How we can improve maternal healthcare before during and after pregnancy Elizabeth Howell
It was chaos as I got off the elevator.
I was coming back on duty
as a resident physician
to cover the labor and delivery unit.
And all I could see was a swarm
of doctors and nurses
hovering over a patient in the labor room.
They were all desperately trying
to save a woman’s life.
The patient was in shock.
She had delivered a healthy baby boy
a few hours before I arrived.
Suddenly, she collapsed,
became unresponsive,
and had profuse uterine bleeding.
By the time I got to the room,
there were multiple doctors and nurses,
and the patient was lifeless.
The resuscitation team
tried to bring her back to life,
but despite everyone’s best efforts,
she died.
What I remember most about that day
was the father’s piercing cry.
It went through my heart
and the heart of everyone on that floor.
This was supposed to be
the happiest day of his life,
but instead it turned out
to be the worst day.
I wish I could say this tragedy
was an isolated incident,
but sadly, that’s not the case.
Every year in the United States,
somewhere between 700 and 900 women die
from a pregnancy-related cause.
The shocking part of this story
is that our maternal mortality rate
is actually higher
than all other high-income countries,
and our rates are far worse
for women of color.
Our rate of maternal mortality
actually increased over the last decade,
while other countries reduced their rates.
And the biggest paradox of all?
We spend more on health care
than any other country in the world.
Well, around the same time in residency
that this new mother lost her life,
I became a mother myself.
And even with all of my background
and training in the field,
I was taken aback
by how little attention was paid
to delivering high-quality
maternal health care.
And I thought about what that meant,
not just for myself
but for so many other women.
Maybe it’s because my dad
was a civil rights attorney
and my parents were socially conscious
and demanded that we stand up
for what we believe in.
Or the fact that my parents
were born in Jamaica,
came to the United States
and were able to realize
the American Dream.
Or maybe it was my residency training,
where I saw firsthand
how poorly so many low-income
women of color were treated
by our healthcare system.
For whatever the reason,
I felt a responsibility to stand up,
not just for myself,
but for all women,
and especially those marginalized
by our healthcare system.
And I decided to focus my career
on improving maternal health care.
So what’s killing mothers?
Cardiovascular disease, hemorrhage,
high blood pressure
causing seizures and strokes,
blood clots and infection
are some of the major causes
of maternal mortality in this country.
But a maternal death
is only the tip of the iceberg.
For every death, over a hundred women
suffer a severe complication
related to pregnancy and childbirth,
resulting in over 60,000 women every year
having one of these events.
These complications,
called severe maternal morbidity,
are on the rise in the United States,
and they’re life-altering.
It’s estimated that somewhere
between 1.5 and two percent
of the four million deliveries
that occur every year in this country
are associated with one of these events.
That is five or six women every hour
having a blood clot, a seizure, a stroke,
receiving a blood transfusion,
having end-organ damage
such as kidney failure,
or some other tragic event.
Now, the part of this story
that’s frankly unforgivable
is the fact that 60 percent
of these deaths and severe complications
are thought to be preventable.
When I say 60 percent are preventable,
I mean there are concrete steps
and standard procedures
that we could implement
that could prevent
these bad outcomes from occurring
and save women’s lives.
And it doesn’t require
fancy new technology.
We just have to apply what we know
and ensure equal standards
between hospitals.
For example, if a pregnant woman
in labor has really high blood pressure
and we treat her with the right
antihypertensive medication
in a timely fashion,
we can prevent stroke.
If we accurately track
blood loss during delivery,
we can detect a hemorrhage sooner
and save a woman’s life.
We could actually lower the rates
of these catastrophic events tomorrow,
but it requires that we value
the quality of care
we deliver to pregnant women
before, during and after pregnancy.
If we raise quality of care universally
to what is supposed to be the standard,
we could bring the rates of these deaths
and severe complications way down.
Well, there is some good news.
There are some success stories.
There are some places that have
actually adopted these standards,
and it’s really making a difference.
