-
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 the 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 ?? 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 ProPublic and NPR
-
a little less than a year ago,
-
and 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 health care 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 healthcare
-
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 healthcare 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 racing 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 OBGYN
-
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 healthcare
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)