The Philip DeFranco Show - MS 3.28 What’s Causing the Maternal Mortality Crisis in America?

Episode Date: March 28, 2019

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Hello, hello, hello, welcome to your Thursday morning show. My name is Philip DeFranco and today We're gonna be talking about what people are calling a maternal mortality crisis in America. Possibly you've seen little bits of this coming up You have people like 2020 Democratic presidential candidates Kamala Harris and Kirsten Gillibrand talking about this crisis in the news recently Also the likes of Bill and Melinda Gates addressing this in fact in a recent interview with Business Insider Melinda Gates said that the US maternal mortality rate is incredibly disturbing. And if you're wondering what maternal mortality is, why are we talking about this today? Simply put, women who give birth in the United States have a greater risk of dying relative to other rich countries. And the concern here is backed up by a six month long investigation from 2017 by ProPublica and NPR that ranks America's maternal mortality rate as the worst in the developed world, and it is by a significant margin. And here's a clip from March of Dimes President Stacey Stewart's testimony explaining what

those stats actually translate to. There are 700 mothers that die every single year, and almost, and over 50,000 who experience dangerous complications that could have killed them, making the US the most dangerous place in the developed world to give birth. And we think, and we know that you agree, that this situation is completely unacceptable. The CDC defines the maternal mortality rate as deaths which occur as a result of pregnancy-related complications before, during, or up to 42 days after childbirth. But the thing is, the research shows that post-pregnancy complications often happen well after the 42-day mark.

So, in 1986, the CDC started collecting data on women who died from pregnancy-related complications beyond the 42-day mark and up to one year after. But also of note, this data is limited because not all of the states have been tracking these deaths. That said though, according to a 2018 CDC-funded report, over 60% of the 700 pregnancy-related deaths that took place last year, they were preventable.

And when we saw that, we automatically wanted to not only know how this is happening, but why. So, to help unpack this massive topic, to answer some of these questions, we had Maria Sosyan from the team dive into the maternal mortality crisis happening in America, and look into some contributing factors that are often overlooked. To really get a feel for what we're dealing with when it comes to maternal mortality in America, we have to start by looking at the statistics. American women are three times more likely to die from childbirth than women in Canada,

and six times more likely than women in Scandinavia. The number of reported maternal deaths in the US has gradually increased, from about 17 per 100,000 pregnant women in 1990 to more than 26 per 100,000 in 2015. And as of 2018, the national rate is 26.4. This means that a woman in America today is 50% more likely to die than her own mother

during childbirth. Dr. Neal Shaw is a physician and an assistant professor at Harvard Medical School. For a mom today, it is costlier, riskier, and frankly scarier to start or grow a family than it was a generation ago. According to the CDC, two major causes of death are pre-eclampsia, or dangerously high blood pressure that often leads to seizures and strokes,

something that Beyoncé experienced after the birth of her twins, and hemorrhaging, which is the equivalent of bleeding. There are other potentially fatal post-pregnancy complications that include things like infections and blood clots, which, if left untreated, could lead to death. And, like Phil said, these deaths are largely preventable. What's worse is that doctors say the treatments that could save the lives of those mothers are neither difficult nor expensive.

For example, preventing a stroke requires something as simple as monitoring blood pressure during and after childbirth, and medicating within an hour. So what's going wrong? Well, first off, risk doesn't end when pregnancy ends. Definitely when people hear about maternal mortality, they're often imagining like an emergency that is happening to a woman in labor who's in a hospital. And you know, I think that's because historically, childbirth is a dangerous event and there are a lot of women who didn't survive.

That being said, it turns out, you know, in 2019 in the United States of America, childbirth, the event itself, is relatively safe. The problem is that once you leave the hospital, there are very, very few touch points with the systems that are meant to care for you or support you until a visit that's usually only about 15 minutes long, six weeks later. And so what we see is actually the majority of the deaths that are related to pregnancy or birth happen in those weeks surrounding the birth, not actually during the birth event itself. These deaths also appear to be more common

with cesarean deliveries, better known as C-sections, than with vaginal deliveries. Let's talk about C-sections for a minute. They're actually the most common surgeries performed in the US. Between 1996 and 2009, the C-section rate in the US shot up by 60%. Overall, the C-section rate in the US has increased more than 500% since the 1970s.

