8.26.2008

"The Life of the Mother"

A common question that comes up when discussing procreation is: "What if the life of the mother is in danger?"

My typical first response to this question is: "The mother's life is always in danger with every pregnancy." Many people in today's world don't really even think of childbirth as being dangerous. Relative to year's past, it isn't. But, just for the sake of perspective, let's consider the actual statistics.

First, let me introduce a technical term: "Maternal Mortality Ratio" (hereafter "MMR"). This is the number of maternal deaths per 100,000 live births. In the United States in the year 2000, the MMR was 17. To put that in terms some might find easier to understand, an MMR of 17/100,000 equates to an approximate 1 in 6000 risk of dying with each childbirth experience. The current MMR of 17 is just a bit higher than the risk of death in automobile accidents (15).

If you happen to be one of those who do not pay much attention to the risks of driving a car, consider that auto accidents represent the number one cause of death in children and young adults. Some people take all kinds of precautions for other risks that they don't realize are relatively negligible and then throw their kids in the car without proper safety restraints and drive down the road talking on their cell phones.

Back to the point of this post... Even with modern medical advances, each pregnancy still places a woman at a relatively high risk of death.

Now, let's put that in some historical perspective. Below is a chart showing the reduction in the MMR since 1890, when statistics were first reliably recorded (source: Irvine Loudon,
Maternal mortality in the past and its relevance to developing countries today, American Journal of Clinical Nutrition, Vol. 72, No. 1, 241S-246s, July 2000 ).



As you can see, the risk of death from childbirth used to be 20-50 times higher than it is today (10 times higher just in our parent's lifetimes). Compare a previous normal 1 in 200 risk of dying with each pregnancy versus today's greatly improved 1 in 6000 risk. One can only speculate what it was like in previous eras. I wonder what the risks were 1000 or 5000 years ago.

So, the honest ethical questions I would like to ask in this post begin as follows:

How much higher than today's normal (15/100,000) would the risk need to be for a mother to decide it is "too dangerous" for her to consider getting pregnant? If you are 50 times more likely than average to die from childbirth because of a particular medical condition, your risk of death is probably pretty close to the average risk of death of a woman prior to 1935 in the United States, and probably much better than the average in Luther's day.

Does the fact that modern medicine has greatly improved one's chances of surviving pregnancy make the risks women used to take morally unacceptable for today?
Should they have refrained from having children back then because of the high risk of pregnancy? Should we refrain now when the risks approach their levels because it isn't normal for today?

It sounds pretty harsh when looked at in these terms, but what do you think?

I give thanks for all the mothers throughout history who have risked their lives to give life. Thanks be to God for our mothers!

19 comments:

Liz said...

I'll answer your questions, but we're going out of town on Thursday, and I don't want to offer you a half baked answer.

Jon said...

A little data is missing.

Of the 17 deaths per 100,000 what percentage had...
1. Some secondary health issue.
2. Drug or alcohol addiction.
3. Little or no pre-natal care.

My guess is that it may be safer than the numbers show.

Of course their are risks. I worry like mad when my wife is pregnant.

I'd like to see the breakdown

Thursday's Child said...

I was listening to or reading something lately (maybe IE?) that said there is nothing that can endanger a woman's life during pregnancy that can be solved by abortion. I wish I could remember where exactly I found that tidbit. It would come handy right about now.

Rebekah said...

I don't know how profitable it is to base our positions today on the way things used to be, although I definitely think the historical perspective is informative and we would be arrogant to disregard it. I don't have any answers, but I think the bottom line is that the ethical landscape has changed and we have to figure out how to function within it.

So some of you smart people figure it out for me, right?

Erich Heidenreich, DDS said...

Jon,

I don't believe reliable statistics are available for what you are looking for. But, please consider that the same type of data is missing from the auto deaths comparison I made for perspective. Some of the maternal deaths could be attributed in-part to secondary health issues, drug or alcohol addition, or little or no prenatal care. But, likewise, many of the auto deaths can be attributed to secondary causes, drugs, alcohol, etc. I maintain that the comparison is valid as presented.

In addition, I think that the factors you mention would have roughly the same effect on the MMR as the factors I mention have on auto accidents. I'd expect over half of all auto deaths would be prevented if people would always drive sober, wear their seat belts, obey the speed limit and other traffic laws, and maintain their vehicles properly.

