[Congressional Record Volume 142, Number 114 (Tuesday, July 30, 1996)]
[House]
[Pages H8794-H8796]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                       THE SAFE MOTHERHOOD REPORT

  (Mrs. SCHROEDER asked and was given permission to address the House 
for 1 minute and to revise and extend her remarks and include 
extraneous material.)
  Mrs. SCHROEDER. Mr. Speaker, today is my 56th birthday. I am very, 
very happy to be here because on my 30th birthday, 26 years ago, I 
spent it in intensive care, getting last rites, suffering from 
complications due to childbirth. Obviously, safe motherhood has always 
been a great concern of mine.
  I am putting today in the Record the report that I asked for from the 
Department of Health and Human Services on the status of safe 
motherhood in America. This report goes right at the myths, and it is 
time we put those myths aside.
  I was startled by the findings that almost 25 percent of the 
deliveries in America, both vaginal and caesarean, have serious 
maternal complications. I was startled to read that probably maternal 
deaths are underreported by at least half. It is time we start dealing 
with this health risk to women very seriously, put the myths aside, and 
I hope everyone reads this report.
  Mr. Speaker, early this century when women were fighting for the 
right to vote, safe motherhood was a rallying cry for them. In 1913, 
more women between the age of 15 and 44 died in childbirth than from 
any other cause except for tuberculosis.
  With all the advances in medical treatment and technology, we have 
moved a long way toward making the goal of safe motherhood a reality. 
But we are not there yet. Young, healthy women still die in this 
country because of complications due to pregnancy and childbirth.
  I have been amazed at how little American, including Members of 
Congress, know about what can go wrong during pregnancy. As a woman who 
almost died in childbirth, I can assure you it can happen. For this 
reason, earlier this year, I asked the Department of Health and Human 
Services for a report on

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the current trends and status of safe motherhood in the United States. 
Today I am releasing that report.
  I was startled by the findings:
  More than half of pregnancy-related deaths are probably still 
unreported. If the U.S. were to improve its surveillance, these deaths, 
pregnancy mortality ration would more than double.
  A quarter of all deliveries--both vaginal and caesarian--are 
associated with serious maternal complications.
  Risks of pregnancy-related deaths vary according to age and race. 
Women older than 40 have nine times the risk of dying compared with 
women ages 20-24. African American women are three to four times more 
likely to die due to pregnancy complications than are white women.
  It's time to cut through all the cultural mystique surrounding 
pregnancy and childbirth and treat it as a serious women's health 
issue. Pregnancy is not a 9-month cruise. I hope my colleagues will 
read this report and then join me in introducing the safe motherhood 
initiative so that we can make every childbirth, a safe one.
  Mr. Speaker, I include the report previously referenced. The material 
referred to as follows:

Information on Health Issues Involved in Safe Motherhood and Improving 
                           Pregnancy Outcomes


                          unintended pregnancy

       More than one-half of all pregnancies in the United States 
     are unintended. Unintended pregnancy is defined, by the 
     National Survey of Family Growth (NSFG), as a pregnancy 
     which, at the time of conception, was either mistimed 
     (desired at a later time) or unwanted (not desired at any 
     time). The proportion of unintended pregnancies, by age of 
     mother, ranges from 21 percent for women aged 25 to 34 years 
     to 77 percent for women over 40 years of age. It is not 
     really surprising that 82 percent of adolescent (aged 15-19 
     years) pregnancies--where the young mother is probably 
     unmarried, has not completed her education, and is not able 
     to adequately support her child--are unintended.
       The most recent information on unintended pregnancy comes 
     from the 1995 Institute of Medicine (IOM) report The Best 
     Intentions. This report notes that when a pregnancy is 
     unintended, women are more likely to seek prenatal care after 
     the first trimester or not at all.
       They are also more likely to use harmful substances, such 
     as tobacco or alcohol, during pregnancy; the newborn is more 
     likely to be of low birth weight. A disproportionate number 
     of women who experience an unintended pregnancy have never 
     been married, are over 40 or under 20 years of age. An 
     unintended pregnancy can also lead to abortion. There are an 
     estimated 1.5 million abortions each year in the United 
     States. If all pregnancies were intended, however, there 
     would be a 45 percent reduction in births to unmarried women 
     and a 90 percent reduction in births to teenagers. The IOM 
     report states: All pregnancies should be intended--that is, 
     they should be consciously and clearly desired at the time of 
     conception.


