Transcript episode #10: Staying Safe & Alive During Pregnancy & The Postpartum Period
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00:01 In this week's episode of the podcast, I'm discussing a really important topic, maternal morbidity and mortality and what you can do to keep yourself safe. You definitely want to hear this.
00:19 Welcome to the All About Pregnancy and Birth podcast. I'm Doctor Nicole Calloway Rankins a board certified Ob Gyn physician and certified integrative health coach. Every week I break down topics, share birth stories, or interview experts to help you have your very best pregnancy and birth. Quick note, the information is for educational purposes only and is not a substitute for medical advice. See the full disclaimer at www.ncrcoaching.com/disclaimer.
00:46 All right, welcome to another episode of the All About Pregnancy and Birth podcast. I am so glad you're here today, especially for this really important topic. So let me start off by telling you a story. One night I received a call through the answering service from a patient that I'll call Michelle. Michelle had an uncomplicated delivery just a few days earlier and she was now at home. She was calling because she felt short of breath. She just felt like she was having a hard time catching her breath. Now on the phone, Michelle didn't sound terribly short of breath to me and I asked her several questions to try and get a sense for what might be going on. Nothing really stood out as alarming in her responses. However, Michelle was just really persistent that she didn't feel right so I advised her that the safest thing to do was to come to the emergency department to be evaluated.
01:43 Now when Michelle got to the emergency department, she was diagnosed with a pulmonary embolism. A pulmonary embolism is a blood clot in the lungs and that can potentially be very life threatening. It's the same thing Serena Williams had. Michelle got the treatment she needed and thankfully she was fine. Now I'm really glad I listened to Michelle's concerns that night, but to be clear, I am not the hero of the story. Michelle is. Michelle was really persistent in voicing her concerns that something was wrong. She did so both with me on the phone and in the emergency department. Now why is this story important? This story is important because pregnancy related morbidity, and morbidity means health conditions that have a negative effect on a woman's well-being and health, and pregnancy related mortality, which is death related to pregnancy, are both on the rise in the United States. This is truly a public health crisis, especially for black women.
02:48 So today what I want to do in this episode, I want to give you a broad overview of maternal mortality, an overview of maternal morbidity. I'll talk about some of the numbers, some of the causes, risk factors, things that the healthcare system can do to help reduce these things. And then I'll end with things that you can do for yourself to help make sure you stay safe during pregnancy in the postpartum period. Now I cannot possibly cover everything related to this topic in a single podcast episode, but you will most certainly get some great information. So keep listening.
03:27 All right, so let's start with maternal mortality. Maternal mortality is pregnancy related death and pregnancy related deaths have nearly doubled since 1990 in the United States. That's in contrast to other areas of the world where pregnancy related death has actually been on a decline. It's been increasing in the United States. So in the United States, for every 100,000 women who have a live birth about 18 will die. Now on its face, that may not sound like a really huge number, 18 out of 100,000 however, there are about 4 million births in the United States each year, so that translates into over 700 women dying from pregnancy related causes each year in this country. And this is significantly worse for black women. Whereas the overall rate is 18 per 100,000 the rate for white woman is 12 deaths per 100,000 and the rate for black women is 43 deaths per 100,000. That's three and a half times the rate for white women.
04:46 Now in the United States, 38% of pregnancy related deaths occur during pregnancy. 45% occurr during the first six weeks of delivery, and then an additional 18% occur between six weeks and one year after delivery. So a little less than half of these deaths occur during pregnancy, just about 40%. Whereas a great deal, the largest majority, occur within that first six weeks after delivery, and then another 20% later on.
