[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.
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