Complications of pregnancy and the conspiracy of silence

Most pregnancies are completely straightforward. A woman gets pregnant, she has a normal pregnancy that lasts nine months, she delivers a healthy baby, and she takes her baby home. End of story. But not all pregnancies are so straightforward. Complications develop. Challenges arise. Doctors guide their patients through unknown experiences, and parents make choices they couldn’t have dreamed possible before embarking on the road to parenthood.

Complications of pregnancy occur anywhere between 10% and 90% of cases, depending on your definition of “complication.”  Such a spread indicates that we really do not know what the real number is, that we do not seem to agree on the definition, or both.

What most people agree upon, tacitly however, is that complications of pregnancy are not  subjects to be discussed openly. Books on normal pregnancy abound. There are no books, for the general public, dealing with complications of pregnancy. TV programs and radio shows cover normal pregnancies with ease, but are uncomfortable dealing with abnormal pregnancies. If a woman asks her doctor or midwife about potential complications, chances are that they would want to know why she asks, since her pregnancy appears to be normal.

I call this unwillingness to publicly discuss complications of pregnancy, a “conspiracy of silence.”

Historically, women have been carrying the burden of reproduction alone. Not having a “normal” pregnancy became a social stigma.  For example, a baby dies before birth, it is the woman’s fault since she cannot carry the child to term. Women today are still facing the unspoken burden of an abnormal pregnancy.

In the early 70s, the American Board of Obstetrics and Gynecology, recognized that the complexities of today’s obstetrical practice required the establishment of a new subspecialty known as maternal-fetal medicine. These new specialists are those carrying for women with complications of pregnancy, be this maternal or fetal.

This, however, did not change the general public, or professional, approach and attitude to not openly discuss problems in pregnancy. This attitude is unique to pregnancy. We speak freely about cancer, heart disease, HIV, diabetes, or any other health problem. Actually, we feel it is our duty to educate the public, so that preventive measures can be taken to decrease and treat these conditions.  Yet, we are quite cavalier when it comes to pregnancy. The fact that the public at large has been very vocal and concerned about the “medicalization” of pregnancy in general and labor and delivery in particular, has helped foster this attitude.

Why is it that this state of affairs exists, and what is conspiring against a change in attitude? There is an unacknowledged superstition, going back to times immemorial, that by not talking about a potential bad outcome we will be able to avoid it. But worldwide, some 500,000 women die in childbirth each year. In spite of concerted efforts, about 400 women still die each year in childbirth in the United States.  Health care professionals, be these family physicians, obstetricians or midwives, perpetuate this unwillingness to openly discuss complications of pregnancy, primarily because they do not want to upset or frighten their patients.

Are we to perpetuate this state of affairs or should we make a concerted effort to change the status quo?

To answer this question, we need to look at some hard facts.

A look at available statistics shows that, prior to pregnancy even being detected, 50% to 70% of all conceptions are lost, most of them during the first month. Once pregnancy is confirmed, about 10-15% will miscarry. One out of 8 pregnancies will end in preterm births, i.e. before 37 weeks gestation, with infants at a greater risk of death in the first few days of life. Survivors are prone to a variety of complications, long term disabilities or intellectual and learning disabilities later in life. Early or premature rupture of membranes prior to term may occur in 8% of all pregnancies.

Early labor and/or infection may follow with potential serious consequences for both mother and infant. Hypertensive disorders occur in 5% to 10% of pregnancies. Serious infection of the kidneys occurs in 1% to 2% of pregnancies. Diabetes in pregnancy (gestational diabetes) is diagnosed anywhere between 2% and 10% of pregnant women.  3%  to 5% of all newborns are born with congenital anomalies.

To these statistics one must add unexpected labor and delivery complications,  pregnancies that occur in women who already have prior medical conditions complicating pregnancy, the increase in multiple gestation as a result of fertility treatments, the risk associated with advanced maternal age at first pregnancy due to career and other life goals, and a myriad of other mishaps.

While pregnancy is a normal occurrence essential to our very existence as specie, it is not always benign in its course or outcome. It is our responsibility to make such information available and break the circle of this conspiracy of silence. Knowledge is not frightening.  On the contrary it does away with the fear of the unknown and allows for preventive measures to be taken, whenever possible. I believe the time has come to lift the veil of silence regarding pregnancy complications. This conspiracy of silence is doing harm, which is a complete contradiction of our oath to “Primum non nocere,”  first do no harm.

Silvio Aladjem is Professor Emeritus, Department of Obstetrics and Gynecology,College of Human Medicine, Michigan State University.

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