Why It Matters
Women in the US are 50 percent more likely to die in childbirth than their own mothers.
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Behind the Headlines about Maternal Mortality

By IHI Team | Thursday, March 14, 2019

Neel Shah, MD, MPP, is Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School, and co-founder of the March for Moms. He’s also working with IHI on the Better Maternal Outcomes Rapid Improvement Network, a new initiative to improve outcomes for women and babies in the US and reduce inequities in maternal health. In the following interview, Shah debunks many assumptions about the current crisis of maternal morbidity and mortality in the US.

Why has the rate of deaths and complications from childbirth grown at such an alarming rate in the US in the past 20 years?

The prospect of starting or growing a family in the United States has become harder, costlier, and riskier today than it was a generation ago. Americans are 50 percent more likely to die in childbirth than their own mothers were. What’s changed between the last generation and this one is we’ve gotten worse at supporting moms. And the experience of motherhood has become more isolating.

It’s important to understand that maternal mortality is part of an even larger problem. There are many ways that moms across the United States suffer short of death. For every death, there are 100 major injuries. For every major injury, there are thousands — if not tens of thousands — of cases of avoidable suffering. This includes often facing relentless pressure to go back to work and earn a living wage while also getting extreme sleep deprivation while parenting an infant. The majority of moms are back to work within a month. I saw a statistic recently that said something like 70 percent of dads go back to work between 0 and 10 days after a baby is born and that’s the expectation of most workplaces. This, of course, has an impact on the mom. We should be providing much better support than this.

You’ve said in the past that it’s wrong to conclude that childbirth is inherently dangerous. Why is this important to understand?

I don’t want to dismiss the fact that there are risks associated with childbirth, but I think people are already afraid enough of childbirth and it’s because of a lot of the dramatization of childbirth that’s in popular media.

What’s important to understand is that most maternal deaths happen after women have the baby and the fundamental failure is not unsafe medical care but lack of adequate social support.

When people think about risks in childbirth, they’re often thinking about the experience of labor and the experience of delivering the child. It’s understandable to be nervous about that. It’s a remarkable thing that women go through over the course of their whole pregnancy. Labor is this incredible athletic event and then the idea of birthing a human being is understandably intimidating. But a lot of the risks around childbirth happen after the baby is born during that vulnerable time when you’re trying to care for an infant while also taking care of your household and doing all the things we expect of moms. We often expect moms to put their own wellbeing last to put their families first and that’s the paradigm that we have to change.

When you read the headlines about US maternal mortality and morbidity rates being worse for women of color, especially African American women, some may assume this is attributable to poverty or lack of access to health care. What’s often misunderstand about these statistics?

There are a few ways of understanding these massive inequities. Racial inequities drive the fact that the number of moms dying in childbirth has been going up in the United States over time. Specifically, black women are three to four times more likely to die in childbirth than white women. That seems to be the case irrespective of education or income or other factors we think of as making people vulnerable.

One factor is what academics call “weathering.” There’s something about the lived experience of being a black woman in the United States that causes chronic stress and appears to mediate health and well-being.

While economic disadvantage is also a contributor to maternal mortality, even being Serena Williams doesn’t entirely protect you. You can be the world’s greatest athlete and have a good understanding of your own body and it can still be challenging to advocate for yourself.

Serena Williams had a known clotting disorder. She’d had a blood clot in her lungs before, so she was familiar with what it felt like. After she had her baby, she developed a blood clot in her lungs and she had to strongly advocate for treatment. The clinicians didn’t initially believe her, and this delayed treatment. Blood clots are life-threatening events.

That’s the common thread in so many of these stories of black women who experience avoidable injury, avoidable death, and avoidable suffering. When they described their symptoms and expressed concern about what was happening to them, particularly around pain, we believed them less. We hear it anecdotally, but there is also research that indicates that we are more delayed in responding to and treating the pain of black women.

It’s important to understand that clinicians are trained to profile people. We are supposed to be able to look at our patients and know if they are sick or not. This results in a thin line between our clinical intuition and what is effectively racism. There is a tremendous opportunity in medicine to do a better job of recognizing when our biases lead us astray.

What will it take to create a better, more reliable, and more equitable maternal health care system?

It starts with basic goal clarity. Most people think that when we’re caring for people in childbirth, the goals are healthy mom, healthy baby. Of course, those are the goals, but they’re not the only ones. Most women have goals in labor other than emerging unscathed. Survival is the floor of what women deserve and we should be aiming for the ceiling. We should strive for not only care that’s safe, but also care that’s supportive and empowering.

In translating this goal into a better system, we will need to provide safety, as well as affirm the dignity of every mother, everywhere, every time. This means recognizing that it’s not pathological to have a baby — pregnancy is a normal event. Birth and death are life’s only two certainties.

It also means recognizing that the mom is the key expert on her pregnancy. We have expertise as clinicians, too, but if there was ever a place for shared decision making, it’s in maternal health. To this day, the best barometer of fetal well-being is not any piece of technology that we have, but a mom’s sense of whether the baby is moving.

Editor’s note: This interview has been edited for length and clarity.

(Having difficulty watching this video? Watch on YouTube.)

You may also be interested in:

How Can You Address Maternal Mortality Inequities?

Why Race Matters in End-of-Life Conversations

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