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It was chaos as I got off the elevator.

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I was coming back on duty
as a resident physician

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to cover the labor and delivery unit.

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And all I could see was a swarm
of doctors and nurses

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hovering over a patient in the labor room.

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They were all desperately trying
to save a woman's life.

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The patient was in shock.

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She had delivered a healthy baby boy
a few hours before I arrived.

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Suddenly, she collapsed,
became unresponsive,

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and had profuse uterine bleeding.

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By the time I got to the room,

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there were multiple doctors and nurses,
and the patient was lifeless.

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The resuscitation team
tried to bring her back to life,

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but despite everyone's best efforts,

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she died.

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What I remember most about that day
was the father's piercing cry.

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It went through my heart
and the heart of everyone on that floor.

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This was supposed to be
the happiest day of his life,

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but instead it turned out
to be the worst day.

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I wish I could say this tragedy
was an isolated incident,

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but sadly, that's not the case.

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Every year in the United States,

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somewhere between 700 and 900 women die

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from a pregnancy-related cause.

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The shocking part of this story

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is that our maternal mortality rate
is actually higher

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than all other high-income countries,

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and our rates are far worse
for women of color.

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Our rate of maternal mortality
actually increased over the last decade,

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while other countries reduced their rates.

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And the biggest paradox of all?

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We spend more on health care
than any other country in the world.

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Well, around the same time in residency
that this new mother lost her life,

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I became a mother myself.

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And even with all of my background
and training in the field,

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I was taken aback
by how little attention was paid

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to delivering high-quality
maternal health care.

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And I thought about what that meant,
not just for myself

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but for so many other women.

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Maybe it's because my dad
was a civil rights attorney

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and my parents were socially conscious

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and demanded that we stand up
for what we believe in.

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Or the fact that my parents
were born in Jamaica,

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came to the United States

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and were able to realize
the American Dream.

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Or maybe it was my residency training,

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where I saw firsthand

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how poorly so many low-income
women of color were treated

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by our healthcare system.

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For whatever the reason,
I felt a responsibility to stand up,

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not just for myself,

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but for all women,

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and especially those marginalized
by our healthcare system.

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And I decided to focus my career
on improving maternal health care.

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So what's killing mothers?

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Cardiovascular disease, hemorrhage,

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high blood pressure
causing seizures and strokes,

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blood clots and infection

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are some of the major causes
of maternal mortality in this country.

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But a maternal death
is only the tip of the iceberg.

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For every death, over a hundred women
suffer a severe complication

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related to pregnancy and childbirth,

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resulting in over 60,000 women every year
having one of these events.

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These complications,
called severe maternal morbidity,

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are on the rise in the United States,
and they're life-altering.

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It's estimated that somewhere
between 1.5 and two percent

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of the four million deliveries
that occur every year in this country

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are associated with one of these events.

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That is five or six women every hour
having a blood clot, a seizure, a stroke,

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receiving a blood transfusion,

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having end-organ damage
such as kidney failure,

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or some other tragic event.

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Now, the part of this story
that's frankly unforgivable

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is the fact that 60 percent
of these deaths and severe complications

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are thought to be preventable.

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When I say 60 percent are preventable,

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I mean there are concrete steps
and standard procedures

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that we could implement

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that could prevent
these bad outcomes from occurring

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and save women's lives.

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And it doesn't require
fancy new technology.

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We just have to apply what we know

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and ensure equal standards
between hospitals.

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For example, if a pregnant woman
in labor has really high blood pressure

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and we treat her with the right
antihypertensive medication

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in a timely fashion,

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we can prevent stroke.

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If we accurately track
blood loss during delivery,

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we can detect a hemorrhage sooner
and save a woman's life.

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We could actually lower the rates
of these catastrophic events tomorrow,

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but it requires that we value
the quality of care

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we deliver to pregnant women

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before, during and after pregnancy.

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If we raise quality of care universally
to what is supposed to be the standard,

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we could bring the rates of these deaths
and severe complications way down.

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Well, there is some good news.

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There are some success stories.

