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Join Alan Lindemann, an obstetrics-gynecology physician and the author of Pregnancy Your Way: Choose a Safe and Happy Birth. We’ll delve into the critical issue of rising maternal mortality rates in the United States, exploring its causes, potential solutions, and why data collection alone may not be the answer. Alan brings over four decades of experience to the conversation and offers unique insights on how to address this complex problem.

Alan Lindemann is an obstetrics-gynecology physician and can be reached at LindemannMD.com, doctales, and Pregnancy Your Way. Follow him on YouTube, Twitter @RuralDocAlan, Facebook, Pinterest, Instagram @ruraldocalan, and Substack. He is the author of Pregnancy Your Way: Choose a Safe and Happy Birth.

He discusses the KevinMD article, “U.S. maternal mortality crisis: a deep dive.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Alan Lindemann. He’s an obstetrics-gynecology physician and the author of the book Pregnancy Your Way: Choose a Safe and Happy Birth. Today’s KevinMD article is titled “U.S. maternal mortality crisis: a deep dive.” Alan, welcome back to the show.

Alan Lindemann: Thanks a lot, Kevin. Happy to be here.

Kevin Pho: So Alan’s been on multiple times. Go to KevinMD.com/podcast; in the upper right-hand corner there’s a search icon to look for his past episodes and hear his story. But today, let’s talk about his most recent article about the U.S. maternal mortality crisis. Alan, how did this article come together?

Alan Lindemann: Well, I’ve been interested in maternal mortality for a long time. As you know, I’ve delivered 6,000 babies with no maternal deaths, not even any eclampsia. So I have a track record. I’m sure many other doctors have a track record that is that good, so I shouldn’t be bragging too much, but I do know what I’m talking about.

Back in 1980, we had a maternal mortality rate of approximately 8 per 100,000, and we reached a low of 7.2 back in 1987. But this has been going up and up over the last years. In 2019, the average rate in the United States was about 19. In 2020 it went up to 21, and as of 2021 it was 31.3. And that’s an average rate. So we’re going up.

If you look at other countries, some people use the excuse, “Oh, we just keep better records than other countries.” I don’t think so. But if you look at Japan, for example, their maternal mortality rate is two. If you look at Norway, Sweden and Denmark, you’re talking about two or three per 100,000. So there are a lot of developed countries that do a better job than we do in this country.

Kevin Pho: Now, what are some hypotheses that can explain our rise in mortality?

Alan Lindemann: Well, like I said, the most common one is that we keep records better, and I don’t think that goes very far. Another one is, “Oh, our population is getting older, and we have more risk factors.” And yes, if you look at the maternal mortality rate for moms 39 and over, it’s 138. The problem with that is that there are not very many moms 39 and over who get pregnant, so other groups account for that rising rate.

As a matter of fact, I read an article in the Green Journal from August of ’23, so not very long ago. They set out to look at age as a determinant of maternal mortality, because that’s one of the reasons, or the excuses, we’ve used. They set out to prove that it was true, and what they actually demonstrated was that it wasn’t true. The maternal mortality rate was rising for every group: 20 to 30, 30 to 40, and over 40. So that alone doesn’t account for what is happening to us.

And of course, you also have a lot of people who talk about health. In other words, we have too many moms who smoke, too many moms who are overweight, too many moms with high blood pressure, all kinds of health excuses. In other words, we’re blaming the patient. The problem with blaming the patient is that it’s not constructive. It doesn’t fix anything. So yes, there are many so-called reasons for this happening.

Kevin Pho: Now, are there any demographic trends within that rise in mortality, any socioeconomic factors that can explain those numbers?

Alan Lindemann: Well, unfortunately there are. If you look at Caucasian, white women, you’re looking at about 20 or 21 per 100,000. Among Native Americans and Alaska Natives, it has now risen to 45 per 100,000. And if you’re looking at women of color, that has now risen to 69.9; I usually round it off to 70 per 100,000. So yes, we have remarkable socioeconomic and cultural disparities, and we do know that socioeconomic factors have some influence on how pregnancies turn out.