05:16 Now as far as causes of maternal death, and I'm just going to list the top 10 causes, this is from the Centers for Disease Control and I'm focusing specifically on the United States. So the number one cause of maternal death in this country is hemorrhage or bleeding after birth. Number two is cardiovascular conditions. So issues dealing with the heart. Number three is infection. It's followed by cardiomyopathy. Cardiomyopathy is a specific type of issue with the heart where the heart muscle is weakened. Number five is embolism. Embolism is a blood clot either in the legs or when an issue with death. Usually it means that it's traveled to the lungs Preeclampsia and eclampsia. Mental health conditions is number seven. Amniotic fluid embolism. This is when amniotic fluid gets into the bloodstream and it's almost universally fatal when it happens. It's very rare. Number nine is homicide, so being murdered related to pregnancy. And then number 10 is stroke.
06:25 Now the circumstances that lead to maternal death are complex and multifactorial and you can tell that based on the varying types of causes for maternal death and it often involves a lot of contributing factors, factors from the provider level, factors from a facility level and factors from a patient or family level. Now the most popular model that is applied to understand and really investigate the complex factors that contribute to maternal deaths is something called the three delays model.
07:04 And let me just tell you about what those three delays involve. They're in no particular order and they all kind of contribute in different ways. So one type of a delay, is a delay in the decision to seek care. It may be the case that a woman doesn't understand what warning signs she needs to look out for. It may be a case that she doesn't understand that the symptoms she's experiencing really necessitate being seen by a healthcare provider. The second delay is the delay in arrival to an appropriate medical care facility. It may be the case that people have poor transportation or no transportation or they may be a long distance from a facility that can provide appropriate care. Many hospitals do not have labor and delivery units. They don't have an understanding of how to take care of women in the pregnancy and postpartum periods, so women may definitely experienced some delays in that regard.
08:11 And then the third delay is the delay in receiving adequate care once a woman arrives to a medical facility. It's possible that women are not seen in a timely fashion, or they're seen and they don't get an appropriate diagnosis. They may get delays in treatment, they may get ineffective treatment. The severity of their conditions may not be recognized. Also, as I mentioned with the second one, it may be that the facility is inadequate to treat their condition, or it's inadequate to treat the severity of the disease. Not all hospitals are equipped with things like intensive care units or have blood readily available to really treat more severe conditions. There may also be a lack of coordinating care between different specialists, and finally a lack of communication between providers, where there's poor communication between various providers in the healthcare team and that leads to potentially bad things happening.
09:17 Now, this framework of these three delays, delays in seeking care, delays in arriving to an appropriate medical facility and delays in receiving adequate care once they get to a medical facility. This framework really allows us to look at the causes of maternal death in a more comprehensive way so we can take into account some of the provider contributions, patient contributions, as well as societal and cultural contributions. Now let's talk about some risk factors for maternal death. A big one of course, as I talked about is race and ethnicity. As I mentioned, black women are three and a half times more likely to die related to pregnancy than white women. Now, the underlying reasons for this disparity are complex. We know that health status plays a role when you enter pregnancy. Black women tend to have a poor health status emotionally, physically. They're also exposed to more chronic stress just from living and being a black woman in the United States and the things that they're exposed to.
10:26 There's also the factor of racism within the healthcare system, whether that's explicit or implicit racism. There are countless stories of black women describing encounters with the healthcare system where they felt like they were automatically being labeled as poor or uneducated, or not having the baby's father around. Some other data that supports the role of racism in this disparity, is that we know that in general when you have more education and a higher socioeconomic status, and when you also get prenatal care, those are things that can protect you against maternal death. However, at all educational and socio economic levels, pregnancy related death for black women is three to four times the rate for white women. So that means that for me as a college educated black woman, as a woman of a higher socioeconomic status, my rate of maternal death or risk of maternal death is three to four times that a white woman that's similar to me.
11:31 Also, the reduction in maternal death that we see with prenatal care is greater for white women. So white women experience a greater benefit from prenatal care than black women do. In addition to race and ethnicity, another big risk factor is age. Young women, and I mean really young women like less than 20, and older women, greater than 35 they have a higher risk of maternal death.