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There are some places that have
actually adopted these standards,

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and it's really making a difference.

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A few years ago, the American College
of Obstetricians and Gynecologists

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joined forces with other
healthcare organizations,

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researchers like myself
and community organizations.

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They wanted to implement
standard care practices

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in hospitals and health systems
throughout the country.

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And the vehicle they're using
is a program called

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the Alliance for Innovation
in Maternal Health, the AIM program.

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Their goal is to lower maternal mortality
and severe maternal morbidity rates

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through quality and safety initiatives
across the country.

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The group has developed
a number of safety bundles

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that target some of the most
preventable causes of a maternal death.

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The AIM program currently
has the potential to reach

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over 50 percent of US births.

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So what's in a safety bundle?

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Evidence-based practices,
protocols, procedures,

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medications, equipment

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and other items targeting
these conditions.

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Let's take the example
of a hemorrhage bundle.

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For a hemorrhage, you need a cart

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that has everything a doctor or nurse
might need in an emergency:

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an IV line, an oxygen mask, medications,

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checklists, other equipment.

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Then you need something
to measure blood loss:

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sponges and pads.

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And instead of just eyeballing it,

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the doctors and nurses
collect these sponges and pads

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and either weigh them

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or use newer technology to accurately
assess how much blood has been lost.

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The hemorrhage bundle also includes
crises protocols for massive transfusions

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and regular trainings and drills.

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Now, California has been a leader
in the use of these types of bundles,

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and that's why California
saw a 21 percent reduction

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in near death from hemorrhage

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among hospitals that implemented
this bundle in the first year.

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Yet the use of these bundles
across the country is spotty or missing.

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Just like the fact that the use
of evidence-based practices

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and the emphasis on safety

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differs from one hospital to the next,

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quality of care differs.

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And quality of care differs greatly
for women of color in the United States.

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Black women who deliver in this country

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are three to four times more likely
to suffer a pregnancy-related death

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than are white women.

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This statistic is true for all black women
who deliver in this country,

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whether they were born
in the United States

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or born in another country.

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Many want to think that income differences
drive these disparities,

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but it goes beyond class.

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A black woman with a college education

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is nearly twice as likely to die
as compared to a white woman

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with less than a high school education.

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And she is two to three times more likely
to suffer a severe pregnancy complication

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with her delivery.

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Now, I was always taught to think
that education was our salvation,

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but in this case, it's simply not true.

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This black-white disparity

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is the largest disparity

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among all population
perinatal health measures,

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according to the CDC.

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And these disparities
are even more pronounced

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in some of our cities.

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For example, in New York City,

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a black woman is eight to 12 times
more likely to die

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from a pregnancy-related cause
than is a white woman.

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Now, I think many of you
are probably familiar with

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the heart-wrenching story
of Dr. Shalon Irving,

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a CDC epidemiologist
who died following childbirth.

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Her story was reported
in ProPublica and NPR

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a little less than a year ago.

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Recently, I was at a conference

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and I had the privilege
of hearing her mother speak.

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She brought the entire audience to tears.

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Shalon was a brilliant epidemiologist,

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committed to studying
racial and ethnic disparities in health.

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She was 36 years old,
this was her first baby,

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and she was African-American.

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Now, Shalon did have
a complicated pregnancy,

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but she delivered a healthy baby girl
and was discharged from the hospital.

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Three weeks later, she died
from complications of high blood pressure.

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Shalon was seen four or five times
by healthcare professionals

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in those three weeks.

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She was not listened to,

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and the severity of her condition
was not recognized.

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Now, Shalon's story
is just one of many stories

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about racial and ethnic disparities
in health and health care

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in the United States,

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and there's a growing recognition
that the social determinants of health,

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such as racism, poverty, education,
segregated housing,

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contribute to these disparities.

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But Shalon's story highlights
an additional underlying cause:

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quality of care.

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Lack of standards in postpartum care.

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Shalon was seen multiple times
by clinicians in those three weeks,

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and she still died.