What we haven't seen as a result of these increases are anybody being better off on average. So babies are not better off as a result of doing more c-sections, and moms on average are not better off. In fact, in many cases they're worse off because taking care of a newborn infant while also healing from a large incision on your abdomen is hard. Though it's declined slightly in recent years, a third of all births in America still involve C-sections. And C-sections now outnumber vaginal deliveries in other parts of the world, like Southeast

Europe, Latin America, Australia, and China. For example, in Brazil, 80 to 90 percent of births in private clinics are now C-sections, compared with about 30 to 40 percent in public hospitals. Even in poor countries, the rates can be extremely high at clinics. For example, in Bangladesh, less than 60 percent of births occur at a clinic, but when they do, about 65 percent of them are C-sections. All that being said, there are instances when a C-section is absolutely necessary for a safe delivery.

An emergency C-section can save lives. And it can sometimes make sense to schedule a C-section when, for example, the fetus isn't properly positioned for birth. Cesareans can also be necessary for a mom with uncontrolled high blood pressure or diabetes, or when she's pregnant with twins, triplets, or other multiples. But for most pregnancies, which are low risk, C-sections aren't necessary. And the concern is that the surgical procedure

has the potential to do more harm than good for both moms and babies. According to Salima Walani, VP of Global Programs at March of Dimes, these high rates are due mainly to an increase of elective C-sections, meaning people choose to do them rather than resorting to them for medical need.

An elected C-section can raise a mom's chance of death by at least 60%. And it can increase a woman's risk of life-threatening complications during childbirth by five times. C-sections involve a more complicated recovery and lead to scarring of the womb, which is often associated with bleeding, abnormal placenta development, ectopic pregnancy, stillbirth, and premature birth. Moms generally have more than one baby. You know, as an obstetrician, I'm one of the only surgeons that routinely cuts in the same scar over and over again. You know, we do the first C-section, it's a pretty straightforward surgery. By the time you do the second C-section and have to cut through all that scar tissue, or the third C-section, it can get really dicey. Surgery gets much more complicated. That's really

what that means. All the scar tissue can sort of fuse together and it can be like operating on a melted box of crayons. The placenta, which is an organ that only exists in pregnancy, that gets 25% of everything your heart pumps and is a big bag of blood vessels, can get kind of stuck to that scar tissue and not detach normally. And what we're seeing is that women with that condition

are bleeding excessively and sometimes to death as a result of this condition, which has become 1,200% more common as a result of doing more C-sections than we should be doing. Another underlying but very important factor that people don't really seem to be talking about has to do with the preferences of the hospital or OBGYN. Some studies have found that when faced with the choice of the right thing to do versus the easy thing to do, some doctors may choose the easy option. There's a saying that I love that every system is perfectly designed to get the results

that it gets, which is a way of just sort of understanding that it's not that doctors are bad actors. In fact, doctors, nurses, midwives, everyone who works in this field is well-intended and relatively well-informed. The challenge is that in the short term, doing the c-section always seems like it's the right decision. So personally, when I do a c-section, if the baby comes out looking perfect, I think, well, it's a good thing I did a c-section. And if the baby comes out looking blue and kind of lackluster, I think it's a good thing I did a c-section.

Along with those points, there are even people who believe that money might be a motivating factor for some hospitals and physicians. Why? Because C-sections cost almost 30% more than vaginal births. Vaginal deliveries require more time and a lot of waiting, which means hospitals have to dedicate more resources and money. You know, it's not necessarily that people are looking to get paid more by doing more C-sections in this country, for the most part, but it is true that getting a normal vaginal delivery requires patience. And ultimately, you know, it's costlier to have, you know, a lot of really highly trained, expensive nurses and doctors waiting around for something to happen. That's essentially how childbirth works.

