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← How we can improve maternal healthcare -- before, during and after pregnancy

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Showing Revision 10 created 07/18/2019 by Oliver Friedman.

  1. It was chaos as I got off the elevator.
  2. I was coming back on duty
    as a resident physician
  3. to cover the labor and delivery unit.
  4. And all I could see was a swarm
    of doctors and nurses
  5. hovering over a patient in the labor room.
  6. They were all desperately trying
    to save a woman's life.
  7. The patient was in shock.
  8. She had delivered a healthy baby boy
    a few hours before I arrived.
  9. Suddenly, she collapsed,
    became unresponsive,
  10. and had profuse uterine bleeding.
  11. By the time I got to the room,
  12. there were multiple doctors and nurses,
    and the patient was lifeless.
  13. The resuscitation team
    tried to bring her back to life,
  14. but despite everyone's best efforts,
  15. she died.
  16. What I remember most about that day
    was the father's piercing cry.
  17. It went through my heart
    and the heart of everyone on that floor.
  18. This was supposed to be
    the happiest day of his life,
  19. but instead it turned out
    to be the worst day.
  20. I wish I could say this tragedy
    was an isolated incident,

  21. but sadly, that's not the case.
  22. Every year in the United States,
  23. somewhere between 700 and 900 women die
  24. from a pregnancy-related cause.
  25. The shocking part of this story
  26. is that our maternal mortality rate
    is actually higher
  27. than all other high-income countries,
  28. and our rates are far worse
    for women of color.
  29. Our rate of maternal mortality
    actually increased over the last decade,
  30. while other countries reduced their rates.
  31. And the biggest paradox of all?
  32. We spend more on health care
    than any other country in the world.
  33. Well, around the same time in residency
    that this new mother lost her life,

  34. I became a mother myself.
  35. And even with all of my background
    and training in the field,
  36. I was taken aback
    by how little attention was paid
  37. to delivering high-quality
    maternal health care.
  38. And I thought about what that meant,
    not just for myself
  39. but for so many other women.
  40. Maybe it's because my dad
    was a civil rights attorney
  41. and my parents were socially conscious
  42. and demanded that we stand up
    for what we believe in.
  43. Or the fact that my parents
    were born in Jamaica,
  44. came to the United States
  45. and were able to realize
    the American Dream.
  46. Or maybe it was my residency training,
  47. where I saw firsthand
  48. how poorly so many low-income
    women of color were treated
  49. by our healthcare system.
  50. For whatever the reason,
    I felt a responsibility to stand up,
  51. not just for myself,
  52. but for all women,
  53. and especially those marginalized
    by our healthcare system.
  54. And I decided to focus my career
    on improving maternal health care.
  55. So what's killing mothers?

  56. Cardiovascular disease, hemorrhage,
  57. high blood pressure
    causing seizures and strokes,
  58. blood clots and infection
  59. are some of the major causes
    of maternal mortality in this country.
  60. But a maternal death
    is only the tip of the iceberg.
  61. For every death, over a hundred women
    suffer a severe complication
  62. related to pregnancy and childbirth,
  63. resulting in over 60,000 women every year
    having one of these events.
  64. These complications,
    called severe maternal morbidity,
  65. are on the rise in the United States,
    and they're life-altering.
  66. It's estimated that somewhere
    between 1.5 and two percent
  67. of the four million deliveries
    that occur every year in this country
  68. are associated with one of these events.
  69. That is five or six women every hour
    having a blood clot, a seizure, a stroke,
  70. receiving a blood transfusion,
  71. having end-organ damage
    such as kidney failure,
  72. or some other tragic event.
  73. Now, the part of this story
    that's frankly unforgivable

  74. is the fact that 60 percent
    of these deaths and severe complications
  75. are thought to be preventable.
  76. When I say 60 percent are preventable,
  77. I mean there are concrete steps
    and standard procedures
  78. that we could implement
  79. that could prevent
    these bad outcomes from occurring
  80. and save women's lives.
  81. And it doesn't require
    fancy new technology.
  82. We just have to apply what we know
  83. and ensure equal standards
    between hospitals.
  84. For example, if a pregnant woman
    in labor has really high blood pressure

  85. and we treat her with the right
    antihypertensive medication
  86. in a timely fashion,
  87. we can prevent stroke.
  88. If we accurately track
    blood loss during delivery,
  89. we can detect a hemorrhage sooner
    and save a woman's life.
  90. We could actually lower the rates
    of these catastrophic events tomorrow,
  91. but it requires that we value
    the quality of care
  92. we deliver to pregnant women
  93. before, during and after pregnancy.
  94. If we raise quality of care universally
    to what is supposed to be the standard,
  95. we could bring the rates of these deaths
    and severe complications way down.
  96. Well, there is some good news.

