On Friday, May 19, Brigham and Women’s Hospital hosts their Annual Women’s Health Luncheon. This year’s conference focuses on reproductive health advocacy and equity, with guest speaker Christy Turlington Burns. You might know her as a model, but she’s also the founder of the maternal health organization Every Mother Counts, dedicated to making pregnancy and childbirth safer for moms everywhere. (Turlington Burns hemorrhaged during labor due to a retained placenta.)
Why is childbirth so fraught, especially in the United States? According to the Centers for Disease Control, Black women are about three times more likely to die of pregnancy-related causes than white women. In Massachusetts, Black non-Hispanic women are almost two times more likely to die during pregnancy or within a year postpartum than white non-Hispanic women, according to the Massachusetts Department of Public Health. Among developed countries, the United States has the highest rate of people dying of pregnancy-related complications during or within 12 months of the end of pregnancy.
Both of my pregnancies were fairly uncomplicated. But I still remember the dread when told that my platelets were too low for a traditional epidural for a C-section, which meant a less localized spinal anesthetic. It was administered a tiny bit high, so the numbing qualities traveled all the way to my chin. Not being able to feel yourself breathe is an experience I don’t recommend, but I wanted to be a compliant patient. I stayed perky and polite to the anesthesiologist, kind of the way it’s awkward to speak up during a painful massage.
My story is minor, but the point is: When we’re pregnant, we’re vulnerable. Brigham and Women’s Hospital houses the Mary Horrigan Connors Center for Women’s Health & Gender Biology, focusing specifically on equity in women’s health care. In advance of the conference, I talked to Dr. Nawal Nour, the hospital’s Chair of the Department of Obstetrics and Gynecology, about what giving birth in the United States — and here in Boston — looks like right now.
What’s going on in the United States? We have such an advanced healthcare system, but we also have the highest pregnancy-related death rate among developed nations. Why?
This is such an important question. I’ll even go back further. It’s heartbreaking because a lot of effort has been made. We’ve known about the data. We recognize that especially our Black and brown patients have a much higher rate of maternal mortality.
We look at programmatic aspects, we look at systems, we’re looking from a state perspective, and the CDC has highlighted it. We’re very aware of the problem. And then [we] find out the data demonstrates that we haven’t moved the needle — in fact, the needle is moving in a direction that’s worse, and even more alarming.
Why? The answers are primarily a few. [Hospitals don’t] always provide wraparound services. And that means making sure that we look at the social determinants of health. Is there housing insecurity? Are patients safe at home? Are they employed? Is there a sense of empowerment? How do we think about our patients as they come into the hospital?
The other aspect is that patients are seen throughout their pregnancy. We see them once postpartum, and then we say goodbye. Again, there’s no wraparound service. We let them go after six weeks and, as you know, as a mom, that’s just the beginning of the journey of motherhood. We really have to take care of our patients long after they’ve delivered their babies.
Other countries have a much more extended maternity leave. They have extended postpartum care. They are well aware of some of the complications that can occur postpartum: postpartum depression, psychosis, elevated blood pressure, eclampsia. We tend to hand our patients off too early.
When we consider maternal mortality, what does that look like? What are the causes of death? I’m thinking about women who are actually dying in childbirth. But that’s not the only way to think about this.
No. During childbirth, of course, [we think about] hemorrhage. But there’s also postpartum hemorrhage. Patients will end up bleeding at home. And high blood pressure, preeclampsia, and eclampsia — two diseases that go along with high blood pressure — really put women at risk, because this can also cause damage elsewhere: to the heart, liver, kidneys. Moms can end up with seizures or strokes. We have not always done a great job of watching the postpartum period and making sure that blood pressure is well-controlled.
I know a healthy woman who died postpartum of sepsis in New York City. It’s shocking, and you don’t hear about it much. But: This actually can happen to women, and we need to be aware of it.
We tend to take for granted that women who deliver are young. I don’t mean ‘young’ as in their twenties. But, overall, when we think of the lifespan of people, these women are young. When it comes to bleeding, young people can look great as they continue to bleed until they die. Young people have such a strong ability to compensate for the blood loss, and the same with sepsis. Someone can look good until they’re near death. When we think about mortality, we need to really pay attention to the near-death experiences.
