This week we're discussing our maternal mortality rates in the U.S. We're talking about the numbers, why they're so high, how communities of color are disproportionately affected, and some of the programs and people working particularly to effect change.
This week we're discussing our maternal mortality rates in the U.S. We're talking about the numbers, why they're so high, how communities of color are disproportionately affected, and some of the programs and people working particularly to effect change.
Maggie, RNC-OB: 0:05
Hey there. Welcome to Your BIRTH Partners. We're here to breakdown barriers and cultivate community as we discuss issues that impact pregnancy, birth and postpartum. We welcome you no matter what your background is, and are so excited to learn together. Today we're talking about something that's been on a lot of hearts and minds throughout the birth community in the last few months. We are going to be discussing our maternal mortality and morbidity rates in our country. So you'll learn a little bit more about the facts, what we're seeing, what are the numbers, how do they compare to other countries around the world that are having better outcomes, and get a greater understanding about some of the particular tasks that we need to take both as, you know, as consumers, as birth professionals, and as a society at large as we're considering this issue. On to the show!
Maggie, RNC-OB: 0:57
So today we're talking about a pretty heavy topic, and it's not one that anyone really wants to really acknowledge. But we have to, because our maternal mortality rates are continuing to rise. Over the last several decades, they've gone up considerably from 2000 to 2018 our right here in the U. S. rose from 12 deaths per 100,000 live births to 17.4 deaths per 100,000 lives birth. Which means that our personal rate in that 18 years went up 45% in the United States. Similarly, that same time frame when we look from 2000 to 2017 which is when the most recent global maternity mortality rates are available, their ratio declined 38%. So why the world as a whole has gone down 38% in deaths, we as our country are rising. There are several different elements that play into it. But I want to make sure that we're being clear that this is happening. And then it's also happening with great inequality across our country. So we see that black women in our country die at a rate of 37.1 deaths for 100,000 live births. And when we compare that to white, non Hispanic women that rate for white women is only 14.7, which means that black women are dying at 2.5 times higher rate. And when we compare it to Hispanic women whose rate is 11.8, that means that they're dying it 3.1 times more often their hispanic counterparts. There are several different issues that play into that. Obviously systematic racism and how that causes implicit bias throughout birth professionals when they're taking care of women of color is a huge component of it. We're also seeing that across the board, you know, we're having more health complications, that there's a lot more chronic conditions that play into pregnancy, and then how people recover both during the initial labor and delivery period and in the significant postpartum period after that. And we're also seeing just a rise in interventio; our cesarean rate has risen right along with those rates. And so I wanted to just have a chance, you know, today to just kind of dissect that a little bit and talk about that and kind of talk from our personal practices, what we're what we're seeing along those lines.
Abby, MD: 3:38
I think the easiest part of this conversation is the part of a conversation that reflects women with more medical comorbidities getting pregnant in our country: women who are older getting pregnant, women who are obese, women who have hypertension and diabetes and other long term medical issues. And assisted reproductive technology, getting women pregnant, older and with more medical comorbidities. I would love it if that was the only part of this conversation, and we could argue away the numbers with that. And I know we can't, and I think as you get into issues of race and implicit bias and such, my job as a provider right now is to probably sit back and listen a little bit because I don't know what the answer is. And I would like to be providing better care to my patients.
