How we can improve maternal healthcare -- before, during and after pregnancy
-
0:01 - 0:03It was chaos as I got off the elevator.
-
0:04 - 0:07I was coming back on duty
as a resident physician -
0:07 - 0:09to cover the labor and delivery unit.
-
0:09 - 0:12And all I could see was a swarm
of doctors and nurses -
0:12 - 0:14hovering over a patient in the labor room.
-
0:15 - 0:18They were all desperately trying
to save a woman's life. -
0:18 - 0:20The patient was in shock.
-
0:20 - 0:25She had delivered a healthy baby boy
a few hours before I arrived. -
0:25 - 0:28Suddenly, she collapsed,
became unresponsive, -
0:28 - 0:30and had profuse uterine bleeding.
-
0:30 - 0:32By the time I got to the room,
-
0:32 - 0:37there were multiple doctors and nurses,
and the patient was lifeless. -
0:37 - 0:40The resuscitation team
tried to bring her back to life, -
0:40 - 0:42but despite everyone's best efforts,
-
0:42 - 0:43she died.
-
0:43 - 0:47What I remember most about that day
was the father's piercing cry. -
0:47 - 0:51It went through my heart
and the heart of everyone on that floor. -
0:51 - 0:54This was supposed to be
the happiest day of his life, -
0:54 - 0:57but instead it turned out
to be the worst day. -
0:58 - 1:02I wish I could say this tragedy
was an isolated incident, -
1:02 - 1:04but sadly, that's not the case.
-
1:04 - 1:06Every year in the United States,
-
1:06 - 1:10somewhere between 700 and 900 women die
-
1:10 - 1:11from a pregnancy-related cause.
-
1:12 - 1:14The shocking part of this story
-
1:14 - 1:17is that our maternal mortality rate
is actually higher -
1:17 - 1:20than all other high-income countries,
-
1:20 - 1:22and our rates are far worse
for women of color. -
1:23 - 1:28Our rate of maternal mortality
actually increased over the last decade, -
1:28 - 1:31while other countries reduced their rates.
-
1:31 - 1:33And the biggest paradox of all?
-
1:34 - 1:38We spend more on health care
than any other country in the world. -
1:39 - 1:43Well, around the same time in residency
that this new mother lost her life, -
1:43 - 1:45I became a mother myself.
-
1:45 - 1:48And even with all of my background
and training in the field, -
1:48 - 1:52I was taken aback
by how little attention was paid -
1:52 - 1:55to delivering high-quality
maternal health care. -
1:55 - 1:57And I thought about what that meant,
not just for myself -
1:57 - 1:59but for so many other women.
-
2:00 - 2:03Maybe it's because my dad
was a civil rights attorney -
2:03 - 2:05and my parents were socially conscious
-
2:05 - 2:08and demanded that we stand up
for what we believe in. -
2:08 - 2:11Or the fact that my parents
were born in Jamaica, -
2:11 - 2:12came to the United States
-
2:12 - 2:15and were able to realize
the American Dream. -
2:15 - 2:17Or maybe it was my residency training,
-
2:17 - 2:20where I saw firsthand
-
2:20 - 2:23how poorly so many low-income
women of color were treated -
2:23 - 2:25by our healthcare system.
-
2:25 - 2:28For whatever the reason,
I felt a responsibility to stand up, -
2:28 - 2:30not just for myself,
-
2:30 - 2:31but for all women,
-
2:31 - 2:35and especially those marginalized
by our healthcare system. -
2:35 - 2:39And I decided to focus my career
on improving maternal health care. -
2:41 - 2:43So what's killing mothers?
-
2:43 - 2:45Cardiovascular disease, hemorrhage,
-
2:45 - 2:48high blood pressure
causing seizures and strokes, -
2:48 - 2:49blood clots and infection
-
2:50 - 2:53are some of the major causes
of maternal mortality in this country. -
2:54 - 2:57But a maternal death
is only the tip of the iceberg. -
2:57 - 3:02For every death, over a hundred women
suffer a severe complication -
3:02 - 3:04related to pregnancy and childbirth,
-
3:04 - 3:09resulting in over 60,000 women every year
having one of these events. -
3:10 - 3:12These complications,
called severe maternal morbidity, -
3:12 - 3:16are on the rise in the United States,
and they're life-altering. -
3:16 - 3:20It's estimated that somewhere
between 1.5 and two percent -
3:20 - 3:24of the four million deliveries
that occur every year in this country -
3:24 - 3:26are associated with one of these events.
