One would think that since we live in the United States with the most expensive health care system in the world, you would not even need to ask that question. After all, in the United States and many other developed nations as well we have great prenatal care, excellent obstetric facilities, and neonatal intensive care units. So no need to worry? Right? Wrong!
A quick look at world Maternal Mortality rates published by the British Medical Journal, The Lancet, will shout out that something is terribly wrong in the maternity wards in the US.
Maternal Mortality Rate by country (Deaths per 100,000 (1)
There are several factors involved. However, my impression in the nearly 40 years that I have been involved in the birthing, breastfeeding scene is that many women and couples have become complacent about their pregnancy and their birth, leaving it all in the hands of the doctor. This, unfortunately, has negative results because the childbirth statistics probably reflect the decline in health in general in the United States. Without some education and extra effort a mother in poor health or poorly nourished before pregnancy is unlikely to become healthier with the stress of pregnancy on her body. As a result, you will see an increase in preterm birth rates, poor neonatal outcomes and maternal illness associated with pregnancy.
According to the White Paper on Preterm Birth published by the March of Dimes, preterm birth rates in the US increased by 29% from 1981 to 2002 with an increase of 13% from 1992 to 2002. (2) Some states showed an increase of 30%. According to the White Paper, Africa ranks first in the incidence of preterm birth (births less than 37 weeks gestation) with North America (the US and Canada) ranking second.
In 2009, the March of Dimes gave the United States a D for Preterm Birth Rate. The ratings were made by comparing preterm birth rates to the National Healthy People 2010 preterm birth goal of 7.6. The preterm birth rate in the United States in 2007 was 12.7%. (3)
A major cause of premature births is preeclampsia (toxemia). Preeclampsia is a disease characterized by an increase in blood pressure, protein in the urine and sudden weight gain from fluid retention in the tissues. Elevated blood pressure that goes away after pregnancy and does not involve protein in the urine is considered gestational hypertension. HELLP Syndrome is a severe form of preeclampsia with hemolysis of red blood cells, low platelets, and elevated liver enzymes. When the mother has a seizure, the diagnosis is eclampsia. The risk of maternal death increases with both HELLP Syndrome and Eclampsia.
A study published in the American Journal of Hypertension showed a 25% increase in preeclampsia between 1987 and 2004.(4) Gestational hypertension increased by 184% during the same period. Women under the age of 20 and women in the South were at increased risk. These statistics are conservative because the clinical parameters for diagnosis were changed in the 90s. These changes would probably decrease the diagnosis of preeclampsia.
The cause of Preeclampsia has been debated for centuries. I remember one announcement of a cause being found. Some little white particles had been identified in the blood of preeclamptic women. Actually, it turned out to be lint on the slide. Teenagers, women having their first baby or having a baby with a new sexual partner and women having a sexual partner that has fathered a pregnancy complicated by preeclampsia are at a higher risk of preeclampsia. Obesity, diabetics, multiple pregnancies and women over 35 also have a higher risk.
Even though the exact cause of Preeclampsia cannot be totally pinned down, there is plenty of completely ignored information on how to prevent it. Bertha S. Burke and H. C. Stuart published an article in the American Journal of Obstetrics and Gynecology in 1943 (46:83) which corroborated the work of Morris B. Strauss Am J. Med. Sci. 190:811, 1935. The studies correlated the incidence of preeclampsia with maternal protein intake. These studies have been largely ignored by American medical practice.
Dr. Brewer was able to repeat these findings in his clinical practice. (6) Immediately following his clinical residency in Louisiana where preeclamptic rates were 25%, Dr. Brewer began to use nutrition education in his clinical practice in Fulton, Missouri. He believed that preterm births, low birth weight babies, and preeclampsia were caused by poor diets, limiting weight gain which made poor diets worse and limiting salt. He stressed a well-balanced diet, with 80 to 100 grams of protein a day and salting foods to taste. No mention was made of weight gain. Women were helped with their diet on each prenatal visit. In 100 deliveries in his practice in Fulton, Missouri, he had only one preeclamptic pregnancy. This was a low-income woman, with a poor diet and no prenatal care.
He repeated these results in the Contra Costa County Public Health Clinic where his patients were primarily low-income women. The NIH studied his clinic’s perinatal outcomes from 1965 through 1970. His outcomes were:
Dr. Brewer’s Clinic Other Public Clinic
|Eclampsia||0 out of 5000 births||unknown|
|Pre-eclampsia||Less than 1%||15 to 40 %|
|Hypertension||Decreased ten fold|
|Low Birth Weight < 5.5 lbs)||2.2%||13.8%|
The NIH (your tax payer dollars) never published these findings. Dr. Brewer’s outcomes were criticized by the medical community because there were no controlled studies. He was unwilling to withhold dietary information from half of his patients. In addition to the Harvard studies of Burke , Stuart and Strauss, other studies had already been completed including a study conducted by Dr. Margaret Robinson and published in 1958 in the Lancet. (3)
Dr. Margaret Robinson, a London obstetrician, studied 2,019 pregnant women in a public clinic. Half of the women were instructed to reduce their salt, and the other half were told to increase their salt intake. Unfortunately, many of the high salt foods were also sources of cheap protein that they could afford to buy. Consequently, the salt restriction resulted in a diet lower in protein. The following table depicts the disastrous results.
Outcomes of Salt (& consequently protein) Restriction
|High Salt Diet||Low Salt Diet|
While Dr. Brewer’s findings have been ignored by the obstetrical community, they have improved pregnancy outcomes for countless women. As a Bradley childbirth instructor, I taught all of my students the Brewer diet. Every woman brought a diet history to class. Not once did I find a woman whose diet was completely adequate. Appropriate recommendations were made and discussed. In all of my years of teaching, I never had a woman admitted for preeclampsia. I had only two preterm births. One was one of two women who didn’t quit smoking and the other a mother of twins who had only come to one class. I did have one woman who went on vacation and began having symptoms of preeclampsia. As soon as she got home and got back to her healthy diet, her symptoms went away. All twin deliveries went to term and were of normal birth weight.
These results have been repeated throughout the country in countless childbirth classes. Even so, we still have shameful maternal and neonatal outcome statistics. How could that be and who is to blame?
There have been, I believe, two converging trends in the United States in the past two decades. Fast foods, French fries and giant servings of soda pop, chips, and prepared foods have replaced home cooked meals. At the same time, for a variety of reasons, the percentage of women who take childbirth classes has decreased. Childbirth classes are the one place where a pregnant woman would be likely to receive good dietary instruction and actually take time to think about it and change her eating habits. It is unlikely that a woman in poor health when she enters a pregnancy will become healthier without a concentrated effort to do so.
If you are pregnant, contemplating pregnancy or know someone who is, the answer to “How can I Have a Healthy Pregnancy” is: Eat a healthy diet with 90 grams of protein a day, salt to taste, avoid empty calorie food, and do not diet to lose weight. I would also add take childbirth classes so you can be informed and better prepared to make sound choices about unnecessary interventions such as elective inductions.
(1) M Mckee, N M Fish, R Atun. The Lancet. Vol. 376, No. 9750, p 1389.
(3) March of Dimes
(4) Wallis, Saftlas, Hsia, Atrash. American Journal of Hypertension | Volume 21 Number 5, 521-528, May 2008
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