Pansay, Doula: 4:29
In my practice with the issue being so real, kind of right in our face. First of all, this was a reality for my family, many, many years ago, before I even knew this was a thing. My brother's wife went into the hospital and they were very young, you know, early twenties or so, and she had a, you know, uncomplicated pregnancy. You know, birth was going okay until it, you know, wasn't. But she kept saying that something wasn't right. "Please look at me. Something's not right." And they felt very much that because off, you know, their age and their race they didn't pay them any attention. Things weren't okay anymore. And that was, you know, once it went through a court case and everything, it was proven that it was negligence on the hospital, and we did lose my nephew. So I know, you know, firsthand how it is to, you know, try to advocate for yourself. Try to, um, tell them something's not going on and they're just not know listening. You know, in my practice, the way that I feel that I can help is to try to keep my clients out of that setting. How can we spend as little time as possible in that setting? And when you're thinking about, you know, complications of pregnancy, that brings me to how do we prevent complications of pregnancy? So we don't have to go there before you know we need to. So focusing very heavily on the naturalness of pregnancy and birth. Food is medicine. How do we get back to those ancient, you know, ancestral ways that kept us very, you know, healthy? From the beginning of my doula practice, you know, to now, shifting, shifting the way I doula, it's working. You know, I see that very heavily as far as the amount of days that, you know, we stay in the hospital as far as, you know, just laboring, majority of the time we're not showing up until Mama's holding baby's head as we're registering, giving them our information. So for myself, it's the education; educating the client on, you know, how do I stay the healthiest during pregnancy, keeping these complications, you know, at bay, learning how to labor at home effectively so that we don't have to arrive until it's time for them to, you know, catch baby. It keeps things simplistic. We have the baby and we, you know, come home. Before I started my midwifery training, I have to say that I did not know a lot of that important information about nutrition. And, um, and how to, you know, secondly, labor at home Um and I and I found that I spent much longer in the hospital setting just days of laboring, you know, in the hospital. So, you know, for me, that's how I'm battling it from Sacred Butterfly Births and it's definitely working.
Ray, CPM: 7:52
I think the two things I want to name on this topic are, you know, why is the U. S. Outcome so much worse? It's capitalism and racism. You know, we have a for profit health care system that doesn't adequately provide preventative health care. So the people who are at greatest risk for complications don't have access to, you know, affordable, comprehensive, preventative, prenatal care. And there is not just the barriers of insurance; it's also the barriers of time, of child care, of transportation, of getting off of work. These systems aren't set up well for working parents, and also the systems that are serving the poorest families don't have, like, long appointments, like there people are not like, believed and listened to. And so, you know, first and foremost like health care is not a right in this country. And secondly, the outcomes of black maternal mortality are so clear that racism and health care providers not believing black women are, you know, leading to worse outcomes. And I always, you know, want to name that I think there's a lot of ways that, you know, midwives are not the answer to all of this. There are a lot more complicated health issues that are also at play, you know, like women who are having heart failure at birth. But Jenny Joseph, who is ah, British midwife, a British-trained midwife who practices in Florida now, she's a CPM just like me, created an easy access clinic. And so the idea of trying to provide comprehensive midwifery care to anyone who's not accessing prenatal care and a one stop shop. Anyone gets to come, we'll figure out the insurance stuff later, regardless of the place of birth. There are some people who are choosing to birth in their birth center, but many are going to a local hospital, which they have a collaborative relationship with, and the goal of this practice was to end neonatal mortality, which is also way too high in the U. S. And much higher for black women, much higher rates of preterm birth; and it's working. You know, she does these great webinars and has this JJ Way Model of Care. And the first like item on the JJ Way Model of Care is like we learn people's names, we learn their partners' names, and we greet them by their names. And then there's like, you know how they provide childbirth education, like passive education in the waiting room, we like, create avenues to like listen to people's needs and concerns, how we like get people set up with the health care that they need. And even if that's someone who's had, like, three C sections and is gonna have her fourth, providing comprehensive midwifery care and then making sure she's set up to like have her fourth c-section, and that if she wants her tubes tied, she gets her tubes tied so she's not having a fifth c-section. In like having a midwifery centered model of care, regardless of the place of birth, like their outcomes are outstanding and they're having like black babies go to term and live, and I think that model of care also applies to parents who have more complex health needs. That care that is slower, that is addressing psychosocial needs, addressing financial needs, helping, you know, subvert the barriers versus being like you have to figure out this insurance thing until you can get care is going to like catch those people who could become very complicated pregnancies.
