirth-related mortality in essentially healthy middle-class pregnant women who were members of a Christian fundamentalist group that did not believe in the use of ‘modern’ medicine under any circumstances. In such circumstances, death is to be ‘accepted’ as God’s will.
Based on such religious beliefs, 344 childbearing women members rejected all forms of prenatal care, followed by purposefully unattended labors (no trained birth attendant present during active labor, birth and postpartum). These families also refused to use emergency medical services when a life-threatening emergency occurred (i.e. excessive maternal bleeding, breathing problems for the newborn baby, and signs of serious infections in mothers or babies).
This resulted in a drastic increase in preventable maternal (6) and perinatal (21) deaths. The death rate for the new mothers in this study was 1 out of 57 live births, and a perinatal mortality rate (stillbirths or baby deaths w/in the first 28 days) was 1 out of 16.
As the study notes, the “perinatal mortality rate {was} three times higher and a maternal mortality rate about 100 times higher than the statewide rates.”
The level of these tragedies was as high as childbirth-related deaths during the 19th century (before the development of scientific medicine), and as we see in 3rd world countries today where women don’t have dependable access to emergency medical services, such as Afghanistan and sub-Saharan Africa (Ethiopia, Sudan, the Congo, etc).
It’s easy to assume this study “proves” that normal childbirth is so fundamentally dangerous that the obstetrical profession should be in charge of all pregnant and childbearing women, period, end of conversation.
However, the real usefulness of the AJOG paper is that it allows us to compare outcomes for “no care/no use of emergency services” against other types of childbirth care that includes regular prenatal, attended labors and birth, and use of emergency services as well as hospital care as indicated. These categories include hospital-based obstetrics and non-obstetrical care as provided by professionally-trained and state-licensed midwives (CNMs & LMs) and experienced, state-regulated lay midwives.
When we measure maternal and perinatal mortality among these categories (a) “no care”; standard hospital obstetrics (b) professional midwives providing care to healthy CB women in both hospital and OOH settings and (c) lay midwives, we are in for a big surprise. It turns out that the biggest ‘bang’ for our collective buck comes from informally trained lay midwives who practice legally under a county registration system.
A study done in North Caroline using data from the same time period (1976-78) and a relatively similar number of births (344 vs. 800), showed a dramatic reduction in maternal mortality in the women who receive care from registered lay midwives. The MMR dropped from 1 out of 57 to none — no maternal deaths, while the perinatal mortality rate (excluding fatal birth defects) was reduced from 1 in 16 births to 1 out of 800.
Studies that track mortalities for professional midwife-attended OOH births by CNMs & LMs were relatively similar to the outcomes of the lay midwives, while studies on professionally-trained and licensed Canadian midwives “RMs” (registered midwives) were substantially better. In a particular study that compared outcomes for midwives both in and out of hospital and physicians providing care to low-risk women in the hospital, the very best of all outcome was midwife-attended OOH births, with an NMR of approximately 0.35 per 1,000 live birth, or 1 per 3,000 live births.
PHB with a lay midwife in the late 1980s.
Take-home Message: What makes childbirth relatively safe is regular prenatal care with referral to medical services for evaluation of care whenever indicated, the full-time presence of a trained birth attendant during active labor, birth and the immediate postpartum, and the use of emergency medical services whenever necessary or requested by the parents.
See full citations in part II of “Identifying the Essential Qualities of Maternity Care: Evidence-based policies and a plan for action
URL ~ http://healthcare2point0.com/MCDG_contrast-studies_feedback_28Aug2010.htm#Part_II
Document Number: 052604
Author(s): Kaunitz AM, Spence C, Danielson TS, Rochat RW, Grimes DA
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY, 1984 Dec 1;150(7):826-31.n
We investigated perinatal and maternal deaths occurring among women who were members of a religious group in Indiana; these women received no prenatal care and gave birth at home without trained attendants.
Members of the religious group had a perinatal mortality rate three times higher and a maternal mortality rate about 100 times higher than the statewide rates. These findings suggest that, even in the United States, women who avoid obstetric care have a greatly increased risk of perinatal and maternal mortality.
Abstract:
All reported perinatal and maternal deaths from 1975 to 1982 among Faith Assembly members living in the state of Indiana were verified. Fetal death and the neonatal mortality rate were defined per 1000 live births; perinatal mortality was the combination of fetal deaths and neonatal deaths per 1,000 births plus fetal deaths; and maternal mortality was calculated per 100,000 live births. 344 live births were identified in Elkhart and Kosciusko Counties among religious members during this period. 291 of these mothers (85%) did not have prenatal care, the prenatal care for the remaining 53 (15%) was unspecified.
The mothers tended to be aged 20-34, white, married, and have a minimum of high school education. 21 perinatal deaths were established among this population sample with 12 fetal deaths and 9 neonatal deaths. 11 fetal and 6 neonatal deaths occurred to members residing in the above 2 counties. Trauma or asphyxia at birth (often as a result of umbilical cord problems) and respiratory problems were responsible for most of the mortality.
Six maternal deaths occurred: 4 due to hemorrhage and 2 caused by infection. During this period there was a total of 61 maternal deaths in Indiana, and thus about 9% of maternal mortality occurred among Faith Assembly members (100% vs. 36% deaths caused by hemorrhage and infection). 3 of the 6 church members who died were 35 or older, and 2% of the births occurred to women 35 or older in these countries.
The estimated perinatal mortality rate for this group was 45/1000 live births vs. 18/1000 for the whole state, almost 3 times higher. The fetal mortality rate was 32 vs. 9 for Indiana (significantly higher); and the neonatal mortality rate was 17 vs. 9, respectively.
The maternal mortality rate was 872/100.000 live births for church members residing in the 2 counties vs. 9/100.000 for Indiana: an astounding ninety-twofold higher rate.
The risk of perinatal and maternal death is greatly augmented even in the US when women do not utilize obstetric care.
Keywords:
United States Indiana Fetal Death Maternal Mortality Neonatal Mortality Antenatal Care Religion Childbirth Age Factors Maternal Age, 35 and Over Cohort Analysis Christianity Causes of Death Self Care Religious Aspects Complications Developed Countries North America Americas Mortality Population Dynamics Demographic Factors Population Infant Mortality Maternal Health Services Maternal-Child Health Services Primary Health Care Health Services Delivery of Health Care Health Pregnancy Outcomes Pregnancy Reproduction Population Characteristics Maternal Age Parental Age Research Methodology Treatment
