Maternal mortality is a crisis in the U.S., with the worst death rates of any nation in the developed world. Those rates doubled between 1990 and 2013, and black women are hit the hardest. The Preventing Maternal Deaths Act was enacted in December 2018 to begin to tackle the problem, leaning heavily on states to collect and analyze maternal death data, but the U.S. still has a long way to go in tamping down maternal mortality rates.
番茄社区 asked four experts to discuss the disparities, causes, and policy efforts, as well as how advocacy groups are trying to make a difference:
- Tamika Auguste, MD, vice chair of women's and infants' services, MedStar Washington Hospital Center, Washington, D.C.
- Haywood Brown, MD, professor of obstetrics and gynecology at the University of South Florida, and past president of the American College of Obstetricians and Gynecologists (ACOG)
- Kathryn Schubert, MPP, chief advocacy officer, Society for Fetal-Maternal Medicine, Washington, D.C.
- Melissa Patti, MSW, LCSW, director of specialized community health, Maternity Care Coalition, Philadelphia
Following is a transcript of their remarks:
Tamika Auguste, MD: Maternal mortality is a big concern not only here in the District of Columbia, but across our entire country. Internationally it's a big concern. The rates of women that are dying surrounding childbirth are skyrocketing, especially for a country of our size and our stature. We have some of the worst maternal mortality rates in the entire world.
Why is this happening? Some of the reasons are our population over time, they are delaying childbirth. That's one. With a delay of childbirth, women have a little bit more time to gain their own illnesses and to then deal with that and childbirth together can be difficult. Overall, our patient population, we are not as well as we were 20, 30, 40, 50 years ago. So we're combating some other maternal illnesses that women are having. Things like obesity, hypertension, diabetes -- combine all of those with pregnancy and you have a higher-risk pregnancy overall.
The other thing that I think is happening that unfortunately people don't like to talk about, are the biases of healthcare providers. It's real. Everyone has a bias, it's a matter of recognizing them and then altering them so that we can properly take care of our patients. This comes out pretty much when you see that black women have a three to four times higher rate of maternal mortality than any other demographic. That is very concerning. So, we need to address all aspects of these contributing factors to maternal mortality in order to move the needle.
Haywood Brown, MD: Social determinants of health are really the background noise that impact all disparity and impact all inequity in healthcare. Social determinants are where you live, what zip code you live in. They are the nutrition status that you have. It's your transportation barriers that might impact your access. It's your insurance status that might impact your ability to seek out care in a timely manner. And it's your support structure in your community.
These are the social determinants that impact your health and well-being. And I think that's where we have to get a better understanding of the real paramount differences that might be playing a role in black women versus white women, even Hispanic women, when it comes to mortality.
Kathryn Schubert: One of the things that we're looking at here within the society is healthcare disparities as the lens with which we view all policy proposals. We're really looking more toward [whether] states have a maternal mortality review committee in place as defined by the CDC. We are looking at whether states have a perinatal quality collaborative in place, also as reported by the CDC. We also looked at whether states were expanding medicaid coverage.
The last thing, which is probably the most important thing we're looking at, is whether states report data by race. And we're really looking there to see, are states making efforts to close their healthcare disparities and those gaps in death rates.
I think that given the bipartisan support of the Preventing Maternal Death Act, that's really exciting. Given the emerging public health crisis that we are seeing, there's a lot of interest for policy makers to want to do something.
Melissa Patti, MSW, LCSW: Ours is a community health worker model. We call them advocates at Maternity Care Coalition, and they're going out into the community. We work directly with women and their families, but we want to meet them wherever is comfortable. So we'll go to someone's home, we'll go to a family member's home. We'll accompany them to appointments. We work with women on goals that they designed. So it's really strength-based and really person-centered.
All of our women have some sort of high-risk concern, whether it's medical, like a chronic health condition like hypertension or diabetes, or if it's a mental health issue or substance use. So we want to work directly with them around their goals, around their health, but also the social determinant of health issues that they may have. So a lot of our women have housing instability. They have a lack of transportation, childcare, mental health, and the lack of resources that go along with all of those things.
One of our advocates was working with a young woman who had a pretty serious heart condition and we were all very concerned about what her outcome would be. Whether the pregnancy would be successful, what the impact it will be on her health. And she arrived to prenatal care pretty late. It was not until around like 28 weeks. And then trying to balance what her needs were at the time it seemed like there were constantly new issues coming up. And she hadn't been that engaged in routine healthcare prior to pregnancy, so she didn't have a well established specialist to manage her heart condition.
So what our advocate did was really talk to the providers during weekly, high-risk meetings about what her needs were and what they were trying to focus on. Then they also helped the woman get connected with a cardiologist, and there was another specialist that she needed to be seeing routinely as well. Our advocate helped to facilitate the communication between all of the providers, and really translate a lot of the heavy clinical medical information that the woman was receiving so we knew that she understood what was going on and could participate in a plan for her care.
I'm hopeful that with a community health worker model like our program, that because we're building that trusting relationship and because we are mirroring that kind of relationship with providers, it can help providers be a different voice, listen more, and really understand where someone is coming from.
Auguste: I think a team-based approach to helping to decrease maternal mortality and morbidity is key. So in that postpartum period, if I have a patient that has high blood pressure and it's not controlled, and it's outside my scope, I'm going to call my internal medicine colleague and say, 'Hey, I have this patient of ours, she just delivered, I'm having trouble managing her blood pressure. Can she come see you tomorrow, this week, so that we can kind of work on controlling her blood pressure together.'
And for healthcare providers, when your patient comes in and is talking to you, listen. I know it's hard, I see patients too. It's hard, you're in and out. But take the time to listen to your patients. And together as a dyad, a patient-healthcare provider dyad, work together towards optimizing a woman's healthcare around pregnancy, delivery, and afterwards, and then also on the continuum towards just well-woman care.