Sara Gardner, MPH
In Public Health the focus is population-wide efforts to prevent sickness and premature death. We are often so focused on population-level statistics we forget that behind every single number there is a human being. We forget that it is a collection of individual stories that make up the whole. Sometimes in public health, to find a way forward, we have to look beyond the numbers and hear the individual stories to uncover the truth.
One of the biggest public health triumphs in recent years has been the worldwide drop in maternal mortality—about a 44 percent reduction, over the last 25 years, according to the World Health Organization. Nonetheless, every day approximately 830 women die from preventable causes related to pregnancy and childbirth. Of those deaths, 99 percent occur in developing countries where mothers in rural and poor communities face a much higher risk of complications.
In the United States, roughly four million women give birth every year. In a country that has some of the finest medical care that money can buy, none of us should go into the experience fearing for our lives. We may worry about a lot of things, like the pain of labor and delivery, the health of the child and uncertainty about being a good mom, but we should be able to approach the experience fairly certain that we will come out alive. But while overall maternal deaths in the industrialized world have mirrored the worldwide trend, the United States has actually seen an alarming increase in maternal mortality and morbidity. In fact, we have the highest rates of any wealthy country. The Center for Disease Control and Prevention reports that in the United States around 700 women die each year as a result of pregnancy or delivery complications and another 60,000 women have a “near miss” or almost die. Research suggests that at least half of them are preventable.
Experts agree that there are probably three major factors contributing to the upward trend: inconsistent obstetric practice, particularly in managing emergencies; the increasing number of women who are presenting with chronic health conditions; and a lack of good data and related analysis on maternal health outcomes.
It appears race is also a factor.
Last fall when Serena Williams shared the story of her near-death experience following the birth of her daughter, she shone a startling spotlight on a growing concern in the United States—an unacceptably high rate of pregnancy-related deaths and disabilities among Black women. In the wake of her disclosure, several other articles were published and radio segments aired, many detailing examples of complications Black women from all walks of life faced while giving birth, many of them fatal.
Unfortunately, in New York City, the trend holds. In NYC, each year approximately 30 women die of causes related to pregnancy with the largest number of deaths attributed to women of color. In our city, Black women are 12 times more likely than White women to die from pregnancy-related causes.
In 2016, funding from Merck for Mothers helped the Health Department and the Fund for Public Health in NYC develop a system for tracking the number of women affected by severe maternal morbidity (SMM) or life-threatening complications. Severe maternal morbidity includes heavy bleeding, blood clots, organ failure, stroke and heart attack that result in the woman almost dying.
The results of the new system, the first of its kind in the nation to track SMM at the municipal level, showed some alarming trends. We learned that each year approximately 2,500 women in NYC experience a life-threatening complication during labor and delivery. For every woman who dies, there are 100 who almost die.
We also uncovered blatant racial disparities. Black women were three times more likely to experience a life-threatening event than White women even after taking educational attainment into account, which is frequently the equalizer. In fact, Black women with college degrees or higher were still more likely to experience a life-threatening event than women of other races and ethnicities that didn’t graduate from high school. The story of Shalon Irving, an epidemiologist at the CDC, who died shortly after delivery, is a tragic and heart-wrenching example of this inequity.
We need to act to right this injustice but first we need to understand it.
This year, FPHNYC and the Health Department announced a new grant from Merck for Mothers to build on the work accomplished during the first grant period. The new grant will work with three hospitals to support detailed reviews of each SMM case to analyze and apply lessons learned to hospital quality improvement processes. In addition, the grant will support efforts to integrate SMM cases into the city-wide Maternal Mortality Review Committee to better understand the root causes of poor maternal health outcomes, the glaring disparities across race, and to help inform individual and community strategies to affect change.
This award opens up new possibilities. It offers the opportunity for public health officials to look beyond the big picture numbers and learn from individual mothers’ experiences to find the answers.