Maggie, RNC-OB: 11:28
Yeah, I love that they're doing that, and I think there's a huge need. So I mean, it's so wonderful to bring that model of care there, and I think it's really important to acknowledge, you know, one thing I heard Dr Joia Crear Perry talk about in her testimony in front of the House panel for the "Expecting More Addressing America's Maternal Infant Mortality and Health Crisis." They had a big panel in front of the House subcommittee for Health, Employment, Labor, and Pensions. And one of the things that she, you know, kind of just identified blatantly is that for a long time we've had this idea that there are different outcomes based on race, you know, perhaps certain people there's some sort of different genetic component that plays into outcomes, and what we're seeing very clearly from all the evidence of that, that is not the case. So it's not an issue of race during birth it's an issue of racism, you know, during care, and what we're seeing come through. And so we need to be really conscious of that. As, you know, we're setting up care, as we're trying to make sure we're meeting people and their needs and also realizing that systemic racism and the way that has played into the way our health care system is set up, that absolutely we see people of color have way less access to health care that there are a lot more barriers to getting to, you know, appointments regularly and, you know, maintaining care that are beyond the individual's control. And so we need to be making systemic changes to help people to have safer pregnancies, to be able to have time for breaks and to be able to get care that they need and that we need that to continue through the late, you know, labor delivery piece of it, that people are getting good access to care, and that also afterwards that during that postpartum that they have support, that they have leave to take from work, so that they can actually be tending to themselves and their baby, and catching some of these, you know, issues that come up health-wise in that initial postpartum period up to that full, you know, year, even after birth. But especially in those 1st 6 weeks that we look, you know, particularly at that high risk time that we need to be doing a better job from a social standpoint. Doctor Neel Shah talks about that, you know, as we are coming together to really support people we're saying that there are absolutely chronic issues and systemic issues. But the biggest piece of it is that people are able to, that they know how to get support, that they have people in their community, they have, you know, family and loved ones who are checking on them and, you know, taking care of them, and that they also have bigger social components of healthcare that let them be well supported and have resources that they can actually turn to, without, you know, having concern about how that's gonna affect every other you know, part of their life that falls apart all of a sudden, if they need to get a higher level of care. In our country, we spend the most on, you know, maternal perinatal healthcare across the globe, and our outcomes rank 55th. That's what we saw in the National Vital Statistics Report that just came out. So we're spending so much money, and when he we even compare ourselves to other similarly wealthy countries, we rank 10th out of 10. So we spend the most money and we're not getting any of the return on that investment that we should be. Like you said Ray, there's definitely the need to from a much bigger scale be really looking at ways that we can change our health care system to better support and to make sure that those health care dollars that we're investing actually have response in the community, and we're not just pushing money away.
Abby, MD: 14:51
It's sometimes really overwhelming to me how many patients I need to see to cover my malpractice insurance as an obstetrician who does C-sections. And I'm not gonna pretend to understand the business of medicine to the extent that I should. But I can tell you, this system from that standpoint is is very broken because I don't always have the time that I would like with patients. I think a lot about effective communication. Somebody, who's a mentor to me, who's actually now dean of the medical school where I did residency training. I remember on a really busy service as a chief resident, we would round on patients, and she would always make a point of, like, bringing a chair in the room and making sure that as we counsel patients, we sat and made eye contact and really tried to effect good communication. I feel like it's a theme of so many of the conversations we've had in this group already. It's just we could be better at communicating and educating. I think the respect piece comes next and comes naturally.
Maggie, RNC-OB: 16:01
Yes absolutely and I think what we need is we need, you know, we need buy-in from the stakeholders, from all of us who are out there providing, you know, direct care to people during this. We need to understand I think where you know we're struggling. And that's why I wanted to, you know, talk about some of these facts because it is hard to hear and not all of us like to think in numbers and kind of get in that head space. But we need to realize what a pervasive issue this is, and that this is not something going away on its own. And so we really need to take strong and clear action, like many other countries around the world are doing as well. This is not just our issue, but, ya know, the leading countries Belarus, their mortality rate is 2 for every 100,000 live births compared to our 17.4. Greece and Finland similarly it's 3 for every 100,000 compared to our 17.4. So you know, there are models you know, around the world, we can look to understand about different ways to deliver health care and different ways to make sure that we're really catching, you know, the issues that that coming to our clients whether those are chronic conditions that need to be managed or systemic issues, you know that we need to look at, and that respect piece of it is key. And I think it's probably going to be a huge part of every conversation we have in this group because that's where we really are seeing that our system falls apart a little bit. Because, like you said, because so many of our birth professionals are really over-taxed because of the way that we pay for health care, you know, here in our country,and the onus there is on providers with malpractice insurance on all of that. We see ratios are set up in terms of how many, you know, patients people are expected to see and care for in any given time, and that that doesn't always allow us to provide optimal care and to really see people for as long as we need to, to know everything that we need to know about them to help them live through birth.