One article (Maternal Mortality—United States, 1982-1996, JAMA, 1998;280:1042-1043) states that:

"Primary prevention of maternal deaths, such as those associated with ectopic pregnancy and some cases of infection and hemorrhage, is possible. However, some complications that can occur during pregnancy cannot be prevented (e.g., pregnancy-induced hypertension, placenta previa, retained placenta, and thromboembolism). ...Hemorrhage, pregnancy-induced hypertension, infection, and ectopic pregnancy continue to account for most (59%) maternal deaths."

Erich Heidenreich, DDS said...

Thursday's Child,

The info in this post can certainly be to abortion, but I'd like to clarify that the main point I was addressing was the question of casuistry when it comes to contracepting in cases when the mother's life is perceived to be "in danger."

Erich Heidenreich, DDS said...

Rebekah,

I'm not sure it isn't profitable to measure our positions today against the way things used to be.

I'm also not sure the ethical landscape has changed as much as our perception of it has.

Since parturition has been made exponentially safer over the years, our perspective has shifted regarding any dangers.

What I have noticed as a health care provider is that people's toleration for morbidity and mortality has become greatly reduced - if not eliminated - by the fact that so much of the what ails us as humans is "treatable." Doctors are expected to make everything better, and eliminate all diseases and discomforts. When we fail, we are deemed incompetent. Most people are barely even willing to tolerate a headache these days!

We're over-diagnosing and over-treating in a dream that we can make a perfect world on earth. In the end, we are only creating more problems. There's a limit to how much pain and suffering you can prevent or cure, and it's not even healthy to try to eliminate it all.


God: "Be fruitful and multiply."

Satan: "Ummm... don't you think that's a bit too dangerous? Maybe now is not the best time. In fact, maybe you're not the right person for the job in the first place. Let someone else do it that doesn't have such a hard time. God said he'd increase your pain in bearing children, but this is getting a little ridiculous. If he didn't want women to find ways of avoiding the punishment, he wouldn't have given them brains and he wouldn't have allowed contraception to be invented. In any case, aren't there plenty of women in this day and age for whom it isn't dangerous?"

Rebekah said...

What I mean by the ethical landscape changing is that there's a lot more information available to us now. For example, should someone who knows s/he has an increased risk of infertility (due to illness or surgery or something) marry? I don't know that it's useful to say, "Well, in the past we wouldn't have known that so we should just pretend like we don't now." Or, more to the point: a woman in her childbearing years is diagnosed with a serious illness whose treatment would be damaging to an unborn child. In the past, there wouldn't have been a treatment and the woman would have died (along with a child if she became pregnant), conveniently precluding the moral dilemma. How helpful is that historical fact in figuring out what the woman should do?

Erich Heidenreich, DDS said...

Those are good points, Rebekah. Modern medicine is certainly able to tell us things we didn't know in the past. I don't deny that there are extreme cases where the answer would, perhaps, call for one to choose the lesser evil.

However, my point is this: Knowing you have a particular complicating factor often makes it possible for doctors to take this factor into account in managing the pregnancy, thus protecting the life of a woman who would likely have died in previous centuries.

The protection offered by modern medicine often makes it possible for women with complications to procreate with approximately the same risk level healthy women have had for the majority of history.

Why would the fact that modern "healthy" women no longer face the same risk level make such historically acceptable risk levels unacceptable to the woman who has complicating factors today? Though she is at greater risk than her healthy sisters, she is perhaps at the same risk her healthy mother or grandmother were.

Why would it be right to say "I will not allow myself to get pregnant because it is more risky for me than what my peers experience in today's modern world"?

Why would it be wrong to say "I will allow myself to get pregnant because modern science makes it possible for me to have a baby without any more risk than my grandmother had, even though I have X condition"?

Those are the basic ethical questions I am raising regarding the common "life of the mother" argument. I make this point agreeing that individual cases must be evaluated individually. However, in an effort to maintain the integrity of the logic of my argument I should point out that the theoretical case you gave, Rebekah, involved the life of the child as much as the life of the mother, adding another factor into the equation that is not directly relevant to my point.

GL said...

I believe it was the great British Prime Minister Benjamin Disraeli who first observed that their lies, damned lies and statistics. There are at least two problems with your use of the statistics which you cite.

First, one means by which maternal mortality has undoubtedly been reduced is by women who are at greatest risk taking steps to prevent pregnancy. Thus, the statistics you cite can be read to actually make the case for the use of contraception in high risk situations.

Second, the risk of death for an individual woman is not 17 out of 100,000. For a woman with no known abnormal risk factors, it is likely much lower.

