Why Women Die After Giving Birth: Part 1

By Louis Keith, MD, PhD

It is no real news that women sometimes die after giving birth, but this fact does not capture headlines, especially in October of each year which is designated “Breast Awareness Month”. Rather, the media is full of grim statistics of how the medical community is exhausting every possibility to fight breast cancer but could do ever so much better if the public gave more money to the various campaigns that support research in this specific area.

Fast forward to other months and the same scenario is trotted out with regularity, but the cast of characters changes. In one month the grim reaper is ovarian cancer; in the next month, it is lung cancer and smoking and so on. For reasons that are not immediately clear, the public is rarely informed of another and perhaps grimmer scenario, that is, the likelihood of bleeding to death in the first two hours after giving to birth. Yes, ladies and gentlemen, you read it correctly; women can bleed to death within two hours after a normal birth, but this is rarely a topic of discussion. Perhaps this is so because the United States has lowered its general maternal mortality rate so markedly in the last century or because most women in our country deliver in hospitals that are equipped to deal with problems of hemorrhage.

The fact remains that at least 200,000 women die from hemorrhage each year world wide, and this number is thought to be a gross underestimate. What is not underestimated, however, is the fact that worldwide the number of female youngsters entering their reproductive years is growing by leaps and bounds, and thus the pool of potential candidates to bleed are ever widening. One does not have to be a math wizard to figure out that in 10 years more than 2 million mothers will die and countless children (newborns and children of higher ages) will be left to fend for themselves as orphans.

The reason that this tragedy occurs is due to a slight aberration in the anatomy of the blood vessels that nourish the uterus in comparison to blood vessels in other parts of the body, the arms and legs, for example. In these two specific areas, the blood vessels run parallel to the muscles themselves, and should bleeding occur, due to a broken limb and torn vessels, for example, it can be controlled by the application of a tourniquet as is taught in first aide classes to Boy Scouts and Girl Scouts and by the Red Cross. Unfortunately, the placement of the blood vessels within the muscular wall of the uterus are different; they pass thru the muscles themselves and depend totally on the firm contraction of the muscles to staunch the bleeding that normally occurs after a birth when the placenta or afterbirth is expelled. When the uterine muscle fibers do not contract, most often for unknown reasons, the area where the placenta had attached itself to the uterine wall represents a 20 centimeter diameter (about 8 inches) wound that continues to bleed.

The process of bleeding after a normal obstetric delivery is termed “Post Partum Hemorrhage”. This condition is truly an equal opportunity killer and represents a risk to every pregnant woman, regardless of her status in society, her education, or the presence of obstetric attendants at the birth. Having said this, it is clear that delivering in a well-equipped hospital is safer in that should the bleeding occur, the woman will be attended by trained medical and nursing personnel who have various therapeutic options available. But here the caveat is being delivered in a hospital with well trained personnel. For most women all over the world, this is more than a dream; it is a frank impossibility, because such institutions do not exist, or because the woman is too poor to afford to go to one, or there is no transportation to take her, or there is transportation and money but the monsoon rains have washed out the roads and the bridges. And so the woman gives birth, bleeds and dies.

In the last few years numerous efforts have been made by governments and non-governmental agencies to change this picture. However, as well intentioned as these efforts may be, they cannot change or remove geographical and institutional barriers. In some instances, hospitals and clinics have been built but these buildings lack something very basic, and that is electricity, so that much of what one would expect from them is still lacking.

Nevertheless, all is not hopeless, as recently a new educational initiative for physicians (and the public who wants to read it) has been published. This textbook attempts to bring much of the useful information relating to this condition in one place, and a full discussion of the book and its objectives will be covered in part 2 of this mini-series.