Atlantic Pulse: Closing the maternal mortality gap and improving outcomes for mothers

On April 30th, Dr. Neel Shah spoke with Dr. Laura Riley, Obstetrician and Gynecologist-in-Chief at New York-Presbyterian and Weill Cornell Medicine and Olga Khazan, Staff Writer at The Atlantic about delivering better outcomes for mothers.

Olga: We are here to talk about a somewhat disturbing trend in health care, which is that the U.S. is actually a global outlier. It is one of the only industrialized countries where the rate of mortality is actually going up, instead of down like you would expect in a wealthy country like ours and there are also huge racial disparities and economic disparities to the extent that where you live, your zip code, can actually in some cases determine the maternal mortality rate in the immediate environment.
We’re here to talk about why this is happening and what we can do about it. So first, just to jump in, why is the U.S. such an outlier on this? Why are these rates going up so much in the U.S.?

Laura: I think it’s probably a number of reasons. Women are older, women have more chronic illnesses. But I think that it’s much more complex than that. I think there are obviously access issues, as you alluded to. There are issues that even if you have access, once you get to the hospital you’re not necessarily taken care of at the level that is appropriate. So,  I think that we have a lot of work to do.

Neel: I would add to that… I mean, there is a generational problem with us. If you’re an American mom today you are 50% more likely to die in childbirth than your own mom was. Three to four times more likely if you’re black compared to whether you’re white- which we should unpack- but the deaths are just the canary in the coal mine of a much deeper problem. For every death, there are tens of thousands of moms out there who are suffering from chronic illnesses. There are tens of thousands that are more socially isolated than their own moms were. We’re more economically disempowered as a result of childbirth. So, there is a challenge we have within the health care delivery system, but we have a much broader challenge actually that’s in the communities where we live that are under-supporting moms during this really universally vulnerable period.

Olga: And I definitely want to unpack that shocking statistic, which is black women are three to four times more likely to die from pregnancy causes than white women. In New York City, it’s actually 12 times more likely to die, which is just an insane disparity when you think about it. What are some of the underlying factors there.

Laura: Neel, do you want to…

Neel: Ah sure, I mean I am not ostensibly a black woman, so I want to stay in my lane as I talk about this. But, you know, there’s a couple of dynamics here. I mean, there is a chronic effect of structural racism and a weathering that I think has been well documented. There’s also a really acute effect I want to explain. In almost every other progressive work environment we’re taught to sort of recognize and mitigate our implicit biases. In medicine, we’re actually trained to hone and amplify them. We essentially profile people for a living, in medicine. Our job is to look at someone and decide if they’re sick or not. When our biases work well we kind of celebrate it as clinical intuition, right? We’re trained to know that if somebody’s pale they may be anemic, but if you’re black you’re not going to look pale. It’s just different.
One of the things that sort of crosscuts a lot of the stories in the media- Serena Williams, Beyoncé- is when black women express symptoms particularly around pain, for some reason the medical system is slower to respond. And that accounts for a lot of the disparity that we see.

Olga: Yeah. I want to break down for people who aren’t experts in this, what does maternal mortality look like? Does it happen while a woman is actually pregnant? You know, we think of “dying in childbirth” but does it actually happen during the birthing or does it happen after the baby is born?

Laura: It can happen at any one of those time periods. It’s probably roughly a third a third and a third. That’s what makes it so difficult for us to start making some inroads because I think that the American College of Obstetricians and Gynecologists has worked on and focused on labor and delivery safety. Making sure when you go to the hospital they know how to handle excessive bleeding and that everyone does the same thing. I think what’s difficult is that so many of these deaths and the morbidity that Neel is talking about, so sort of the near-death, which is even more important in some ways, that can happen even before the delivery. The prenatal care aspect of it, things can go wrong, especially for women with chronic illnesses that are worsened by pregnancy or worsen the pregnancy.
Then the post-partum period that I really worry about wraps up in things other than just “medicine” specifically. You know, you have your baby, and everyone’s happy. Mom and baby go home and they may not see their physician or their midwife until six weeks postpartum, so they essentially are dropped off. Many things can happen during those six weeks. Many things can also happen after the six weeks, and the structure that we have in this country is that many women will have access to prenatal care and coverage until the six-week visit. Then boom! You’re dropped off. The fact that if you have chronic illnesses that have been made worse by pregnancy, those don’t get taken care of possibly until you have your next pregnancy. Which is now even more high-risk. You can see where this cycle is really a difficult issue. So, people are looking at different interventions. Will telehealth actually help us for those women in that gap? Who knows. But I think we need to start working at it

Olga: Right, and kind of extending that continuity of care, it sounds like, until the mom has actually gone home.

