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  • 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.