Why It Matters
The dominant cause of maternal suffering in 2019 is not lack of knowledge, but systems failures.
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How the Maternal Health System Is Failing

By Neel Shah | Tuesday, April 16, 2019

Neel Shah, MD, MPP, is — as he says — “an obstetrician and a dad who wears many hats.” He is an Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School, and co-founder of the March for Mom. He also works 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 first half of this two-part interview, Shah addressed the influence of race and racism on the current crisis of maternal morbidity and mortality in the US. In the following interview, Shah talks about how systemic problems are failing pregnant women, their families, and their care providers. 

It might be easy to assume that reliably providing recommended maternal care is all that’s necessary to improve maternal health. What more is necessary?

We’re at a moment where there’s broad recognition that we need to improve the safety of childbirth in our country. The American College of Obstetricians and Gynecologists has taken the lead in trying to integrate the evidence and provide it to clinicians and hospitals. They formulated evidence-based expert guidance to improve safety as these things called bundles, a very important step toward making things better.

That being said, the dominant cause of [maternal] suffering in 2019 is not lack of knowledge — it’s lack of execution. There are cases at the frontlines where people don’t have the right knowledge and, in these cases, professional guidance is critical. But I’ve also seen with my own eyes that most clinicians are very well-informed and well-intentioned, and they’re failing anyway. These are systems failures. That’s what we need to figure out. Fundamentally, we’re working in systems that don’t serve our moms and they don’t serve our clinicians either.

How is the system doing a disservice to moms and clinicians?

It’s hard to be an obstetrician, labor and delivery nurse, or a midwife. It’s backbreaking work. We can’t get to any improvement unless we figure out how to make the right thing to do also the easy thing to do. The bundles are great because they define the right thing to do, but the next step is to also make the right thing the easy thing through designing a more effective system.

Now, 99 percent of moms today deliver their babies in hospitals and on every hospital labor and delivery unit, there’s a set up that is functionally the same thing as an ICU. What defines an ICU is not a ventilator, but it’s the ability to have one nurse attached to one patient. The cardiac ICU does that. The labor floor does that. The cardiac ICU can titrate medicine on a minute-to-minute basis, and so does the labor floor. The cardiac ICU has telemetry to monitor vital signs in real time, and so does the labor floor. The only difference between the cardiac ICU and the labor floor functionally is that the labor floor has its operating rooms attached. What that means is that in 2019 the most intense treatment environment of our entire hospital is the labor and delivery unit for what are fundamentally the healthiest patients.

Then if you roll it back even further and you think about the care and support that every mom needs. Every single pregnant person benefits from support, careful monitoring, and coaching. Many also benefit from modern medicine and very few truly benefit from surgery, but we’ve designed the system completely backwards where 99 percent of American moms deliver in ICU-like environments, surrounded by surgeons. What falls short is the support piece. What we have is a lot of great people who are not being set up for success because of a system that’s not designed to provide some of the fundamental services people need.

What makes labor and delivery unique in health care?

It’s my bias, but I do think that the people who are attracted to this field are special. I think that’s important as we talk about all the ways we need to improve. The people are great. They’re the best people.

You go through your residency and you do cancer surgery and you deal with very sick people at the end of life and you also deliver babies. I found it more difficult to deal with the bad outcomes in labor and delivery than to spend an entire rotation doing oncology because of the whiplash of being there for some of the most joyful moments and some of the most terribly tragic.

To be a labor and delivery nurse, you need a different wiring than most other kinds of nurses. It’s not just about thinking babies are cute. You’re sitting with women, supporting them through really challenging events even when there is a good outcome.

How is maternal mortality different in the US than other countries?

One thing that makes the United States very different from Western Europe — and other countries that we often compare ourselves to — is health care outcomes. The fundamental difference is access.

The access problem in our country, particularly around maternal health, has a few dimensions. One dimension is insurance. It’s important to note that there’s mandated insurance coverage for pregnant women, but not after the baby is born beyond six weeks. Maternal mortality is counted out to a year, so there’s a problem where we seem to care a lot about women when they’re being vessels for pregnancies and seem to care less after the baby is out.

There’s an insurance churn problem that’s quite stark in our country. The other issue around access is physical access to obstetricians. Our country is 75 percent rural and if you live in a part of the country that’s rural, you have coin flip odds of being near anybody qualified to take care of your pregnancy and baby.

We’re seeing this very disturbing trend where — because labor and delivery units are often loss leaders for hospitals — they shut first. Rural hospitals in general in our country are struggling, but labor and delivery units always go first. We’re seeing that there’s not only a rapid erosion in access because there’s nowhere to have a baby, but the obstetricians follow. The family doctors and midwives follow too and there are real consequences as a result that we’re starting to see.

What has helped to bring more public attention to the maternal mortality problem in the US?

There have been many stories that have been prominent in the headlines around maternal mortality in the last year. There’s one individual who I think of as being the animating strength behind the larger movement to do something about this. We were able to get federal legislation signed by the president largely due to the relentless efforts of a man named Charles Johnson.

Charles Johnson’s wife, Kira, was healthy. She ran marathons. They went to a world-class hospital and she was the kind of person you would expect to be able to advocate for herself. Her husband also advocated on her behalf.

Kira had a routine C-section and ended up having some bleeding. Whenever you do a surgical procedure, you’re at risk of complications. As Charles tells it, he repeatedly expressed concern that something wasn’t right. He saw blood in the catheter. He felt Kira wasn’t quite acting right.

Ultimately, those concerns were not responded to quickly enough. By the time Kira was brought back to the operating room, it was too late.

Charles has been going around the country for the last couple of years telling Kira’s story. He says that there’s no statistic that can convey what it was like for him to leave the hospital and tell his two-year-old son that his mom wasn’t coming home.­­­­­

Kira’s death was an entirely avoidable situation and it helps illustrate the core of the problem. We can’t only attend to people’s safety. We must attend to their dignity. This starts with understanding that [women are] the experts in their own lived experience. They’re the only ones that can tell you how they’re feeling and, as an ordering principle in delivering health care, that always has to come first.

Why are you personally committed to this work?

I’m a little unkempt and unshaven right now because I’ve got an infant and a toddler in my household and I was up all last night in my hospital delivering babies. This is what I do 24/7. I am very fortunate for so many reasons, but even for me, the process of going from being a normal civilian to being a parent was so humbling.

It is an all-consuming thing to have a new infant and modern society is set up in such a way that — I think because so many people have babies — we are less empathetic than we could be. We’ve normalized an absurd situation in the United States where 1 in 3 moms get major surgery to have their baby and 1 in 10 of our babies go to the Neonatal Intensive Care Unit. It seems like we can do better than that. That’s why I’m so committed to this work. The vision is a world in which every person can start or grow their family with dignity. We’re not there yet.

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

You may also be interested in:

The Better Maternal Outcomes Rapid Improvement Network is a free, six-month initiative focused on improving maternal outcomes and respectful care. Join a free information call on Thursday, April 25, 2019 at 12:00 PM ET to learn more.

Neel Shah interview Part 1: Behind the Headlines about Maternal Mortality

How Can You Address Maternal Mortality Inequities?

Why Race Matters in End-of-Life Conversations

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