Neel: I mean, Dr. Riley taught me everything that I know so I just want to amplify something in particular. There’s a public narrative about what a maternal death is that isn’t the whole story, which is what you’re highlighting. It’s not a woman necessarily who comes into the hospital and has an acute emergency. That’s about a third of it. I was part of a team that worked with the CDC to develop a report on the 800 young, otherwise healthy women in this country every year who died in the period surrounding childbirth and how much that is truly preventable. A lot of it is an opportunity to make our health care delivery systems more reliable for people, but a lot of it is, as Dr. Riley said, people who go home. We’ve got people living with sleep deprivation, because they’ve got to care for a new infant and are trying to earn a living wage at the same time. In our country, that’s a really difficult thing to do. We don’t have paid family leave. It is a broader societal issue.

Olga: And why don’t you talk about some of the initiatives that you’re working on both in the hospital and outside of the hospital to combat some of that.

Laura: I think there’s a lot of initiatives going on, as I mentioned. There’s the ability to focus on the labor and delivery aspect itself, but again, as Neel’s saying, not all of the deaths or near-misses are just related to some acute event. And the other thing about obstetrics which is particularly scary is that you can be a “low risk” woman and have a bad event happen, so I think that it brings up the fact that people have to be ready. We are in the process at Weill Cornell of opening a new Women’s Hospital and it’s an opportunity for us to see how we deliver care and do a better job of figuring out how we’re going to make the safest possible experience. I think the antepartum issues- meaning before you get to the delivery- that’s where I think that people are trying to make sure that women are getting care for their chronic illnesses. That their hypertension is taken care of before the pregnancy, that they have the ability to plan the pregnancy, that they have access to contraception so they can plan their pregnancy and get their medical problems in order. I think post-partum, that’s the one we’re really struggling with. I think one thing that I have learned over the course of my very long career, (she gestures to Neel) long enough to train this guy-

Neel: I’m not that old either.

Laura: Neither one of us is that old. But I have learned something we don’t do well in medicine or I think especially in obstetrics is we don’t listen to the community, so some of our interventions are going to fall flat on their faces because we haven’t listened to what the women in the community want and need. So that’s something that I’m going to be working on trying to understand; the new community that I live in now which is New York City, and the very diverse population. It’s not going to be one size fits all. What works on the Upper East Side is not going to work in Queens.

Olga: Definitely, and Neel, before you go, (to the audience) I wanted to tell you guys to just to remind you to type your questions into slide o because we’re going to be taking those in a minute, so take a minute, type in your questions, and make sure you tell us who you are also. (Back to Neel) Go ahead.

Neel: I was just ready to jump in with exactly where Dr. Riley left off, which is a lot of the solution really resides within the community of people who are most impacted by it. And at the end of the day, let’s at least point out that women have goals in labor other than emerging unscathed from the process. Survival is the floor of what women and their families deserve, and if what we’re trying to do is design a better system we should be aiming for the ceiling. So, care that’s not just safe, but is supportive and empowering. As a principle, I think we’ve lost sight of that. Everything about the way our delivery system is designed, everything about our expectations as a society is really anchored to this notion of survival. One of the things we’re trying to do actually is just to start with women. Women are really good, and moms in particular are really good, at organizing for every progressive cause except for their own well-being. There’s Moms Against Drunk Driving, Moms Against Guns, but fundamentally moms are used to putting themselves last to put their families first. When you go to Capitol Hill and there’s a meeting about breast cancer, you can push a button and there’s a thousand pink ribbons, but for maternal health we haven’t been organized in that way. One of the that we’re going to do is on May 11th, the day before Mother’s Day, we’re going to put a 50-foot-tall rock concert stage on the National Mall right in front of the Capitol building and we’re going to get thousands of people to show up in orange t-shirts like this (gesturing to his March for Mothers t-shirt) and create a platform for families to tell their stories and offer their ideas of where the solutions lie.

(Audience Applauds)

Olga: We can start to take some questions I think we might have some coming in already… (reading a question submitted from the audience) Is infant mortality affected by this increase in maternal morbidity.

Laura: Yes!

Olga: How so?

Laura:  You can’t have a healthy baby without a healthy mother and so infant mortality is not going to make the inroads that it needs to until we can take care of the mother. But, I think that this question is something that in addition to moms not focusing on their own health, frankly, for my 30-year career, we’ve been very slow to focus on maternal health. We were laser-focused on infant mortality, infant morbidity, prematurity, it was all about saving those little tiny babies. Not that that’s not important, but as we were laser-focusing on it, moms were getting sicker and we weren’t focused on that. Thankfully, the conversation has changed, and now we’re sort of realizing ‘okay, it’s time to stop counting, morbidity is bad, we need to do a better job’.

Olga: I read somewhere that the mom was treated like the wrapper and the baby was the candy.

Neel: (in reference to the quote) Dr. Alison Stuebe, a colleague of both of ours, she’s praised

Laura: Oh yeah.

Neel: I mean, at the end of the day, women are treated as vessels for pregnancies. Societally and clinically. Obviously, the mom and the baby’s health are related. This is one of the only windows in healthcare where you can impact the long-term well-being of two humans, which is part of why I was so drawn to it. But it is a false choice in the majority of cases between the mom and the baby. In the highest levels of the profession and of the delivery system, we haven’t had that clarity not for the longest time.

