OB/GYNs Lobby for Solutions to Maternal Mortality
We meet in the middle of the emergency room bay. She is holding her three-day-old son, with her husband standing by her side. She says her delivery was uncomplicated. The trouble started only after she went home.
“It’s become swollen down there, and it’s getting worse” she says. “I almost fainted from the pain this morning.”
An hour following our initial encounter, she is in the operating room. The diagnosis of necrotizing fasciitis is confirmed as scalpel meets dead tissue from her perineum. Following the surgery, she is brought to the ICU. That night, she clinically worsens. She is taken back to the operating room. There, she codes and dies.
I stand there, shaken. It is the first maternal death I have witnessed as a young physician.
Sadly, it will not be the only maternal death I witness this year.
Four months later, I sit in a conference room in Washington, D.C. We are gathered for the 2018 American College of Obstetricians and Gynecologists Congressional Leadership Conference (CLC). At this annual conference, OB/GYNs from around the country gather to raise a united voice to our elected representatives around issues affecting our patients. This year, maternal mortality is high on the agenda, as it should be because more women in the U.S. die from pregnancy complications than in any other developed nation.
The U.S. has seen a 26% increase in maternal mortality rate in less than 15 years, from 18.8 deaths per 100,000 live births in 2000 to 23.8 in 2014. We are the only industrialized nation with a rising maternal mortality rate. African-American women, in particular, are disproportionately affected. In 2011, the maternal mortality rate for non-Hispanic white women was 12.5 deaths per 100,000 live births compared with 42.8 deaths for non-Hispanic black women — almost four times as high. Most causes of maternal deaths can be prevented by better management of obstetrical hemorrhage and preeclampsia. However, special attention must be directed at mental health conditions, including suicide and overdose, as they are quickly becoming the leading cause of maternal mortality in a growing number of states.
Reducing maternal mortality in America will be a process. So far, some states have been more successful than others. California became one of the first states to institute interdisciplinary maternal mortality review committees (MMRCs), which are comprised of OB/GYNs, nurses, social workers, and other health professionals who review individual maternal deaths and recommend policy solutions to prevent them in the future. MMRCs have contributed significantly in lowering maternal deaths in California from 16.9 maternal deaths per 100,000 live births in 2006 to 7.3 deaths in 2013. Although other states have joined California in instituting their own MMRCs, many are underfunded, and seventeen states have no MMRCs at all.
Currently, members of the U.S. House of Representatives and the U.S. Senate are debating The Preventing Maternal Deaths Act and Maternal Health Accountability Act. Though they are given different names in the different branches of Congress, these two pieces of proposed legislation both authorize the CDC to assist states in creating or expanding MMRCs to collect consistent data to help understand the causes of maternal mortality and to create initiatives to reduce them. Additionally, these bills will fund the U.S. Health and Human Services (HHS) to research disparities in maternal health outcomes.
The three-day CLC ends with us talking to our elected representatives, urging them to support these bills. As I sit in the Congressional lobby, my mind keeps returning to the day my patient died.
I see her body being wheeled out in the hospital bed with her husband still standing steadfast by her side. His eyes hold a pain too deep to be masked. Watching him, I realize that what we all fear most about death is not that death is coming, but rather that it will come and pass us by, taking our loved ones instead and making us orphans in the singularity of a moment.
The next day, I run into him in the hospital lobby. He is carrying his now four-day-old son. I am unsure of what to say, so we speak more through our silences than through the hollowness of our words. And as we say our goodbyes, I cannot help but hope that in the collective of his and his son’s existence, he finds the reservoir of hope and optimism required to move forward. I witness his exit from the hospital with his newborn in his arms, two hearts beating collectively in homage to a mother lost.
Jerome Chelliah, MD, MPH is an OB/GYN resident physician at Kaiser Permanente Medical Center in Santa Clara. He completed medical school at the University of California San Francisco (UCSF) and received his MPH from Johns Hopkins Bloomberg School of Public Health, where he was a Sommer Scholar.