However, some women do have known abnormal risk factors. My sister-in-law had two pregnancies. The first ended in a miscarriage due primarily to my sister-in-law's rapidly deteriorating health which her physician attributed to the pregnancy itself. The second resulted in a live birth which was induced two-and-a-half months before the due date to save both the life of the child and the mother. Again, her doctor attributed my sister-in-law's deteriorating health to the pregnancy itself and warned her that another pregnancy might kill her. As a second example, our former pastor and his wife have six children. His wife nearly died during the birth of the sixth child. Again, her doctor warned that another pregnancy would present a very high risk of mortality.

In both of those cases, the couples took steps to prevent future pregnancies. For them, the risk of maternal mortality was much higher than 17 out of 100,000. I don't know the level of risk nor whether they were given such a level. It would, however, be very misleading to use the statistics you cite to judge their situation.

The risk would have to be known for a given woman to know how reasonable the concern is. For most women, use of this reason to justify using contraception is specious, as your cited statistics demonstrate. For others, however, the concern is all too real. Then the questions become how can such concerns be effectively addressed and what means are morally licit.

Erich Heidenreich, DDS said...

Greg,

You bring up an important point to consider, but I believe it is speculative without statistics to back it up.

I would point out that for most of the years in which the MMR began to be reduced, contraceptive information and devices were still not easily obtained by women - especially the women at highest risk of death from pregnancy. There are indications that contraception still tends to be used the least (and least effectively) by those segments of the population who are at greatest risk.

The rise in midwifery and improvements in prenatal care are most often cited as the main reasons for reduction in the MMR - at least in the studies I reviewed for this post.

Also consider that the risk continued it's downward pattern even during the baby boom after WWII.

No doubt the use of contraception in cases of increased danger to the life of the mother has contributed something to the improvement of the MMR, but how much of the change this accounts for is unclear.

Many of the risks of pregnancy cannot be predicted.

If anyone is aware of studies that flesh out the questions and points that have been raised here by Jon and Greg, please post some links!

Erich Heidenreich, DDS said...

Just to clarify, I would consider using non-abortifacient contraception in "high risk" situations, classifying it as being the lesser evil.

The question I haven't figured out is how high a risk is when it becomes a "high risk" situation. I have a feeling that my definition of "high risk" would be much higher than most.

Thankfully, this is not a serious question for the majority of people, and therefore is totally irrelevant to the greater question of the morality of contraception for the average person.

As I have pointed out before when discussing conflicting absolutism, in cases when it appears two absolutes come into conflict we must make our choice of the perceived "lesser evil" realizing that we could very easily be wrong. Conflicting absolutism depends entirely upon the forgiveness that is certain in Christ.

When faced with a true moral dilemma, make the best informed decision you can in a given situation and throw yourself on the mercy of Christ.

Rebekah said...

Dr H, I'm tracking. You said in the post that this can all sound harsh. I'd say that it doesn't sound harsh in itself, but people are going to get really excited to infer that you're saying, "Damn the cancer, full baby ahead!" That's not what you're saying, but it's what people want you to say because then they can write you off as a nut.

Here's how I see the application of history in the discussion: in the past, people had to gamble (or, more piously, trust). A couple got pregnant and hoped and prayed that Mom wasn't one of the women who would die as a result. We have a lot less physiological gambling these days. Heck, people know what the insides of their own personal intestines look like. So we can look to the gamblers as figures of personal courage and spiritual faithfulness (blessed are you, Mr and Mrs Ambrosius Berndt), but not necessarily as specific historical precedents or for purposes of casuistry in the the complicated situations people find themselves in today.

As for modern women . . . I'm sitting here laughing right now remembering a person I know who won't get pregnant because "I think it might mess up my body." ROFL, if I weren't so decrepit from all this dreadful childbearing! My kingdom for a wheelchair!

Devona said...

This pertains to a recent conversation that I had with a good friend of mine, who is not a Christian for what it's worth. She almost died in her first pregnancy, hemorrhaged, lost a ton of blood and had to be resuscitated. They proceeded to have a second child about 5 years later, and in this birth she nearly died again and they almost lost the life of her baby as well. Fortunately both are well now, though her daughter is slightly developmentally delayed.

What is striking to me is that she and her husband really wanted to have a large family, but since she nearly died twice they are afraid to have anymore children. She is still not convinced that either of them should be sterilized, so they are in pretty constant conflict over what to do contraceptively.