You got to wait unless you don't wait, which is to do the C-section. So, I mean, I think that nuance is important because I think some people think that doctors are sort of greedily doing a lot of C-sections so they can get paid more. It's not that, it's just that, you know, in the trenches, when you're trying to make the decision between doing a C-section and not doing a C-section,

a C-section will always be the easier way out for everybody involved. A 2013 study by Truven Health Analytics found that on average, hospitals charged roughly $51,125 for a standard C-section and newborn care. For an uncomplicated vaginal birth, the cost dropped to a little over $32,000. Insurance typically covers a large chunk of those costs,

but families are still responsible for the remaining amount. Another study published in 2014 by researchers at UC San Francisco found that some California medical centers charge 8 to 11 times more than other hospitals for deliveries. A lead researcher of that study told Kaiser Health News, Healthcare pricing is kind of like the Wild West. There is no real system of healthcare pricing. The system is that hospitals are allowed to charge whatever they want and whatever they feel they merit. The argument is that the difference in cost may come down to the hospital, not necessarily the doctor. Something else that's interesting is that recent findings show that in the U.S.,

fewer babies are born on holidays like the 4th of July or around Thanksgiving or Christmas. A common perception among mothers is that doctors don't want to cut into their vacation time. Proving that doctors are purpose want to cut into their vacation time. Proving that doctors are purposefully avoiding those dates is hard, but this graph by NPR seems to back that up. I mean, there is a convenience factor, right? I mean, in the 90s, most of the deliveries that happened in hospitals were spontaneous, meaning we waited until people went into labor.

Today, in many settings, nearly half are scheduled, either a C-section or an induction of labor, where we try to get people to go into labor using medicine. You know, some of that is indicated, meaning that we've got good reasons for it. Some of it is probably based a little bit on convenience. And, you know, the extreme example is I've been to places in the world that have a 100% C-section rate during the day and a 0% C-section rate during the night. You know, it's obviously not a naturally occurring phenomenon. And when you're seeing more deliveries on the lead up to a holiday and less on the actual holiday, that's not a naturally occurring phenomenon. It means that something about the way that we're going about things is not based on a

woman's needs, but based on the needs of a broader system and requires more thoughtfulness. For Shaw, the biggest risk factor is the hospital a mother delivers in and how busy it is. A Consumer Reports investigation of more than 1,300 hospitals across the U.S. revealed that C-section rates for low-risk deliveries in the U.S. vary dramatically from hospital to hospital.

Some are as low as 7% and others are as high as 70%. For example, if you have HMO insurance, you're limited on your hospital selections. Meaning that if you're in California, where the target rate for C-sections is almost 24% and live in Merced County, you may have no choice but to deliver in a hospital with a higher than average C-section rate. But if you live a little south of Merced, say in Madera, then you may have a better chance of delivering in a hospital with a lower C-section rate. Another thing to consider is the stress and pressure that doctors may feel when the delivery floor gets unexpectedly busy. In cases like these, well-intentioned doctors can end up rushing a delivery to free up beds, especially if they're short staffed.

At the end of the day, you've got a finite number of resources, whether they're beds or staff or whatever. And for the average woman, you know, the difference between being on a non-busy labor floor and a busy labor floor is really substantial when it comes to your risk of getting a C-section, having a hemorrhage, or a lot of other outcomes that we care about. Although providers might have their patients' best interests at heart, these practices increase the risks related to maternal mortality. According to Dr. Shah, a fundamental failure of communication is also another major cause. 70% of all adverse outcomes,

meaning bad avoidable things that happen to people in healthcare, at the end of the day are failures of communication and teamwork. You know, in childbirth, it's always been a team sport. Ever since Homo sapiens have existed, we've needed help to give birth. And so making sure that we've got a way to efficiently organize the information that lives in the brains of not just the doctors but the woman in labor who can

tell you things that nobody else can not just her symptoms and preferences but things that are neither like how much energy she has to push as well as the nurse who spends more time at the bedside than anybody else. So one of the things that we've started to do is just create a way for everybody in the room to share the information that they have so that when they're making decisions, they're making them together with all the information that should be available. Women who have just given birth experience POW levels of sleep deprivation. They're also highly medicated, and because of this,

their nurses and physicians are at times reluctant to believe them and the symptoms they're complaining about. But the problem is bad communication or failure to believe patients can't be cited on a death certificate. Dr. Shah believes this is especially the case for African American women, which is a possibility, considering in America, black women are three to four times

more likely to die due to pregnancy-related causes than white women, and in New York City, they're 12 times more likely to die due to pregnancy-related causes than white women. And in New York City, they're 12 times more likely to die. And Serena Williams' recent experience with her pregnancy is a perfect example of why listening to and believing patients is so important in preventing maternal deaths. Last year, Williams told Vogue about how she nearly died a few days after giving birth to her daughter.