-
3:27 - 3:32That is five or six women every hour
having a blood clot, a seizure, a stroke, -
3:32 - 3:34receiving a blood transfusion,
-
3:34 - 3:37having end-organ damage
such as kidney failure, -
3:37 - 3:39or some other tragic event.
-
3:41 - 3:44Now, the part of this story
that's frankly unforgivable -
3:44 - 3:48is the fact that 60 percent
of these deaths and severe complications -
3:48 - 3:50are thought to be preventable.
-
3:50 - 3:53When I say 60 percent are preventable,
-
3:53 - 3:56I mean there are concrete steps
and standard procedures -
3:56 - 3:58that we could implement
-
3:58 - 4:00that could prevent
these bad outcomes from occurring -
4:00 - 4:02and save women's lives.
-
4:02 - 4:05And it doesn't require
fancy new technology. -
4:05 - 4:07We just have to apply what we know
-
4:07 - 4:10and ensure equal standards
between hospitals. -
4:11 - 4:15For example, if a pregnant woman
in labor has really high blood pressure -
4:15 - 4:18and we treat her with the right
antihypertensive medication -
4:18 - 4:20in a timely fashion,
-
4:20 - 4:22we can prevent stroke.
-
4:22 - 4:26If we accurately track
blood loss during delivery, -
4:26 - 4:29we can detect a hemorrhage sooner
and save a woman's life. -
4:30 - 4:34We could actually lower the rates
of these catastrophic events tomorrow, -
4:34 - 4:37but it requires that we value
the quality of care -
4:37 - 4:39we deliver to pregnant women
-
4:39 - 4:42before, during and after pregnancy.
-
4:42 - 4:47If we raise quality of care universally
to what is supposed to be the standard, -
4:47 - 4:51we could bring the rates of these deaths
and severe complications way down. -
4:52 - 4:54Well, there is some good news.
-
4:54 - 4:56There are some success stories.
-
4:57 - 5:00There are some places that have
actually adopted these standards, -
5:00 - 5:02and it's really making a difference.
-
5:02 - 5:06A few years ago, the American College
of Obstetricians and Gynecologists -
5:06 - 5:09joined forces with other
healthcare organizations, -
5:09 - 5:12researchers like myself
and community organizations. -
5:12 - 5:15They wanted to implement
standard care practices -
5:15 - 5:19in hospitals and health systems
throughout the country. -
5:19 - 5:21And the vehicle they're using
is a program called -
5:21 - 5:25the Alliance for Innovation
in Maternal Health, the AIM program. -
5:25 - 5:30Their goal is to lower maternal mortality
and severe maternal morbidity rates -
5:30 - 5:33through quality and safety initiatives
across the country. -
5:34 - 5:37The group has developed
a number of safety bundles -
5:37 - 5:41that target some of the most
preventable causes of a maternal death. -
5:41 - 5:44The AIM program currently
has the potential to reach -
5:44 - 5:47over 50 percent of US births.
-
5:47 - 5:49So what's in a safety bundle?
-
5:49 - 5:52Evidence-based practices,
protocols, procedures, -
5:52 - 5:54medications, equipment
-
5:54 - 5:56and other items targeting
these conditions. -
5:57 - 5:59Let's take the example
of a hemorrhage bundle. -
6:00 - 6:02For a hemorrhage, you need a cart
-
6:02 - 6:05that has everything a doctor or nurse
might need in an emergency: -
6:05 - 6:09an IV line, an oxygen mask, medications,
-
6:09 - 6:11checklists, other equipment.
-
6:11 - 6:13Then you need something
to measure blood loss: -
6:13 - 6:15sponges and pads.
-
6:15 - 6:17And instead of just eyeballing it,
-
6:17 - 6:20the doctors and nurses
collect these sponges and pads -
6:20 - 6:21and either weigh them
-
6:21 - 6:26or use newer technology to accurately
assess how much blood has been lost. -
6:27 - 6:33The hemorrhage bundle also includes
crises protocols for massive transfusions -
6:33 - 6:34and regular trainings and drills.