A few years ago, the American College
of Obstetricians and Gynecologists
joined forces with other
healthcare organizations,
researchers like myself
and community organizations.
They wanted to implement
standard care practices
in hospitals and health systems
throughout the country.
And the vehicle they’re using
is a program called
the Alliance for Innovation
in Maternal Health, the AIM program.
Their goal is to lower maternal mortality
and severe maternal morbidity rates
through quality and safety initiatives
across the country.
The group has developed
a number of safety bundles
that target some of the most
preventable causes of a maternal death.
The AIM program currently
has the potential to reach
over 50 percent of US births.
So what’s in a safety bundle?
Evidence-based practices,
protocols, procedures,
medications, equipment
and other items targeting
these conditions.
Let’s take the example
of a hemorrhage bundle.
For a hemorrhage, you need a cart
that has everything a doctor or nurse
might need in an emergency:
an IV line, an oxygen mask, medications,
checklists, other equipment.
Then you need something
to measure blood loss:
sponges and pads.
And instead of just eyeballing it,
the doctors and nurses
collect these sponges and pads
and either weigh them
or use newer technology to accurately
assess how much blood has been lost.
The hemorrhage bundle also includes
crises protocols for massive transfusions
and regular trainings and drills.
Now, California has been a leader
in the use of these types of bundles,
and that’s why California
saw a 21 percent reduction
in near death from hemorrhage
among hospitals that implemented
this bundle in the first year.
Yet the use of these bundles
across the country is spotty or missing.
Just like the fact that the use
of evidence-based practices
and the emphasis on safety
differs from one hospital to the next,
quality of care differs.
And quality of care differs greatly
for women of color in the United States.
Black women who deliver in this country
are three to four times more likely
to suffer a pregnancy-related death
than are white women.
This statistic is true for all black women
who deliver in this country,
whether they were born
in the United States
or born in another country.
Many want to think that income differences
drive these disparities,
but it goes beyond class.
A black woman with a college education
is nearly twice as likely to die
as compared to a white woman
with less than a high school education.
And she is two to three times more likely
to suffer a severe pregnancy complication
with her delivery.
Now, I was always taught to think
that education was our salvation,
but in this case, it’s simply not true.
This black-white disparity
is the largest disparity
among all population
perinatal health measures,
according to the CDC.
And these disparities
are even more pronounced
in some of our cities.
For example, in New York City,
a black woman is eight to 12 times
more likely to die
from a pregnancy-related cause
than is a white woman.
Now, I think many of you
are probably familiar with
the heart-wrenching story
of Dr. Shalon Irving,
a CDC epidemiologist
who died following childbirth.
Her story was reported
in ProPublica and NPR
a little less than a year ago.
Recently, I was at a conference
and I had the privilege
of hearing her mother speak.
She brought the entire audience to tears.
Shalon was a brilliant epidemiologist,
committed to studying
racial and ethnic disparities in health.
She was 36 years old,
this was her first baby,
and she was African-American.
Now, Shalon did have
a complicated pregnancy,
but she delivered a healthy baby girl
and was discharged from the hospital.
Three weeks later, she died
from complications of high blood pressure.
Shalon was seen four or five times
by healthcare professionals
in those three weeks.
She was not listened to,
and the severity of her condition
was not recognized.
Now, Shalon’s story
is just one of many stories
about racial and ethnic disparities
in health and health care
in the United States,
and there’s a growing recognition
that the social determinants of health,
such as racism, poverty, education,
segregated housing,
contribute to these disparities.
But Shalon’s story highlights
an additional underlying cause:
quality of care.
Lack of standards in postpartum care.
Shalon was seen multiple times
by clinicians in those three weeks,
and she still died.
Quality of care
in the setting of childbirth
is an underlying cause
of racial and ethnic disparities
in maternal mortality
and severe maternal morbidity
in the United States,
and it’s something we can address now.
Research by our team and others
has documented that,
for a variety of reasons,
black women tend to deliver
in a specific set of hospitals,
and those hospitals often have worse
outcomes for both black and white women,
regardless of patient risk factors.