In her Vogue interview, she explained how the day after delivering her baby via C-section, she had trouble breathing and immediately recognized the warning signs of a serious condition. She walked out of her hospital room and approached a nurse. She said she was afraid of another blood clot and requested a CT scan and an IV of a blood thinner. The nurse responded by telling Williams

that her pain medication was making her confused, but Williams did what most women unfortunately don't do. She insisted that something was wrong and didn't stop until she was finally sent for the lung CT scan. The scan showed several blood clots, but it didn't end there. Severe coughing had opened her C-section incision

and another surgery showed hemorrhaging at that site. When she was finally released from the hospital, she had to be on bed rest for six weeks. With hemorrhaging, Williams experienced one of the most common causes of death among new moms, and communication saved her life. Serena is an example of a wealthy, successful, and super famous black woman. If she had difficulties being heard and taken seriously, then what can everyone else expect? On the plus side, major efforts are now being made to find solutions to combat the high maternal mortality rate in America. In recent years,

the CDC and nonprofit organizations like the Preeclampsia Foundation and California Maternal Quality Care Collaborative have been working to provide hospitals with evidence-based strategies and practices to lower birth-related risks and the maternal mortality rate. You may have heard that just a few months ago,

Congress unanimously passed a bill called the Preventing Maternal Deaths Act, authorizing $12 million a year for five years to address this crisis. And President Trump signed the bill into law on December 21st. The money will fund maternal health review committees in all 50 states, enabling them to collect data

on what's killing women both during and after childbirth. Prior to the passing of this bill, seven states did not have a maternal mortality review panel, and two of those seven didn't even plan to implement one. One of these was Idaho, which has a maternal mortality rate panel, and two of those seven didn't even plan to implement one. One of these was Idaho, which has a maternal mortality rate of 21.2, but a review panel doesn't necessarily equate to a better rate because despite having one,

Georgia and Louisiana are ranked the worst in the country. In these states, the rates are 46.2 and 44.8, respectively. This rate is often attributed to the lack of funding for hospitals in rural areas, as well as the lack of Medicaid in Georgia. And in 2014, they passed a law requiring maternal mortality review. Findings from 2013 indicated that the areas of highest concern were inadequate follow-up of cardiovascular symptoms and delayed recognition and treatment of hemorrhage in postpartum women. When does fast grocery delivery through Instacart matter most? When your famous grainy mustard potato salad

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It turns out 50% of U.S. counties don't have any qualified provider to take care of you, which means that a lot of Americans have to go through a lot of hardship just to access basic care, sometimes driving hours to go to prenatal visits or to deliver their baby. And so that's another dimension of what makes our country different and unique and requires a solution. Even in places where there are hospitals, as you said, they're really under-resourced when it comes to childbirth.

And if you think about it, childbirth services ought to be one of the most fundamental services that a community-based hospital provides. But because childbirth is still treated as a cost societally rather than an investment, almost every hospital that provides childbirth services loses money on it. And so if you're a rural hospital getting paid by Medicaid, you know, and you've got to make a tough choice about which service line to close down, obstetrics almost always goes first. And so one of the things that we're seeing across the last couple of years, decades really,

is that the number of rural hospitals that even offer OB services is going down. At this moment, while we're seeing a rising maternal mortality rate, rather than having more access to care, it's actually going down in Georgia and Louisiana and some of those other places. But not all states are in such bad shape. For example, California has the lowest maternal mortality rate, with only four and a half deaths out of 100,000. Massachusetts and Nevada aren't too far behind. Given California's progress in the last decade alone, the state could potentially serve as a blueprint for the Preventing Maternal Deaths Act.

