529,000 women and girls die every year from pregnancy-related causes in the world. Ten million more suffer injury, infection, or disease as a result.

    Five direct causes account for 73 % of these PREVENTABLE maternal deaths.

    Hemorrhage 25%
    Infection 15%
    Unsafe abortion 13%
    Eclampsia 12%
    Obstructed labor 8%

And this, our ranking in neonatal mortality among nations in the world as of 2006, calculated as the number of neonatal deaths per 1000 live births:

      44. Lithuania 6.68

      43. Belarus 6.63

      42. Croatia 6.60

      41. United States 6.37

      40. Korea, South 6.05

      39. Cuba 6.04

      38. Faroe Islands 6.01

But while we are behind the Faroe Islands, Cuba and S. Korea, we are definitely ahead of Croatia, Belarus and Lithuania; and every nation in Central and South America, Africa, Central Asia and the Middle East (CAASA,A,CAAME).

These numbers were steadily falling and our ranking in the world was steadily rising for most of the decades before the disastrous presidency of George W. Bush and his administration "served" by the incompetent zealous fundamentalist Christian religious toadies and outright criminals who have manned the regulatory barricades of most federal agencies during the Bush years.

If one counts the number of America's dead children and dead mothers, and those still alive but bearing lifelong and massive injuries in this country, these numbers far exceed those of 9/11 and the disastrous numbers of dead and injured Americans in Bush's "War on Terror" in Afghanistan and Iraq.

Darrel Royal, the former Hall of Fame football coach at the University of Texas used to say about passing, "If you pass the ball, three things can happen, and two of them are bad."

He could have said the same thing about getting pregnant, if you consider abortion a bad thing.

Now follow me carefully here, because this might get a little confusing,  especially for those who feel that all pregnancies are joyous events following God's plan.  When a girl or a woman discovers she is pregnant, there are only three ways it can end.  Either she continues the pregnancy in an attempt to deliver a child, or she will spontaneously or electively abort.  At least 50% of all pregnancies abort before she even knows she is pregnant, and 25% will spontaneously abort sometime after she knows she is pregnant.  And in the US today, at least 40% of those who have an unplanned pregnancy will seek elective abortion care in the states where it remains accessible and available to them.

Let's suppose she decides she wants to have a baby and DOES NOT spontaneously abort.  Most pregnancies implant inside the endometrial cavity, but some small percentage are "ectopic pregnancies," meaning that they are NOT implanted in the endometrial cavity, but somewhere in the fallopian tube, the ovary, the abdomen, or the cervix.  Although a tiny fraction of these might continue to term, and a minuscule fraction of these be delivered alive and well.  The most common thing that happens is that these pregnancies cause the death of the mother if untreated, or they end up as a fetal death.  And in CAASA,A,CAAME, most women will die as well.

But let's say she is pregnant inside the womb just where she should be, as are most pregnancies.  For a wide variety of reasons, at least 25% of all pregnancies spontaneously abort after the woman knows she is pregnant.  Not all spontaneous abortions end up with a spontaneous discharge of the fetus.  Sometimes women have a "missed abortion."  And if the fetus lies dead within the uterus for a few weeks, the girl may develop what is known as DIC - disseminated intravascular coagulopathy.  DIC causes uncontrollable hemorrhage, and prior to blood transfusions and the availability of fractionated blood clotting factors, women with DIC died.  And some still do without excellent care.  When I was an ObGyn resident from 1968 to 1972, I was involved in the treatment of perhaps a score or more of these unfortunate patients.  In each instance we were able to save these patients by eventually effecting the delivery of the dead fetuses, but I knew of several of these patients who died before they reached our hospital.    

And now lets look at a few other risks every girl and woman faces when she seeks to carry a pregnancy to term.

Maternal hemmorhage has many fathers: Incomplete spontaneous or elective abortion, especially when abortion services are provided by the patient herself or an unskilled other; cervical or uterine tears and perforations that may occur as a factor in any delivery or any abortion; uterine atony - when the uterus fails to contract after delivery;  unrecognized spontaneous tears of major arterial vessels that may cause massive bleeding into the retroperitoneal space.  And next comes problems with retained placental fragments, with placenta accreta, increta and percreta.

Then there are many types of common infections, including routine postpartum endoparametritis which occurs in 1 to 13% of pregnancies. Infections of the episiotomy site and cervico/vaginal/vulvar tears.  And then there are the breast infections that sometimes occur with breast feeding; urinary tract and kidney infections, and maybe worst of all the so-called flesh eating bacteria infections that sometimes cause disastrous lose of skin, fat and muscle in the vulvar/anal and abdominal areas.  

