The numbers are going in the exact wrong direction. The American maternal mortality rate has doubled over the last two decades, according to one recent estimate, a phenomenon unique to the United States among developed countries.
"For example, today, an American mom is 50% more likely to die in childbirth than her own mother was," says Dr. Neel Shah. "That's a startling statistic. And if you're African-American, you're three to four times more likely to die than if you're white, irrespective of education or income."
Shah is an assistant professor of obstetrics at Harvard Medical School and founder of the March for Moms, a group that's organizing a maternal march in Washington, D.C., this coming Saturday, the day before Mother's Day.
Shah says the march aims to empower mothers to advocate for better care and support, including — at the very least — survival. "You see that moms are great at advocating for almost every progressive cause except for their own well-being," he says. "There's Moms Against Drunk Driving, Moms Against Guns. We wanted to build a 'Moms for Moms.' "
"[T]oday, an American mom is 50% more likely to die in childbirth than her own mother was."Dr. Neel Shah
I reached Shah at the national convention of the American College of Obstetricians and Gynecologists, which has just issued a new set of guidelines on treating what it calls the leading cause of American maternal deaths: heart disease in pregnancy. "It constitutes 26.5% of pregnancy-related deaths, with higher rates of mortality among women of color and women with lower incomes," the college says.
Here are some edited excerpts of our conversation.
What should we make of these new guidelines?
First and foremost, this is an advance in our professional thinking about how to make sure that mothers are getting the best possible care.
We are seeing that, for example, today an American mom is 50% more likely to die in childbirth than her own mother was. That was a startling statistic. And if you're African-American, you're three to four times more likely to die than if you're white, irrespective of education or income. And that's also a really startling and deeply disturbing statistic.
And of course, every one of these deaths is just the canary in the coal mine of a deeper, underlying problem. For every death, there are tens of thousands of women who are suffering from chronic illnesses.
And then you couple that with the fact that compared to a generation ago, motherhood is much more socially isolating than it used to be and it's much more economically disempowering than it used to be.
All of that together has led to a point where, for many Americans, it's mortally dangerous. If you're living on the margins of wellness and illness, or basic security and insecurity, having a baby in America can push you over the edge.
The guidance is basically just trying to take that next step: "OK, we've seen now that we've got a large problem on our hands. Let's try to break it down." And this bucket of cardiovascular disease is a big one. This is a really important professional effort to try to unpack that and prepare clinicians to respond to it.
Does heart disease seem to be the biggest driver of the rise in maternal mortality?
Thankfully, maternal mortality is relatively rare. Depending on who you ask, it may be somewhere around 24 per hundred thousand. When you step back, that's 800 otherwise young healthy women in our country dying every year.
Those numbers are small enough that it's very, very hard to statistically understand the trends and exactly what's driving them. But it's very clear that cardiovascular disease is important, and that as obstetricians, we need to know how to recognize it and respond to it.
Is there a deeper explanation?
When you count maternal mortality, a lot of people think there's a woman who's in labor and then there's an emergency that happens and that's maternal mortality. But the overwhelming majority of deaths happen in the period surrounding the birth, including pregnancy and until the infant is 1.
And when you think about what the average American goes through during that whole period — first of all, pregnancy is the body's biggest physiologic stress test. After you have your baby, you're getting POW-level sleep deprivation. And then, if you're an American, there's no paid family leave. So you're trying to earn a living wage at the same time. I really think that situation is different today than it was a generation ago.
How would you sum up the changes in guidelines?
The big messages that I'm getting are that it's our professional responsibility to really attend to cardiovascular disease during pregnancy. It takes the existing body of evidence and distills and summarizes what we most need to know in order to recognize cardiovascular disease in pregnant women — which manifests differently than it does in a 65-year-old man — and the skills to respond and manage it appropriately.
The guidance calls for better identification of high-risk women from the get-go, and being aware that higher risk extends for a year after the birth.
And one concrete thing it recommends is a follow-up visit with a primary care physician or a cardiologist within a week or so after birth for women with high blood pressure or heart disease. That's not current practice, right?
One of the biggest opportunities that we have, that is emphasized in the new guidance, is better coordination with primary care doctors. I've got to say that the amount of times in my own practice where I have picked up the phone and called the primary care doctor of a woman in order to coordinate is not many. There's clearly a huge opportunity.
There are many reasons why that's not common practice right now. For a lot of otherwise young, healthy women, this is like their first health care episode and they don't necessarily have a primary care doctor. The second thing is that after you have a baby, just getting to a doctor's office is a big deal. It's really hard to get particularly the most vulnerable women back in the care. So there are structural changes needed.
The guidelines note that if all women were assessed for cardiovascular disease using something called the California tool kit algorithm, the projection is that 88% of women who die would have been identified as high risk and their lives could have been saved. Is this the core of the thinking now, that picking up risks better could make a huge difference?
Yes, that's just logical. Identification upfront is really important. But the dominant cause of suffering in the world in 2019 is not lack of knowledge, it's lack of execution. Really getting to a place where we're making a difference is going to require not just knowing the lot, which is what these guidelines start us down the pathway of, but really figuring out the how. That is a larger challenge which ultimately is going to require the profession working in concert with the end users, which at the end of the day are moms and their families. That is where the March for Moms comes in.
What is its goal?
Really to empower moms to expect more than survival in 2019. That should be the floor of what moms expect. But most moms and their families have goals other than emerging unscathed from labor, so we want to design a system that's really aiming at the ceiling, which is care that's not just safe but also supportive and empowering. And that really starts with moms demanding better care and support.
This year, we're also creating a national maternal health week. Both [Massachusetts Gov.] Charlie Baker and [Boston Mayor] Marty Walsh have issued proclamations to formalize this. We think it is a really important anchoring point for everything else we want to do.
Readers, did you have an experience with heart disease or high blood pressure in pregnancy or after?