When public state officials realized that the rate of California women dying from childbirth had doubled, they decided to bring together nurses, doctors, midwives, hospital administrators, and other officials to launch a statewide effort to keep as many mothers alive as possible. And in 2006,

the California Maternal Quality Care Collaborative was created, where a newly formed Maternal Mortality Review Committee was able to access details for the very first time on how every mother had died over the previous five years. The committee found that proper and timely treatment of hemorrhage and preeclampsia actually offered the best chance of survival. They concluded that these complications could be prevented through early recognition, teamwork, and a list of well-rehearsed treatments. The collaborative even created toolkits that contain everything needed to tackle an emergency complication, anything from checklists to

equipment to medications. As a result, from 2006 to 2013, the maternal death rate in California fell 55%. These protocols, the toolkits, treatments, drills, and teamwork not only saved women from dying, but also dramatically reduced the rate of women who nearly died. Considering that one in eight infants born in the U.S. is born in California, its impact could make a huge difference. California's success in combating maternal mortality

is one of the reasons why other states with relatively high rates have decided to push for access to better data and resources. And with the creation of maternal health review committees in all 50 states, the U.S. is hopefully on its way to implementing best practices across hospitals nationwide and making sure that more women are protected from

pregnancy and birth related complications. Now like Maria just said, with the passing of the Preventing Maternal Deaths Act this past December, maternal health review committees are gonna be able to collect the data needed to help ensure that hospitals and physicians are doing all they can to help lower the number of deaths among women. In poor countries, complications from pregnancy and childbirth are a leading cause of death among women, and high fertility rates in those countries increase the likelihood of problematic labor.

But, like we explained in this video, maternal deaths in the United States are way higher than they should be, considering we're the richest country in the world. When we compare our maternal mortality rate to that of other developed countries, the difference is staggering. On that note, a lot of people think that the difference may also have something to do with the way childbirth is generally perceived in the United States. That said, for years, you have had people pushing

for things like federally funded paid family leave so that parents don't have to immediately go back to the pressures of work while also having a brand new child. Which actually regarding that, here's a little bit more from Dr. Shah. For moms today, it's harder in almost every dimension. So if you're earning minimum wage in this country today, two thirds of your income go to the cost of childcare.

That's the same income that you'd use for paying the rent, for food, for everything else. And so in the United States compared to every other country, the number of women who stay in the workforce after having a baby drops sharply. And that's because having a baby in 2019 in the United States of America is actually economically disempowering in ways that don't make sense. We have the worst, we don't actually have

a paid family leave policy. We have the least generous policies for new parents than any other developed country. And he's right, outside of California, Rhode Island, New Jersey, and now New York, we don't have paid family leave in America. What we do have though is the Family and Medical Leave Act, which provides new moms with up to 12 weeks of unpaid leave.

But a lot of the women don't even take the full 12 weeks. Instead, they just go back after six weeks because of societal pressures, finances, or fear of falling behind. And research shows that some of the complications women experience, things like blood clots and postpartum depression, they happen well beyond six weeks after giving birth timely care is

Incredibly important and oftentimes these women these new moms They don't have a time or capacity to address the symptoms they're experiencing until it's too late This is why physicians like dr. Shah are advocates not only for medical support but also social support services for women who have just given birth But with all of that said it brings us to the part of the video where we pass the question off to you What do you think in general? Are you surprised by the statistics and numbers in this video? Have you or anyone you know experience post pregnancy complications? Do you think that there are areas where the medical support system can improve and do you live in a country where women are given?

More than 12 weeks of leave to recover from childbirth and those are just some questions I threw out there Of course, I'd love to hear anything you think in here But with all that said if you like this video you like this deep dive Let us know hit that like button Also, if you're new here you you like this deep dive, let us know. Hit that like button. Also, if you're new here, you want more of this, more of the regular Philip DeFranco show, be sure to subscribe. We try to help you understand the world

with one to two videos a day. But with all of that said, thanks for watching. I hope you have a fantastic day. And in fact, I'll see you later today, right back on this channel with a brand new Philip DeFranco show.