-
6:35 - 6:39Now, California has been a leader
in the use of these types of bundles, -
6:39 - 6:42and that's why California
saw a 21 percent reduction -
6:42 - 6:44in near death from hemorrhage
-
6:44 - 6:48among hospitals that implemented
this bundle in the first year. -
6:48 - 6:53Yet the use of these bundles
across the country is spotty or missing. -
6:53 - 6:56Just like the fact that the use
of evidence-based practices -
6:56 - 6:57and the emphasis on safety
-
6:58 - 7:00differs from one hospital to the next,
-
7:00 - 7:02quality of care differs.
-
7:02 - 7:07And quality of care differs greatly
for women of color in the United States. -
7:07 - 7:09Black women who deliver in this country
-
7:09 - 7:14are three to four times more likely
to suffer a pregnancy-related death -
7:14 - 7:15than are white women.
-
7:16 - 7:20This statistic is true for all black women
who deliver in this country, -
7:20 - 7:22whether they were born
in the United States -
7:22 - 7:23or born in another country.
-
7:24 - 7:28Many want to think that income differences
drive these disparities, -
7:28 - 7:29but it goes beyond class.
-
7:30 - 7:32A black woman with a college education
-
7:32 - 7:36is nearly twice as likely to die
as compared to a white woman -
7:36 - 7:39with less than a high school education.
-
7:39 - 7:44And she is two to three times more likely
to suffer a severe pregnancy complication -
7:44 - 7:46with her delivery.
-
7:46 - 7:51Now, I was always taught to think
that education was our salvation, -
7:51 - 7:53but in this case, it's simply not true.
-
7:54 - 7:56This black-white disparity
-
7:56 - 7:58is the largest disparity
-
7:58 - 8:01among all population
perinatal health measures, -
8:01 - 8:02according to the CDC.
-
8:03 - 8:05And these disparities
are even more pronounced -
8:05 - 8:07in some of our cities.
-
8:07 - 8:09For example, in New York City,
-
8:09 - 8:12a black woman is eight to 12 times
more likely to die -
8:12 - 8:16from a pregnancy-related cause
than is a white woman. -
8:17 - 8:19Now, I think many of you
are probably familiar with -
8:19 - 8:22the heart-wrenching story
of Dr. Shalon Irving, -
8:22 - 8:26a CDC epidemiologist
who died following childbirth. -
8:26 - 8:29Her story was reported
in ProPublica and NPR -
8:30 - 8:31a little less than a year ago.
-
8:31 - 8:33Recently, I was at a conference
-
8:33 - 8:36and I had the privilege
of hearing her mother speak. -
8:36 - 8:38She brought the entire audience to tears.
-
8:39 - 8:41Shalon was a brilliant epidemiologist,
-
8:41 - 8:44committed to studying
racial and ethnic disparities in health. -
8:44 - 8:48She was 36 years old,
this was her first baby, -
8:48 - 8:49and she was African-American.
-
8:50 - 8:53Now, Shalon did have
a complicated pregnancy, -
8:53 - 8:57but she delivered a healthy baby girl
and was discharged from the hospital. -
8:58 - 9:02Three weeks later, she died
from complications of high blood pressure. -
9:03 - 9:07Shalon was seen four or five times
by healthcare professionals -
9:07 - 9:09in those three weeks.
-
9:09 - 9:10She was not listened to,
-
9:10 - 9:14and the severity of her condition
was not recognized. -
9:15 - 9:18Now, Shalon's story
is just one of many stories -
9:18 - 9:22about racial and ethnic disparities
in health and health care -
9:22 - 9:23in the United States,
-
9:23 - 9:28and there's a growing recognition
that the social determinants of health, -
9:28 - 9:32such as racism, poverty, education,
segregated housing, -
9:32 - 9:34contribute to these disparities.
-
9:34 - 9:39But Shalon's story highlights
an additional underlying cause: -
9:39 - 9:40quality of care.
-
9:40 - 9:43Lack of standards in postpartum care.
-
9:43 - 9:46Shalon was seen multiple times
by clinicians in those three weeks, -
9:46 - 9:48and she still died.