Next, we come to obstructed labors when the labor has stopped and And now let's look at a few other risks every girl and woman faces when she seeks to carry a pregnancy to term.

Maternal hemorrhage has many fathers: Incomplete spontaneous or elective abortion, especially when abortion services are provided by the patient
herself or an unskilled other; cervical or uterine tears and perforations that may occur as a factor in any delivery or any abortion; uterine atony - when the uterus fails to contract after delivery;
unrecognized spontaneous tears of major arterial vessels that may cause massive bleeding into the retroperitoneal space.  And next comes problems with retained placental fragments, with placenta acreta, increta and percreta.

Then there are many types of common infections, including routine postpartum endoparametritis which occurs in 1 to 13% of pregnancies.  
Infections of the episiotomy site and cervico/vaginal/vulvar tears.  And then there are the breast infections that sometimes occur with breast feeding; urinary tract and kidney infections, and maybe worst of all the so-called flesh eating bacteria infections that sometimes cause disastrous loss of skin, fat and muscle in the vulvar/anal and abdominal areas.

Next, we come to obstructed labors when the labor has stopped and the uterus is either too weak or the head is too large or the presenting part of the baby can't fit through the pelvic bones.  These may occur for any of these reasons. Sometimes, all that is needed is medication to increase the strength of the uterine contractions.  Sometimes, rupturing the membranes accomplishes this.  Or sometimes, turning the head with forceps can effect a more favorable position of the fetal skull and allow the head to negotiate the pelvis and often, a skilled obstetrician can do a forceps delivery or a suction cup extraction of the baby.  And when these don't work, a c-section is resorted to.

Forceps rotations and forceps deliveries are becoming more and more rare because the vast majority of young Ob-Gyns have never had the opportunity to develop these skills.  When I was a resident, a c-section rate of more than 3 to 5% was frowned on.  And we did some incredibly difficult very risky rotations and deliveries because we avoided c-section at almost any price.  Today, our national rate of c-section is approaching 30% and some feel that even this rate may need to be increased.  My c-section rate never went above 15%, but I never did a section I regretted, and didn't do a goodly number that I regretted NOT doing.  I have lost a few babies because I didn't do a c-section soon enough or not at all.  I have never lost a mother because I DID a c-section.

And now we come to eclampsia and pre-eclampsia, usually unpredictable and often striking apparently young healthy women, often in their first pregnancies.  Two of the maternal deaths that I was involved in, either as a consultant or as the receiving physician when I was a resident, involved severely pre-eclamptic women, one of whom died within 45 minutes after she presented to our ER with a blood pressure of 240/140 and a urine so full of protein, a marker for pre-eclampsia, that it looked like milk.  Almost as soon as she arrived at the labor and delivery floor, she ruptured her liver and died.  She was unmarried, 42, mother of 7 children, and when we reviewed her previous prenatal history, she had developed evermore severe pre-eclampsia with each pregnancy.  This was in my first year of residency; a shattering experience for her family and a young doctor.  

There are many theories about the causes of pre-eclampsia and eclampsia.  But so far as I know, no one has claimed a Nobel Prize in medicine for finding either a cure or a way to prevent it.

We have not even addressed the many pre-existing and acute illnesses and conditions that can increase risk of M&M events for affecting both mother and child.  Here are a few: obesity, diabetes, high blood pressure, illegal and some legal drug use, several types of anemias, vitamin deficiencies, many congenital and chronic disease processes, tobacco and alcohol abuse, and a myriad of others that I either have forgotten or can't think of at the moment.

Many states, including mine, force abortion care providers like me to give information about the risks of receiving safe, legal, professional abortion care.  These risks are miniscule when compared to the risks that face even the healthiest young woman over her 9 months of pregnancy and year or so of post partum follow up.  I think if we Ob-Gyns were forced to hand out warnings of the amazing numbers of risks and potential consequences facing every pregnant woman, it would be a miracle that any girl or woman ever accepted those risks.

And yet, millions of girls and women gladly accept these risks every day.  Even nurses and physicians who know first hand exactly what the risks entail.

Woman is an amazing, and amazingly courageous gender.

It is a very good thing we males were not assigned this task by the creator of this universe, or the human race would have died off as soon as men knew what was causing all this suffering and destruction.  We would have just said NO!

Next week on Thursday, 7:30 a.m. Part II  Neonatal Morbidity.  Going Up!...