We MUST Do Better on Maternal Health

The first time I saw a new mother die, I was early in my career. A healthy, young woman had a complication during labor and needed a C-section. While the care team delivered a healthy baby, the mother never regained consciousness and eventually passed away. I remember seeing her husband late that night in the hospital, holding his new baby. It was supposed to be the happiest moment of his life, but instead he looked completely lost.

That moment had a profound effect on me and is one of the reasons I’ve committed my career—and now my ACOG presidency—to reducing preventable maternal mortality. As I said last week at the 2018 ACOG Annual Meeting in Austin, Texas, where I was sworn in as the 69th president of ACOG, “To achieve our full potential not just as women, but as a country, and as a global community, the health of women MUST be a priority.”

As ob-gyns, we dedicate our lives to advancing women’s health, and there is no contradiction more stunning than the rise of maternal mortality and morbidity in the United States. While other countries have been able to reduce maternal deaths over the last 20 years, the U.S. continues to see rates grow. Worse yet, African American women are two to four times as likely to die from pregnancies than Caucasian women.

During my year as president, ACOG will continue its good work surrounding the issue of maternal mortality through three initiatives:

  1. Advocacy on the state and federal level to establish maternal mortality reviews. These state-based reviews offer a valuable opportunity to understand maternal death through a detailed review of medical records and autopsy reports. By finding causes of and contributing factors to maternal death, we can identify opportunities to prevent them.
  2.  A stronger culture of patient safety in hospitals. ACOG helped found the Alliance on Innovation on Maternal Health (AIM), a national maternal safety and quality improvement initiative to reduce maternal mortality and severe morbidity. Together with 19 partner women’s health care organizations, ACOG has worked with hospitals and health systems to implement patient safety bundles across the country. Today, 23 states are part of AIM, and it’s our goal to sign on all 50 states.
  3. A taskforce devoted to heart disease in pregnancy. Cardiovascular disease is the number one cause of death in women in the U.S. (400,000 deaths annually), and cardiovascular events and cardiomyopathy are the leading causes of maternal mortality, accounting for nearly 25 percent of deaths. This multidisciplinary taskforce will concentrate on creating evidence-based, best practice guidelines addressing screening for, diagnosis, and management of cardiovascular disease in women, before, during and after pregnancy. It will also address the pregnancy-related contributions to lifelong cardiovascular risk by evaluating the evidence, making recommendations, and prioritizing research that will drive better care.

While I’m excited to have this opportunity to focus on safe motherhood, one of the most enjoyable aspects of this position is to meet you, my fellow members. I look forward to working with you, and our new class of Fellows who took the oath last week, to provide the best clinical care to women of this country. Please connect with me on Twitter @TXmommydoc, and follow @acognews to keep up with the latest news in our profession.

A Look Back: A Year Spent Advocating for Women’s Health

Throughout my long career as an ob-gyn, I’ve never been witness to a more intense national focus on the health care provided to American women than I have in this past year as president of ACOG. We’ve seen the deaths of pregnant women during and after childbirth take center stage as our understanding of the embarrassing U.S. maternal mortality rate grew. Countless labor and delivery unit closures at rural hospitals across the country have drawn attention to access to care, and many were shocked to learn that nearly half of U.S. counties lack a practicing ob-gyn. Legislative attacks on women’s health care have spread like wildfire, as both federal and state governments have attempted to restrict women’s ability to obtain health coverage and contraception, obstruct their access to abortion care, and institute punitive measures for pregnant women suffering from drug addiction. From the beginning, it was clear that the challenges facing our specialty—and to us, the physicians who care for women throughout their lifespan—are immense.

Before I officially took the reins in May 2017, we were already in the midst of the work, advocating against efforts in Congress to strip health care from millions of women through the repeal of the Affordable Care Act (ACA). Women stood to lose access to no-copay contraception, affordable maternity care, and essential preventive services. Women were at risk of returning to a time where they might have been denied coverage based on a prior C-section or had to pay more for insurance based on their gender, and Medicaid coverage for hundreds of thousands of low-income women would have been in jeopardy.