  97. There are some success stories.
  98. There are some places that have
    actually adopted these standards,
  99. and it's really making a difference.
  100. A few years ago, the American College
    of Obstetricians and Gynecologists
  101. joined forces with other
    healthcare organizations,
  102. researchers like myself
    and community organizations.
  103. They wanted to implement
    standard care practices
  104. in hospitals and health systems
    throughout the country.
  105. And the vehicle they're using
    is a program called
  106. the Alliance for Innovation
    in Maternal Health, the AIM program.
  107. Their goal is to lower maternal mortality
    and severe maternal morbidity rates
  108. through quality and safety initiatives
    across the country.
  109. The group has developed
    a number of safety bundles
  110. that target some of the most
    preventable causes of a maternal death.
  111. The AIM program currently
    has the potential to reach
  112. over 50 percent of US births.
  113. So what's in a safety bundle?

  114. Evidence-based practices,
    protocols, procedures,
  115. medications, equipment
  116. and other items targeting
    these conditions.
  117. Let's take the example
    of a hemorrhage bundle.
  118. For a hemorrhage, you need a cart
  119. that has everything a doctor or nurse
    might need in an emergency:
  120. an IV line, an oxygen mask, medications,
  121. checklists, other equipment.
  122. Then you need something
    to measure blood loss:
  123. sponges and pads.
  124. And instead of just eyeballing it,
  125. the doctors and nurses
    collect these sponges and pads
  126. and either weigh them
  127. or use newer technology to accurately
    assess how much blood has been lost.
  128. The hemorrhage bundle also includes
    crises protocols for massive transfusions
  129. and regular trainings and drills.
  130. Now, California has been a leader
    in the use of these types of bundles,

  131. and that's why California
    saw a 21 percent reduction
  132. in near death from hemorrhage
  133. among hospitals that implemented
    this bundle in the first year.
  134. Yet the use of these bundles
    across the country is spotty or missing.
  135. Just like the fact that the use
    of evidence-based practices
  136. and the emphasis on safety
  137. differs from one hospital to the next,
  138. quality of care differs.
  139. And quality of care differs greatly
    for women of color in the United States.

  140. Black women who deliver in this country
  141. are three to four times more likely
    to suffer a pregnancy-related death
  142. than are white women.
  143. This statistic is true for all black women
    who deliver in this country,
  144. whether they were born
    in the United States
  145. or born in another country.
  146. Many want to think that income differences
    drive these disparities,
  147. but it goes beyond class.
  148. A black woman with a college education
  149. is nearly twice as likely to die
    as compared to a white woman
  150. with less than a high school education.
  151. And she is two to three times more likely
    to suffer a severe pregnancy complication
  152. with her delivery.
  153. Now, I was always taught to think
    that education was our salvation,

  154. but in this case, it's simply not true.
  155. This black-white disparity
  156. is the largest disparity
  157. among all population
    perinatal health measures,
  158. according to the CDC.
  159. And these disparities
    are even more pronounced
  160. in some of our cities.
  161. For example, in New York City,
  162. a black woman is eight to 12 times
    more likely to die
  163. from a pregnancy-related cause
    than is a white woman.
  164. Now, I think many of you
    are probably familiar with

  165. the heart-wrenching story
    of Dr. Shalon Irving,
  166. a CDC epidemiologist
    who died following childbirth.
  167. Her story was reported
    in ProPublica and NPR
  168. a little less than a year ago.
  169. Recently, I was at a conference
  170. and I had the privilege
    of hearing her mother speak.
  171. She brought the entire audience to tears.
  172. Shalon was a brilliant epidemiologist,
  173. committed to studying
    racial and ethnic disparities in health.
  174. She was 36 years old,
    this was her first baby,
  175. and she was African-American.
  176. Now, Shalon did have
    a complicated pregnancy,

  177. but she delivered a healthy baby girl
    and was discharged from the hospital.
  178. Three weeks later, she died
    from complications of high blood pressure.
  179. Shalon was seen four or five times
    by healthcare professionals
  180. in those three weeks.
  181. She was not listened to,
  182. and the severity of her condition
    was not recognized.
  183. Now, Shalon's story
    is just one of many stories

  184. about racial and ethnic disparities
    in health and health care
  185. in the United States,
  186. and there's a growing recognition
    that the social determinants of health,
  187. such as racism, poverty, education,
    segregated housing,
  188. contribute to these disparities.
  189. But Shalon's story highlights
    an additional underlying cause:
  190. quality of care.
  191. Lack of standards in postpartum care.
  192. Shalon was seen multiple times
    by clinicians in those three weeks,
  193. and she still died.
  194. Quality of care
    in the setting of childbirth
  195. is an underlying cause
    of racial and ethnic disparities
  196. in maternal mortality
    and severe maternal morbidity
  197. in the United States,
  198. and it's something we can address now.
  199. Research by our team and others