-
9:48 - 9:51Quality of care
in the setting of childbirth -
9:51 - 9:54is an underlying cause
of racial and ethnic disparities -
9:54 - 9:57in maternal mortality
and severe maternal morbidity -
9:57 - 9:58in the United States,
-
9:58 - 10:01and it's something we can address now.
-
10:02 - 10:04Research by our team and others
-
10:04 - 10:07has documented that,
for a variety of reasons, -
10:07 - 10:10black women tend to deliver
in a specific set of hospitals, -
10:10 - 10:14and those hospitals often have worse
outcomes for both black and white women, -
10:14 - 10:17regardless of patient risk factors.
-
10:17 - 10:20This is true overall in the United States,
-
10:20 - 10:22where about three quarters
of all black women -
10:22 - 10:25deliver in a specific set of hospitals,
-
10:25 - 10:28while less than one-fifth of white women
deliver in those same hospitals. -
10:29 - 10:33In New York City, a woman's risk
of having a life-threatening complication -
10:33 - 10:34during delivery
-
10:34 - 10:38can be six times higher
in one hospital than another. -
10:38 - 10:42Not surprisingly, black women
are more likely to deliver -
10:42 - 10:44in hospitals with worse outcomes.
-
10:44 - 10:46In fact, differences in delivery hospital
-
10:46 - 10:49explain nearly one-half
of the black-white disparity. -
10:50 - 10:52While we must address
social determinants of health -
10:52 - 10:56if we're ever going to truly have
equitable health care in this country, -
10:56 - 11:00many of these are deep-seated
and they will take some time to resolve. -
11:00 - 11:03In the meantime,
we can tackle quality of care. -
11:03 - 11:07Providing high-quality care
across the care continuum -
11:07 - 11:11means providing access to safe
and reliable contraception -
11:11 - 11:13throughout women's reproductive lives.
-
11:14 - 11:19Before pregnancy, it means
providing preconception care, -
11:19 - 11:22so we can manage chronic illness
and optimize health. -
11:22 - 11:26During pregnancy, it includes
high-quality prenatal and delivery care -
11:26 - 11:29so we can produce healthy moms and babies.
-
11:29 - 11:34And finally, after pregnancy, it includes
postpartum and inter-pregnancy care -
11:34 - 11:38so we can set moms up
to have a healthy next baby -
11:38 - 11:39and a healthy life.
-
11:39 - 11:42And it can literally spell the difference
between life and death, -
11:42 - 11:44as it did in the case of Maria,
-
11:44 - 11:48who checked into the hospital
after having an elevated blood pressure -
11:48 - 11:50during a prenatal visit.
-
11:50 - 11:52Maria was 40, and this
was her second pregnancy. -
11:53 - 11:57During Maria's first pregnancy
that had happened two years earlier, -
11:57 - 12:00she also didn't feel so well
in the last few weeks of her pregnancy, -
12:00 - 12:02and she had a few
elevated blood pressures, -
12:02 - 12:05but nobody seemed to pay attention.
-
12:05 - 12:07They just said, "Maria,
don't worry, you'll be fine. -
12:07 - 12:10This is your first pregnancy.
You're a little nervous." -
12:10 - 12:12But it did not end well
for Maria last time. -
12:12 - 12:14She seized during labor.
-
12:15 - 12:17Well, this time her team really listened.
-
12:17 - 12:20They asked smart and probing questions.
-
12:20 - 12:24Her doctor counseled her about
the signs and symptoms of preeclampsia -
12:24 - 12:26and explained that
if she was not feeling well, -
12:26 - 12:28she needed to come in and be seen.
-
12:28 - 12:30And this time Maria came in,
-
12:30 - 12:33and her doctor immediately
sent her to the hospital. -
12:33 - 12:37At the hospital, her doctor
ordered urgent lab tests. -
12:37 - 12:40They hooked her up
to multiple different monitors -
12:40 - 12:42and paid special attention
to her blood pressure, -
12:42 - 12:44the fetal heart rate tracing
-
12:44 - 12:47and gave her IV medication
to prevent a seizure. -
12:47 - 12:51And when Maria's blood pressure got
so high it put her at risk for a stroke, -
12:51 - 12:54her doctors and nurses jumped into action.