I really pity them. But it's surprising to me that they really are the "high risk" family, but they want a large family so bad that they still hold onto the hope that something will change. It's a stark contrast to the women who have a C-section for "failure to progress" and then stop having children and call it "health reasons."

Joy said...

Brothers and sisters, I believe this is where we should offer our bodies as living sacrifices. If I know in advance that a pregnancy would jeopardize my life, then not using a contraception is equivalent to willful self-injury, and that is sinful. But life comes from God, and He can create with or without contraception--wtih or without sex, in fact! His will, His timing, not ours.

(Rebekah, you told me to keep my can of worms open and we'd talk, then shushed my input on the NFP discussion at CSPP. What gives? I'm interested in your perspective.)

Erich Heidenreich, DDS said...

Joy,

Welcome to Lutherans and Procreation! Your comments, questions, and arguments are welcome here. I understand CSPP to be more of a "ladies night out" kind of discussion. They generally refer the weightier theological debates over here.

Now, as to your comment here... My point in this post is that you put your life in danger with EVERY pregnancy. Some pregnancies are more dangerous, some are less dangerous.

By analogy, you also put your life in danger every time you get into your car and drive down the road. If you can't afford the latest model vehicle with all the latest safety features, does that mean you shouldn't be driving?

This is where the principles of conflicting absolutism comes in. Do the best job you can of choosing the lesser evil and rely upon Christ's mercy to forgive our sins, knowing our choices may have been the wrong ones.

In the final analysis, everything we do is infected with sin - even my best works are but filthy rages. Whenever I do any good work, I know sinful pride will infect it the moment I identify it as a good work. So, do I stop doing good works?

As for God creating with or without contraception, certainly anything is possible for God to accomplish. Isaac was born to a barren old women, and Christ was born to a virgin. But our actions do have consequences. Contraception is not without effect just because we have an omnipotent God. A great deal fewer children are born today due to the effectiveness and widespread use of birth control.

Joy said...

This touches on some of the things I said in response to you on the CSPP site. As Lutherans, we should always ask, "What does this mean?" What does my use of bith control (even NFP) say to God?

I will never claim to own the die-hard absolute truth on contraception! My husband is an LC-MS pastor, septalingual, and on the brink of a PhD. And we go around, and around, and around the block on this issue. Like Rebekah, it's not that I adore children and want as many as possible, but I love and trust God, and He claims they're a blessing. (maybe He hasn't met my 3-year-old)

If pregnancy carried the same risk as playing hopscotch, it wouldn't be a big deal. If motherhood were stress-free, it wouldn't be the toughest job in the world. So I guess the question is, where is the line between perfect trust in the Lord and medical recklessness, or mental sanity, or fiscal prudence? Again, I don't claim to have the answers. :)

Erich Heidenreich, DDS said...

Joy,

BINGO!

"I don't have all the answers"
is the correct answer to this post's questions. That's where the Gospel as taught in the Lutheran Confessions is so vitally important on this and every other issue we face in this broken world. We cannot answer these questions infallibly, and therefore we must rely upon the free forgiveness which is in Christ.

But, we must not use Christ as an excuse to do whatever we want. We must do the hard work of examining ourselves in light of God's Word.

The moral of this post is summed-up by St. Paul as follows:

"Moreover the law entered that the offense might abound. But where sin abounded, grace abounded much more, so that as sin reigned in death, even so grace might reign through righteousness to eternal life through Jesus Christ our Lord. What shall we say then? Shall we continue in sin that grace may abound? Certainly not! How shall we who died to sin live any longer in it?"
[Romans 5:20-6:2]

And here is Luther's paraphrase of this:

"Be a sinner, and let your sins be strong, but let your trust in Christ be stronger, and rejoice in Christ who is the victor over sin, death, and the world."

Source: Project Wittenberg

Luther's words "let your sins be strong" were meant to advise us not to minimize our sins, but rather to let the law's mirror show us all our sins in their full ugliness. These are also the words which are commonly mistranslated as "sin boldly" - something Luther never said.

This post is the law speaking in its full harshness, and we can never keep the law perfectly. Therefore, to quote Luther's wife, Katie:

"I cling to my Lord Christ like a burr on cloth."

Joy said...

Well, German tanslation is often a matter of who's translating. When we quote Luther as saying "Sin Boldly", we must include what comes next: "But believe in Christ all the more boldly."

As you rightly said, we don't use Christ as an excuse to do whatever we want. Like so many things, living on this side of the cross gives us the freedom to do what we OUGHT, not what we want.

And therein lies the rub.