11:57 Now, the reason that this issue is truly a public health crisis is that 40 to 60% of maternal deaths are considered preventable. Let me say that again. 40 to 60% of maternal deaths are considered preventable. So we have a lot of work that we can do in order to reduce the burden of this problem in the United States. We truly have enough resources to address this issue. The United States is the richest country in the world, but we need to do a better job of using the resources that we have.
12:42 Now we know in the United States that deficient medical care, the medical issues that women have going into pregnancy and social circumstances all contribute to maternal mortality, especially for black women. So efforts have really focused on a lot of different things. Efforts have focused on things like training clinical teams, so training people to work together as a team in the hospital to care for women. Also focused on individual level training. Hospitals are doing things like simulations and drills, developing protocols, guidelines, checklists to really standardize things as well as some basic education. And the goal of these efforts is to really make sure we are diagnosing these conditions early and that appropriate medical care is being initiated promptly. California has done some great things with this. A lot of the things that are implemented are based on work that's done in California. California has been able to cut their maternal mortality rate by 50% so again, they've been doing some really great things in California and what they have done is spreading to other areas of the country.
13:58 Now let's switch gears and talk about morbidity. The World Health Organization defines near miss morbidities as conditions or events that would have resulted in a maternal death during pregnancy, childbirth or within the first six weeks after birth if there hadn't been a significant medical intervention. And the Centers for Disease Control and the American College of Obstetricians and Gynecologists, centers for Disease Control and Prevention is the national organization that does a lot with public health and ACOG, the American College of Obstetricians and Gynecologists is the organization that sets maternity care standards for the United States, particularly for physicians. They use the term severe maternal morbidity to describe unintended outcomes of labor and delivery that result in significant short or long-term consequences to a women's health. So you'll see those kind of definitions used similarly. Now severe maternal morbidity events. These life threatening near miss events are 50 to 100 times more common than maternal mortality. Again, 50 to a hundred times more common than maternal mortality.
15:22 So there are lots of times where we are having these near miss events in the US. Data shows that between 2006 and 2015 there's been a 45% increase in severe maternal morbidity. In 2006 that number was 101 per 10,000 delivery hospital admissions and in 2015 it was 146 per 10,000 delivery hospitalizations. And to translate that into numbers, there are about 4 million births in the United States, as I said. So that equals in 2015 there were about 58,400 severe maternal morbidity events. Let me say that again. 58,000 of these events. So this is a very serious problem and a true public health emergency.
16:22 Now the most common disorders that are associated with these events are the same things that are associated with maternal death, so bleeding, hypertension disorders in pregnancy, and also infection. Some of the risk factors are also the same. Women are more likely to experience these events if they're young, younger than 20 or older. Also those who are black, Hispanic or considered of an other race or ethnicity. These women are at more risk. A couple other factors that we know increase risks are if you have multiple gestations or if you have a history of a prior cesarean delivery.
17:00 Now as far as reducing risk is the same thing as for maternal mortality. Doing that team training, a team approach to health care, where everybody has a role in ensuring the health and safety of mom and baby, individual training, simulations, drills, protocols, guidelines, checklists to make it so that if there's not a question, that you see something, you act on it and you act on it quickly. Again, the goal is to diagnose things, find things early and get them treated early.
17:35 Now that I've given that overview, what I want to do now is give you five things, five tips that you can keep in mind in order to make sure that you stay safe both during your pregnancy and after your delivery.
17:49 Now, the first thing I want to say is that even though I presented these numbers, even though they're frightening, even though they're on the rise, it is still unlikely that you will have any problems during your pregnancy or after birth. By far the most likely thing that's going to happen is that you're going to have an uncomplicated pregnancy and an uncomplicated birth and everything's going to be just fine. However, I do want you to be prepared just in case of just listened to these five quick tips to help you stay safe both during pregnancy and after delivery.