Abby, MD: 17:58
We really don't have a system that facilitates easy access to health care, and I think the way that our health care system is structured. It's actually pushing providers out of inner city, and other sort of challenging practice environments. I think that we're seeing sort of a void and vacuum of care in the areas in this country that actually need providers most.
Ray, CPM: 18:23
Yeah, and also I'll mention that like there's only like, 13 states that Medicaid covers home births. And so there's also like a lack of options because, you know, like this slower model of care that, like can be preventative is also not accessible to the people who are most at risk. But in saying that, I also want to mention the fact that the black maternal mortality statistics are across the board, regardless of income. We can focus definitely on the people who, like have the least amount of access to resource is, but you know, black women with Ph.D's are also having outcomes that are twice as worse as white women.
Maggie, RNC-OB: 19:02
Yes; it's so important to note that, because when we when we accounted for every potential other factor with education and socioeconomic factors, all of that; these rates are still significantly higher for black women. And then I, you know, I do think is important to highlight obviously there is positive work being done. ACOG's Alliance for Innovation in Maternal health, they've developed a lot of these bundles of care that are being pushed out to different hospitals for kind of best practices for how to manage some of the both chronic medical conditions, and, you know, labor and delivery-specific complications that can come up. They have ones for, you know, postpartum hemorrhage and, you know, postpartum kind of care basics. They have those that cover for people who are delivering with opioid use disorder, safe reduction of primary Caesarean birth. And so I think so far, all of the research that goes that is coming out of those we are definitely seeing impact. We are seeing improvements and care on those, but we need to see more use, you know, of the research that we already have that are working at a broader level and, like you said again, that goes into the buy in for people at the bedside, not being resistant to this. Because I know I can speak to that. It is hard, as you know, as a nurse where constantly there's new policies coming out and things are shifting, and you're just trying to keep up and make sure that you're providing, you know, good care. And so I think we have to make sure when we're educating and telling, you know, birth professionals about these issues, and what we're seeing come out of research, we need to make sure that they're understanding why we're doing it, why we're changing it, and that it's not just it's not arbitrary. We're not changing things just to change. We're changing things because, you know, there's real issues that are happening that need, you know, that need differences to be made. And we see that there are lots of organizations, the March of Dimes, obviously they do a ton of this. Dr Joia Crear Perry, who I talked about earlier, her National Birth Equity Collaborative is focused on reducing the disparity we see for, you know, especially for black people during perinatal health care. So I think we need to make sure that we're tuning into those resources and these people who are really doing this good hard work and that we're getting this awareness out there. Well, thank you all so much for having this tough conversation today. And I know we're certainly gonna explore a lot of these themes further. As we get into what we all can do as birth workers and consumers to try, you know, make progress on this issue. Thanks for tuning in.
Maggie, RNC-OB: 21:19
We love to talk birth and would love to talk about it with you. Please join the conversation by finding us on Facebook, Instagramm Twitter, we're Your BIRTH Partners on all platforms. We'll be sharing statistics from today's episode on our show notes blog, yourbirthpartners.org and we really would love for you to share your personal experiences. We know this is a really heavy topic, and we want to hear what's happening in your community. Whether that's personal or professional experiences that you've had. We'll be sharing on the show notes blog some of our information about what other countries are doing, and some of the stuff people are taking in, the work they're doing here in our country to combat this issue. As we work to get this information out as far as it can go, we really appreciate you sharing this with friends or colleagues. And if you feel called, donating to a nonprofit, thanks for your support. Until next time.