                           maternal mortality

       Although deaths related to pregnancy have declined 
     dramatically in this century, our ability to fully describe 
     the magnitude of maternal mortality in the United States is 
     still less than optimal. Indeed, there is strong evidence 
     that maternal mortality is underestimated in developed 
     countries, including the United States. Not all developed 
     countries use the same methods for identifying pregnancy-
     associated deaths. In the United States, although at least 
     six different sources are used to count such deaths, the 
     actual number and rates of maternal death are unknown. It is 
     also difficult to discern which of these deaths are casually 
     related to pregnancy. An understanding of the characteristics 
     of maternal deaths is the first step toward developing 
     appropriate prevention strategies.
       The Centers for Disease Control and Prevention (CDC), in 
     collaboration with the American College of Obstetricians and 
     Gynecologists (ACOG), has expanded the definition of maternal 
     mortality to pregnancy-related mortality, which includes any 
     death caused by pregnancy or its complications during or 
     within one year of pregnancy. Pregnancy-associated deaths, on 
     the other hand, are those that occur during or within one 
     year of pregnancy, regardless of the cause.
       The pregnancy-related mortality ratio in the United States 
     increased from 7.2 per 100,000 live births in 1987 to 10.0 
     per 100,000 live births in 1990, probably as a result of 
     improved surveillance (Berg et al., in press). Although 
     relatively rare, a higher risk of pregnancy-related death is 
     observed with increasing maternal age, increasing live birth 
     order, no prenatal care, and among unmarried women. Black 
     women continue to have mortality ratios three to four times 
     that of white women. The major causes of pregnancy-related 
     deaths are hemorrhage, embolism (blood clots or amniotic 
     fluid), pregnancy-included hypertension, and infection. The 
     leading causes of death, however, vary by the outcome of the 
     pregnancy.
       For women who die after a spontaneous or induced abortion 
     (6% of all pregnancy-related deaths), the leading causes of 
     death are infection (50%), hemorrhage (19%), and embolism 
     (11%). For women who die of ectopic pregnancy (11% of all 
     pregnancy-related deaths), 95 percent die of hemorrhage. For 
     women who die prior to delivery (8% of all pregnancy-related 
     deaths), the leading causes of death are embolism (34%), 
     hemorrhage (15%), and infection 12%). Most pregnancy-related 
     deaths follow a live birth (55%); of these deaths, the 
     leading causes are pregnancy-induced hypertension and 
     embolism (23%) and hemorrhage (21%).


                       international comparisons

       Several special studies done by states using linkage of 
     live birth vital records with deaths of women of reproductive 
     age, as well as studies in Europe, indicate that current 
     methods of counting pregnancy-related deaths only capture 
     one-half to one-third of all such deaths. For example, Berg 
     et al. (in press) describe the results from a study of all 
     deaths to women of reproductive age in France, which found 
     that 1.3 percent of deaths to women in this age group 
     occurred during or within 42 days of pregnancy and were 
     casually related to pregnancy. Assuming that the 
     underlying risk and distribution of death among U.S. women 
     in this same age group is comparable to that in France, 
     Berg et al. observed that if the 1.3 percent mortality 
     estimate is applied to the 70,130 deaths to reproductive 
     age women in the United States, one would expect a 
     pregnancy-related mortality ratio of roughly 23.5 per 
     100,000 live births. Thus, the magnitude of the problem is 
     several times greater than generally reported.