Olga: The next question is, is there anywhere in the U.S. where we are doing a good job caring for mothers? Any king of over-performing or good-performing areas?

Laura: There’s lots of places! This is an interesting question, I think that it’s something that I actually struggle with in the office and it’s that I think because we’ve now raised everyone’s concern about maternal morbidity and mortality, which needed to happen, we are scaring women. So, we need to figure out a way of gathering people’s interests and their concerns without making this “you’re gonna come in the hospital and you’re gonna die!” That is not the case, so we need to put it into perspective as well. We can do better across the country, no question.

Neel: What I’d add to that- I mean, we just heard Zeke Emmanuel, and I couldn’t hear what exactly he was saying but I have a good sense of how he thinks about the health care system. You know, maternal health is really exceptional compared to the rest of the delivery system in so many ways, but one of them is just the degree to which the quality of services varies. Like C-section rates. C-sections are the most common major surgery performed on the people in this room right now. The C-section rate from hospital to hospital in the city of Boston and across the country varies from 7% to 70%.

Olga: Wow.

Neel: There is no other health care service that varies by an order of magnitude, and after you account for the risk level of women, it doesn’t vary by one order of magnitude or tenfold. It varies 15-fold. There is no other health care service where after you account for risk you see more variation not less. There’s more unevenness in the quality of services. But what that means is there are some places that need to do way way better that we need to put on notice, but there are also places that are achieving great outcomes on behalf of women that we need to learn from.

Olga: Yeah, absolutely. So, the next question is that the ACA brought some positive change to maternal health with things like birth control and time/space to pump and things like that, what should be the next thing we lobby for? What are some of the policies you guys have on your wish list?

Laura: One policy that I have on my wish list is that we need to extend the coverage. You can’t drop people off at six weeks. It is not over at six weeks, your health goes on, and we need to lobby for that.

Neel: And not only does your health go on, but the worst time to pull someone’s insurance out from under them is when they’ve got a six-week-old infant. I mean, you are getting POW-level sleep deprivation, somehow trying to earn a living wage at the same time. It’s one of the cruelest things about the way our healthcare system is set up, and it goes back to the ‘treating women as vessels for their pregnancy’ thing.
“We’ll cover you while you’re pregnant, but then afterwards we sort of disregard your well-being,”. What I’d add to this is that the ACA was really successful in covering a lot of essential services, but it didn’t fundamentally make health care more affordable for the average American. This is the least affordable health care has been for the average American in a half-century. If you’re pregnant and you have a high-deductible health plan, you are guaranteed to blow through the whole deductible during your pregnancy. That’s real money. You’re feeling that every ultrasound, every prenatal appointment, and during an initial prenatal appointment we get this huge battery of tests that generates a massive bill. What we’re seeing across the profession is that the trust in the profession is falling out from underneath us from these affordability issues.

Olga: That’s so interesting, yeah, because then you might be de-incentivized to do everything because you can’t afford it.

Neel: You might not come in for the care that you need.

Olga: (Turning to a new question) That’s an interesting one. Are their programs or projects that are specifically geared towards dads, to support the moms?

Laura: (to Neel) You wanna handle that?

Neel: YES! Wherever you are, you have a great question. Honestly, I’m an OB, I’ve cared for thousands of pregnant women at this point, delivered thousands of babies, but fatherhood for me was still an abstraction until I actually saw my baby for the first time. A mom feels a baby for months, and one of my favorite parts of my jobs is the moment where a dad realizes he’s a dad. There was one time I got to see it on a big screen because the dad was in Afghanistan, and the moment he actually physically saw his child is one of my greatest memories from practice. There are so many opportunities to get dads more involved, but there are a lot of reasons right now why they’re on the margins. It’s because historically we haven’t really given them the permission or the opportunities to do so. Thank you for that question. Dads, fathers, families, have a really important role to play in making sure that mothers are better supported.

Laura: I think also that this is an area where going into the community is super important because it’s really about supporting families, and those family structures, as you know, are different everywhere. Some communities where the most important person is mom and sisters and having that other part of the support system, that’s where we need to figure out how do we bolster education for all of them. Because really, that’s who’s going to take care of mom and her newborn, etc.

Olga: Let’s try to do a rapid-fire last question, which is how are some of the ways technology can actually help solve some of these issues?

Laura: I know in New York there’s a lot of hope in Telehealth because I think access is one of those things…you know, having worked in Uganda as well, it is amazing what we can do with our iPhones. Because everyone has one of those. Even if they don’t have good water, they seem to have an iPhone, so we are hoping that that will increase access for women across the world, actually.

Neel: I know there are a lot of technologists in the room, but there is no app, widget, AI, or block chain that’s going to fix healthcare unless we have a good underlying system at the end of the day. I know we’re at time so I’ll leave it at that, but I have plenty to say about that.

Olga: Find him afterwards, guys. Thank you so much, Neel and Laura.

Laura: Thank you.

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