100 years ago, maternal mortality in the U.S. was about 500 per 100,000 births. Today it stands at about 15 per 100,000 births. Around the world, maternal mortality rates in parts of the third world are higher than they were in developed countries 100 years ago. Key quote…..
The countries with the highest maternal mortality ratios are Sierra Leone (with 2,100 maternal deaths per 100,000 live births), Niger (1,800), Afghanistan (1,800), Chad (1,500), Somalia (1,400), Angola (1,400), Rwanda (1,300), and Liberia (1,200)……..
Lifetime risk is the probability that a woman will die from complications of pregnancy and childbirth over her lifetime; it takes into account both the maternal mortality ratio (probability of maternal death per childbirth) and the total fertility rate (probable number of births per woman during her reproductive years). Thus in a high-fertility setting a woman faces the risk of maternal death multiple times, and her lifetime risk of death will be higher than in a low-fertility setting. The lifetime risk of maternal death in the developing world as a whole is 1 in 76, compared with 1 in 8,000 in the industrialized world. This gap becomes a yawning chasm if the countries with the best and worst records are compared: In Ireland, women have a 1 in 47,600 lifetime risk of dying during pregnancy or from a birth-related cause, whereas women in Niger face a 1 in 7 lifetime risk.
The reasons for the improvement are many. Better pre-natal care, better birth attendant care and better training are among them. A contribution which continues to interest me, is making the C-Section safer. We long ago learned that avoiding general anesthesia, reserving it for emergencies for the most part, made for a safer C-Section. In fact, we have become so adept at avoiding general anesthesia for C-Sections that some residents are going through training with little or no exposure to the technique of administering a general anesthetic in an emergency C-Section. The first one they may see is when they are out in practice, on their own. Program directors are working to find ways to prepare residents for this now uncommon, but not rare event.
How do we prepare for the really rare events? The one in a million events. In medicine we prepare by reading about them. We prepare by understanding basic anatomy and physiology, by understanding the pharmacology of our drugs. In general, few of these one in a million events require an instant decision. We usually have time to sort things out. We can run tests to eliminate diagnoses. Still, especially when we are time and circumstance limited, we may guess wrong. We may have chosen the most likely treatment for an emergency to later find out we were facing that one in a million patient. Lucky for the average physician, he/she will not treat a million patients in their practice. We will see very few truly rare problems.
Now, what happens if we are dealing with rare events as they happen in the national security arena, specifically a TSA agent inspecting people getting on airplanes. The odds of any specific passenger carrying a bomb on board is one in very many millions. Any specific TSA agent will spend their whole career searching people and never find anything. They will most likely not know anyone who has ever conducted a successful search. Day after day of searching cranky people who all know that they are not terrorists.
In this type of scenario, how do we get relatively low paid workers to maintain adequate vigilance? What we are doing is insisting that people from certain countries all be intensively searched. Some want to engage in profiling, usually meaning that we intensively search everyone who looks Arab or has a funny name. In other words, large numbers of people who will not be carrying bombs. Rather than creating big lists that never get investigated or searching huge numbers of people with no findings, we need to reduce the number of people who are actively searched. Behavioral profiling, technology used judiciously and enhanced intelligence, starting way before the airport, seems like a better way.