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Quality of care
in the setting of childbirth

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is an underlying cause
of racial and ethnic disparities

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in maternal mortality
and severe maternal morbidity

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in the United States,

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and it's something we can address now.

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Research by our team and others

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has documented that,
for a variety of reasons,

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black women tend to deliver
in a specific set of hospitals,

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and those hospitals often have worse
outcomes for both black and white women,

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regardless of patient risk factors.

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This is true overall in the United States,

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where about three quarters
of all black women

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deliver in a specific set of hospitals,

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while less than one-fifth of white women
deliver in those same hospitals.

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In New York City, a woman's risk
of having a life-threatening complication

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00:10:32,932 --> 00:10:34,091
during delivery

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can be six times higher
in one hospital than another.

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Not surprisingly, black women
are more likely to deliver

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00:10:41,943 --> 00:10:43,547
in hospitals with worse outcomes.

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00:10:43,571 --> 00:10:45,644
In fact, differences in delivery hospital

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00:10:45,668 --> 00:10:48,601
explain nearly one-half
of the black-white disparity.

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While we must address
social determinants of health

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if we're ever going to truly have
equitable health care in this country,

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many of these are deep-seated
and they will take some time to resolve.

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00:11:00,129 --> 00:11:03,002
In the meantime,
we can tackle quality of care.

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00:11:03,373 --> 00:11:07,384
Providing high-quality care
across the care continuum

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00:11:07,408 --> 00:11:10,929
means providing access to safe
and reliable contraception

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00:11:10,953 --> 00:11:13,391
throughout women's reproductive lives.

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00:11:13,801 --> 00:11:18,529
Before pregnancy, it means
providing preconception care,

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00:11:18,553 --> 00:11:21,709
so we can manage chronic illness
and optimize health.

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00:11:22,081 --> 00:11:26,239
During pregnancy, it includes
high-quality prenatal and delivery care

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00:11:26,263 --> 00:11:29,099
so we can produce healthy moms and babies.

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And finally, after pregnancy, it includes
postpartum and inter-pregnancy care

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00:11:34,473 --> 00:11:37,810
so we can set moms up
to have a healthy next baby

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00:11:37,834 --> 00:11:39,324
and a healthy life.

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And it can literally spell the difference
between life and death,

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as it did in the case of Maria,

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who checked into the hospital
after having an elevated blood pressure

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00:11:47,812 --> 00:11:49,629
during a prenatal visit.

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00:11:49,653 --> 00:11:52,467
Maria was 40, and this
was her second pregnancy.

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00:11:53,044 --> 00:11:56,620
During Maria's first pregnancy
that had happened two years earlier,

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she also didn't feel so well
in the last few weeks of her pregnancy,

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and she had a few
elevated blood pressures,

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but nobody seemed to pay attention.

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00:12:04,797 --> 00:12:07,264
They just said, "Maria,
don't worry, you'll be fine.

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00:12:07,288 --> 00:12:09,983
This is your first pregnancy.
You're a little nervous."

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00:12:10,007 --> 00:12:12,443
But it did not end well
for Maria last time.

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00:12:12,467 --> 00:12:14,383
She seized during labor.

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00:12:14,910 --> 00:12:17,344
Well, this time her team really listened.

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00:12:17,368 --> 00:12:19,785
They asked smart and probing questions.

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00:12:19,809 --> 00:12:23,713
Her doctor counseled her about
the signs and symptoms of preeclampsia

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00:12:23,737 --> 00:12:25,973
and explained that
if she was not feeling well,

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she needed to come in and be seen.

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And this time Maria came in,

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00:12:30,079 --> 00:12:32,695
and her doctor immediately
sent her to the hospital.

249
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At the hospital, her doctor
ordered urgent lab tests.

250
00:12:37,379 --> 00:12:39,816
They hooked her up
to multiple different monitors

251
00:12:39,840 --> 00:12:42,134
and paid special attention
to her blood pressure,

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the fetal heart rate tracing

253
00:12:43,824 --> 00:12:47,014
and gave her IV medication
to prevent a seizure.