All of this played out in the news as ACOG fought fiercely alongside five other provider organizations in a coalition called the Group of 6. We batted down every iteration of legislation that would have been detrimental to the health of the women in this country. We lobbied, we rallied, we spoke to the media, and we galvanized ACOG members in support of this common cause. I am proud of what we accomplished, and I count the tremendous effort to defeat ACA repeal as one of the successes of my presidency. But, of course, there was much more work to be done.

In addition to my time at ACOG, a large focus in my career has been on perinatal health disparities and maternal mortality. More than 60 percent of maternal deaths are preventable, and more than 65 percent occur within the first week postpartum. One way ACOG is trying to address this is through the Preventing the Maternal Deaths Act. It would provide grant funding to states to establish or bolster maternal mortality reviews committees tasked with studying the causes of these deaths, and how they can be prevented. But these statistics also indicate that as providers, we need to change the paradigm when it comes to postpartum care.

As part of my presidential task force, “Redefining the Postpartum Visit,” we began with the premise that postpartum care is the gateway to lifelong health. It is not sufficient for women to have one visit six weeks after childbirth. It is critical for women to be seen within the first three weeks and then on an ongoing basis as needed—up to 12 weeks—to address several issues, including breastfeeding complications, postpartum depression, and chronic conditions such as diabetes and heart disease that often persist long after pregnancy. Women have multiple intersecting health needs, so we must facilitate care coordination between multiple providers to ensure women are able to seamlessly access the support and care they need. The task force just released a Committee Opinion this week and, in the coming months, a companion online toolkit for providers will be developed to assist in providing more holistic care. The latest article from ProPublica outlines how this reinvention of postpartum care will require “sweeping” changes in medical practice and throughout the maternal care system if we are to truly optimize the health of moms.

Another focus of my presidency has been on innovation in technology to improve women’s health, particularly telehealth and telemedicine. According to a Health Affairs study, nine percent of rural counties experienced the loss of all hospital obstetric services between 2004 and 2014. Through my “Telehealth Task Force,” we have been working to develop best practices in ob-gyn to improve access and address fragmentation in care. This has significant implications for the Levels of Maternal Care initiative, which focuses specifically on care access in rural settings. It relies on communication and care coordination between hospitals and birthing centers so that women can be transferred to and receive care from a facility that offers the level of care that best suits their needs. Telemedicine will be key in fostering that communication.

The task force remains committed to addressing issues regarding safety, payment, experimental e-obstetrics, virtual education, video conferencing, virtual monitoring, apps, and the crossover between inpatient and outpatient care. In the future, a telehealth Committee Opinion will be developed, and an ongoing work group will be established to continue this important effort. We are also combating the access issue from a legislative perspective through the Improving Access to Maternity Care Act. It has been passed in the House and currently resides in the Senate. Through this legislation, an official maternal health designation through the Health Resources and Services Administration will be created to better determine shortage areas. This in turn will allow more providers to serve in these areas through loan forgiveness programs and scholarships offered by the National Health Service Corps.

However, in our efforts to improve care on a systematic basis, we must not forget how critical it is to address implicit biases that permeate every aspect of care delivery and contribute to the racial health disparities that have led to our high maternal mortality rate. An often-repeated statistic, is that black women in the United States are three or four times more likely to die during childbirth than white women. It is shocking to most, but it shouldn’t be. Racial health disparities have a long history, and events as recent as what happened in Charlottesville last year remind us we still have a long way to go.

Even when black women have access to health care and advanced education, they are still at a disadvantage when it comes to receiving the quality of care on par with their white counterparts, and the constant stressors of racism and racial biases often put them at higher risk for chronic health conditions. Cardiovascular disease disproportionately affects black women, and stress has been linked as a possible contributor. I have been working with Dr. Lisa Hollier, ACOG’s incoming president, to partner on initiatives with the American Heart Association to address issues with women and cardiovascular disease, and I am confident that she will make marked improvements in this area.

It has been a whirlwind. I have traveled the country and the world in pursuit of advancing women’s health and ensuring that the clock is not turned back. I have worked alongside ACOG leadership and Fellows, including my esteemed colleagues, Drs. Hollier and Gellhaus, to improve maternal health for all women in the United States and serve as a model for women’s health care throughout the world. It has been a rewarding journey, and we have made incredible progress, but I am ready to pass the torch, and wish Dr. Hollier success as she carries it forward—there is much more work to be done, and I look forward to working with her this year as immediate past president.