A new study shines light on the risk factors for severe maternal morbidity and the reason why morbidity is rising. The overall quality of maternal health care has traditionally been measured by maternal mortality.
Severe maternal morbidity during delivery hospitalisation was estimated to occur in 5.1 of every 1000 US deliveries from 1991 to 1993, affecting approximately 20 000 women annually. The distribution of maternal demographic and obstetric characteristics among cases and controls was examined. In the chart below, I’ve highlighted the risk factors that are most strongly associated with severe maternal morbidity. Although this study investigated risk factors at the level of the patient, both provider and health care system factors may also play a critical role in the development of SMM. The bottom line is that the increase in severe maternal morbidity reflects the changing demographics of the childbearing population, not the quality of obstetric care.
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Maternal characteristics included age, race, level of education, marital status, maternal smoking during pregnancy, payer source, parity and preexisting conditions.
None of the 5 most important risk factors modifiable, either by the patient or her provider. Homebirth advocates like to pretend that these are not risk factors, but they are and all women who face them should be counseled that they are not safe candidates for homebirth. The increase in severe maternal morbidity can be explained by the rise in prevalence of the risk factors. Contrary to the insinuations of NCB advocates, it is not the overuse of technology that leads to poor maternal outcomes, it is the underuse of technology. And when it comes to the quality of obstetric care, the main problem is underuse of technology, not overuse. Adequacy of prenatal care as measured by the Kotelchuck index, delivery method, having a multiple birth, delivering a low birthweight infant. Women with SMM were more likely to have a multiple birth, to deliver by caesarean, to deliver a low birthweight or preterm infant and to have received intensive prenatal care as compared with controls. These are advanced maternal age, race, pre-existing medical condition, twins or higher order multiples and previous C-section.


Natural childbirth advocates also like to pretend that these are not risk factors but, as usual, they are wrong. Maternal age has increased, and therefore the incidence of pre-existing medical conditions have also increased. Unfortunately, the study did not distinguish between women who attempted a VBAC and women who scheduled a C-section, so we cannot determine if it the previous C-section that is the risk factor or whether the complications are a result of attempted VBAC.
Therefore, increased reliance on midwives has little to no place in any efforts to reduced severe maternal morbidity and homebirth has no role at all. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984.
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Women who face these risk factors may need additional monitoring and interventions in order to have a safe birth.



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