18:21 Number one, ask your doctor how the hospital where you intend to give birth is prepared to deal with emergencies, especially bleeding after birth. As I mentioned, the number one cause of maternal death in the United States is postpartum bleeding. And postpartum bleeding or death from bleeding is largely preventable if it is recognized quickly and it is treated quickly. There was a article in the New England Journal of Medicine. The New England Journal of Medicine is perhaps one of the most prestigious medical journals and they published this editorial in November of 2018 on how to quickly address maternal mortality. I actually wished it was available for free and they wouldn't put it behind a paywall. But anyway, this article in November, 2018 it recommended that all hospitals institute something called a safety bundle that's produced by the Alliance for Innovation on Maternal Health. Now the Alliance for Innovation on Maternal Health is a collaboration that's led by ACOG, the American College of Obstetricians and Gynecologists, but it involves 30 other organizations including the American College of Nurse Midwives, including the Association of Women's Health Obstetric and Neonatal Nurses, that's AWON. As well as patient advocates in this group. And what they've done is they have developed these bundles of best practices to help improve safety and maternity care. And this article in the New England Journal of Medicine recommended implementing those bundles.
19:55 One of those bundles is on obstetric hemorrhage or bleeding after birth. And I will link to the show notes the website and the bundles so you can see what things that they have available. Now, key features of these bundles are readiness, recognition and prevention, response and reporting and having systems to learn from those reports. So in the case of postpartum bleeding, this means having something called a hemorrhage cart, where everything is readily available in one place, supplies and medications, to quickly address bleeding so you're not scrambling looking around for supplies and medications. Everything is centrally located in one place. It also means formally measuring the amount of bleeding. In many ways in medicine, we just kind of estimate the amount of bleeding. And study after study shows that we tend to underestimate the amount of bleeding we see. So this calls for really carefully measuring the amount of blood loss by weighing the pads of the blood. And then finally being sure that there are protocols in place to respond to bleeding quickly, including who to call.
21:09 So if a nurse is concerned about bleeding, she knows exactly who to call. And also this is really important when care needs to be transferred to another facility. If you happen to be giving birth at a hospital that's a smaller hospital, then you want to know what are their processes, what's in place, or at least that they have something in place. You don't have to know all the details, but that they have something in place where you can be smoothly transferred to another facility that can provide a higher level of care if need be.
21:40 Now again, I don't want to scare you with any of this. I know it's hard to think about the possibility of something like this happening, but there's story after story after story of women who wished they knew these things ahead of time. So you would really rather know ahead of time and feel confident that the hospital is prepared than to find out otherwise when it's potentially too late.
22:02 Now number two, if you don't feel right, pick up the phone and call. No matter the time of day or night. Most obstetric care providers, doctors, midwives have a way for you to reach someone 24/7. I guess I take this for granted and I get surprised that a lot of women don't necessarily realize this or maybe offices aren't communicating that this is the case, but the vast majority of offices will have a way for you to reach someone 24/7. Maybe a doctor, maybe a nurse, maybe a nurse practitioner, but you can reach that person usually by calling the regular office number, even if it's after hours. That regular office number will connect you to an answering service and that answering service will connect you to whoever is on call.
22:50 Now, there may be a few practices that don't have someone on call after hours. That may be the case with smaller solo practitioners. And in that case, you may get a message that directs you to go to the emergency department if you have concerns or to call the hospital. Just definitely check with your office to see what the process is for reaching someone after hours. And if you don't feel right, be sure to call, no matter the time of day or night.
23:18 Number three, if you're not feeling well and you're concerned, then by all means please go in to be seen. Even if you've talked to someone and they're saying that, ah, I don't know if you need to come in. If you don't feel right, if you have a concern, if there is something in your gut that's saying something is not right, then please go in to be seen. Do not let things linger. During office hours, you want to try it and get into the office for an appointment because it's ideal if your regular doctor can see you, or if another person in the practice who has access to your records can see you, but if you can't get into the office, then go to the emergency department. And if you have to go to an emergency department, ideally you really want to go to a hospital that has a labor and delivery unit associated with it at that hospital. They will just be so much more familiar with treating problems related to pregnancy. Now if the closest thing to you is a hospital without a labor and delivery unit, and that's where you can get to, you know, get there. But ideally, if you can get to a hospital that has a labor and delivery, that's going to be your best option for receiving the best care.