I think partly that’s because of moms who, for example, have a job as a waitperson, and that’s their only income, and they don’t have very good insurance and don’t have time off for pregnancy. They can’t even get to their doctor’s appointments. I think that is one group of access problems. But I think there are other problems, too. If you look at NPR, for example, and we’ve talked about this before, they give specific, individual reasons, and if you think it’s appropriate at this time, I can talk about one of those examples.

Kevin Pho: Sure.

Alan Lindemann: This has already been public, and the name is Johnson. Of course, there are a lot of Johnsons, but this was a woman of color. She went in for her first repeat C-section, so that should have been a slam dunk. A repeat C-section is a very simple, straightforward surgery. She had her surgery at about 1 in the afternoon, and then at about 4 in the afternoon she was beginning to have pain and losing some of her color. Her husband went to the nurses, and they were told that she would get a CT scan. Well, by 8 o’clock there had been no CT scan and no doctor visit, and she wasn’t scheduled for a return to the operating room. At midnight they decided they would take her back to the operating room, and they said, “We’ll be done in 15 minutes. Sometimes these things happen.” Well, she died in the operating room. She had two-thirds of her blood volume in her abdomen, and that of course is not a good situation in which to give general anesthesia, because patients collapse. They tried to resuscitate her but couldn’t. This was at Cedars-Sinai, by the way, so a good hospital. At 8 o’clock, when the husband went in again, before they took her to the operating room, the nurses said, “Mr. Johnson, your wife is not our priority right now.”

So this is really what happens. Patients are in the middle of all of this care, but they can’t get at it. If you look at death as the canary in the coal mine, there are about 1,200 maternal deaths in the United States per year, and that’s up from about 700 in the last few years. Well, this canary would have been dead for a long time, because the real problem is severe maternal morbidity, and that is about 50,000 cases, or 50 to 100 times more than deaths. So we have a problem that’s much bigger than it seems to be if we’re just looking at maternal mortality.

Kevin Pho: So what are some of the ways that you suggest we can help tackle this worrisome trend?

Alan Lindemann: Well, it is complicated. If you just look at what happened to Mrs. Johnson, what needed to happen there was that the people who were taking care of her should have been bothered. They should have taken another five minutes to think, “Maybe she’s telling us something important.” You can’t simply tell nurses or doctors that they have to listen to everybody, but that would be the advice I would give: Listen to your patients and take them very, very seriously. It doesn’t take long to walk into a room and see that this woman has no red anyplace, that her lips aren’t red, her conjunctivae aren’t red, her belly is getting bigger, and she’s complaining. So we have to stop being dismissive. And if you look at all of the deaths, and there are many deaths recorded on NPR, it’s the same problem. There’s health care all over the place, but not the kind of health care that is doing people any good.

If you look at this problem, it’s not one problem. People sometimes give the analogy of the airplane crash: It’s not one system that fails; it’s many systems that fail at the same time, and that’s really what we have here. If you got all the players in a room, for example, big Medicare, Medicaid, several insurance companies, the AMA, a group of doctors and patients, and tried to talk about what could be done to solve this problem, everybody would have something different to say, and they would all blame everybody else. That’s really the main problem we have right now: Nobody is taking responsibility for any of this.

Now, we do have a grassroots movement. Take not smoking cigarettes: In 1960, people thought we were kind of crazy for thinking in those terms, and this probably happened before your time. But it didn’t come from Big Tobacco, and it didn’t come from big government. It came from the people, and that’s what’s happening now. This movement is coming from the people, and unfortunately it’s because people are tired of it. They’re hearing about it and thinking about it.