This is something that’s problematic nationwide — but what do you see in Boston? What do you worry about day to day?
I’m actually very grateful that we live in Boston, in Massachusetts. We embrace reproductive health and reproductive justice. Maternal mortality is top of mind. We have amazing health centers. We really focus on these things together, as a unit, because we all care about this. From that perspective, I would say that your readers should know that they’re in a good state that really pays attention to this and cares about it deeply.
How can women and families take steps to advocate for themselves and to protect themselves against these outcomes? What might be done for them here that might not be done elsewhere? What are those safeguards?
Every patient should be an advocate for themselves, for their families and friends. I think patients are becoming more sophisticated; I truly enjoy the fact that our patients will say, ‘I read this’ or, ‘I’m worried about that’ and have a dialogue with me.
Just to take a step back, we are all human, and there are systems put in place so that errors don’t get made. But if there isn’t a transparent discussion between patient and provider, things do get missed. And then we’ve lost the opportunity to provide quality care. It’s a circle, between patients and providers, of communication.
I want to drill down briefly on that for a minute, because we hear the word ‘advocacy,’ and that’s a big word. But what does that really look like in an appointment? I think people sometimes feel overwhelmed. Maybe a doctor seems rushed.
It can be as simple as asking the questions. ‘Am I on the right medication?’ ‘Something happened to me, and I’m really worried about it.’ And then the provider might give a response to say, ‘I didn’t understand what you said. Can you explain it differently?’ Simple, clarifying questions are critical.
I have to say, this has been a very interesting time because the more the media highlights this — which is wonderful — the more patients will come in, Black patients will come in, and say, ‘I’m at an increased risk of dying. Are you going to take care of me? Are you going to make sure I don’t die?’
From my perspective, that’s advocacy at its best. Patients are keeping us accountable and so we’re able to do the reassurance of: ‘I’ve looked at your chart, and you’re not at risk’ — or you are at risk. Having transparent, honest conversations with your patients is critical.
I get to the point where some patients will continue advocating, saying, ‘I’m really, really worried about this.’ And I say, ‘Look, I’m a Black doctor. I understand your concerns. And I understand also that if you come in, in labor, I may not be there. But I can guarantee that I’ve also documented your concerns in the chart.’
Why are Black and brown women at increased risk?
I think there’s systemic racism. We think about that when we discuss how patients are heard. We all have implicit bias, right? Sometimes patients will speak up, and we may not hear what they’re trying to tell us. And so we miss that opportunity of caring for patients.
There’s the implicit bias that comes into play, but also systemic racism: Are we doing the exact same thing if a white patient comes in and says something? Do we do the exact same labs or ultrasound imaging that we would do if a Black or brown patient does? If we do, that’s great. If we don’t, then we have disparities in care. And, when we have disparities, then the outcomes also demonstrate these disparities.
On that note: What do you hope that people gain from this event and learn? What’s next?
I would hope that all the efforts that we have put in place — and when I say ‘we,’ I mean all the efforts in different states to ensure that we have what we call equitable care bundles; we do safety bundles to ensure that we deliver the same kind of care to every patient — not only brings down maternal mortality for Black and brown women but also reduces maternal mortality for all women.
I do believe the efforts that we’re putting in place are the right ones. Now we need to identify when these issues occur: Are we actually analyzing every chart and finding out where the system failed? More than anything, I think we really need to hone in on our near-misses. We’re lucky when mom doesn’t die, but we can’t pat ourselves on the back. We should be thinking: How did we even get to the near-miss? Focusing on those efforts is critical.
Anything we didn’t talk about? What else do you want women to know?
What I’d really like them to know is pregnancy and delivery is — because we’re talking about mortality — it’s frightening, right? But enjoying pregnancy and delivery is the norm. I really want patients to understand that when we talk about maternal mortality, or near-misses, that’s the dark side of pregnancy. But really, my job and my heart go into ensuring that every one of my patients has a wonderfully healthy pregnancy and enjoys being pregnant, and then enjoys the delivery and postpartum. That’s what we’re looking for: the joy of delivering a baby.
Interview has been edited and condensed.