How we can improve maternal healthcare — before, during and after pregnancy | Elizabeth Howell


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. And when Maria’s blood pressure got
so high it put her at risk for a stroke, her doctors and nurses jumped into action. They repeated her
blood pressure in 15 minutes and declared a hypertensive emergency. They gave her the right IV medication
according to the latest correct protocol. They worked smoothly together
as a coordinated team and successfully
lowered her blood pressure. As a result, what could have been
a tragedy became a success story. Maria’s dangerous symptoms
were controlled, and she delivered a healthy baby girl. And before Maria was discharged
from the hospital, her doctor counseled her again about
the signs and symptoms of preeclampsia, the importance of having
her blood pressure checked, especially in this first week postpartum and gave her education about
postpartum health and what to expect. And in the weeks and months that followed, naturally, Maria had follow-up visits
with her pediatrician to check in on her baby’s health. But just as important, she had follow-up visits with her ob-gyn to check in on her health,
her blood pressure, and her cares and concerns
as a new mother. This is what high-quality care
across the care continuum looks like, and this is how it can look. If every pregnant woman in every community received this kind of high-quality care and delivered at facilities that utilized
standard care practices, our maternal mortality and severe
maternal morbidity rates would plummet. Our international ranking
would no longer be an embarrassment. But the truth is, we’ve had decades
of unacceptably high rates of maternal death and life-threatening
complications during delivery and decades of devastating consequences
for moms, babies and families, and we have not been moved to action. The recent media attention on
our poor performance on maternal mortality has helped the public to understand: high-quality maternal health care
is within reach. The question is: Are we as a society ready to value
pregnant women from every community? For my part, I’m doing everything I can
to ensure that when we do, we have the tools and evidence base ready to move forward. Thank you. (Applause)

43 Replies to “How we can improve maternal healthcare — before, during and after pregnancy | Elizabeth Howell”

  1. Everyone who sees this, even if life isn't your friend now, better days will come! Keep going strong 💪! (Message brought to you by a small YouTuber 💕 ♥️)

  2. USA claims to be land of the free but what society can consider itself free when it values the ownership of machine guns over universal decent healthcare for it citizens. USA legislates to deny its own citizens basic healthcare.

  3. I appreciate having both anecdotes and stats It rounds out the presentation to make it for more understandable for me. Thank you .

  4. One problem for the protocols is that they often require an increase in staff in hospitals that are already fighting hard to reduce staff, especially the highly qualified professional RNs and even doctors. They are only interested in the money aspect and patients take a rear seat when it comes to care in those for profit public institutions with stock listings.

  5. My mother died in 1967 just like you described, as a result of kidney failure. It took over a month of agonizing pain for her to die. Worse yet, she was white and she worked for the hospital in the data processing department. She had also been a nurse in the Air Force during the Korean War.

  6. I am unable to understand these videos up to now i dont know what they want to say i have seen one video in galgotia …but i was unable

  7. Omg I read studies on this and she is falsifying everything, literally. Healthcare cost more, because we make way more. Women of color death during birth is well known because they have a much higher chance of untreated and undiagnosed high blood pressure. They have a higher chances for genetic conditions that affect birth and bleeding like sickle cell anemia. Ethnic diets are an issue also. The best way to fix this is by starting comprehensive fitness management for everyone, in a society that now celebrates fatness and unhealthy behaviors. Read some studies on it, it's very interesting. Also this is a bold faced lie. https://ihpi.umich.edu/news/study-nearly-41000-women-who-almost-died-giving-birth-shows-whos-most-risk

  8. Babies are not Pizzas by Rebecca Decker breaks down these statistics and provides evidence-based practices for pregnant women, parents, and care providers.

  9. Have children when you are young and healthy. Stroke and hemorrhage and kidney failures a direct result of preventable complications that arise from waiting too long to have kids. Have kids when you are young and healthy, its not rocket science no matter how much the propagandists want to make it seem that way.

  10. We spend more in healthcare than all of the other countries COMBINED! The reason for the major decline is due to the financial concerns of the patients, NOT THE HEALTH CONCERNS OF THE PATIENTS! Ahhh yes treat them with drugs not naturally, another misnomer in the Allopathic Medical World!
    El Salvador has a much lower maternal death rate and they still use midwives! Moral of story -Go to a midwife to have your baby, it doesn’t matter what color you are!
    And stop giving them those toxic vaccines while they’re pregnant, you’re killing their babies in Utero as well, by the way, we’re also number one in infantile deaths within the first day of life in the “civilized world” ! High quality healthcare is NOTHING compared to high quality nutrition! It’s a shame no Allopathic Doctor in this country has any idea what high quality nutrition is!

  11. If you're gonna talk racism, provide links to studies. Otherwise I'm forced to see this as just opinions. Sorry, it's called science for a reason

  12. So the US is a 3ed world country in respects to Maternal health care…
    why is this here? and not in front of Congress? …

  13. Large part of why there is so much maternal death in the us is the dumb legal system / insurance system / fucked up government interventions.
    As in, for example,the doctor might know that X procedure would have better outcomes in certain situations, but he also knows that he would be more likely to get sued for millions if something goes wrong.

  14. In south india when married women get pregnant. They'll go back to their parents house. Being a pregnant in south india is pretty sensitive so the family will do pretty much everything for her needs and desires.

  15. The first thing you have to do is stop programming our kids in school that the family unit is a bad thing and that starting a family is a bad thing. There fragile delicate dolts of today are useless, none of them can even take care of themselves let alone give up their time for a family of their own.

  16. This is a coverup. Dr Howell speaks for 15 minutes about maternal mortality, without mentioning that most of the deaths are from cesarean surgery. The reason maternal mortality has doubled since 1987 is because cesarean (now 35%) and induction (now 25%) and augmentation (now 25%) have doubled . Its a lie that more health care will save women. The opposite is true. Less interventions in terms of induction augmentation and cesareans is what is needed.

  17. Education IS the answer: If Dr Howell was being honest about maternal mortality, she would say, " A low risk woman in all high income countries will never die at homebirth if she has a trained attendant. In the past 50 years, the scientific literature has not documented a single maternal death at a birth with a trained midwife or doctor present. On the other hand, hospital birth risks her life. Her risk of an unnecessary cesarean in hospital is over 30% in the USA. Among cesareans, 1 in 5000 die to 1 in 10,000 women bleed to death from the surgery. The average blood loss at a cesareans is 1 liter of blood. Pregnant women only have 3.2 liters of blood. If they lose 3 liters, they die. also, 50% of women undergo induced or augmented labor in which they receive dangerous chemicals to speed up labor and have their water broken. This results in 1 in 15,000 women dying of amniotic fluid embolism- in which some amniotic fluid is pushed into the veins or arteries by the artificially induced contractions. These deaths are avoidable by staying home with a trained attendant. " It is obvious Dr Howell is lying because her whole talk does not mention the word CESAREAN in her talk. NB. At homebirth, there is no increased risk to the fetus or newborn.

  18. I was lucky being in a good hospital, as soon as my baby started not moving regularly my doc had me come to the hospital and monitored me. Turns out my son needed to get it so I was induced and had a c section. He was born sooo healthy and well. Though I had some complications they addressed those right away. I’m much better now nearly 11 months later

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