  200. has documented that,
    for a variety of reasons,
  201. black women tend to deliver
    in a specific set of hospitals,
  202. and those hospitals often have worse
    outcomes for both black and white women,
  203. regardless of patient risk factors.
  204. This is true overall in the United States,
  205. where about three quarters
    of all black women
  206. deliver in a specific set of hospitals,
  207. while less than one-fifth of white women
    deliver in those same hospitals.
  208. In New York City, a woman's risk
    of having a life-threatening complication
  209. during delivery
  210. can be six times higher
    in one hospital than another.
  211. Not surprisingly, black women
    are more likely to deliver
  212. in hospitals with worse outcomes.
  213. In fact, differences in delivery hospital
  214. explain nearly one-half
    of the black-white disparity.
  215. While we must address
    social determinants of health

  216. if we're ever going to truly have
    equitable health care in this country,
  217. many of these are deep-seated
    and they will take some time to resolve.
  218. In the meantime,
    we can tackle quality of care.
  219. Providing high-quality care
    across the care continuum
  220. means providing access to safe
    and reliable contraception
  221. throughout women's reproductive lives.
  222. Before pregnancy, it means
    providing preconception care,
  223. so we can manage chronic illness
    and optimize health.
  224. During pregnancy, it includes
    high-quality prenatal and delivery care
  225. so we can produce healthy moms and babies.
  226. And finally, after pregnancy, it includes
    postpartum and inter-pregnancy care
  227. so we can set moms up
    to have a healthy next baby
  228. and a healthy life.
  229. And it can literally spell the difference
    between life and death,

  230. as it did in the case of Maria,
  231. who checked into the hospital
    after having an elevated blood pressure
  232. during a prenatal visit.
  233. Maria was 40, and this
    was her second pregnancy.
  234. During Maria's first pregnancy
    that had happened two years earlier,
  235. she also didn't feel so well
    in the last few weeks of her pregnancy,
  236. and she had a few
    elevated blood pressures,
  237. but nobody seemed to pay attention.
  238. They just said, "Maria,
    don't worry, you'll be fine.
  239. This is your first pregnancy.
    You're a little nervous."
  240. But it did not end well
    for Maria last time.
  241. She seized during labor.
  242. Well, this time her team really listened.

  243. They asked smart and probing questions.
  244. Her doctor counseled her about
    the signs and symptoms of preeclampsia
  245. and explained that
    if she was not feeling well,
  246. she needed to come in and be seen.
  247. And this time Maria came in,
  248. and her doctor immediately
    sent her to the hospital.
  249. At the hospital, her doctor
    ordered urgent lab tests.
  250. They hooked her up
    to multiple different monitors
  251. and paid special attention
    to her blood pressure,
  252. the fetal heart rate tracing
  253. and gave her IV medication
    to prevent a seizure.
  254. And when Maria's blood pressure got
    so high it put her at risk for a stroke,
  255. her doctors and nurses jumped into action.
  256. They repeated her
    blood pressure in 15 minutes
  257. and declared a hypertensive emergency.
  258. They gave her the right IV medication
    according to the latest correct protocol.
  259. They worked smoothly together
    as a coordinated team
  260. and successfully
    lowered her blood pressure.
  261. As a result, what could have been
    a tragedy became a success story.

  262. Maria's dangerous symptoms
    were controlled,
  263. and she delivered a healthy baby girl.
  264. And before Maria was discharged
    from the hospital,
  265. her doctor counseled her again about
    the signs and symptoms of preeclampsia,
  266. the importance of having
    her blood pressure checked,
  267. especially in this first week postpartum
  268. and gave her education about
    postpartum health and what to expect.
  269. And in the weeks and months that followed,
  270. naturally, Maria had follow-up visits
    with her pediatrician
  271. to check in on her baby's health.
  272. But just as important,
  273. she had follow-up visits with her ob-gyn
  274. to check in on her health,
    her blood pressure,
  275. and her cares and concerns
    as a new mother.
  276. This is what high-quality care
    across the care continuum looks like,

  277. and this is how it can look.
  278. If every pregnant woman in every community
  279. received this kind of high-quality care
  280. and delivered at facilities that utilized
    standard care practices,
  281. our maternal mortality and severe
    maternal morbidity rates would plummet.
  282. Our international ranking
    would no longer be an embarrassment.
  283. But the truth is, we've had decades
    of unacceptably high rates

  284. of maternal death and life-threatening
    complications during delivery
  285. and decades of devastating consequences
    for moms, babies and families,
  286. and we have not been moved to action.
  287. The recent media attention on
    our poor performance on maternal mortality

  288. has helped the public to understand:
  289. high-quality maternal health care
    is within reach.
  290. The question is:
  291. Are we as a society ready to value
    pregnant women from every community?
  292. For my part, I'm doing everything I can
    to ensure that when we do,

  293. we have the tools and evidence base ready
  294. to move forward.
  295. Thank you.

  296. (Applause)