Aren't we over-reacting to the maternal mortality rate?

 

From a brief zoom interaction with my colleague, Holly Mattix-Kramer, earlier today on maternal mortality rates:

Reacting to your posting in the chat, Holly, it is a source of great sadness that a woman should die becoming a mother.  If my wife, sister, daughter was the woman who died, this would be the biggest tragedy in my entire life. 

But thinking about this from the standpoint of the community as a whole, maternal mortality is a small blip on the screen of preventable deaths in the US.

In 2022, the MMR was 22.3/100,000.  That is a total of 817 deaths.  OK, so I picked a low year.  So in 2021 MMR was 32.9/100,000, which is 1204 deaths.  And the highest number I could find on how many of those deaths might be preventable was 80%.  That is 963 in 2021 and 654 in 2022.  Why the variability with MMR?  I am not a statistician, but I bet the fact that we are dealing with a small base of numbers is an important factor; wouldn’t this make slight differences look very large?

Motor vehicle accidents in 2022 were 42,514.  That is 65 times higher than maternal deaths that year.

Kidney disease deaths (hitting you where you live, Holly) in 2022 were 57,987.  That’s 89 times higher than maternal deaths.

And remember that, even though we are properly focused on the differential between white and Black moms, the number of Black moms who die is an even smaller number.  About 1/7^th of all births in the US are to Black moms.  Around 500,000.  If the Black MMR is 3 times the total MMR, then it is 66.9/100,000.  (I know that isn’t right, because we should multiply by the white births, but I don’t know that number.)  That means about 67 time 5, or 335 Black moms die.  Again, a terrible, unspeakable tragedy, but an even smaller number from a public policy standpoint, particularly if only 80% are preventable, which lowers the number to 268.

Yes, I know that every preventable death is worth saving, but I am not arguing we do nothing about this.  I am just arguing that we take into account that how much money and energy and attention we allocate to MMR should be at least roughly proportional to the size of the problem.  About 480,000 people in the US still die from smoking.  That’s 1,315 per day, higher than the maternal death number for the entire year of 2021.

Yet our colleagues in public health continue to rank MMR as a huge problem deserving of the designation of a “crisis.” 

I usually start this discussion in my classes by asking the class how many people have to die from a disease, condition or life event before we start really focusing on it and spending a lot of money to lower it.  The consensus is usually 10,000.  Maternal mortality isn’t anywhere near that.

I am not saying we shouldn’t put some focus on MMR.  And we should definitely focus on the disparities between Black and white mothers.  But in my opinion, we are over-reacting to the problem as a whole.  Beyond my opinion that we are over-reacting to this problem, there is also the point I tried to raise with the student today.  Something with a small “n” is not a very good thing to use as our outcome measure to address poor access to maternal care.  There will be too much variability, and at some point some one opposed to putting more money into caring for poor, Black moms, is going to do the math and say “this isn’t that big a problem.” 

So, we should look for more compelling measures to highlight the problem of maternal care deserts.  Numbers of primary care docs per population served?  Numbers of dollars spent on maternal care per population served?  Money spent on FQHC’s?  Maybe some measure of morbidity?  Extra money spent on intensive care?  I don’t know what would be best to use; this is not my expertise.  But the people with the expertise keep insisting this is a crisis!

That would have been a much more interesting and compelling result of the policy analysis presented. 

OK, thanks for listening.  I feel better now.

DS

PS, Don’t get me started on K-12 school shooting deaths.  Between 1999 and 2022, this number has peaked at 50, with most years well below that.  https://www.security.org/blog/a-timeline-of-school-shootings-since-columbine/.  Yet we have produced an entire generation of children, whom we routinely run through gun detectors to get to their classrooms, scared to death of going to school.  In some of those 23 years, more people died of lightening strikes than being shot at school.  I get that the media blows this sort of thing up, but too many public health experts are doing the same.  ds

 

This election showed the power of passion over reason

I am still processing this election, but I have a few preliminary thoughts.

Passion not reason

Overall, I don't think this was a fight over policy or rational positions.  Trump won because he stirred up passion among a lot of unhappy people, a lot of angry people, and among another group who wanted to believe passionately in "someone," maybe "anyone." The key is "passion," not raciocination.

My friend Sagar, a doctor and former student of mine, said this was an amygdala election, not a cerebral one.  Another friend, Alan, who is a psychologist, likened this idea to “the reflexive response seen in youth challenged by complex trauma.”  Simply put, we are not talking about executive function-like decision-making.  It is emotions, like anger and rapture, not reason.  Something more akin to spirituality, with the many associations between Trump and God as evidence.

So, if that is true, then Harris lost the election the day she announced, because nothing she did or could have done would have evoked greater passion than did Trump. He got people from around the country moving in his direction.  Best results for a Republican in Chicago in decades! All the recriminations against the Democrats are misguided. To use the old cliche, we brought a knife to a gunfight.  And if you scan the likely Democratic candidates for President, it seems clear that none of them could have beaten Trump this year.

It couldn’t have been reasoned analysis that led to his 75 million votes; Trumps biggest positions were patently refutable.

Undocumented immigrants

There aren't 25 million undocumented, and removing the ones who exist will sink agriculture, construction and hospitality. Plus he killed the bipartisan immigration bill.  And study after study shows, contrary to Trump’s dark scenarios, that undocumented immigrants are less likely to commit violent crimes than citizens.  But people who cared about immigration were passionate, and Trump incited that. Not reason. Passion.

Inflation

Inflation, caused almost entirely by the pandemic, peaked at 9.1% in July 2022. It started dropping soon thereafter and is down to 2.1% now (without a recession!). But prices didn't come down, on eggs or rents or a dozen other things people buy every month. So people blame the Dems for causing the high prices (they didn't) and not lowering them (no one knows how to do that). "Aaargh! Look at that grocery bill!"  First Biden, then Harris, talked sense on this, but were met with vivid anger and sadness, not thoughtfulness.

Tariffs

Raising tariffs has sounded simple for centuries, and people feel passionately about fighting economic wars with other countries, with "those goddamn foreigners."  

You can argue logically that high tariffs have never worked and have repeatedly caused severe problems, like more inflation. All you get is passionate shouting in return. Trump led those shouts.

Climate change

Climate change is good science, and that science has been presented by lots a calm discourse by our leaders and pundits. But "drill, baby, drill" is a battle cry. Trump led his followers in that passionate cry and they followed him, amygdalae aflamed.

The “good old days”

More than 1,000,000 Americans died because of Trump's failures in responding to COVID. And one of the very few things he positively championed was tax cuts for the rich, decidedly not in the interest of most of his voters. Yet many of his voters remember his first four years as a wonderful time in the country's history. What did we liberals do?  We offered rational arguments based on solid history, sound science and powerful economic analysis. And, of course, we utterly failed in the face of the passionate memories of that great first Trump term.

Nothing we could do

Nope, there was nothing we could do. Harris was a very strong candidate if this had been an ordinary election. But she was totally out of her league in a hard fought contest of passion over reason.  As would have been any other likely Democrat.

If all of this is accurate, and whoever comes after Trump is as good a rabble-rouser as he was, then we have to find our own purveyor of passion and then come together around a set of values we can champion to fight against the anger, selfishness, and resentment that Trump stoked. I am open to thoughts about who that might be. But I think it is a pretty short list.  

Maybe the next election (if we get to have one) will go back to the standard contest of a mix of emotions, values and reasoned policy discourse. But a roused rabble seldom settles quickly.