This is true overall in the United States,
where about three quarters
of all black women
deliver in a specific set of hospitals,
while less than one-fifth of white women
deliver in those same hospitals.
In New York City, a woman’s risk
of having a life-threatening complication
during delivery
can be six times higher
in one hospital than another.
Not surprisingly, black women
are more likely to deliver
in hospitals with worse outcomes.
In fact, differences in delivery hospital
explain nearly one-half
of the black-white disparity.
While we must address
social determinants of health
if we’re ever going to truly have
equitable health care in this country,
many of these are deep-seated
and they will take some time to resolve.
In the meantime,
we can tackle quality of care.
Providing high-quality care
across the care continuum
means providing access to safe
and reliable contraception
throughout women’s reproductive lives.
Before pregnancy, it means
providing preconception care,
so we can manage chronic illness
and optimize health.
During pregnancy, it includes
high-quality prenatal and delivery care
so we can produce healthy moms and babies.
And finally, after pregnancy, it includes
postpartum and inter-pregnancy care
so we can set moms up
to have a healthy next baby
and a healthy life.
And it can literally spell the difference
between life and death,
as it did in the case of Maria,
who checked into the hospital
after having an elevated blood pressure
during a prenatal visit.
Maria was 40, and this
was her second pregnancy.
During Maria’s first pregnancy
that had happened two years earlier,
she also didn’t feel so well
in the last few weeks of her pregnancy,
and she had a few
elevated blood pressures,
but nobody seemed to pay attention.
They just said, “Maria,
don’t worry, you’ll be fine.
This is your first pregnancy.
You’re a little nervous.”
But it did not end well
for Maria last time.
She seized during labor.
Well, this time her team really listened.
They asked smart and probing questions.
Her doctor counseled her about
the signs and symptoms of preeclampsia
and explained that
if she was not feeling well,
she needed to come in and be seen.
And this time Maria came in,
and her doctor immediately
sent her to the hospital.
At the hospital, her doctor
ordered urgent lab tests.
They hooked her up
to multiple different monitors
and paid special attention
to her blood pressure,
the fetal heart rate tracing
and gave her IV medication
to prevent a seizure.
And when Maria’s blood pressure got
so high it put her at risk for a stroke,
her doctors and nurses jumped into action.
They repeated her
blood pressure in 15 minutes
and declared a hypertensive emergency.
They gave her the right IV medication
according to the latest correct protocol.
They worked smoothly together
as a coordinated team
and successfully
lowered her blood pressure.
As a result, what could have been
a tragedy became a success story.
Maria’s dangerous symptoms
were controlled,
and she delivered a healthy baby girl.
And before Maria was discharged
from the hospital,
her doctor counseled her again about
the signs and symptoms of preeclampsia,
the importance of having
her blood pressure checked,
especially in this first week postpartum
and gave her education about
postpartum health and what to expect.
And in the weeks and months that followed,
naturally, Maria had follow-up visits
with her pediatrician
to check in on her baby’s health.
But just as important,
she had follow-up visits with her ob-gyn
to check in on her health,
her blood pressure,
and her cares and concerns
as a new mother.
This is what high-quality care
across the care continuum looks like,
and this is how it can look.
If every pregnant woman in every community
received this kind of high-quality care
and delivered at facilities that utilized
standard care practices,
our maternal mortality and severe
maternal morbidity rates would plummet.
Our international ranking
would no longer be an embarrassment.
But the truth is, we’ve had decades
of unacceptably high rates
of maternal death and life-threatening
complications during delivery
and decades of devastating consequences
for moms, babies and families,
and we have not been moved to action.
The recent media attention on
our poor performance on maternal mortality
has helped the public to understand:
high-quality maternal health care
is within reach.
The question is:
Are we as a society ready to value
pregnant women from every community?
For my part, I’m doing everything I can
to ensure that when we do,
we have the tools and evidence base ready
to move forward.
Thank you.
(Applause)