                           maternal morbidity

       Pregnancy-related morbidity is more difficult to define and 
     is not as well studied as mortality. Pregnancy-related 
     morbidity may occur before, during, or after delivery. 
     Problems which occur may be untreated, treated in some type 
     of ambulatory setting or, less frequently, may lead to 
     hospitalization. Because of these problems, an overall 
     picture of pregnancy-related morbidity has been difficult to 
     assemble. With the current drive in the health care system to 
     avoid hospitalizations, evaluating this issue presents 
     special challenges.
       Using hospitalization for pregnancy complications as a 
     measure of serious morbidity, in 1986 and 1987, it was 
     estimated that for every 100 deliveries, there were 
     hospitalizations for pregnancy loss (spontaneous abortions 
     and ectopic pregnancies), and 15 antenatal hospitalizations, 
     mainly for preterm labor, genitourinary tract infection, 
     diabetes mellitus, excessive vomiting, pregnancy-induced 
     hypertension, and early pregnancy hemorrhage. Among pregnant 
     women in the military in 1987 to 1990, complications of 
     pregnancy resulted in about 27 percent of the women being 
     hospitalized antenatally. The leading causes of 
     hospitalization before delivery in this population were 
     preterm labor, pregnancy-induced hypertension, excessive 
     vomiting, genitourinary tract infection, vaginal bleeding, 
     and diabetes mellitus). (See enclosed articles 
     Hospitalization for Pregnancy Complications, United States, 
     1986 and 1987 and Antenatal Hospitalization Among Enlisted 
     Servicewomen, 1987-1990)
       National data on complications during labor and delivery 
     have not yet been published. Based on a preliminary analysis 
     using data from the 1993 National Hospital Discharge Survey, 
     it is estimated that 24.5 percent of all deliveries (both 
     vaginal and caesarean) are associated with a serious maternal 
     complication. These include obstructed labor in 4.7 percent, 
     third or fourth degree perineal lacerations in 4.8 percent, 
     other obstetric trauma in 3.1 percent. diabetes in 2.9 
     percent, and pregnancy-induced hypertension in 2.6 percent.


                         improving surveillance

       Continuing enhancement of surveillance activities in this 
     area will provide a more complete picture of the factors 
     associated with pregnancy-related deaths. CDC has advocated 
     surveillance of adverse pregnancy outcomes and pregnancy-
     related mortality to assess the incidence or magnitude of the 
     problem, monitor trends, and identify risk factors and 
     clusters. During the past 10 years, CDC staff have been 
     working with representatives of state and local health 
     departments as well as national organizations in charge of 
     providing care to pregnant women, including American College 
     of Obstetricians and Gynecologists, American College of Nurse 
     Midwives, Association of Maternal and Child Health Programs, 
     CityMatCH and other Federal agencies to develop surveillance 
     activities for pregnancy-related mortality and morbidity. As 
     a result of these collaborations, CDC collected information 
     on over 5,000 maternal deaths for the years 1979 to 1990. CDC 
     also funded research projects to examine issues of maternal 
     mortality and morbidity at several universities and State 
     health departments. Data provided by CDC can be used by other 
     agencies, professional groups, advocacy groups, and 
     practitioners to identify problems, plan clinical studies, 
     and alter practices and develop appropriate interventions.


             opportunities for intervention and prevention

       Opportunities for preventing or reducing adverse pregnancy 
     outcomes health status, ensuring access to and use of 
     appropriate care, and improving the content and quality of 
     the care provided. As noted earlier, preconception and 
     prenatal care are important elements in promoting healthy 
     pregnancies and optimal birth outcomes. Preconception are 
     includes risk assessment, diagnosis, and

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     treatment, as well as health promotion activities such as 
     counseling about contraception, pregnancy spacing, early 
     entry into prenatal care, and other health practices and 
     behaviors that should lead to optimal pregnancy outcome. It 
     also provides an opportunity to identify psychosocial and 
     medical risks or conditions before a pregnancy occurs, which 
     facilitates early and appropriate intervention and treatment 
     to address any problems that may complicate pregnancy. Such 
     care initiated prior to pregnancy should continue during 
     prenatal visits and subsequent educational sessions with 
     prenatal care providers. (See attached chapter form Maternal 
     and Child Health Practices, 4th edition, 1994)


             experiences in other industrialized countries

       In essentially all countries in Europe, pregnancy services 
     are a part of the larger, organized health care delivery 
     system. In almost all of these countries, prenatal and 
     delivery care are provided without any out-of-pocket expense 
     to the woman. Some countries even pay women to attend 
     prenatal care. All of these countries provide paid prenatal 
     and postnatal leave for women, with job reinstatement 
     guaranteed. Other types of financial grants and social 
     benefits are given to pregnant women, including paid leave 
     from work for prenatal care visits, family allowances, 
     transportation and housing benefits, and assured day care. 
     Extra support for single women may also be provided.
       The prenatal care systems in almost all European counties 
     include prenatal home visiting, if needed, as well as 
     postnatal home visits. Pre- and post-natal care are viewed 
     not just as medical check-ups but also as social and 
     educational opportunities. Benefits are available to all 
     women and their families in these countries.
       Given the challenges of assessing maternal morbidity and 
     mortality in these countries, as outlined above, it would be 
     difficult to determine the impact of these social policies on 
     maternal health.

                          ____________________