254
00:12:47,038 --> 00:12:51,020
And when Maria's blood pressure got
so high it put her at risk for a stroke,

255
00:12:51,044 --> 00:12:53,601
her doctors and nurses jumped into action.

256
00:12:53,625 --> 00:12:55,795
They repeated her
blood pressure in 15 minutes

257
00:12:55,819 --> 00:12:57,979
and declared a hypertensive emergency.

258
00:12:58,003 --> 00:13:02,198
They gave her the right IV medication
according to the latest correct protocol.

259
00:13:02,222 --> 00:13:05,180
They worked smoothly together
as a coordinated team

260
00:13:05,204 --> 00:13:07,685
and successfully
lowered her blood pressure.

261
00:13:09,246 --> 00:13:12,976
As a result, what could have been
a tragedy became a success story.

262
00:13:13,000 --> 00:13:15,238
Maria's dangerous symptoms
were controlled,

263
00:13:15,262 --> 00:13:17,847
and she delivered a healthy baby girl.

264
00:13:18,489 --> 00:13:21,020
And before Maria was discharged
from the hospital,

265
00:13:21,044 --> 00:13:24,941
her doctor counseled her again about
the signs and symptoms of preeclampsia,

266
00:13:24,965 --> 00:13:27,629
the importance of having
her blood pressure checked,

267
00:13:27,653 --> 00:13:29,848
especially in this first week postpartum

268
00:13:29,872 --> 00:13:34,189
and gave her education about
postpartum health and what to expect.

269
00:13:34,213 --> 00:13:36,290
And in the weeks and months that followed,

270
00:13:36,314 --> 00:13:39,102
naturally, Maria had follow-up visits
with her pediatrician

271
00:13:39,126 --> 00:13:41,355
to check in on her baby's health.

272
00:13:41,379 --> 00:13:42,689
But just as important,

273
00:13:42,713 --> 00:13:45,385
she had follow-up visits with her ob-gyn

274
00:13:45,409 --> 00:13:47,830
to check in on her health,
her blood pressure,

275
00:13:47,854 --> 00:13:50,858
and her cares and concerns
as a new mother.

276
00:13:50,882 --> 00:13:54,721
This is what high-quality care
across the care continuum looks like,

277
00:13:54,745 --> 00:13:56,647
and this is how it can look.

278
00:13:56,671 --> 00:13:59,249
If every pregnant woman in every community

279
00:13:59,273 --> 00:14:02,449
received this kind of high-quality care

280
00:14:02,473 --> 00:14:06,099
and delivered at facilities that utilized
standard care practices,

281
00:14:06,123 --> 00:14:10,325
our maternal mortality and severe
maternal morbidity rates would plummet.

282
00:14:10,349 --> 00:14:13,913
Our international ranking
would no longer be an embarrassment.

283
00:14:13,937 --> 00:14:18,756
But the truth is, we've had decades
of unacceptably high rates

284
00:14:18,780 --> 00:14:23,526
of maternal death and life-threatening
complications during delivery

285
00:14:23,550 --> 00:14:28,668
and decades of devastating consequences
for moms, babies and families,

286
00:14:28,692 --> 00:14:30,834
and we have not been moved to action.

287
00:14:31,336 --> 00:14:35,174
The recent media attention on
our poor performance on maternal mortality

288
00:14:35,198 --> 00:14:37,532
has helped the public to understand:

289
00:14:37,556 --> 00:14:40,557
high-quality maternal health care
is within reach.

290
00:14:40,581 --> 00:14:41,786
The question is:

291
00:14:41,810 --> 00:14:47,018
Are we as a society ready to value
pregnant women from every community?

292
00:14:47,042 --> 00:14:51,713
For my part, I'm doing everything I can
to ensure that when we do,

293
00:14:51,737 --> 00:14:54,829
we have the tools and evidence base ready

294
00:14:54,853 --> 00:14:56,216
to move forward.

295
00:14:57,001 --> 00:14:58,183
Thank you.

296
00:14:58,207 --> 00:15:03,206
(Applause)