If you look at ACOG, for example, the American College of Obstetricians and Gynecologists, they have the opportunity to take leadership here, but they’re not. Medicare is in the same position. They’ve recently come out with $168 million and named nine centers of excellence, and their centers of excellence mostly involve data gathering. That’s one of the things our government does best: gathering useless information. And even if you think they could gather something useful, it’s going to take seven or eight years to get any results from that. So we really need to start thinking right away, and unfortunately, like I said, this is probably going to be grassroots. Access could be something that Biden fixes tomorrow with the stroke of a pen. We could talk about our legislators helping out. We could ask ACOG, “Where are you on this maternal mortality issue?” But we’re not doing those things, so it’s going to be grassroots.

Kevin Pho: Now, if you were in charge of policy, if you were in charge of ACOG or could make decisions on behalf of our government, what would you like to see done?

Alan Lindemann: Well, first of all, they need to come out and say, “We think this is a problem. We are going to take this very seriously, and these are the things we’re going to do.” For example, everybody is going to have access to all the prenatal care they need. We are not going to deprive any patients of visits. One of the problems we have right now is limits on the number of visits you can get. I think one of the reasons I had 6,000 births with no maternal mortality is that I had my own practice, so if I didn’t get paid for a visit, it wasn’t a problem. I was the only one who had to worry about that. But we have doctors now who have to worry about getting paid, because a lot of them are employed doctors, so their bosses are looking over things. So I really would improve access.

The other thing I would do is make sure that everybody had all the care they needed up through the first year. In this country, we shut off postpartum care at six weeks, because that’s how long the uterus takes to return to normal size. I saw my patients as often as they needed to be seen. One week was my favorite time to see them, because that’s the time you can head off troubles. And of course, anytime somebody comes in with a complaint like bleeding, they have to be seen right away. We should have absolutely no deaths from bleeding in our country. Nobody should bleed to death.

One of the things that I tried to do 30 years ago was make sure that moms didn’t have mental health problems, moms and dads. To that end, I saw everybody: moms, dads and kids were welcome at every visit. I think that’s really important, because you get to see how the family reacts, how they interact with each other, who’s the boss, how they respect each other, whether they like each other, whether they love each other, whether they can work together.

Take the number one cause of maternal mortality today: It’s called behavioral, so suicide, homicide and drug overdose are in that group. Well, I think that is preventable. I know people are going to call me a heretic for saying that, but it’s preventable. And the people who fall through the cracks have to be seen immediately, the day they call. They need treatment, and you have to listen to them. I always had a psychiatrist I could call, so we talked about what kinds of meds to give. I liked Ativan and Effexor, because the Ativan worked right away and the Effexor worked really well, and then they’d see the psychiatrist within the week. There are a lot of doctors now who don’t think that behavioral health even falls within their purview, and yes, they can say that, but it doesn’t fix the problem. We still have the problem, and we still have the opportunity to fix it. So if I could wave a magic wand, I would fix prenatal care and postpartum care.

Kevin Pho: We’re talking to Alan Lindemann. He’s an obstetrics-gynecology physician and the author of the book Pregnancy Your Way: Choose a Safe and Happy Birth. Today’s KevinMD article is titled “U.S. maternal mortality crisis: a deep dive.” Alan, let’s end with some of the take-home messages that you want to leave with the KevinMD audience.

Alan Lindemann: Well, thank you, Kevin. One of the reasons we wrote our book is what I was talking about: mental health during pregnancy. Mental health during pregnancy is not mysterious, it’s not magical, and it’s not complicated, but you have to care about it. Everybody has to care about it.

Years ago, we could keep moms and dads and babies in the hospital as long as we wanted after birth. Today they’re kicked out after 24 hours. If I could wave a magic wand, I’d fix that. I’d say, keep them in the hospital like we used to until they’re ready to go home. They need to know what to do when they go home: how often to feed the baby, when the baby is hungry, who should do the dishes, who should fix the food, clean the bathroom and wash the floors. These are the things that people have trouble with when they go home, and if they had a plan, they’d do better.

Kevin Pho: Alan, thank you once again for sharing your perspective, time, and insight, and thanks again for coming back on the show.

Alan Lindemann: Thank you.