24:35 Number four, and this one is so crucial, so important. Actually. They all are. But this is a really big one. Be persistent. Keep voicing your concerns until your concerns are adequately addressed. I cannot stress this enough. Please do not be afraid to advocate for yourself. And if you don't feel comfortable advocating for yourself, then have someone there who feels comfortable advocating for you on your behalf. Do not worry about being perceived as annoying. Do not worry about hurting anyone's feelings. I am not exaggerating when I say that this really could be a life or death situation in certain circumstances. So please be persistent about getting your concerns address.
25:37 Now, persistence is especially important if you are a black woman. The unfortunate truth is that black women are more likely than other racial and ethnic groups to have their concerns dismissed or outright ignored by healthcare providers. So if you're a black woman, then please, absolutely be persistent in making sure that your concerns are addressed.
26:02 All right. Number five, you're not out of the woods after your baby is born. A lot of people may think, you know, I have the baby, I'm home, everything's okay. And again, most likely everything is going to be just fine. But over 60% of maternal deaths actually occur after delivery, as I mentioned earlier. About 45% are within that first six weeks after delivery, and then another 18% within the first six weeks to a year after delivery. So you're actually at the highest risk of problems happening after your baby is born.
26:37 Now to help you with this, I've created a little one page tip sheet of warning signs that you can look out for after birth. You can print it out, stick it on your refrigerator, keep a copy on your phone, it's just a little pdf. You can grab a copy at www.ncrcoaching.com/warningsigns, pop in your email address and I'll send it to you. That link to grab that one page Tip Sheet is in the show notes.
27:01 Okay, so to recap the five things that you can do and they're not that complicated. Number one, ask your doctor how the hospital is prepared to deal with emergencies, especially bleeding after birth. And if you're in a small hospital, ask how they are prepared to transfer you to a place that has a higher level of care if needed. Number two, if you don't feel right, call no matter the time of day or night. Be sure you know how to reach somebody from your office any time of the day or night. Number three, when in doubt, go in. Do not let things linger. Number four, be persistent. Keep asking until your concerns are adequately addressed, especially if you're a black woman. And number five, you are not out of the woods after your baby is born, there's still a pretty high risk after your baby's born. So grab that tip sheet of warning signs to look out for. And again, that link is in the show notes and it's www.ncrcoaching.com/warningsigns.
28:01 So that is it for this episode. I'm really curious about your stories on this topic. If you know about other women's experiences, I would really like to hear that. If you could let me know in the podcast community Facebook group. If you're not a member already, it's really easy to join. It's called All About Pregnancy and Birth podcast community. So please join me there and let me know your stories and your experiences.
28:26 Now be sure to subscribe to the podcast in iTunes or wherever you listen to podcasts and if you feel so inclined, I'd really appreciate you leaving an honest review on iTunes. It definitely helps other women find the show.
28:37 Now next week on the podcast, it is a birth story episode. I invited my virtual assistant Tarynn Saling to come on and share her experiences giving birth in a rural area of the country. We had a great conversation and you're really going to enjoy it. So come on back next week. Until then, I wish you a healthy and happy pregnancy and birth.
29:04 Today's episode is brought to you by Women's Wellness Coaching by Doctor Nicole Calloway Rankins. Head to www.ncrcoaching.com to check out my free one hour mini course on how to make your birth plan, as well as my comprehensive online childbirth education class, The Birth Preparation Course, with over eight hours of content and a private course community. The Birth Preparation Course, will leave you knowledgeable, prepared, confident, and empowered going into your birth. Head to www.ncrcoaching.com to learn more.