-
12:54 - 12:56They repeated her
blood pressure in 15 minutes -
12:56 - 12:58and declared a hypertensive emergency.
-
12:58 - 13:02They gave her the right IV medication
according to the latest correct protocol. -
13:02 - 13:05They worked smoothly together
as a coordinated team -
13:05 - 13:08and successfully
lowered her blood pressure. -
13:09 - 13:13As a result, what could have been
a tragedy became a success story. -
13:13 - 13:15Maria's dangerous symptoms
were controlled, -
13:15 - 13:18and she delivered a healthy baby girl.
-
13:18 - 13:21And before Maria was discharged
from the hospital, -
13:21 - 13:25her doctor counseled her again about
the signs and symptoms of preeclampsia, -
13:25 - 13:28the importance of having
her blood pressure checked, -
13:28 - 13:30especially in this first week postpartum
-
13:30 - 13:34and gave her education about
postpartum health and what to expect. -
13:34 - 13:36And in the weeks and months that followed,
-
13:36 - 13:39naturally, Maria had follow-up visits
with her pediatrician -
13:39 - 13:41to check in on her baby's health.
-
13:41 - 13:43But just as important,
-
13:43 - 13:45she had follow-up visits with her ob-gyn
-
13:45 - 13:48to check in on her health,
her blood pressure, -
13:48 - 13:51and her cares and concerns
as a new mother. -
13:51 - 13:55This is what high-quality care
across the care continuum looks like, -
13:55 - 13:57and this is how it can look.
-
13:57 - 13:59If every pregnant woman in every community
-
13:59 - 14:02received this kind of high-quality care
-
14:02 - 14:06and delivered at facilities that utilized
standard care practices, -
14:06 - 14:10our maternal mortality and severe
maternal morbidity rates would plummet. -
14:10 - 14:14Our international ranking
would no longer be an embarrassment. -
14:14 - 14:19But the truth is, we've had decades
of unacceptably high rates -
14:19 - 14:24of maternal death and life-threatening
complications during delivery -
14:24 - 14:29and decades of devastating consequences
for moms, babies and families, -
14:29 - 14:31and we have not been moved to action.
-
14:31 - 14:35The recent media attention on
our poor performance on maternal mortality -
14:35 - 14:38has helped the public to understand:
-
14:38 - 14:41high-quality maternal health care
is within reach. -
14:41 - 14:42The question is:
-
14:42 - 14:47Are we as a society ready to value
pregnant women from every community? -
14:47 - 14:52For my part, I'm doing everything I can
to ensure that when we do, -
14:52 - 14:55we have the tools and evidence base ready
-
14:55 - 14:56to move forward.
-
14:57 - 14:58Thank you.
-
14:58 - 15:03(Applause)
- Title:
- How we can improve maternal healthcare -- before, during and after pregnancy
- Speaker:
- Elizabeth Howell
- Description:
-
Shocking, but true: the United States has the highest rate of deaths for new mothers of any developed country -- and 60 percent of them are preventable. With clarity and urgency, physician Elizabeth Howell explains the causes of maternal mortality and shares ways for hospitals and doctors to make pregnancy safer for women before, during and after childbirth.
- Video Language:
- English
- Team:
- closed TED
- Project:
- TEDTalks
- Duration:
- 15:17
Oliver Friedman edited English subtitles for How we can improve maternal healthcare -- before, during and after pregnancy | ||
Brian Greene edited English subtitles for How we can improve maternal healthcare -- before, during and after pregnancy | ||
Oliver Friedman approved English subtitles for How we can improve maternal healthcare -- before, during and after pregnancy | ||
Oliver Friedman edited English subtitles for How we can improve maternal healthcare -- before, during and after pregnancy | ||
Camille Martínez accepted English subtitles for How we can improve maternal healthcare -- before, during and after pregnancy | ||
Camille Martínez edited English subtitles for How we can improve maternal healthcare -- before, during and after pregnancy | ||
Camille Martínez edited English subtitles for How we can improve maternal healthcare -- before, during and after pregnancy | ||
Joseph Geni edited English subtitles for How we can improve maternal healthcare -- before, during and after pregnancy |